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Home My WebLink About0016 BONNIE BRIAR DRIVE - Health 6 Bonnie Briar Qsterville� >;,,, _ A'= 145 4,,Ot i Town of Barnstable Health Inspector Office Hours Regulatory Services 8:30-9:30 pUt rqy� Thomas F.Geiler,Director 3:30—4:30 Public Health Division * BAMSfABLE, 9 Mass, Thomas Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 f Office: 508-862-4644 Z" U Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date: 9/3/08 1. General Information: Size of Property: 1,056 sf Address: 16 Bonnie Briar Drive Map 145 Parcel 031 Name:Bonnie Isaacs Phone#: 508-737-3764 2a. How many bedrooms exist at your property now?3 2b. Are you planning to add any bedrooms? Yes If yes,how many? 1 2c. How many bedrooms total are proposed at this property(including the amnesty unit)?4 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? YES o NO If the dwelling is connected to public sewer, skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or toLU PUBLIC WATER? 7,:,Js a'disposal works construction permit on file? �ESor NO C) 8_If yes,how many bedrooms were approved according to this permit? Bedrooms. 9" Wc1fere any`;bung permits obtained for construction of additional bedrooms? GDOr NO cry w R.4;s there an engineered septic system plan on file at the Health Division? YES or 1.0, CIT.-3 Has the je,�ic system been inspected by a DEP certified inspector within the last two years OYESor AFOY ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: s Date: Q;/health/wpfiles%amnestyapp i Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary-Assessments M 16 Bonnie Briar Drive Property Address Richard Torrise-357 Commercial Street- Unit 708, Boston, MA 02107 Owner Owner's Name information is t required for -Osteryille MA - - 02655 10/10/07 - every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection.forms may not be altered in any i way. hen` "t filling out W A. General Information When forms on the �� \�- computer,use ' c. only the tab key1., Inspector: ; to m o� move your Robert J. BOrtOlOttl 1 1 1 " a LL� cursor-do not I s use the return fame of inspector - key. Bortolotti Construction, Inc. I Company Name P. O. Box 704 -45 Industry Road — Company Address ; Marstons Mills MA 02648� `�•, City/1-own State Zip Code"" 508-771-9399 Telephone Number License Number B; Certification I certify that l-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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: dpas,ses ❑ Conditionally Passes ❑ Fails ❑ Needs,Furth valuation by the Local Approving Authority In2pectoT'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: l5insp•08/66 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Q. W Title 5 Official Inspection Form ^, Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments 16 Bonnie Briar Drive Property Address Richard Torrise- 357 Commercial Street- Unit 708, Boston, MA 02107 Owner Owner's Name c information is required for Osterville MA 02655 10/10/07 every page. City(Town State Zip Code Date of Inspection i B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: +� i have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not.evaluated are indicated below.. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,.upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no,or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out-or high static water level in.the distribution box due to broken or obstructed pipe(s).or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health):, ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 15 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 16, Bonnie Briar Drive Property Address Richard Torrise-357 Commercial Street- Unit 708, Boston, MA 02107 Owner Owner's Name information is Osterville - MA 02655 10/10/07 required for every page. Cityrrown State Zip Code Date of Inspection i B! Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: } ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The i system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: i C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. .System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, i 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. l5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Bonnie Briar Drive Property Address Richard Torrise-357.Commercial Street- Unit 708, Boston, MA 02107 Owner Owner's Name information is Osterville MA. 02655 10/10/07 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.):, ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent.and the presence of ammonia-nitrogen and'nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate".Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or El ❑ 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 ❑ ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ElRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: i ❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. El ElAny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of.15 Commonwealth of Massachusetts F Title 5 Official , Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments M 16 Bonnie Briar Drive Property Address Richard Torrise-357 Commercial Street-Unit 708,,Boston, MA 02107 Owner Owner's Name information is required for Osteryille MA 02655 10/10/07 every page. Cityfrown State Zip Code Date of Inspection B: Certification (coat.) D); System Failure criteria Applicable to All Systems (cont.): . Yes No ❑ ❑ Any portion of a cesspool or, privy is within a Zone.1.of a public well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet { from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ 10,000gpd: ❑ ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. 4 Yes No i ❑ ❑ 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 j ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 , i 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments' 16 Bonnie Briar Drive Property Address Richard Torrise- 357 Commercial Street-.Unit 708, Boston, MA 02107 Owner Owner's Name I information is requ red for Cisterville MA 02655 10/10/07 I every page. City/Town State Zip Code Date of Inspection i I i. C. Checklist . i Check if the following have been done. You must indicate"yes" or"no" as to each of the following: i Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health I ❑ ® 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 El this inspection? i ® ❑ 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? . . i ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? i The size and location of the Soil Absorption System (SAS)on the site has been determined based on 4 ® ❑ 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 CM 15.302(5)] t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System,•Page 6 of 15 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 16 Bonnie Briar Drive Property Address Richard Torrise-357 Comm ercial Stree t- Unit 708 Boston, stop, MA 02107 Owner Owner's Name information is required for Osterville MA 02655 10/10/07 every page. City/Town State Zip Code Date of Inspection D: System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 µ :x DESIGN,flow,based:on 310,.CMR.15.203 (for example; 11A gpd x#of bedrooms): 330 , . Number of current residents: vacant Does residence have a garbage grinder? ❑ Yes ® No I Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes. ® No Laundry system inspected? ❑ Yes ® No Seasonal use? , ® Yes ❑ No I -7?hd Water meter readings, if available (last 2 years usage (gpd)): p Sump pump? ❑ Yes ® No I Last date of occupancy: seasonal_ residence Commercial/Industrial Flow Conditions: I 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 i I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No #Water meter readings, if available: , i Last date of occupancy/use: Date ' Other(describe): i l5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 I I Commonwealth of Massachusetts ° u W Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 16 Bonnie Briar Drive Property Address Richard Torrise-.357 Commercial Street Unit 708, Boston, MA 02107 Owner Owner's Name information is requi-ed for Osterville MA 02655 10)10/07 - t every page. Cify(rown State Zip Code Date of Inspection is D. System Information (cont.) General information i Pumping Records: . Source of informatics: Pum iM f istor unknown 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of.information: 4/21/81 -compliance date Were sewage odors detected when arriving at the site? ❑ Yes ® No l5insp•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 r— Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 16 Bonnie Briar Drive Property Address Richard Torrise-357 Commercial Street_-Unit 708, Boston, MA 02107 , Owner Owner's Name information is required for Osterville 3. MA 02655 10/10/07 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): ` Depth below grade: feet Material of.construction: , ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well'or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: Inite 16"-Outlet 14" 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: 8.5'x 6'x 5' 3 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness N/A Distance from top of scum to top'of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? physical observation t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth, of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Bonnie Briar Drive Property Address Richard Torrise-357 Commercial Street- Unit 708, Boston, MA 02107 Owner Owner's Name information is Osterville MA 02655 10/10/07. required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): It's a 1000.gallon precast septic tank with inlet cover 16" and outlet 14"to grade, it has cement inlet and outlet tees with no scum and 3" sludge at time of