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Commonwealth of Massachusetts
.
Title 5 Official Inspection Fora
's Subsurface Sewage Disposal System Form-Not for Voluntary Assessments nn
y 30 Blossom Ave.
Property Address
Deb Brodeur �1
Owner Owner's Name
information is Osterville MA 02655 3-27-15
required for every E:st
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
` �gpuuuu�4�i
on the computer, `��\�� tN OF
Inspector:
use only the tab 1. InS /Q 9c'a
key to move your I ` o� yG
cursor-do not JA M E S _
James D.Sears m
use the return f I Name of
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CapewideEnterprises,LLC...... •.o� o
" —w Company Name
153 Commercial Street ,���F`-5 1 N Sp�c```��.
Company Address
Mashpee _ _._ __ ___.. MA _ 02649,_.
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of
Title 5(310 CMR.15.000).The system:
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority G .
3-28-15
pedor's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
***"This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Tilt 5 Oftial Ikon Forth:Subsurface Sewage Disposal System•Page 1 or 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
�
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1500 Gal.Tank D Box and two chambers.
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.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or 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.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-3M3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property,Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cunt.):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner owner's Name
information is required for every Osterville MA 02655 3-27-15
page. Cityrrown State Zip Code Date of Inspection
B. Cerfification (cunt.)
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, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis 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
❑ E 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 gmaspod is less than 6"below invert or available volume is less
than %day flow,C EAC/1//yX'
t5ins•3/13 Idle 5 official hnspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`t 30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or 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.
❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ 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.
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Z 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)
0 ❑ Was the facility or dwelling inspected for signs of sewage back up?
Z; ❑ Was the site inspected for signs of break out?
Z ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is Osterville MA 02655 3-27-15
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal.Tank D Box and two chambers.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2013-141,000Gal
g ( y g (gpd))' 2014-97,000 Gal s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
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:
t5ins•3/13 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°f 30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other'(describe below):
General Information
Pumping Records:
Source of information: 2010/2012
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'l 30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) .
Approximate age of all components, date installed (if known)and source of information:
2007 Permit # 2007-200.
Were'sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 40"feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
bistance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4"PVC SCH 40.
Septic Tank(locate on site plan):
30"
Depth below grade: feet
Material of construction:
concrete ❑ 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
Dimensions: 1500 Gal, Precast H-10
Sludge depth
1"
t5ins•3/13 Title 5 official inspection forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. Cdyr town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or-baffle
29"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-TapeSludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank at working level. Tank at 30"below grade w/both covers at 15". In and outlet Tee's. No sign
of leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
El concrete D metal ❑fiberglass El 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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Ownnfbff er Owner's Name
require for
is Osterville MA 02655 3-27-15
required for every
page. Cityfrown 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.):
{
Tight or Holding Tank(tank must:be pumped:at time.of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
bate of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. City/rown State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 16"-45"below grade w/cover at 22". Box is clean and solid w/two tines out. No sign
of over loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ Ne-
Alarms in working order: ❑ Yes ❑ No`
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
"If pumps or alarms are not in working order, system is a conditional pass.
Soil Absoiption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
� I
t5ins•3113 rille 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
i Type:
leaching pits number:
® leaching chambers number: 2
❑ 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.):
Leaching is two 500 Gal.dry well chambers w/4'stone. Chambers at 56" below grade w/cover at
28". Chambers are wet on bottom.Wall clean like new.
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I
r
Commonwealth of Massachusetts
Title 5 official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
01
0 0
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17
i
Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owners Name
required fo is Osterville MA 02655 3-27-15
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells o
� 10'+
Estimated depth t high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: 2007
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
T.H. on file 2007 NO G.W.at 10'. Bottom of chambers at 7' below grade. Bottom of chambers at T
above T.H.Depth.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
30 Blossom Ave.
Property Address
Deb Brodeur
Owner Owner's Name
information is required for every Osterville MA 02655 3-27-15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-W 3 We 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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nn TOWN OF BARNSTABLE
/✓WCATION 30 105fFg ✓7 /9v.e SEWAGE# 2007 a00
VILLAGE ASSESSOR'S MAP&PARCEL .11 7 ,570
INSTALLERS NAME&PHONE NO. j, `!ate 97 737
SEPTIC TANK CAPACITY- /SOOg
LEACHING FACILITY: (type) ,A,-,74 S' (size) a��,�/�.�3 Xa
NO.OF BEDROOMS 3 /
OWNER ArIU4 lr � r�11/G h
PERMIT DATE:" 5---l.6 '0 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
y
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FEE /222
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COMMONWEALTH OF MASSACHUSETTS ;
Board of Health,
`U APPLICATIO
N Y R DISPOSAL SYSTEM C®NSTRUCTI®N PERMIT
Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) - /complete System ❑Individual Components
Location miner's Name
Map/Parcel# 1 Address
Lot# Telephone#
Installer's Name Designer's Name STEPHEN J.DON LE AND ASSOCIATES
Address Address EAST FALMOUTH,MASSACHUSETTS 025M
Telephone# Telephone# 2534
TYPe Building Lot Size 17, 10 2�j sq.ft.
