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HomeMy WebLinkAbout0320 GRAND ISLAND DRIVE - Health L Grand island DriveII6 F/R ; w 1 I� c 'It J • � �. I� t r ' 'i t �s I' TOWN OF BARNSTABLE, - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS: .�"` /l/ //rE `f/a/�t�/r . I '�- + MAP NO. PARCEL NO. �1.. OWNER NAME: -,�a '. 'l �'yI , � °J _..- VILLAGE: ". �_. . INSTALLATION DATE: / 9 BY: "l-o� 1��,t t rf.! y yz ' ADDRESS• / �/ l��a <3�1i 11 !,'1 �.+', CERT. NO. Pr 'v � 0 i TANK INFORMATION LOCATION OF TANK: CAPACITY _ 0 TYPE r_�� AGE FUEL/CHEMICAL TESTING .CERT I F I CA``T//ION C ] PASS C I FAIL DATE LEAK._DETECTION yI CHECK IF N/A TYPE/BRAND ` /) 'Ala ZONE OF CONTRIBUTION C I YES C ] NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED IV YES C I NO DATE CONSERVATION CX] CHECK IF N/A DATE BOARD OF HEALTH TAG NO. ]C ]C ]C ] DATE PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD t 1 9 r J� �,� �� -� 5 .� /V �_ CENTERVILLE • OSTERVILLE MARSTONS MILLS FIRE DISTRICT UNDERGROUND TANK REGISTRY PROGRAM w = Owner of Property: o �l Date of Installation: g �� > ' / /J�- a4 '' Address: 3a0 o}s f�, �a� 4.eS. aAW [, � SOV O (l�[kk Description: 5 Ic' e Installer: PAw , Size: Certification: �� E A' Location of Tank: INFORMATION� INSPECTION INFOR��A•�.�:� DATE COMPLETED BY fi Site Inspection ' Air Test on Tank—Above Ground llx Air Test on Tank—Within Hole Test on Piping Cathodic Protection Test � 1 ;i Continuous Monitoring System Type t BackfillOperations ' - � Vent and Fill Pipes a Other: n�-.� Plt`fi _. .� ✓ r t to Y,S."�x W� IUD M -.. � ! :..:.�-- '.. 1 '''Y k - a•� TOWN OF BARNSTABLE LOCATION ax SEWAGE # -?413-o?�i VILLAGE CSrI�. ��/� p f ASSESSOR'S MAP & LOT QS2`()(3 INSTALLER'S NAME&PHONE NO.. SEPTIC TANK CAPACITY, %Sao LEACHIN" FACILITY: (type) foe t, (size) i7 jl y? pro i NO.OF BEDROOMS " BUILDER ORr! L��Chr.,s PERMTTDAFTE: � /,&/03 COMPLIANCE DATE: R- I 1—C)3 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 Furbished by l�o �Tft C�iv+fP,�s y3 G9 O sd(� r a r � TOWN OF BARNSTABLE LfX"ATION IM 1 SEWAGE # VILLAGE � ///J(�7 1— ASSSEES°•OR'S MAP & LOT®5Z 013 �S NAME&PHONE NO. 1�:L L SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) (size) /ODD NO. OF BEDROOMS 12e j BUILDER OR WNE PERMIT DATE: COMPL CE 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 �. � I i I I= f _. p G� �. o may, , . ._ �� 3- . � c No. 3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS ZIPPYication for Miopogal 6p.5tem Construction Permit Application for a Permit to Construct( . )Repair( )Upgrade Abandon( ) ❑Complete System 2o6ividual Components Location Address or Lot No. yyy Owner's Name,Address and Tel.No. grg P'Par IS Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. — sal lz Type of Building: , Dwelling No.of Bedrooms �-/ Lot Size sq.ft. Garbage Grinder(/�� Other Type of Building G° No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets ! Revision Date Title J"' Size of Septic Tank Type of S.A.S. © Description of Soil- Z Nature of Repairs or Alterations(Answer when applicable) Date last inspected: .Agreement: The-undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issuedk this Boardyf Health. Signe Date Application Approved by Date f° /19 . c�) Application Disapproved for the following reasons Permit No. �0—3 '9k. Date Issued G►- No. 'C7 3 Fee ` `� Entered in computer: VS THE COMMONWEALTH OF MASSACHUSETTS P Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLES MASSACHUSETTS Application for Mig;Pogar *pgtem (Construction Permit Application for aTermit to Construct( . )Repair( )Upgrade(I/)Abandon( ) ElComplete System W Individual Components F . Location Address or Lot N. I Owner's Name,Address and Tel.No. 3Z� �/"1�j1 . s�ll`1dd A,5s or az�J ® ,j tee. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. &I Type of Building: �j Dwelling No.of Bedrooms `✓ Lot Size sq.ft. Garbage Grinder A92 Other Type of Building k /G" No.of Persons Showers( ) Cafeteria( ) � gP ' Other Fixtures a t� Design Flow r9 gallons per day. Calculated daily flow gallons. Plan Date f /1A AI3 Number of sheets / Revision Date Title .7 S Size of Septic Tank �- /��d�'�� �'/S�`. Type of S.A.S. ? Description of Soil Nature of Repairs or Alterations(Answer when applicable) + ) ' lsy Date last'inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until,a Certifi- cate of Compliance has been issued y this Board of Health. / signed Date Application Approved by \ Date /b G—) Application Disapproved for the following reasons Permit No. -:;LG C--3 oY `'� - Date Issued JG 716 70 ---- ' -----------'---------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT FY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(10' ) Abandoned( )b at 7_-D gS has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2.00 3' Z(-9 dated L` 03 Installer `. Designer n The issuance of s pe t shall not be construed as a guarantee that the system f estnne'd. Date "1 lO 3 Inspector- ------------- �� No. �j^2�°6, ——————————— -----1 .— Fee (J 06 THE COMMONWEALTH OF MASSACHUSETTS LIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS MtgpogaY *p6tem Congtructton Pe rmit Crtmssion is hereby granted to Construct,(,/ ) U Repair ) grade(✓)Abandon( ) System located at 31.0 07/�L7�Gf LS� �'J� and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to f comply with Title 5 and the following local provisions or special conditions. Provided: C//onssttr`ucti n must be completed within three years of the date of this er nit. Date:_ b!/ 6 7 _3 Approved by TOWN OF BA.RNSTABLE LOCATION 3a19 &,Chd /7/C SEWAGE # �0kl32�i% VILLAGE Ille / ASSESSOR'S MAP & LOT QSZ-013 INSTALLER'S NAME&PHONE NO. /�- 1��1• Ca��r�i�.�.o� 5�• $ � 1� SEPTIC TANK CAPACITY -5Z. G�L LEACHING FACILrTY: (type) f-.Oe ed C6a.n A—) (size) i 3 NO.OF BEDROOMS r / BUILDER ORS FR G(yiG/�,af PERMTTDATE: /ram/off COMPLIANCE DATE: R- 19— 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility j Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �- Feet Edge gf Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Do I ' r - i O O ot y3 i LJ l c Y/ , t -� COMMONWEALTH OF'MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. ~C DEPARTMENT OF ENVIRONMENTAL PROTECTION �H Sys TITLE 5 OFFICIAL.. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name"? / 9 7 Owner's Address: �. Date of Inspection: Name of Inspector lease print) cif—'T Company Name: Mailing Address: Telephone Number: } `? CERTIFICATION STATEMENT 1 certify that I have.personally inspected the sewage disposal system at this address and that the informatioq-Xeported below is true, accurate and complete as of.the time of the inspection. The inspection was performeh 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority. Fails Inspector's Signature: Date:, j 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 own;r shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection,and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title,5 Inspection Form 6/15l2000 page 1 Page 2 of l 1 OFFICIAL INSPECTION FORM-NOT FOR .VOLUNTARY ASSESSMENTS` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:� � < ldel.