inspection. r Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time.of inspection) (locate on site.plan): Depth below grade: Material of.construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments ,•''L 16:Bonnie Briar Drive Property Address Richard Torrise-357 Commercial Street Unit 708, Boston; MA 02107 Owner Owner's Name information is required for Osteryllle MA 02655 10/10/071 every page. CityrTown State Zip Code Date of Inspection I D System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm'present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): l i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Working level 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.): Distribution box is 28"to grade and at working level at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No , I Alarms in working order: El Yes ❑ No i l5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Wo Subsurface Sewage Disposal System Form :Not for Voluntary Assessments a I 16 Bonnie Briar Drive Property Address Richard Torrise'-357 Commercial Street- Unit 708, Boston,MA 02107 Owner Owner's Name information is Osterville MA 02655 10/10/07 required for every page. City/Town State Zip Code Date of Inspection i. D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances,,etc.): x i Soil Absorption System (SAS) (Locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: 1 ❑ 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.): It's a 1000 gallon precast leach pit with cover and top of pit 28".to grade with.1' water and staining indicating up to 18"from bottom at point in time. i. '5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 12 of 15 Commonwealth of Massachusetts u W Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 16 Bonnie Briar Drive Property Address Richard Torrise-357 Commercial Street Unit 708, Boston, MA 02107 Owner Owner's Name information is required for Osterville MA 02655 10/10/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-_top of liquid..to inlet.invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of.construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: !Dimensions Depth of solids Comments (note condition,of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.); I, t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection. Form o Subsurface Sewage Disposal System Form = Not for Voluntary Assessments 16 Bonnie Briar Drive I Property Address Richard Torrise-357 Commercial Street- Unit 708, Boston, MA 02107 Owner Owner's Name information is required for Osterville MA 02655 10/10/07 every page. City[Town State Zip Code Date of Inspection. D.-System Information (cont.) Sketch Of Sewage Disposal System:.Provide a sketch of the.sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. _ 1 • Vr { ra'� ' do i py+ 006 ja liinsp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Bonnie Briar Drive Property Address Richard Torrise-357 Commercial Street- Unit 708, Boston, MA 02107 Owner Owner's Name - information is Osterville required for MA 02655 10/10/07 every page. City/Town. State Zip Code Date of Inspection D. System Information(cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: v feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of.Health -explain: ❑ Checked with local excavators, installers- (attach documentation) Accessed USGS database-explain: You must describe how you established.the high ground water elevation: t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Permit Number: Date: • Completed by: / HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 19�'/fps' � �� , Lot No. - Owner. -e Address: Contractor: ' .L ✓ i�f Lci1� 1 � Address: Notes: i STEP 1 Measure depth to water table to nearest 1/10 ft. ......:......:..._.............. .......:. Date.:,../9)11, 7 .................... month/day/year STEP 2 Using Water-Level Range Zone and Index.Well Map locate .site and determine: �r O:Appropriate index well.................... .... .... ./........... �i OWater level range zone ................................ STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to . ® , water level for index well :....:..........:.:...... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water,level for index well (STEP 3), and water level.zone (STEP 213)r. ._.__ . 47��j .q determine wat.er level adjustme_ .nt ........ ......... ...................:. ................................. .......: STEP 5 Estimate depth to high water by subtracting the water level`adjustment (STEP 4) from measured depth to water J level at site,(STEP 1) .......:..:................. ............................................................ �. i Figure 13.-Reproducible computation form. 15 100. IAM,147 If r _ Town of Barnstable o Regulatory Services svwsri►sce Thomas F. Geiler, Director 116A3.S.. •�� Public Health Division prFp�.