welling_90.of Bedrooms peti, ���pcJyi.�� Garbage grinder ( )
er-Type of Building No.of persons. Showers ( ),Cafeteria( )
Other Fixtures
Design Flow(min.required) :!z'3D gpd Calculated design flow '33® Design flow provided 3APj gpd
Plan: Date Atj 14 )�p Number of sheets 1 Revision Date
Title T��Y'�1 �s��� t�DdL `17c) !`4r5_
Description of Soil(s) i�.aC�'.i �✓�9��. Lo 1 1
Soil Evaluator Form No. l\bq t> Name of Soil Evaluator W'�. Date of Evaluation Z-J�
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersi a agre o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire s t no place th tem' per on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date to —
in ce
I I WV
FEE
r ; %--X,COMMONWEALTII OF MASSACHUSETTS
Y Board of Health,
`U APPLICATION YRpair(
R DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(`) ) Upgrade( ) Abandon( ) - /CompleteSystem ❑Individual Components
)
Location -51P Tj L_0- Ay ,,, ZD�'+fit.\;�L�&ner's Name
Map/Parcel# 1-7„ t Address
Lot# �ry�` Telephone#
-= " '-Installer's Name t Designer's Nam$TEPHEN J. DOYLE AND ASSOCIATES
Address Address EAST FALMOUTH,MASSACHUSETTS 026M
Telepb6ne# Telephone# 595/540-2534
Type of Building Lot Size !o Z .sq.ft.
eDwe�rTyp
o.of Bedrooms Garbage grinder( )
Oth of Building No.of persons Showers ( ),Cafeteria( `
Other Fixtures
Design Flow(min.required) 1130 gpd Calculated design flow `5, 0 DesignIflow provided '3A Pj gpd
Plan: Date H\/hrJ 14 D�P Number of sheets Revision Date
r
Title G�.1�C-�1 `� ��t�� 1 �!� iJ,t��1 Y��YI� `-5D
f -
Description ofSoil(s)
t,
Soil Evaluator Form No. 11 bq� Name of Soil Evaluator •��l N`�. Date of Evaluation 4 -i%-tr
DESCRIPTION OF REPAIRS OR ALTERATIONS k'
1
The undersign agrees"to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to,place the,systemm in,
n,operation
.�until a Certificate of Compliance has been issued by the Board of Health.
Signed s %�I7(/1 !/�'�� Date -7,
is ecttfVOJ///J +'�� ��% ����it'%l / fl tt/���l/ Uff1/ L//(//� �'lei?'7 e%/ ✓1n'd _ l 1 /�/t / /00,
/
U / ,
v
No. /N/f FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
_ CERTIFICATE OF COMPLIANCE
..,Description of Work: ❑Individual Component(s) O'Complete System
r • `: The undersigned hereby certify that the Sewage Disposal System; Constructed (�),,-6paired ( ),Upgraded ( ),Abandoned ( )
at aY /
has been installed ailed in accordance with the provisions of'310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. � �, dated Approved Design Flow s 7 (gpd)
Installer I } A/ 11-40 r / t` _
Designer: Inspector//1 '4 A1%,471t�y -06 )Date:�/ A0/ X
,
The issuance of this permit shall not be construed as a guarantee that thecsy m will function as designed. /
No.
4
4� FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, 1`)!1 AN A 6 M6-
� r
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby,granted to- Constructt(>� Repaiir,(� )-�Upgrade
j( /) .Abandon( ) an individual sewage disposal system
at _c 'X _ .,J Jy � �/ /�j/ li?,, as described in the application for
Disposal System Construction Permit No M19 dated 1//.2/191-1
Provided: Construction shall be completed`with°in three years of the date o tf� h s p` mit/mil local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date / // // / Board of Health // J
;- --
Q'
Town of Barnstable
ofVE
R la e t r o Se vices
� 1 Y.
Thomas F.Geiler,Director
MAM Public:Health Division
039• �0
'''�► " Thomas McKean;Director
2,00 Main Street,Hyannis,MA 02601-
Office:.508-862-4644 Fax: 508-790 6304 .
Installer &Designer Certification'Form
Date: 7 `- Sewage Permit#a 007-a o o Assessor"M- - ap\Pareel ,1 - J
Designer: Installer o t N. IkL D
STEPHEN J.DOYLE AND'D ASSOC-UXTES
42 CANTERBURY LANE P . oX 33� /19ar iT��S
Address: MASSAei 2536
Address o,
EMT-FAWBUT! ,
608/540-2534
oar�i�
On Y'a0V 7 was issued a permit to install a
(date) (installer)
. septic system at S 0 ►J L.o S5 D NI Av r-_ based on a design drawn by
(address)
S ,� -0 a 4 _ sso dated --/y 7
(designer)
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. Stripout (if required) was inspected and-the soils
were found satisfactory.