�'Lr A Owner. Date of Inspection: J. Inspection Summary: Check: A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have-pot found any,information which indicates that any of the failure criteria described in 310 CMR 15:303.or jn 310 CMR'15304 exist.Any failure criteria.not.evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as-describ.ed 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.20years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration of exfiltration or.tank failure is imminent:System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance. indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than,*4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL.INSPECTION'FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM PART A CERTIFICATION(continued) Property Address: w OwnerkZLG�. ��n-- ► Date of Inspection: ` .. . r 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 H6aith determines in acco"rdance with 310`CMR 15.303(1)(b)'that the system is not functioning in 'a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is,within 100 feet of 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. i 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 coliform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must,be attached to this form. 3. Other: 3 Page 4 of l l O,FFICIAL.INSPECTION:FORM-.NOT'FOR VOLU I TARY ASSESSMENTS SUBSURFACE SEWAGE;DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) T Property Address: � a ,C�,d� i��/X.�� Owne J '� Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: i Yes No _ l�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 tq an overloaded or.clogged SAS or cesspool. _ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow �/. Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the.SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a.surface water supply. j . 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 privyis: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 coliform bacterial and volatile organic compounds indicates that the well is.free from pollution from that.facility and thepresence.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,pr�ovided.that no other failure criteria are triggered..A copy of the analysis,mustbe attached to this form.] i (Yes/No)The system fails. I have determined that one or more of the above failure criteria.exist as described in 310 CMR 15.303,therefore the system fails. The-system-owner should contact the Board of Health to determine what will be necessary to cor~,ect'the failure.. i . 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• You must indicate either"yes"or"no"to each of the.following: (The following criteria apply to large systems in addition to the criteria above) yes no - _ the system is within 400 feet:of a.surface drinking water supply — _ the system is within 200 feet of a tributary-to a surface drinking water supply _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I1 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.T he•owrier 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. i Page 5 of 1 I OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST A Property Address: � ���� ,��/ J� -/� Owner. Date of Inspection: Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No Pumpna,information was provided by the owner,occupant, or Board of Health Were any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period? `� Have large volumes of water been introduced to the system recently or as part of.this inspection? -b� Were as built plans of the system obtained and examined? (If they were not available'note as N/A) V Was the facility or dwelling inspected for signs of sewage back up ? ` V _ Was the site inspected for signs of break out? l/ 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 stte has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C.is at issue approximation of distance is unacceptable) [310 CMR 1.5.302(3)(b)J Page 6ofIL OFFICIAL INSPECTIOIN.FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INF.ORMATION A Property Address: Pi y�gu : �Y f Owner. ^,,r ,,� a ,f w•2�"C:.,.m • Date,of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): DESIGN flow based on 310 C 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: 'e'a-/,L , Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system.(y or no):/ [if yes separate inspection required] Laundry system inspected ye .or no):/ � Seasonal use:(yes or no): Water meter readings, if a)dilable (last 2 years usage (gpd)): 0 i�`�00 Sump pump(yes or no): � 11 Last date of occupancy I COMMERCIAL/INDUSTRIAL. Type;of establishment: Design flow(based on 310 CMR 1.5.203): gpd Basis of design flow(seats/persons/sgfc,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):- Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: lf-I Was system pumped as part of thorEspectioin(,yts or no`l�, If yes, volume pumped: gallons--How was quantity pumped determined?. Reason for pumping: TYy'iE.OF SYSTEM V Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if ally) _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) anj source.of-ijiforma on: Were sewage odors detected when arriving at the site(yes or no): Page 7 of 17 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C SYSTEM.INFORMATION(continued) „ �L PropertyAddress: eta Owner Date of tnspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction'line: _ s Comments(on condition of joints, venting, evidence of leakage, etc.): ' SEPTIC TANK:-(locate on site plan) Depth below grade_(iJ CZ Material of construction; , concrete metal_fiberglass polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) _ Dimensions: A/ ,: Sludge depth: 49 -�._ Distance from top of sludge to bottom of outlet tee or baffle: �= 5 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: How were dimensions determined: A"%�' , Comments(on pumping recommen ations, let and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invgl, evidence of leakage,etc.) JR Y, 2-&ot1.6 00(,V.#J teL 'Z�ez-g 62/) telo GREASE TRAP�IOlocate on site plan) �'�%> L/ Depth below grade: Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom'of outlet tee or baffle: Date of last.pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 0 d 7 Page 8 of I 1 'OFFICIAL.INSPECTION FORM=NOT:FOR.YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM.INFORMATION(continued) Property Address: Owner. _..(V-� APALt.0 Date of Inspection_ �U 4 TIGHT or HOLDING TANK:,(tank must be pumped at time of inspection)(loc.ate'on..site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain),-. Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float.switches, etc.): DISTRIBUTION BOX: /✓ if resent must be o ened (locate on site plan) ( P P ) P . T Depth of liquid level above outlet invert: C� Comments(note if box is level.and distribution to outlets equal, anyeviaence of solids carryover, any evidence of akage nto or out of box,etc.): fey PUMP CHAMBER: 1 b(locate on site plan).. / Pumps in working order(yes or no): _ S Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pace 9 of I 1 OFFICIAL INSPECTION FORM—'NOT.FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: " Owner , Q.2e.r Date of Inspection:_ /„ ��.CX) SOIL ABSORPTION SYSTEM (SAS): 01ocate on site plan,excavation not required) If SAS not located explain why: Type IX aching pits,number:_ V 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): �s-oo,5,�aeeelx hA_ e-A ZLe 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 or 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.): 9. Pace 10 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL. SYSTEM INSPECTION FORM PART-C. SYSTWINFORMATION(continued) Property Address: , ) Owner• / Date of Inspection: Z/4 0�49 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. ocate.where public water supply enters the building. 1 0 -� f) .� 9 lu � 1�9® tl1 1) U JQ 61 10 t Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,— �. OwneC�+. b a > .Date of Inspection: �. 