�A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Altho ugh the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. � L0 CA T ION SEWAGE PERMIT qA. Z VILLAGE INS,TA LLER'S NAME & ADDRESS ® U I l D�yE R OR OWNER DATE PERMIT ISSUED DAT E C0MPLIARICE ISSUED � t H� W /.21L L THE COMMONWEALTH OFUuMASSS//�ACHUSETTS BOARD OF 171 �........O F......... ........... Appliratinn for U€,i oiiai WorkD Toastrurti rn Vautit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System 4�� /� n .._. iW.<._ !! �-�-� ' -----•--•----- ----•-------------------------•--..._...-- La..0 Address or Lot No. .. ... .- ................................. .......---••-.... ._.....------•-----.. ......._...•-----.........-----------.....---- . er Address ... ... Install Address ��----,,qq ��ss Q Type of Building - Size Lot_ ---?Sq. feet aDwelling—No. of Bedrooms.......... ................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons......---------------- Showers (Z) — Cafeteria ( ) Otherfixtures ..-- ........................... ----•---------••-------••----•----•-------•-------------------••• ------ -- W Design Flow.......................:�J...........gallons per person per day. Total daily flow--_--------`3_�.....................gallo s. WSeptic Tank—Liquid capacit/WjO.gallons Length-- _-- Width_,.!t.Y_LF___ Diameter._._ u�-__-________ Depth_ '__�--.. x Disposal Trench—No. .................... Width._----__-_--_--__-- Total Length......._._._____... Total leaching area. J ,.__ _sq. ft. Seepage Pit No..................... Diameter...... Depth below inlet_-_ _ JJ p _______ Total leaching area._ .._.sq. ft. Z Other Distribution box ( ) Dosing tail ( ) ' `" Percolation Test Results Performed by------. VV � Date... . �1�1. Test Pit No. 1.......... minutes per inch Depth of Test Pit.................... Depth to ground water•-__-----_----_-____--_. 44 Test Pit No. 2_.4-- minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ............................ ........ .... ------------- ... x ---- --•- ------- ---- =•� � - - --- -- -------- Description of So Q Z _ ..- -----•--- - -------------•----------------•----------••----••------••-----••---- U 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'TIL E of the State Sanitary Code— The undersigned further agrees not to place the sy tem in operation until a Certificate of Compliance has #issud by the boar healt Signed_ _ I� nnoo Date Application Approved By.......................................... Date Application Disapproved for the following reasons------------------------------------------------------------------------ --------------------------------------- ------•-------------------------------•---•--------------•--•---------------...------........-----•......._ O Date PermitNo......................................................... Issued-------�------------ Date 13. THE COMMONWEALTH OF MASSACHUSETTS _._ BOARD OF HEA THE `l--....._OF.......... .. ,e,e•............... Appliration for Uhipooal Workii Tomitrurtiou ramit Application is hereby made for a Permit to Construct (, or Repair ( ) an Individual Sewage Disposal System .....,.:.. .......... _...-...... �-''�t`��'��t��'��%� ...-�<'� '................ -•------------•---------•----•--•---....-- LdCnTfo"n�Address or Lot ..o r ---...----•-------•---------- ---....:° ---------------------------•--..........- --........-----...........-------•-•----•------- / t �r Address ...................................... ................................................................................................•. a Installer Address QType of Building Size Lot. ��f-l [' ...t___Sq. feet U Dwelling—No. of Bedrooms........... ...............................Expansion Attic ( ) Garbage Grinder ( ) pa-, Other—Type of Building ............................ No. of persons......__�'__................. Showers Cafeteria ( ) Otherfixtures -------------------------------------------------------------------------•--------------------•------------------------------•-••--------- WDesign Flow........................ .............gallons per person per day. Total daily flow........... -`9.�,�-�....................gallo s P4 Septic Tank—Liquid capacity `-. Ogallons Length ._-.--- Width,j. eVA... Diameter................ Depth-ti,6_.._ .... Disposal Trench—No. .................... Width.............. Total Length.................... Total leaching area-- sq. ft. Seepage Pit No--------------------- Diameter......-.___..------- Depth below inlet....,... ........ Total leaching area.26A....sq. ft. Z Other Distribution box ( ) Dosing ta�z) Percolation Test Results Performed by.._._._._ __'" f. + f'�1 �-� Date.....................a e - =t 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........................ O Descri ion ofoil__ _. �� ?- . '- - W .....................------------••------------••---------•-------------...........--•--•-•-••---•-------•-••------.