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. Stripout (if required) was inspected and the soils
were found satisfactory.
�*Aesa4,
���jH or 1,1,4:HRISs� a�
�O AIR TIN TERFO��yG��9
Installer's Signature) ; IVa 926 o STEPHEN -A 1s
J.
DOYLE
ccels, xr ® �� #37559 P
s
SAWITrPill
—� ®�9N0 S U R�' i®
(Desi er's Si a e (Affix Designer's.Stamp a v a
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic\,Designer Certification Form Rev 03-09-06.doc
a 45` a archon of Yians.anti J ecmcanu,� r, •. r<all be prepared as follows:
—
The plans and specifcations for,every on-site system sh
(1) Every system shall be designed by a Massachusetts Registered Professional Engineer
or a Massaclfusetts Registered 5anitaZian provided that such Sanitarian shall tint-design I.
system designed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203.
Any other agent of the owner.-may p1ep.a=-plans for the repair of a system.designed to
discharge not more than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided
they are reviewed by.
a Massachusetts Registered Sanitarian and approved by the approving
' authority;
(2). -Every:glary submitted for approval must be dated and bear the stamp and signature of -
the designer,
} Every plan for a new system or plan for the upgrade or expansion of an existing:system-
(3
(3h requires a variance to a property Mine setback distance,:must reference a plan
which bears the stamp and signature of a Massachusetts; Licensed Land Surveyor in
accordance with 14'61- c: 112,
(4) Every plan for a system shall be of suitable scale(onc inch=40 feet or fewer for plot
plans and one inch ZU feet or fewer for details of system camponenLs). �td.shall include.
depiction of:
(a) the legal boundaries of the facility to be served:
(b) the holder and location of any casements appurtenant to or which could impact the
. . . system; ... .... .__. . -. -. - . . ..
/ (c) the locadon-of the all dwdlling(s)or building(s)existing and propos_d an the facility
V and identifieaddr of those to be served by.the system;
�(d) -.the'i_acarion of ekistirig or proposed imper dOus areas; ineluhzng..driveways and
,parking areas - -
(e} location and dirricrsions:cf ih'e system (including, reserYe area);
(f). system design calculations, including design daily sewage flow, septic rank capacity
/ (required and provided; soil absorption system capacity (required.and provided); and
V whether systerri is designed for garbage grinder;
{ } North arrow and existing and proposed contours;
(h) Ioratiowand*log of deep'obs„crvation hole tests including the date of test, existing
grade elevations marked on tacit test, and he nairtes of the rcpresentativc of the
approving authority and soil evaluator;
(i) location and results of percolation'tests including the ante of test and the names of
the representative of the apptoving authority and soil evaluator; .
} name and ccrtifzcation number of the Soil Evaluator of record;
(k) location.a£everX water supply,public and'private,
1. wi.thia 400 feet of the proposed system location in the case of surface water
supplies-and gravel packed public water Supply wells,
2. withi'n 250 feet of the proposed system location in the case;of tubular public
water supply wells, and
3. within 130 feet,
of the proposed system•location It the. case of private water -
supply wells; v etated
1) location of-any surface waters of the Comm.0awealtfiv�rivers, bordering.. eg
wetlands, salt marshes, inland or coastal banks• regulatory flaodway, yzlocity tons,
surface water supplies, tributaries to surface water supplies,certified vernal pools,private :
water sulplies or suctinit lines, gravel packed or tubular public water Supply wells, ' -
/ subsurface drains, leaching catch basins, or.dry wells; aced the Iacati.on of any nitrogen
/ sensitive area identified in 310 CMS 15.215 within which portions of the proposed
t/ stern are located. w
(rz). location of water]fines and other subsurface Utilities on the facility;
(n) observed and adjusted ground=water elevztian in the vicinity of the system;
o} a complete profile of the systern;
(p) -a note on the plan listing all variances to the provisions of 310 CIMR 15.000 sought I
in conjunction with the plan; n
(q) . the location and.elevation of one benchmark.within 50 to et of the facility
which is not subject to dislocation at Iasi during construction ori'the aciI ty,
(r) when dosing is'pzoposed, 'camplcte design'aiid sPecsflaation of the,dosing system
prepared including but not lirrd, to dosing,ehambecl spend deacity pth er�cycle;
provided),'
urnp curves and.specifications, number.of d'osia, Y p p required or
(s) when a.Recircula=g Sand Filter or equivalent alternative technology is nq
roposed, a complete plan and specification for the system,including a hydraulic profile;
(t a locus plan,to show the location of the facility including the nearest existing street;
the street t#uinbcl and lot number, if any, of the facility; and
v) the materials of constructoiz.and the specifications of the system.