1��(J� SITE EXAM Slope Surface water Check cellar - Shallow wells Estimated depth7to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers- (attach documentation) Accessed USGS database-explain: e elevation:You must describe how you established the high ground water le anon: ti 11 Permit Number: Date: 13 Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location:- Lot No. Owner: 7 Md e Address: k }4 } Contractor: °/r � / 6511t.6 ddress: t f Notes: 1��z5 ®1''s STEP 1 Measure depth to water table to nearest 1/10 ft. ...:...... ..:.... .Date l month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: r OAppropriate index well..................................e?'�'1�..��.. 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 2B) determine water-level adjustment ............................ f' STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water .level at site (STEP 1) ................:............................................................................................ ° Figure 13,-Reproducible computation form. 15 D �I 5r b Qoorn -------------- r �l l01� 3 COMMONWEALTH OF MASSACHUSETTS. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS c ' DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED V FEB 1'9 2003 TOwN OF BRftNSTABLE TITLES HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT,FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE1 DISPOSAL SYSTEM FORM PART A CERTIFICATION. Property Address: o � r� Owner's Name: MAP Owner's.Address: / O 1 3 PARCEL ' Date of Inspection: 62 LOT Name of Inspecto please print) Company.Nam Mailing Address: O- • Telephone Numbers 'FAILED INSPECTION CERTIFICATION STATEMENT' I certify that I have personally inspected the sewage disposal.system at this address and that the information reported below is true, accurate and.complete as of the time of the inspection.The inspection was performed based on,my training and experience in the proper function and maintenance of on site.sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of.Title 5(310 CMR'15.000). The system:. Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority . Fails �Insp.ector's Signature: Date: /33 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. Notes and Comments - ****This report only describes conditions at.the time.of inspection and under the conditions of use at that time. This inspection does not addre.is how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/20.00 page I ! 1. Page 2 of I I } OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: %? Owner: 7 Date of Inspection: Y,-;uzqw Inspection Summary: Check A,%C;D or E/ALWAYS complete.all of Section D A. System Passes: I have not.found any information wh-ich indicates that any of the failure criteria described in 310 CMR 15:303 or in 110 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. 1--­Cominents:, {; B. System Conditionally Passes.- One or more system components as described in the"Conditional Pass"section need.to be replaced or repaired:417he,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 exfiltraticn 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 pipes)are replaced , obstruction is removed distribution box is.leveled or replaced ND explain: The system required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will. pass inspection if(with approval of the Board of Health):, broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ? Owner: Date of Inspection:, 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 failingto protect public health; safety or the environment. 1: System will pass unless.Board of Health determines in accordance with 31-0 CMR 15 303(1)(b)that the system is not functioninb in a manner which wi11 protect public health,safety and the.environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is-.vithin 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 mariner 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 surface water supply or tributary to a surface water supply: The system has a.septi:rank 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 coliform bacteria and volatile organic:compounds indicates.that the well is free from pollution-from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I] OFFICIAL INSPECTION FORM- :NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM .PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS'or cesspool _ y/ 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 invertdue to an overloaded or clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy,is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface.water supply or tributary to a surface water supply. . Any portion of a cesspool or.privy is within a Zone 1 of a,public well. _ Any portion of a cesspool or privy is within 50 feet of a.private water supply well. _ Any portion of a cesspool or privy is less than: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 coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided,that no other failure criteria are triggered. A copy of the analysis must be'attached to this form.] bel (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correctthe 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any questibn 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 156304.The system owner_should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—.,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ) >/i " Owner Date of Inspection: b Check if the following have been done. You must indicate"yes."or"no"as to each of the following: Yes No Pumping.information was provided by the owner,occupant, or Board.of Health Were.any of the system.components pumped out in the previous two weeks (/Has the system received normal flows in the previous two week period? V//Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of tine 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 breakout? Were all system components, excluding the SAS, located on'site V _ 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 basedon: Yes . no _ Existing information.For example,a plan.at the Board of Health. . _✓ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Ad ress: P y Owner: " Date of.,Inspection: / '6. LOW CONDITIONS RESIDENTIAL Number of bedrooms(:design): Number of bedrooms(actual): DESIGN flow based on 310, R 15.203 (for example: 11.0 gpd x#of bedrooms):. Number of current residents: Does residence have a garbage grinder(yes or nol;4k T - Is laundry on a separate sewage system es or no): [if yes separate inspection required] Laundry system inspecte y s or nj Seasonal use: (yes or no): Water meter readings, if a ilable(last 2 years usage(gpd)): Dl�"3 �i�/�02, IV Yf/&P Sump pump(yes or n L�o Last date of occupancy: COMMERCIAL/INDUSTRIAL/K& Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records -Source of information..V1 1-rwlovz� ,J 040- Was system pumped as.part of the i spection(yes(ir no),.�y� If yes,volume.pumped: gallons--How was qu titafi yipumped 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 copyof'the DEP approval �ther-(describe):� d.4,.L21� C <--�A,pprox�age ofal] components,dafe installed(if known)and source of information: Were;sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM.—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM..INFORMATION(continued) Property Address: Owner: Date of lnspection: 0 BUILDING SEWER(locate on sie plan)` Depth below grade: Materials of construction:_cast i_on 40 PVC other(explain): _ Distance_from private water supply.we.11 or suction liner Comments(on condition of joints;-venting,evidence of leakage,etc.): SEPTIC TANK: locate on site plan) Depth below grade: ' Material of construction: ✓ncret:_metal fiberglass polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: X 9 Sludge deptli ,(y� .Distance from top of sludge to bottom of outlet tee.or baffle: 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: How were dimensions determined: -/, �v�� h Comments(on pumping recommen ad aons�in`le-t and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert,e idence ofleak ge, etc.). Al 641Y YAW 2 GREASE TRAP)/ C`ocate on site plan) Depth below grade:_ Material of construction:_concrete_metal fiberglass polyethylene_other (explain): Dimensions: Scum.thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottora of outlet tee or baffle: Date of last pumping:. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM=NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ uJy Owner: YJ Date of Inspection: 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): r DISTRIBUTION BOX: if present must be opened)(locate on site plan) Depth of liquid level above outlet.invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER• �i(to cate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):. Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): I 8 Page 9 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FARM PART C SYSTEM.INFORMATION(continued) Property Address: s Owner Date of Inspection: (1 SOIL ABSORPTION SYSTEM (SAS): locate on site,plan,excavation not required) If SAS not located.explain why: Type leaching pits,number:_ leaching chambers,number; leaching galleries,number: leaching trenches,number,length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technolocy Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil;condition of vegetation, CESSPOOLS (cesspool must be pumped as part of inspectiony(locate on site plan) Number and-configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of pond ing;,condition of vegetation,etcj - PRIVA&(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.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC.E'SEWAGE DISPOSAL".SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of � Inspection: / (20 P � 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. . .0 I0 Page 1'l of 1 I " OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM"INFORMATION(continued) Property Address: Owner: i Date of Inspection: M /,c;60,3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.deptli to groundwater feet Please indicate(check)all methocs used to determine the high ground water elevation: . Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting.prop-.rty/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavato-s, installers-(attach documentation) _Accessed USGS database-ex-)lain: You must descr ibe how you establ.shed the high,ground water elevation: ]l Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: ,3w �/%Zy / �lyl � Lot No. / R Owner: < .//�S Address: Contractor: /�0,/ 6 / L- f�'/t 5, Address: �r� 1�v .�"yp/S�O/�5 ✓�y'��� Notes: STEP 1 Measure depth o water table . to nearest 1/10 ft. ..................................... ...................................... .Date F month/day/year STEP 2 Using Water-Level Range Zone _ and Index Well.1'llap locate site and determiner OA Appropriate ndex well.................................................... Z OB Water-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions determine current depth to 01�03 g°,Z water level for index well .:...:.::.................. month/year STEP 4 Using Table of Water-level Adjustments for index well (ST=P 2A), current depth to water level for i-idex well (STEP 3)., and water-level.zone (STEP 26) ��7 determine water-level adjustment-........_..:.........:....:................................................:............. STEP 5 .. Estimate depth to high water by subtracting the water level adjustment (S EP 4) from measured depth to water f�J? levelat site (STEP 1`) ....................................:........:.........................:.....:................................ Fgure 13.--Reproducible computation form. 15 l � I i 05-14-1998 03r06PM CENT OST FIREDEPT '� 5087902385 P.02 mane appuc4uvr1 w twat rare ueparunenL l=tre Department retains original application and issues duplicate as Permit Vol,, oJ- o��%��4��!/I�9 V�X�tiGC2d— ✓cJO�XQ.O�V'G�✓ ?�EY� APPLICATION and PERMIT Fee: ' L0.o0 for storage tank remcv-d and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 14a,Section 38A, 527 CMR 9.00, application is hereby made by: Tank Owner Name(piece print) Judson Mohl X sw9mitrre apumo for OOM/0 Address 320 Grand Island 1,rive Osterville )!!A s orry Sum zP Company Name Advanced Emrilronmental Co.or Individual P:lm - Print Address 1 Atlantic Ave. S. Dennis Address POW r Signatur f.applying fcr=erm Signature(if applying icrpermit) IFCI Certf� Other iFCI Certified Other � Tank Location 320 Grand Island Drive Osterville MA SISS(AWIM .7Z Tank Capacity (gallcrs; 2000 Substance Last Store= 02 fuel oil Tank Dimensions emf x length) Remarks: Firm transporting wss's James Grant,. State Lic.# MV5083856100 Hazardous waste mares E.P.A. # Approved tank dispose! ,s d James Grant Tank yard# 008 Type of inert gas venting Tank yard address R�-adv5,11e, X& City or Town Ostervi- le F01D# 01920 Permit# Date of issue May 14,' 1998 Date of expiration Dig safe approval nun• 982000253 ig Safe Tca . Number-80.0-322-4W Signature/Title of Ofi9crar ranting permit After removal(s)send Fcr-?-290R signed by Local Fire Dept. to UST Regulatory Comptiarx-m Unit,One Ashburton Place, Room 1310, Boston. MA .c:•8-1618. FP.�q�/nwicAr4,ARfa\ TOTAL P.02 1� l� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI;SOLE�VEO DEPARTMENT OF ENVIRONMENTAL PROTECT ;ONNOV 7 1997 ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 TOWN OFBARNSTABLE W HEALTH DEPT. 44 WILLIAM F.WELD XE Governor ecretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION 320 Grand Island Dr Property Address: Oyster Harbors, Osterville Address of Owner: Judson Mohl Date of Inspection: /,0'—o?.1l 9- ? (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: WM E Robinson Septic Servi Mailing Address: PO Box 1089 Cent-r-rvi 1 1 t , MA 02632 Telephone Numbers 5 0 8 �. 77 5_R Z-7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By.the Local Approving Authority _ Fails �J Inspector's Signature: F2, ►. `( ..� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) S EM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria.not evaluated are indicated below. COMMENTS: BI 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) page 1 of 10 e` DEP on the World Wide Web: http:l/www.magnet.state.ma.us/dep e'j Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 320 Grand Island Dr, Osterville Owner: Mohl Date of Inspection:& '7 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] F THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 320 Grand Island Dr, Osterville Owner: Mohl Date of Inspection: /a D) 5ys EM FAILS: You mus indicate ei;t;er "Yes" or "No" as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis r thislure.de t e fa itermination is identified below. The Board of Health should be contacted to determine what will be necessary to correct Yes ISO Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or pond:.ng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level it 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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 qualiy analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE YSTEKI FAILS: You must in irate either "Yes" or "No" as to each of the following: Th following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to publ c health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 =eet 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) The owner o operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program ` requirement of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 4 - (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 320 Grand Island Dr, Osterville Owner: Mohl Date of Inspection: oe6. _ a e✓ 'd Check if the following have been done: You must indicate either"Yes" or "No" as to each of the following: Ye No ~ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ; _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does-not receive'non-sanitary orindustrial waste flow. _ The site was inspected for signs of breakout. t✓ — All system components, excluding the Soil Absorption System, have been located on the site. l/ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: 41/ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] -.. (revised 04/25/97) Page 4 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 320 Grand Island Dr, Osterville Owner: MOhl Date of Inspection: /6 FLOW CONDITIONS RESIDENTIAL: Design flow: JJ 0 e.