--------------•---•••-----••--•----•--•--••--•--•------•--•--•--a•-•-------------•- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- --------------------------------------------------...........................--•-------------•--•--•----•-••---------••...•..--------•.----•-.--•--•..••----.--•-•--•--a-•--••---••--...........---•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f'1TT E 5 of the State Sanitary Code— The undersigned further agrees not to lace the -system in the provisions of t:..� y g g p operation until a Certificate of Compliance has een issu d by the board of health 41 �. r :....._. . Signed. - -�:�=�==-'�-=='.E._-------_ � -- ...._.._.._ g f � -- 41� l/ Date ApplicationApproved By................................................................................................. ........................................ Date Application Disapproved for the following reasons------------------------•------------------------•-----------................................................... -------------••----a-----••-----•----•---•-----••-a-•--a-----•....••-----•--•--••-•••--......--•--•••----...---------•---•----------a--•a----••---•--•---•-•-----a-----a-----•--••-•a-•-••----•-•-_------ Date PermitNo--------------------------------------------------------- Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS �,,.•• -�"� BOARD OF HEALTH f r- .» ....OF.... .ac-' ��: .a. '`- ........... (Intifiratr of Toutphattrr HIS IS TO CER-T,1EF, Ighat the Individual Sewage Disposal S-stem constructed . or Repaired g P �' �`)" ( ) f by... ..---- - . ...... -•-•---•----. - +y \•------Install•• •-••___•___--••_•_-_'. Installer at..........................sio--•--v=f 6i s:if: s E_ ------�z..►......P= - has been installed in accordance with the provisions of T _ 5cd The State Sanitary Code as described }I the application for Disposal Works Construction Permit No.- .._.._ ............. dated........ j........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM Wl FUNCTION SATISFACTORY. DATE----... ........................................... Inspector..------------..... = - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / .......OF.t ` .- '- ate.-! ' N .�l---t�•f-•-• .... .................................. �io�oo�t1 ork� �otto�ra�r�ion rrmi� , `� Permission is hereby granted....ea• a!° '?'rg, p!R..< ,.: :t-------------•-•-----a•-...--••-----•............................. to Cons tru r Re a� ( ) an Individual Sewa posal S stem { at No.: sl � .c A!-- ............. Street ` as shown on the application for Disposal Works Construction Permit No.._--a•-------------- ated.__. ? _�-. ._ ............ . ------•-----• _- ---_ Board df alH€ th DATE---------------•----._.........•---•-----------------------....------a---.-•---- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS . A( .re�i tvV<k ;,�p,,� u i a iy o r— , f 0 �. Off. w _. f f 4 a" { 1 ` a r C4• •vi G 1��v� ��.Y� �Bt I tip lc ttG + GsC IF, t0'� tk y J art M f, -J S .I t pil . '+ t x5 L.EGEND Kaf ski q ' Mgss� CERTIFIED PLOT PLAN � � i,04k '. SPOT ELEVATION 0%0 �, \ o ROBERT , f o Q:. CONTOUR �� a vC f r e O P arCJ-Y".f3cJdm t15 Eb SPO:T ELEVATION ' 0 0 o f t 'S`HEV0':C0 N TOUR 0 — A ¢,No 2216z�0 - 1 Rb\VEO` BOARD OFJ HEALTH /srE�'��> '% a ij NAL A AG£NT SCALE " =3u' DATE .��5�1' &/ `0 5T' i�VrJ =EDGE ENGINEERING CO.'IN CLIENT ,�f_ig1" _____ ._ I CERTIFY THAT THE PROPOSED IIJGIS?Epf REGISTERED JOB N0. .84�UHP�' . BUILDING SHOWN ON THIS PLAN . CIVILF LAND CONFORMS TO THE ZONING LA1Y:5 D R. B Y --- —i 1� NEE r. SURVEYORS OF BARNSTAB E , MASS. 71Z MAIN 3 T. CH. B Y NYANIVIS,. MASS. SHEET:L OF DATE REG. LAND SURVEYOR I .4 .N.O TLT /f' E/TNG'R .7NE SEP7 C T. N IeC .OR _- 'EACH//o/G 'P/T .Q RE /490IPE= T'N A"/V ✓Z 11 BELO id SNA L L ®,F PO<Ia—V T ,eE're �rPt✓C PIPE ILiE.4Vy CAST /,eON C0veR SHALL SE USE.0 w h/N J coYEI�<S /A/. PITCH N" D IF/ RIVE Y, WA e: CC) ✓E,Ar CLEAAl .SAND &A L i. L/Qu/O LEVEL ' ! , " 2 Z-AYER .1 ®oX oo o�o IRON P/PL • e � • v o • e o. r• a� ED 577NE TCN DIST. • o V I • 1 Pox S-r SEPTIC TA • ° r � • • DEPTNo • e . • �, . WASHED STaNE �;:..a` ao�o e o o • e o • • . o p o -• • e PRECAST SEER46E o a. u • • e .• • ► D •;o y P/7 OR E041/V. a i,VV&AT EL E IVAT/ON S 1MYc'RT AT SU/LDING c7� J FY. sj C(-dWS 7)WU4ATI01VI) /AIL ET APT/L' Ti4/ViC .: .N« FT O/i4A9. 1 I ry OUTLET SEPTIC TANK ��° ' FT. �. INLET D/STR/OI/T/ON BO/r f, O Ir7 SECT/aN OF GROU11/o1TER TA®LE OdTLE7_D/5TRIB[/T/OIm OOX F7 INLET LEACHINCr / wl T 94:".s: FT ; .S�ym/AGE O/5�05.4 L SYSTEM '-T*g41j_AT/DNI w..., LEACf1//V6 �/T p//d1ENS/ON A FT SCALE %4~ $ FT. DES/6AI C/t/TER/A p/HENS/ON G '"� FT. .4.4 y � N�UA4BER OF®EDiROONS � '� 'ti�,sRO,AGED/SP05.4LUN/r SOIL LOG $D.'✓L TEST TOTAL ESTl^%4TED FLAW s.4L.1DA� SO/L TEST /`: SOIL 77EST#2 MUMAER OF 40ACIVtNG P/TS /. fEtL�Y ` '+. . DATE OF SOlL ,TEST SYOEL<ACN/N6 PER PIT .51� PT. G ' °1 RESULTS BOTTOM LBi'aCH/N& PE1�P/T A NCOLATIO/V XA T •4RE<A TO`Ti1 L LEACa/NG RE/s6RYELSACN/NeAREA � SQ FT. ^.. d G�'1 q gWNIKIS ini �.8vcr' • tv'.: No.49(1 .O t, �ffi@7r'