Town of Barnstable P#
. _ dime
' $ Department of Regulatory Services
Public Health Division Date a 2 e i to
200 Main Street,Hyannis MA 02601
ED MAGI►
Date Scheduled Time Fee Pd. J --�`
Soil Suitability Assessment for Sewage. Disposal
Performed By: G L/ Witnessed By: �• �1 0 MA,1`\�1
LOCATION& GENERAL INFORMATI0
Location Address Joy /3� v , Owner's Name
Address 3n '�jl rJ 5 Sry�1
Assessor's Map/Parcel: `/�� Engineer's Name .
NEW CONSTRUCTION i/ REPAIR Telephone#
Land Use S Slopes(45) G �i y' Surface Stones D
Distances from: Open Water Body ►S J ft Possible Wet Areaft Drinking Water Well —>—�ft
Drainage Way _} ; ft Property line V'ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands In proximity to holes)
Cos
' C
yJ �
rA
(AC I lk
eo t
lT�(6%3
(a4�=
pvt .�
Parent material(geologic)_`��—� Depth to Bedrock IJ A
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face XAoorge
Estimated Seasonal High Groundwater. Lo
DETERNUNATION FOR SEASONAL HIGH WATER TABLE
Method Used: 41 S. 1"'t D
Depth Observed standing in obs.hole: In. Depth to soil mottles:
Depth to weeping from side of obs.hole: in, Groundwater Adjustment
Index Well# Reading Date: Index Well level .... Adj,factor_ Adj.Groundwater bevel,,
PERCOLATION TEST n8119 AV--10. '
Observation
Hole# t __ Time at 9"
Depth of PercQa_ ._3i; Time tit 6" f
Start Pre-soak Time @ to-too... 01 '•D Time(9"-6'7 r•.Tl
. �o �� ;k� �Z A �L V . u�
End Pre-soak 1 D
Rate Min./inch
Site Suitability Assessment: to Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the..
Barnstable Conseli'vation Division at least one(1) week prior to beginning.
Q:XSEPTICIPERCFORM.DOC
I
DEEP.OBSERVATION HOLE LOG Hole# i
Depth from Soil Horizon Soil Texture
Soil Color Soil ther
Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,Boulders.
istenc % rave
D GII A tG�f't cots4�� >J
�� t.5 1oyK 5
DEEP OBSERVATION HOLE LOG Hole# z Depth from Soil Horizon Soil Texture Soil Color
Surface(in.) Soil Other
(USDA) (Munsell) Mottling (Structure,Stones,Boulders.
6-b I` Consi t c % v
`'
ZL-12� C�- r. 5a t> 2,
DEEP OBSERVATION HOLE LOG Hole# -1
Depth from Soil Horizon Soil Texture Soil Color
Surface(in.) Soil ther
(USDA) (Muusell) Mottling (Structure,Stones,Boulders.
It o i to c O vel
S L 1 t, 1 tz, `s Z N s�5 .►.4
65 ,Dye 4
zto-1 ti``
o •a
S► � Z��� �I 7 L 1• h/a�/'.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil
Surface(in.) . Other
(USDA) (Munsell) Mottling (Structure,Stones;Boulders.
tt �. e71_ 1C 3 .� L�U514
o ,r
it �/4
- C �
Flood Insurance Rate Mae:
Above 500 year flood boundary No Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No.AIIYes .
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervio4fi material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pery ous material?
Certification
I certify that on :? (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training,experti a and experience described in 310 CMR 15.017.
Signature Date �� G
Q:%$EMC BRCFORM.DOC
NWT....................
THE COMMONWEALTH OF MASSACHUSETTS
'� 'b� BOARD OF HEALTH
..........0F.-e ...............................
Appliration for Uiiipasal Works Tontitrurtion ramit
Application is hereby made for a Permit to Construct or Repair ( &-j"an Individual Sewage Disposal
System at:
.. .........AtI4..!......e�ax_llkl-,Ile----------------------------------------------------------------------------------
o.c.ation,,.46d4ress or Lot No.
.. .........
...L.110.121&5 111-13aw... .............. ...................... ----------------- ......... .......Owner Address
A . .... . .................
. . Installer Address
U *........... ..........------------*
Type of Building Size, Lot............................Sq. feet
Dwelling o. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
44 Other fixtures .................................................................................. ...............................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter____.___.._..... Depth....._........_.
Disposal Trench—No..................... Width....._...._.._..._.. Total Length_.............._.... Total leaching area....................sq. ft.
> 6
Seepage Pit No..................... Diameter.............__..... Depth below inlet.................... Total leaching area.............--...sq. f t.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.._................. Depth to ground water....................___.
......... .. . ..... ...................................................................................................
0 Description of Soil......ly, W n
........Vt.......oww/1'i/
W...................................................................................................
..........................................................................................................................................................w..............................................
U
................................................................................................................. ....................../- .......................
-X .......... -—-----------_--------
U Nat e of epai or Alterations—Answer when applicable_/-:!.� .... ........ ..
*. .,.v.e..............................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n issued b the board of health
Si
ApplicationApproved By............ ........ ................................................................... ... . ..............
Date
e of Compliance has be n issued Si........... ..........................
Application Disapproved for ollo * reasons:.................................................................................................................