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):,A--0 Laundry connected to system (y s or no):kite Seasonal use (yes or no): Q 1995 - 1 6 2 , 0 0 0 ga 1 s Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): O 1996 - 1 1 9 , 0 0 0 ga i s Last date of occupancy:,Lo '7-<i`7 CO ERCIAUINDUSTRIAL: Type o establishment: Design ow: gallons/day Grease t ap present: (yes or no)_ Industria Waste Holding Tank present: (yes or no) f _ Non-san ary waste discharged to the Title 5 system: (yes or no)_ Water eter readings, if available: Last d to of occupancy: OTHER: (Describe) Last dat of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ti AA Syste pumped as part of inspection: (yes or no)__jj—4> If yes, volume pumped: >;allons Reason for pumping: TYPE OF S TI eptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous'inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: -S ✓� O (14 Sewage odors detected when arriving at the site: (yes or no)'/L (ravisad 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BU ING SEWER: (Local on site plan) Depth low grade: Material of construction: _cast iron _40 PVC _other (explain) Distan from private water supply well or suction line Diam r Comm ts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on $ite plan) Depth below grade:—Z—O � Material of construction: Le6ncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) e ). 1 Dimensions: lg Sludge depth: " : '" Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: /" 3 ' Distance from top of scum to top of outlet tee or baffle: , v Distance from bottom of scum to bottom of outlet tee or baffle: ► 2' How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees cirbaffles, depth of liquid level in relation to outlet invert, structural j integrity, evidence of leakage, etc.) GREAS TRAP: (locate site plan) Depth ow grade: Material f construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimen ons: Scum ickness: Dist ce from top of scum to top of outlet tee or baffle: Di ance from bottom of scum to bottom of outlet tee or baffle: Dat f last pumping: Comme ts: (recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ,t integri , evidence of leakage, etc:) (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 320 Grand island Dr, Osterville Owner: Mohl Date of Inspection: /d ? ` i TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth low grade: Material f construction: _concrete _petal _Fiberglass _Polyethylene —other(explain) Dimen ions: Capa ty: gallons Desig flow: gallons/day Alarm le el: Alarm in workin€ order_Yes; _ No Date of p evious pumping: Comment (conditio of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: 1""/ _ (locate on site plan) Depth of liquid level above outlet invert:� 6 OL Comments: (note if level and distribution is equal,-evidence of solids carryover, evidence of leakage into or out of box, etc.) PU CHAMBER:_ (Io a on site plan) Pumps 'n working order: (Yes or No) Alarms working order(Yes or No) Comme ts: (note co dition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/45/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 320 Grand Island Dr, Osterville Owner: Mohl Date of Inspection: lO " ?^g '7 SOIL ABSORPTION SYSTEM (SAS):tz (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 7 .k leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: 1 (note condition of soil, signs f hydraulic failure, level of ponding, c ndition of vegetation etc.) r -a Aga C- SPOOLS: _ (loca on site plan) Num and configuration: Depth-t p of liquid to inlet invert: Depth o solids layer: Depth of cum layer: _ Dimensio s of cesspool: Materials f construction: Indication of groundwater: nflow (cesspool must be pumped as part of inspection) Comm nts: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate n site plan) Material of construction: Dimensions: Depth f solids Comm nts: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 i r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 320 Grand Island Dr, Osterville Owner: Mohl Date of Inspection: /o--A7- `i 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two}permanent references landmarks or benchmarks locate all wells within 100 (Locate where public water supply comes into house) !N J / K c) b— l ) �e ,. r 1' F (revised 04/25/97) Page 9 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 320 Grand Island Dr, Osterville Owner: Mohl Date of Inspection: ? Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions J/Check with local Board of health Check FEMA Maps. Check pumping records Check local excavators, installers ✓/Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 EA tA -COO V\ks GF THE Tp — i2 Wl CiQL 1 G UeS, DATE: » FEE: NLO i�1 » IARNSTABLE, MASS. 9� 1639• REC. BY n of Barnstablegi SCHED. DATE • �O r` ` oard of Health 6 RE��vEO in Street, Hyannis MA 02601 D E C 2 p 199J Office: 508-790-626 F 700or AA 9AMBLE Susan G.Rask,R.S. FAX: 508-790-6304 REU NDWE Sumner Kaufman,M.S.P.H. e Ralph A.Murphy,M.D. ARIANCE REQUEST FORM LOCATION Property Address: 3'40 G V— CJ �Dz\Q Assessor's Map and Parcel Number: 52, /< < 5 Size of Lot: Wetlands Within 300 Ft. Yes X Subdivision Name: No Business Name: APPLICANT CONTA PERSON Name: C?bkE Name: 0 Address: 32D Address: )? �A�.iL �O ►� Phone: 142!� ^ � Phone: FAX: FAX: VARIANCE FROM REGULATION(List Res.) REASON FOR VARIANCE(May attach if more space needed) Checklist(to be completed by office staff-person receiving variance request application) K Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals(same owner/lessee only],outside dining variance renewals(same owner/lessee only),and variances to repair failed sewage disposal systems(only if no a<pansion to the building proposed)) Variance request submitted at leas ays prior to meeting date VARIANCE APPROVED Susan G. Rask, R.S., Chairman NOT APPRO Sumner Kaufman, M.S.P.H. REASON FOR DISAPPROVAL Ralph A. Murphy, M.D. Q:/WP/VARIREQ A j ✓�` dw r . O 1 ' _ x .Y S3 rK 1. Y. f s',d .i` N i`y• a1 •. . �T'a �) .. Ju/V O4 BORTOCOTTI' CONSTRUCTION, INC. po - 45 INDUSTRY ROAD,MARSTONS MILLS,.MA 02648 " � � 508-771-9399 508-428-8926. 'FAX: 508-428-9399 �� @ SUBSURFACE SEWAGE E DISPOSAL SYSTEM INSPECTION FORIVI`— f'` PART A CERTIFICATION ` Property Address U P Y Date Of Inspection Inspector's:Name: ner's Name and Ad ress: n AY A CERTIFICATION STATEMENT: I Certify that I have personally Inspected the Sewagc'.Disposal System at this address and that the.informa- tion reported below is true,accurate and.complete as of the time of Inspection. The Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.TV system: Passes, 5 k Conditionally:P es c .y—: r , Needs Furt valuat' ' the L'ocal'Approving Authority , Failure Inspector's Signature Dater { a, TheSystem Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. if the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Offie of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority: INSPECTION SUMMARY; C A) SYSTEI PASSES: f I have not found any Information which i ndicates that the System violates any of the fail- ure criteria as defined_in 310 CMR 15.303. Any Failure Criteria not evaluated'are Indi- cated below �. B) SYSTEM CONDITIONALLY PASSES:- One or more System Components need to be Replaced or Repaired: The System,upon -f` completion of the Replacement or Itepair,Passes Inspection Indicate yes,nor,or not determined,(Y,N,OR ND).