........................................................................................................................................................................... ............................
Date
PermitNo......................................................... IssuedL.......................................................
Date
TOWN OF BARNSTABLE
LOCATION 3�A"�, Q�,�3Som Av e SEWAGE#o?00f
VILLAGE 05leyvd Ile ASSESSOR'S MAP&PARCEL OS L
INSTALLERS NAME&PHONE NO. C. A9 lfJ
SEPTIC TANK CAPACITY c - /5 00�,
LEACHING FACILITY:(type) r; (size) y.Z,5'X A/
NO.OF BEDROOMS
OWNER
PERMIT DATE: /a a 3-0 -1 COMPLIANCE DATE: 2
2 L (/
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
G •
e 4 3 f' A-3 a9
,D- ��� ,f�pl 0�4of
TOWN OF BARNSTABLE
3�LOCATION lossoevn A VL. SEWAGE #
VILLAGE 0STtrV1 ILL ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY CUS06011
LEACHING FACILITY: (type) CQSS iS (size)
NO. OF BEDROOMS_
BUILDER OR OWNER 120,11it— W1 1k)�S �
PERMITDATE: 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 leac rig facility) Feet
�` Furnished by ^SOcL,I
LA
Li
r
3
a
Y
Colm9c-,
TOWN OF BARNSTABLE
IV ,
i
LOCATION6lo SEWAGE #
VILLAGE 0 S��2�``�'`� ASSESSOR'S MAP & LOV/7- 05'6"
INSTALLER'S NAME & PHONE NO. p/�c 1,Pa vD S ► 6r
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) � ��T'"j �' (size) rp� G�-
NO. OF BEDROOMS �� PRIVATE WELL OR
BUILDER OR OWNERS
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
coo
100
4�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/.f�/�f ...............OF..../`h,'..+�r k�d.�.;,i ....:? =s. - a-... .........................
. ppliration for Bhipviittl Workii Ton,itrur#inn Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( --ran Individual Sewage Disposal
System at:
...... o--- ., . 0.jll_�........ 114-.1...--- Z.7. ..................................................................................................
ocation dress o or Lot No.
.Q �2 ... s..1,�-&..................? -- ----------------_--------•-•-•-•----------•-•-----•--------------••----------------------•---•----
Owner ________________________________Address
>..
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling-✓1 o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building ............ No. of persons............................ Showers
P.I YP g ---------------• P ( ) — Cafeteria ( )
a' Other fixtures --------------------------------- -
d --.---•-----• -----------------------------•--•-•---------.------............
•••--------.-.--------
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........................................
Test Pit No. 1.............:..minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----------------- •-•--•-•------ -----••------•-------- ...._••--•-.•--•- . ..........................................................
Description of Soil-------... ......4....... sit4"la-4....................................................
V
W ----------------------------- -•--•----••-------•-•---.....--••--•---•---•---•-•---•----------•---•------••......- --- - - - ----
VNatu,� of Repairs r Alterations—Answer when applicable_..f-_� �✓/7 !J. �� .
-------------------------------
Agreement:
The undersigned agrees`to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T U 5-of the State Sanitary Code— The undersigned further agrees not to place.the system in
operation until a Certificate of Compliance has been issued by the board of health.
a� D e
Sizad
Application Approved By......................... . = :....._.. --••------------•• .... _.�.1 ........
Date
Application Disapproved for ollo reasons:-------•------------------------•-----------•----•--•-.....------------------....---------:.........._._........
-•-------------------------••----•--------------•--------------------------------•-•-•••-•.........--_....................-•--•-.....-•••---••---•--•-••-••-••---•----------•----•.•••--•-..-•----••-•--.
Date
PermitNo------------------ - �- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF/IHEALTH
`.; 1.46 . :.................
Trrtgfiratr of Toutpliattre
THIS IS TO CERTIFY, That the Individual Sewa e Disposal System constructed ( ) or Repaired
b vt P.. � jw.
Installer P
at...... .:-! =C<.'�YYC..........?!� ,,..-----...--. r_ �--------------------------------------- ----
has been installed in accordance with the provisions of TITLB 5 of The State Sanitary Co as I ed in the
application for Disposal Works Construction Permit No._�_� . . ................. dated_.i- __/Z_... _............_._......
THE I SIJ NCE OF THIS CERTIFICATE SHALL NOT BE CONS AED AS A GUARANT E THAT THE
SYSTEM IL CTION SATISFACTORY.
DATE.�..)t -----••------------ Inspector. ...-••------•----------------------------------•.......-••-••......••---.......:
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD Of HEALTH
3 .... ...' .....OF........... F J `,f':.+. ' �<°� '�✓..t'.a............
No........................
FEE.... . ...
Di5potia1 jVorkv (Epnotrur#ion ramit
Permission is hereby granted.... ft. .• -----.�A.------t dd 1?/.--------Z,u�-----------------------------------
to Construct ( ) or Repair (A_-),`an Individ 1 Sewage Disposal System
at N
Street
as shown /nth application for Disposal ��'orks Construction Permit No: .. ._____________ Dated..........................................
/ ---- ---- ------------------------------------------------------------------------Board of Health
DATE ----•---....
FOR%i 1255 A. M. SULKIN, INC., BOSTON - . _
_ _ __ titiu�ui►tite � -
— - _ � ■■ - VTR\ i�����. �`` STRAPPING
- - - -
1}�lIi1Ul1l1! _- \_�'%t]f-Ir7�lOf7fl��,l.
.�- -■ - -�:i IIIMABIEDROOMNeUL. ' ►,_
OG STRAPPING
1/2"WALLBOARD
.: ..�..� CL
.-....■-..- ..-..-..-..� - :�::�::•- - - - - - - - - -
■ _
...
:�� •I i�.
PAN
�I .
LOLLY CIOLUML
12
4"CONC.SLAB
NO
Or
_• •AW
FBIv
-
INe
- -STR ,;�
"MILLBOARD ►� -
BEDROOM 03
, �__ -��, �,•W.
- - - -_• - - it
..�... n-. - �■.�.0 �n
R- • _ _ u i� _ DO STRAPPING
- _TEM -EAM STEEL _
�.�n�n� • �n�n���■�U . _ ■ ��. �I F.t7iStiI•':!if,�h
NNIs
-
ii�u��n� • emu-i
LrVING DINING
���� —_�7 � �.-3 -■.��:�.:�■:�■:�.:�:=•,•�.■.L_ ��l Imo. �I!
�. :5::• � .: —.
N.M.W.—
_ { �E , '- ■■■ "i ■■■1�.�. l 32i2b2ifitit
010
ORnFamana
lTW1f .y if�w lT wli �.. �.i��i��■ �� , Q - _.I
sa - _Ili - - i�� �_���■��■�����u�■�����•1:.��.��u-.1TI� ��
Al ITO
— -- u�■-- — — — — — - _ .—..—.■
.—..—..—..—u—..—
11 �, -r�•
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PROPOSED THREE BEDROOM HOME DATE REVIsloN DRAWN Br PAGE SCALE
g 30 BLOSSOM AVENUE �! WItH tW0 GAR GARACsE. I cf� 17c�819'r18
aI fCENDALL a WELCH OSTERYILLE, MA, 05-03-07 N .e • of vs:r-o• ;, , .. .
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25'-0" 30'-0° 17'-0° 24'-0°
36'-0' '
FIRST FLOOR PLAN
2 DATE REV1610N DRAWN BY PAGE SCALE
V OS ME _
PROPOSED THREE BEDROOM }-10
g 05 BLOSSOM AVENUE I J,8 �rro8�9'/98
I KENDALL 4 WELCH p WITH TWO GAR GARAGE, 05-03-0'1 N .e •4-�
a v OSTERYILLE, MA. _
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"L—c1DGE VET.
2XI2 RIDGE SIDING
2XIO RAFTERS o 16'O.G.
1/2"PLY.SHEATHING
150 ASPHALT PAPER
2XIO RAFTERS o 16"O.C. ASPHALT SHINGLES ASPHALT ROOFING TYVEK OR EQUAL
1/2"PLY.SHEATHING 15•ASPHALT PAPER 1/2"PLY.SHEATHING
15•ASPHALT PAPER 2X10 RAFTERS•16"O.G. V2°PLY.SHEATHING
ASPHALT SHINGLES i/2°PLY.SHEATHING '
2X8 RAFTERS o 16'O.C. 15•ASPHALT PAPER
I/2°PLY.SHEATHING ASPHALT SHINGLES
15*ASPHALT PAPER SHINGLE STARTER
ASPHALT SHINGLES COARSE
_ ZXIO'e C.J,0 16"O.G. 2XI0'e C.J.+P 1 "O. DRIP EDGE
2X6 P.T.SILL
5"GUTTER 1/2°X6°SILL SEALER
2-2Xi0'e ® TYP.HURRICANE TIER o"? I ° 2-•5 TOP RING 2"CLEAR
Q R30 INSUL.
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5/8"XI2"ANCHOR BOLTS
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`° 6400 VENT SILL I BILL DETAILS
3/4"T/G PLY. 1X SOFFIT
NAILED A GLUED. D 14/2'BED MPG.
-- E—9.1/2°ENG.1 JOIST EAVE IX FREIZE
• 4 STEEL BEAM D(3 STRAPPING 3
1p IR°WALLBOARD
1/2"WALLBOARD RO RD SAVE DETAILS
2X4'e N I6°O.C. ENTRY KITCHEN
R13 IN6ULA ION
1/2"PLY,6HEA ING
TYVEK WRAP OR EQ JAL
SIr ING 3/4'T/G PLY.