`Describe bases of determination in all instances. If:"not determined",explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound;shows Substantial Infiltration or exfil- tration,or Tank Failure is iimminent. The System will Pass Inspection if Existing Septic Tank -. is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to broken or obstructed,pipe(s)or due to a broken,settled or uneven Distribution Box..The System will pass Inspection if(With Approval of the Board Of Health): -1- SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s),replaced Obstruction is removed Distribution Box is levelled or replaced. The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass.inspection if(with approval of The Board of Health): Broken pipe(s)are replaced' Obstruction-is removed - C)FURTHER EVALUATION IS REQUIRED_BY�THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF„HEALTH DETERMINES THAT THE SYSTEM IS.NOT-TUNCTIONING IN A MANNER WHICH WILL PROTECT THE, PUBLIC HEALTH;AND,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 APPROPRIATE-);DETERMINES THAT THE SYSTEK IS.FUNCTION. ING IN A MANNER THAT.PROTECT THE PUBLIC HEALTH AND,SAFETY AND THE ENVIRONMENT: _;• , =ri The system has a septic tank and soil absorption.system and is within 10Q Feefto a surface - water supply or tributary to a surface water supply. The system has,a septic tank and soil absorption system and is with a Zone I of a public water supply,well. The system has a septic tank and soil absorption system and is within 50 Feet of a private' water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 it is for coliform. F r more from private water supply well unless a we water anal Feet o o e a p pp Y analysis bacteria and volatile organic compounds indicates that the well is free from pollution from' the facility_and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303, The basis for this determination is identified below. The Board of Health F should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluehuto the surface of the ground or surface waters due to an.. overloaded or clogged SAS or cesspool. "Static liquid level hfthe distribution box aliovi outlet'invert'due to:an'overloaded or clog- >t.,:s, z° ged'SAS`orcesspod1-'. • , .F..-, k �r3x. F.:,S �. :w : E' Liquiddepth in cesspool is less,than 6 belowInverf dr ivailable`volume is less than 1!2 day flow. Required pumping`niore than 4 times in the last-year NOT due to clogged-or obstructed. pipe(s). Number of times�pumped , -2- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC.TION'FORM , PART A. CERTIFICATION (continued) " Any portion of the Soil Absorption System,cesspool or.privy is below the high groundwater s " elevation. ; Any portion of a 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 F 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. If the well has been analyzed . to be acceptable,attach copy of well'water analysis for coliform bacteria,volatile organic , compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEMFALLS: . The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one'or more of the following` conditions exist x 6 The system iswitlun 40U 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 WellheadProtection Area. -(IWPA).or'a mapped Zone.Il of a.public water supply well: • '"" . The owner or operator of any such system shall bring the system and facility into full compliance.with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. `Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B T CHECKLIST Check if t following have been done: Pumping information was requested of the owner,occupant,and Board of Health. _i,::�None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been troduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. ' e;system does not receive non-sanitary or industrial waste flow.., The site was inspected for signs of breakout Y:. All system componentsexcluding:the Soil,Absorption.System,,have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in z . : .specfed for condition of baffles;or tees;�rnaterial of construction,,dimensions,:depth of liquid, epth of sludge,depth of scum. . - �. r =i e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- t� SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) ZTheacility owner(and occupants,if different from owner)were provided with information on the proper,maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS Design Flow: v bons Number of Bedrooms:L�5 Number of Current Residents: V Garbage Grinder: Laundry Connected To System: (JA9 Seasonal Use: Cjya Water Meter Readings,if av ' able: Last.Date of Occupancy:. COM_MERCLA-11ANDLIST1114 : Type of Establishment: s,' Design Flow: ._ ._- `"' salloiis/day'Grease Trap.Present:..(yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V,System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection If yes,v lume p ped: Rallos Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/soil Absorption System Single Cesspool Overflow.Cesspool Privy hared System(If s,attach previous inspection records, if any)p Other(explain): c)• S. e _Oz�. AP ROXI MIATE AGE of all components,date installed_(if known)and source of.;information: . - ,•i t -<t^. PS- -�l i..iD f, i9,'' .�i.:;ir:.S. ,{ ' _ `�..�•; Sewag ors detected when arriving at the site Ile . r - 4 5UIiSURFACE SE ~ .WA GE UI. SPO s�: .. �,rig ,, SALS.YSTEM INSPECTION FOE►1VI ..°E ;. •.PART . . . A . GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: 4 Material of Constntction:kl concrete metal FRP Other (explain) ' . — Dimisions: ' r S Slud e De the g P � Scunr Thickness: i, Distance from top of sludge to bottom of outlet tee or battle: " Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,cbndition.of inlet and outlet tees or baffles,depth of liquid level in relation to ou t invert,structural integrity,eviden of leakage,etc.) t GREASE TRAPr Depth Below G de. Material of Construction: concrete metal -FRP Other (explain) - a _ -- Dimensions: •-} Scum Thickness: - Distance from top of scum to top of outlet lee or baffle: ..< Comments: (recommendation for pumping,condition of inlet and outlet tees`or baffles,depth of ligwd s x level 1wrelation to.oudet•inyert,structural integrity,evidence of-leakage;etc:) y , TIGHT OR HOLDING TANK: J' " Depth Below Grade: Material of Construction:_concrete_metal_FRP_Other(explain) Dimensions: - Capacity: _gallons Design Floe: gallons/day Alarm Level: Comments: (condition of inlet tee,.condition of alarm and float switches. etc.) DISTRIBUTION BOX Depth of liquid level above outlet invert:. Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER w 11 mp,Js to workin ,-.g order xe,Comments:,(note condition of pitmp,,cliamber,.condition_of pumps and appurtenances,etc) .._ '•.M",.t.4.i.';^+. '.;. i'" jt _ ;:ze.�'�-.i:,..'"{. ." +tit � �.f.t.,. - e;z� F xT"SUBSURFACE SEWAGE'DISPOSAL'SYSTEM'iNSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type Leaching pits,number: l Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comm ts: (note condition of soil,signs hydraulic failure evel of po ing,conditio of vegetatipri, CESSPOOLS: �. Number and ooguration: 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(cesspool must be pumped as part of inspection) Comments:(note condition of soilk,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY Materi s of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6- f SUBSURFACE SEWAGE DISPOS.AL'SYSTEM"INSPECTION FORM g PART C q. 