NAILED L GLUED. 5'-3K° DORMER 20'-6"
_ F 9.1/2"ENG,1 JOIST 4'-016" 12'-616" 3'-S" 3'-11" 3-916° 3'-816" 4'-946 b'-0° i2.-0. 6'-0"
3-2X12'e GIRDER RIS INSUL
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DORMER
PROPOSED THREE BEDROOMR
HOME DATE EVI610N DRAWN BY PAGE SCALE
KENDALL a WELCH 30 BLOSSOM AVENUE �) WITN TWO CAR GARAGE 0$-03-01 M .s •—S—oF Z u��-0- J� DPislglns
OSTERVILLE, MA. ,.
LLB It I rl lD M^ W IV V"KWAFAY%R E1¢1PEA.'#ftWA ~&We&W :;V -1 AL.L CGNq�TE fe rp" (CA F1N LL fIXJI1HSe NULL FJf1EAfD GlA�N11/.�E YH¢6r D�11L ��: Pa BGlY lA4 lCG1BlDSOS90
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Top of Foundation El. 43.5,
POND
2-1SAM
POND 79,g3+29�E 40 `P FNO Finish Grade El. 40"t
Z ��• N / 6„ 6„ ] Finish Grade El 40t
INV EL RISER
6„
/ I !!
/ 37 5' 20"Dia. 0 Dia.
/ RISER
S-\p,T1pN
Flo J / Ain. 6" INV EL
O 10' Min. 14 Min
i " . INU EL
IN EL INU EL sump 36.47'
5pM MAIN PARCEL J� N 37.17' ^_ BeIoW Flo Line�� 36.92' 36.67' - -6"Stone _
�pS Liquid Level 46"'
e PEE oPy Ro FgSTeq 39 17,623±S.F. 4 HOLE DISTRIBUTION BOX
86
9L� N
1500 GALLON SEPTIC TANK
Locus SAP
4= / 1/8" to 1/.2"' Washed Stone 3' Thick
PRECAST REINFORCED CONCRETE DISTRIBUTION BOX 12.83' Finish Grade El 40'-& Max.
34
�ii�iii»�� �l ll�l�ll �����ll��flllllll�llll��lllll Install on a le vel base ,.,._. - ` f •.00` , o p.'• _
Minimum wall thickness = 2,y a 24" 6„
133' PROPOSED SAS _ _ aa" 5$' ash � 8.5' -�i FER 37.0,
Minimum Inside dimension 1,_"' CHAMBER TRENCH �� � �-�I
Outlet inverts shall be equal to each other and at o
_ a• a o o a o o . • . El. 34.17
22 minimum below inlet invert. Number of Trenches - 1 INt� EL
.The distribution lines from the distribution box shall all have 40 t5' Number of Chambers - 2 36.17' 48" 314 - 1 1/2" Washed Stone 48"
equal inverts as determined by flooding the distribution box to -- _ 25'
the height of the distribution line invert after all lines have LA �'_1PROPOSED LEACH TRENCH END VIEW N. T.S.
been sealed in place. f 4o Install Two 500 Gallon Units
2 �TP with Four Feet of Stone at Sides and Ends.
Invert adjustments shall be made by filling with durable and ® N
nondeformable material permanently fastened to the line or TP1 PROPOSED LEACH TRENCH
reconstructing the lines until all inverts are of equal elevation. \0 2500
4 40 t\(vlg° ® Bottom of Deep Observation Hole El. 28.0,
Ws_ PROPOSED / Health Agent: D. Mkandi
\p 315oo/GAL Test Date: 04-23-07
1500 GALLON REINFORCED CONCRETE SEPTIC TANK 5 Eo 0 0 20' TANK p / Soil Evaluator- S. Doyle High Ground Water <Ele v. 20' (GIS Topography)
Minimum Construction Materials Per 310CMR 15.226(2) o / High Ground Water <Elev. 20 (GIS Topography)
Tees shall be constructed of Schedule 40 PVC and shall extend a o / 90AO\JE
minimum of 6" above the flow line of the septic tank and be On RE0� a ^ FENCE TH #1 EL. 40.0' TH #2 EL. 40.0' TH #3 EL 40.0' TH #4 EL. 40.0'
the centerline of the septic tank located directly under the FEN moo' w�/� PERC <2 MIN/INCH PERC <2 MIN/INCH PERC <2 MIN/INCH PERC <2 MIN/INCH
clean-out manhole. r--� , ___V_ I_ 0„ 011 0„ 0„
The inlet pipe elevation shall be no less than 2 nor more than 3 N r / r o
P P __ r A A
- __ _
-_ _ ._-�.. _ ..__.�r.....�.a ,��.. _ -•.,-_ _�:.--- -..� _ :_ - __ __ _SL 1DY-P..3 ". - _.. -_ _,�� ..,.ft ..f?_ ._ .,.� c �� ,G fR--�
above the invert elevation of the outlet pipe. rn R posEo ; , { 6„
P 6,; 6" 6„
Septic tank shall be installed level and true to grade on a Level, 'o A ow LL\NG ,; o,
stable base that has been mechanically compacted and on which ,0 5 �` C13 B LS 10YR 5/4 B LS 1 oYR 5/4 B LS 10YR 5/4 B LS 10YR 5/4
6 of crushed stone has been placed to ensure Stability and / i �r� •'t� , 41 EL. 37.8 ' 26" EL. 37.8 26" EL. 37.8 26" EL. 3T8 ' 26"
to prevent settling.
Septic tank shall have a minimum cover of 9': �� ,LP / PERC 48" PERC 48"
r I / C MED. TO C MED. TO C MED. TO C MED. TO
TWO 20" manholes with readily removable impermeable covers t 32.66' ♦ FINE FINE FINE FINE
of durable material shall be provided with access ports / ; \ ; / SAND SAND SAND SAND
The outlet tee shall be equipped with gas baffle / '; / 2.5Y 7/3 2.5Y 7/3 2.5Y 7/3 2.5Y 7/3 REF DEED. 9760 82
40 j r jANW 91'
t 144" -120" 132" 144" ASSESSORS MAP 117 PARCEL 50
Design Data: RATNG NO WATER ENCOUNTERED NO WATER ENCOUNTERED No WATER ENCOUNTERED NO WATER ENCOUNTERED LOCUS ADDRESS:
REMOVE t . EX�S G EL. 28.0' EL. 30.0' EL. 29.0' EL. 28.0' 30 BLOSSOM AVE, OSTERVILLE
Three Bedrooms = 3 X 110 gpd = 330 gpd Required Flow OLD SEPTIC ' ;
No Garbage Disposal Allowed SYSTEM i r r l FEMA DATA: ZONE 'C"
1 i 10.2 FIRM PANEL' 250001 0016 D
Use: Chamber Trench 25 L x 12.83 W x 2 Eff/Depth +
GRAPHIC SCALE MAP REVISED. JULY 2, 1992
[25' •f- 25' -1 12.83 + 12.83] x 2 0 = 151 c- - �� i '� 20 a 10 20 40 eo ZONING DISTRICT- RC
25' X 12.83 = 320 41 - - pSED ri ,'� ims
OVERLAY DISTRICT NP & ROPD
471 x 0.74 = 348 GPD Total Design Flow �� (, ; owP \No_ "' �� 42 BUILDING SETBACKS
r r { IN FEET ) FRONT - 20'
r t 1 SIDE & REAR - 10'
1 inch = 20 ft
GENERAL CONSTRUCTION NOTES r
� �` � 24' � �1 1. All the workmanship and materials shall conform to R E.P Title 5 I PA �Z SITE AND SEPTIC pI,A ,•
and the Town of Barnstable rules and regulations for the subsurface . ! , �x�sT1N
<
disposal of sewage. �\< �' �� pw����N Prepared Fora
,2. At 'least one access port over tank tees shall be accessible '+ Q BLOSSOM A V.�, N-UF►.
�ZN OF
within 6 42 of finish grade, with any remaining access ports M,�,
brought to within 6" of finish grade. , i ,
g g � � � � � �° c►�alsrrNF �y •�
3. All components of the sanitary system shall be capable of t + BM: TOQ Ce a FAiRNenn, OStervzlle Mc�S,Sc`t Ch ZIS'e t tS
withstanding H--10 loading unless they are under or within 10 ft ', i `� 52.�' sLw. 44.29' No, 92a
of drives or parking: H 20 loading shall be used under or within REMOVE Gist �F�rsTE��� ti '
10 ft of drives or parking unless noted Plastic equals may be EXISTING 1; t
P g q Y DRIVE ti 1 sArirraRlPA Scale: 1 = 20 Date. May 14, 9007
used in lieu of all precast units
4. The excavator/contractor shall call dig safe and verify the location ; % ', 1 /43 Prepared By.-
PROPOSED all site utilities prior to any excavation, and shall be responsible for PROPosED - _ ce FNo U Stephen J. IJoyle and Associates
all matters relating to electric easements DRIVE i ti, ` 4.03 ` - d7 42 Canterbury Lane, E. Falmouth, MA 02538
„ l 1 1 6 S-I't- Telephone: 508/540--2534
5. Sewer pipes shall be 4 Schedule 40 PVC laid at a min. 0.02 slope. ; 1 W __
6. Any masonry units used to bring covers to grade shall be S?9' �06 Av���N� ►►►���� R ► v-i i c>z-a- .]3.2 ca
mortared in place. y -- pF -� �' �r ��(H of 4fASS �w
7 Finish grade shall have a minimum slope of 0.02 ft per foot. .,43p��- J � �a �sT� 40
:
8. The excavator/contractor shall be responsible to check all grades /� � `�' STEPHEN
and elevations and to contact Doyle Associates of any discepancies, '" uT\�/Po�� '4 " J. N
A 4 DOYLE ►
prior to construction. 'ti-.' -oOn375rs�P
9. The excavator/contractor shall be responsible to contact f'o i►!4 FPS'°yoQ C
Doyle Associates 24 hours prior to any required inspections. 1:5 ' 0
NO. DATE DESCRIPTION