'SYSTEM INFORMATION (continued) SKETCH.OF.SEWAGE DISPOSAL SYSTEM: Include ties to adeast two permanent references,landmarks or benchmarks: Locate all wells within 100 Feet. :441 1\1k . •. _ _.4-...,;� ..t. s .kaf- 4 i3�� i a' R 'a i £ �t .+} a DEPTH TO GROUNDWATER: i Depth to groundwater: / Feet Method of Determinatio or proximation: /?� �10 Ara* GLS. de D 7- 1 _... -..-. .. ... ..... �___--- �• � ' �� � b �•_.S.i.=.:�' _ ��!�:��',�-�3 �.—��Z7 Sri.-. ... �� ' � - , � S. 77 ji 12 ._ 11 - F .. .. I - 1 v v v u 0 _ , • r Asa 77 �571 ..,., , XI jjS 34 r + ! ` - -L�, .._..__-• ............... �_ Win' Tr H�5 - -- . r . ►10 ZL& Ata.�»`' r tt 47 Ij ?©6 L- _ ' STO R AC c i. i i TOP FNDN. AT EL. 32,5' SYSTEM PROFILE TEST HOLE LOGS - » PPOVIDE INSPECTION PORT "WITHIN ACCESS COVER 70 WITHIN 6 OF FIN, GRADE (NOT 70 SCALE) ACCESS COVER (WATERTIGHT) 70 s" KNISH GRADE ENGINEER: ARNE H. OJALA, PE MINIMUM ,75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN, GRADE 2% SLOPE REQUIRED OVER SYSTEM 32.0' WITNESS: SAM WHITE EL. 3Q.b' RUN PIPE LEVEL 2" DOUBLE WASHED PCASTONE 6 3 03 r`m sT DATE: / / ------ EXISTING 1000 FOR FIRST 2' PERC. RATE - < 2 MIN/INCH Z ` moo►s�A,,o / GALLON SEPTIC L11 28,6 t 2$doom .$ CLASS I SOILS P# 10498 TANK (H-jo ) GAS TT- 1 017-1G717-I 0 rim COC:I '^ BAFFLE 28.32' 6§9s� 28.0 Cl I7 CI C7 0 C7 C] C, ' CjCONFIRM OUTLET INVERT PRIOR TO INSTALLATION " © © M 0 M oD7 C E1OFANY PORTION OF SEPTIC SYSTEM 6 CRUSHED STONE OR MECHANICAL �lELEV. 'COMPACTION. (15.221 [2]) 2 d d C7 CJ CI CI a 26.0 0 33.0 LOCUS DEPTH OF FLOW 4' MIN MIN „ „ O/A 3/4 TO 1 1/2 DOUBLE WASHED STONE TEE SIZES: ( 1 *!, SLOPE) ( ?: SLOPE) ORGANIC INLET DEPTH - 10.E FINE LOAMY OUTLET DEPTH 14" SAND FOUNDATION— EXI5T, SEPTIC TANK 18' 5" 10YR 3/1 rLOCATION MAC' NTS FOUNDATI M D' BOX 17' LEACHING FACILITY E 5, FS ASSESSORS MAP 52 PARCEL 13 ACCESS COVER TO WITHIN 6" OF FIN. GRADE 13" 10YR 6/1 ACCESS COVER (WATERTIGHT) TO B 33'7' IV�NIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE LFS FROM EXIST. l 10YR 5/8 0.1' GARAGE RUN PIPE LEVEL 1 34" 3 PROP. 1500 -ja FOR FIRST 2' GALLON SEPTIC , ' ��.� TEE ! 70 PROPOSED LEACHING FACILITY `� 28,83 (SEE ABOVE) C � TANK (H- 16 ) ,� GAS _ "CONFIRM SUITABLE SOILS AND NO 17 BAFFLE 29.0' WATER AT 5' BENEATH LEACHING PeRC FS ��"""---- 6" CRUSHED STONE OR MECHANICAL FACILITY PRIOR TO INSTALLATION ' . . 2.5Y 6 4 DEPTH OF FLOW - 4 COMPACTION (152212])[ / 28' TEE SIZES: ___--_ 12' I INLET DEPTH 10" .� OUTLET DEPTH a 14'p 12023.0 NO WATER ENCOUNTERED NOTES SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLQWED ) 1. DATUM IS ASSUMED DESIGN FLOW: 5 BEDROOMS ( 110 GPD) = 550 GPD 2. MUNICIPAL WATER IS EXISTING o USE A 550 GPD DESIGN FLAW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. I 4. DESIGN nAnlNr Ff°R AI �RF C7 ! T ! F n FPTIO A>\It . atin r-or, i 'a . _ 11 no _. G L• _ L G l NITS () FcL CATCH BASIN _ S. PIPI JOINTS 'CU bE MADE WA I LI•;i 1G:ff. ELEV - 2).65 USE A 1 p00_ GALLON SEPTIC TANK (RE-USE EXISTING) �}z9.>'3 -- 6. CONSTRUCTION DETAILS TO BE IN AGC'ORDANGE. °'•'IT11 MASS, o t> $s & ADD A 1500 GAL. SEPTIC TANK ENVIRONMENTAL CODE TITLE V. U LEACHING: 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT TH �2 SIDES: 2(42 + 12,83) 2 (.74) - 162 TO BE USED FOR ANY OTHER PURPOSE. �33a9 j t 42 x 12.83 (.74) - 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40--4" PVC. t3x'7 398 !- - r> -- "' --- ~ - �o �'� BOTTOM.PAWO +� s9 ,"19. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT ' DRIVEWAY^ ' 758 560 INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED 0TOTAL: S.F, GPD +3` � $--- - _ _ _ - _ i FROM BOARD OF HEALTH. +32 x ,�$3.ez +�� - ' _ � _ _ � .' � USE (4) 500 GAL, LEACHING CHAMBERS (ACME OR 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) FAILED LEACH 'PIT f 3 � , g•trsaet ,.�3�ss' EQUAL) WITH 4' STONE ALL AROUND �o � t +29.eti t29.6e GARAGE � ��' .�•x3a '�I1 i � 3eA7 LEGEND TITLE 5' SITE PLAN P MP �3- ,, 0' DXWELL. WATER LINE IN `�� cD iD- 0, TF-32.5' FRONT `� +rn. po i 1 Q0,0 PROPOSED SPOT ELEVATION OF SEPIPRO 1 AN GAL �._._ i FLAGSTONE �'� 3� �, 320 GRAND ISLAND DRIVE SEPTIC TANK ; PAnO •, 100x0 EXISTING SPOT ELEVATION a +32.67 -,i' O 1 IN THE TOWN OF: j SPHEAD yyRE$ 00 PROPOSED CONTOUR ( OYSTER HARBORS) BARNSTABe E + ' j£� - gao�ia 100 EXISTING CONTOUR p Pool PREPARED FOR: BORTOLOTTI CONSTRUCTION/WILKINS 2e � ONCE i i 30 0 30 20 90 32.9e 3a rs "2 APPROX. LOCATION � • Cl�,x LOC ON OF EXISTING aaAlza OF xEA1.'>'H 1 aot POSSIBLE LEACH PIT SEPTIC TANK, CONFIRM MIN, 1000 GAL SIZE PRIOR TO INSTALLATION 3oze �� OF ANY PORTION OF SYSTEM, - APPROVED DATE MA SCALE: 1" = 30' DATE: JUNE 6, 2003 M REV 7/10/03 (5 BR) 329.00 _ BENCHMARK: USE CORNER OF off 508-362-4541 POOL APRON HERE AT EL. J lax 5" 362-9wo 33.75' down cape engineering, inc. t» of Mqs� �tN of Mq $° ARNE �� ��o ARNE CIVIL ENGINEERS H. = 0JAILA LAND SURVEYORS "p 26340 °' 3 �� sue: �s ERA �- 03-- 105 939 main st. yarmouth, ma 02675 AR .."`OJALA, S. DATE y 10. Finish - TI s "`{ITitne AP ♦ © ° ' Grade Pt Pt A o aQ s rtf ystkr w Compacted Fill 3' Maximum Filter NoisPy s 7?• bore' Fabric •'o ,° USo o �. Pea Stone 101 4 0 Perforate D� PVC Pipe 3/4"-11/2%oubte Washed D s ) o b •bF n 00 3''O" 3=0" 3'-0' Oo ©0 3 a _ ^a OAK 3 t2=0" S 'NOTE Blu zo Remove 5',AlIAround Leaching Bed, NOTES Pt T1drI , Ffpt* * ... a.(GUEST COTTAGE) •„ , s of Unsuitable Material as Required. I.Water Supply ForThis Lot is Municipal Water .,;, 77, PP Y P e �t t#r ......3. CROSS SECTION OF LEACHING BED Replace With CleanSuitobleMaterial. 2LocationotUtilitiesShownonThisPlanAroApprox. - Not to scale At Least 72 Hours Prior to Any Excavation ForThis Project The ContractorShall Make The Required LOCUS PLAN Notification to Dig Safe(1-800-322-4844) a The Contractor is Required to Secure Appropriate Scale : I"= 2000' F.G.14.0 Permits From Town Agencies For Construction ' F.G.I3.0 Defined b Assessors Map 52 ri• DESIGN DATA yThis Plan. Guest Cottage-Minimum Design 4: Install Risers as Required to Within 12'ot Parcel 13 ��12.0 , With no Garbage Grinder Finished Grade. Zoning RF- Daily Flow=330 GPD 11.8 1500 Gallon Inv. 11.2 a S.All Structures 8uyied Four Feet or More or Subject' Setbacks 1 11.6 Septic Tank:330 GPD x 200/0=660 GPD Septic Tank I 5 Sot.E1.10.7 Use 1500 Gallon Septic Tank to Vehicular Traffic to be H-20 Loading. Front 30' 11.3 6fi Septic System to be Installed in Accordance With :• •.••• •j LEACHING AREA 310 CMR 15.00 Latest Revision And The Town of Side 15' Bedding as 330 GPD/0.74=446 SF Required Barnstable Board of Health Regulations Per Title 5 5.0 10' 10.5 10' •10' 12 � ' 7. All Piping Lobe Sch.40 PVC. Rear 15 . Bottom Area=12 x3B =456 S.F. Lot Area: 1.31 Ac. 456 S.F.Total Provided 8.Septic.Tank Shall be a 2000 Gal.,2 Compartments. Bottom of Test Hole Elev.2.7 LEACHING.BED DESIGN The First Compartment SholI Have a Volume of Not Adj.Ground Water Elev.•5.7 Less Than 1100 Gal.And The Second of Not Less At Pipes to be Schedule 40.PVC 'Than 550 Gal.(Main House Only) (GUEST COTTAGE) Perforated With Capped Ends.Use 3-46"Distribution Lines in a 12'x 38' DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM Washed Stone Field as Shown. F Not to Scale ' 2,000 Gallon Septic FG.14.0 Tank,2 Compartment Pump Chamber F.G. 12.7 r � Inv. 11.5 N/F 12.0 Joan E. Geany 11.9 11.7 Bot.El.11.0 ctf 84136 nn II.t3 ❑V 5.3' AL 10 Bedding as Bottom of Test Hole Elev.2.7 / / / / ✓ DEVELOPED (MAIN HOUSE) Per Title 5 Adj.Groundwater Elev.5.7 N 80 05 1,3 E /, D / �j E ELOPED PROFILE OF PROPOSED SEPTIC SYSTEM / 9.00, / -�'� - 0 :$ Not to Scale 1 / #9 / / / / / / r NOTE / /1 / P�� ,� Remove 5',All Around Leaching Bed, 11 r / d / // �O`,y�0 / of Unsuitable Material as Required. I / / / / 0 F 0.10 Replace With Clean Suitable Material / 00 cP (4P/ ToQ.�Q�er :; 24°0 Opening Above For M.H. / / / / Io p�.(� Gaiv Pipe For Frame a Cover. / / / „ 0 4r�� / GA - I A Float Support l Pump Power a Float Control / To D Box / / x / + Cables Installed in Accordance - Z / / // // tw l3 0� � 12 , �``x ' / / �/ W © 0 1 With Local Bldg.a Elec.Codes. \ -` ` O .,, ./ / / � / �'/ i• � • ip G=:J �n a� 4"0 From.Septic �. Tank.Sch.40 PVC Precast Pump 1�13tw tw / / / co / 50/ /0 /70 i P '1 / O ?: / g'-O��Chamber Cedar/Maple Swamp / O / / / / 5 Wetland Limit / 4' _ ' / / .•.'r ,,.•.•� ,.•;.,•,& as flagged by ENSR /• / / / / / / i�. .-- PgRKI l °, ,�• cR; .: Cp: a ; / / / / / � • ,� 5 ' M f � PLAN _ tw In :a / /x-, rms.LIJ / 1k. M6 x \ I /#6 P / / / �-!'Q7 / e i p 0 40 i" R / /Q 4vo / /// / �o / , 0:�5 / \ AD / / / / • a�� �' / :/ / / is 5c \ Sri 4 0 Sch.40 PVC Finished fw l�0 / T \ i-,�Ni't G y1r.8' DESIGN DATA From Septic Tank Grade Q• / /.: „ fRR I� a 1 Single Family5 Bedroom / .. 4. $uis It w• 0 �.. • With Garbage Grinder I- Daily Flow-'110x 5_550 GPD 0 0 000 �A� ` .� / Septic Tank:550 GPD x 200%+50%=1650 GPD Conduit Thru Chamber ►n / �'' o ' S / MrNUse 2000 Gallon Septic Tank -, For Power a Float Iv. / c / EpTIC /� / Emergency Storage Chain q ox \o : O 'IgwK 1w120 Pui�ilt'... c,t LEACHING AREA Vo1.565Ga1 Cables. o" Min..2Cover . Illh / / / / / // / W/ DWELLING CH►.>`At3r:R aoX O :74 - . .. .,, .... .. F DW ELLI -' ca° i ' l sty W/F x tw F F 14.5 I ASPHALT DRIVE I ` /0.7 4�SF+50%- Alarm on E1.9.5 :8 2"0.. l5 1 ........ $2 5 6 GPD 4' PumponEl. 9.0 urYF v GARAG 5 \......... .................... ` Bottom Area=12 z93 = 1116 S•F. Sw chs-3Rt 'd Threaded Pi Bot m r Mired eq 40pePVC 1116 S.F.Total Provided I~: I -� Pum off El. 8.4 Check Valve / GRASS / LEACHING BED DESIGN It�/►Afi`) }: Secure PipeatTopa / / / / `••- ; ;:e P� - / :.,.` All Pipes to be Schedule 40.PVC Bottom of Chamber ss ,• +.,, Perforated With Capped Ends.Use Bottom El. 6.9 3-4"Distribution Lines in a 12'x 93' ,".•'•;: , e.;;. ,•a AA 6 Washed / / / / / / / / ,� $ I: Washed Stone Field as Shown. A ► Stone Min. / SECTION / / / / / / FF=15.1' i (I000 Gal Ion) PUMP CHAMBER DETAIL / LAWN / Ica ✓ Not to Scale ��' �ffs�R sia ... :. ...... .&i iv�uc �II►c PA no 2 sty :'�� // / / \ \ \ �h :::.............. . ©WELL G ` I:� GRASS N / �.� / , FF .4' ` Finish ' ' i GRASS ! ' , Grade ORA -to Compacted. 3 Maximum Filter AL '1 Fabric 3' i c i : f Pea Stone Wid@ �i J / 1 )) - ,,. , ,. ... I �- ..' (jt/lY .,:• :" .uV i. , 4"0 Perforote u , / Path cc.;.; - io PVC Pipe 3/4 -I I/Z'Doubte VAL►Es 1'� w/: .J,:c:. ! W. :�,� washed K ry" 3'�' 'S''O" 3'-O" 3'-p' I POST FENCE / .. T k RAIL .. / / / • . / 329.02 (MAIN HOUSE) - !�~- NOTE c /, / S. / c / '• 13 •• CROSS SECTION OF LEACHING BED CWIt ti° Remove 5' Al I Around LeachingBed PLAN VIEW Not to Scale , , / .......... ......... " " of Unsuitable Material as Required. q Q Replace With Clean Suitable Material. NIF � ...... Scales l =20 George Sarney Ctf. 139205 TEST HOL¢ EL., 12.-r GROuo+Q WATt312 AoJUSTMe:NT . Title: PREPARED BY.• PREPARED FOR:. Notes/Revision: oac�Ntc MAT. ^ „ LstAVE,f�INE r1EED GROUNIO VVATER `P 9.S': tFL. 3,2 The Proposed foundation shown hereon complies t ►N o�>, weLL : r`n Iw 29 Z e,v A SITE PLAN (��� with the sideline set back requirements for the Town E oRN. coAas SAND ADTUSTMEV4T: 2.5, Nov. ►9 9 9 Sullivan Engineering, Inc. C�s�j�' ST EPH EN DEM I RJ IA N of Barnstable and is not located within the 100 year '�YR s/ r ADJUSTED GROUN h WATER, CLEV. S.� CD fI00d 6-rmoma eiRN. COAR5& PO Box 659 7 Parker Road plain. a� sAND . I o YF, T/& �- PROPOSED SITE IMPROVEMENTS 12 WOODR I DGE CI RCS E A Portion of The Guest Cottage is Located in The Mapped I Osterville, MA 02655 Osterville MA 02655 320 GRAND ISLAND DRIVE WESTON MASS. Flood Plain., r32 c3RW'tsN YEL co,,R5E (508)428-3344 Y(508)428-3115 fax (508)420-3994 (508)420-3995 fax s H 2" SANO 10 V Ik `/G LT. YEL'15H• 5RN 0 OSTERVI LLE , MASS. 120, c COARs6 SAKI, 20 0 10 20 40 Field: Draft: TEST HOLE By SULLIVAKI EN&%t4-.EKING 1tAC-% Date: Scale: _ Comp.: Review: 0 ATE' It l Cl 9 9:, NOV. 18 , 1999 AS SHOWN Prof• # Drawing # 3 3 DEMIIIMAN 6 GH 6 GH 6 28'-78° GH VH GH It �Sllll�lTl�l� 28'-78" 1'-102" 2" 4_94 9° 15'-38" 116 GRAND ISLAND DRIVE 0YS7F_R HARBORS OSTERVILLE, MA ———————————— — — — — —————— ell GFI • • GFI OO 03 � 102 4" CONC. SLAB W/ 6X6 (/ \ , \\ 1 I I M U D D I / \ II W1.4 X W1.4 WWM OVER II 6 MIL POLY VAPOR BARRIER 1 001 I R R \ a II BSMT—MECH. / I i I \ , ;o / i I .c / �o \ I / I DN GENERAL NOTES: \ ' I T-IN I I J. I N II — � — — — I I ,, Cl I N N - - - - - - - - - - - - - / I \ 2�2 � UP I I - \ I - I - - THE DRAWING AND ALL OF THE IDEAS SIN to to I / \ �N // I \\BUNK RM. I I I I I i ARRANGEMENTS, DESIGNS AND PLANS \ N INDICATED THEREON OR REPRESENTED I I T R 1 2 R � / I \ I I \ I I 4 101 \ 2 4 \\ / +1 Z THEREBY ARE OWNED BY AND REMAIN GH R M DD 0 GH GH I I \ GH THE PROPERTY OF DOREVE NICHOLAEFF, J I SITTING\ I I I \ / \L----y ARCHITECT INC. NO PART THEREOF 903 \ \ \ SHALL BE UTILIZED BY ANY PERSON, FIRM OR CORPORATION FOR ANY PURPOSE: V�T EXCEPT WITH SPECIFIC WRITTEN PERMISSION I I / nr: / I I \ \ / . /\ \ / I I --------- - - - ---y \\ � -- ---� / I �p OF THE FIRM DOREVE NICHOLAEFF 1I ARCHITECT, INC. / SINIz ANY ERRORS OR DISCREPANCIES ON N I p II 4" CONC. SLAB W/ 6X6 / I R / �// THE DRAWINGS, SHOP DRAWINGS AND %o W1.4 X W1.4 WWM OVER 4"C USHED I DETAILS ARE TO BE BROUGHT TO THE II GRAVEL OVER COMPACT FILL II j / ATTENTION OF THE ARCHITECT BEFORE / - THE WORK HAS COMMENCED. 6 — —— — — — — — — — — 6 6 L - ---------- ---- -- - - / DIMENSIONS ARE TO BE USED AND NO GH GH GH DRAWINGS ARE TO BE SCALED. 9� " 9'-6" 2_0 1_8� 3-10�° 1 6'-81° 2 9 8 8 2 2 ILI u 9 13'-5:" 7-108" I 30'-28" I 1 1 GH GH I I I FOUNDATION PLAN 1 SCALE: 1/4" = T-0" GHI-1 FIRST FLOOR PLAN 1 SCALE: 114" = 1'-c" G HI-2 SECOND FLOOR FL_ N SCALE: 1/4" = I'-o" GHI-3 I I I 3 GH 6 6 6 GH GH GH FLUSH MAIN FLOOR BEAM - W10X19 WITH 2X SIDE NAILERS SCUPPER THRU-BOLT W/ 1/2" DIA. BOLTS STAGGER SPACED ® 16" O.C. -——— — ———— —— -\ - - -------------- - - ----- - - - \\/ - - - ----I— ---- --- \\ SCUPPER (D 11 /8" TJ1 TERI S 250 1 16" O.0 RO S BRIDGING, TYP. I I _ METALI � OI I I co — — — i 11 /8" 7J1 �MRIES 2 O 0 16" O.0 \ i METAL R S BIZI ING, TYP. \ GH O I I I — - - - - - � /�—�\ \ / / O I I I I -1---- — — —-I- --- - ----Z— t -t -+ +-/ I \ / bI / ——— — ——————— 2X5 1 I � / I / / 6 -- - - - - — — — — — — g 6 GH VH GH I I I � I GH DOREVE NICHOLAEFF I ARCHITECT INC. 812 MAIN STREET OSTERVILLE,MA 02655 FIRST FLOOR FRAM1 G SCALE: 1/4" = -o" IGHI-4 SECOND FLOOR FRAM1 G SCALE: 1/4" = �'-o" GHI—S THIRD FLOOR FL N SCALE: 1/4" _ � -o" GHI-6 FAX50�420-2240 ELECTRICAL LEGEND: ELECTRICAL NOTES: 6 GH - All outlet receptacles and fixures must WALL SCONCE BE SQUARELY INSTALLED. - ALL OUTLETS TO BE LOCATED IN BASEBOARD, O�— WALL MOUNTED LIGHT FIX. TURNED HORIZONTALLY, AND CENTERED. 3 CEILING MOUNTED LIGHT FIX. - OUTLETS SHOWN IN PLAN RELATE TO FURNITURE 2X _H R. LAYOUT. ADDITIONAL OUTLETS TO BE LOCATED / \ FILE NUMBED: BY ELECTRICIAN AND TO MEET NEC. 2 HANGING LIGHT FIX. - LOCATE ALL SWITCH PLATES WHICH ARE (3) X HDR. 2X 2 �— — — ---- / 0 6" .0 \ ADJACENT TO DOOR CASING MIN. 1 1/2" TO I I (T ) O PiZOJECT NUMBER: 9804 RECESSED WALL-WASHER MAX. 2 112" FROM FACE OF CASING. I I RECESSED DOWNLIGHT - AT CORNERS WHERE THERE IS NO CASING, 'I �j \_ / LOCATE SWITCH PLATES 6" FROM EDGE. � 7 2X // \ DT�A W N B I �/ GNG LOW WALL MTD. FOOTLIGHT R TE S( YP ) - GANG SWITCHES UNDER ONE FACE PLATE �I DUPLEX RECEPT. OUTLET WHEN GROUPED. pl 2X12 RID E I I SCALE: 114" _ 1'—O" Ifil DUPLEX RECEPT. OUTET IN FLOOR - ALL OUTLETS IN BATHROOM TO GO IN BASEBOARD (NO OUTLETS AT SINK). dbv TELEVISION/CABLE OUTLET �I i n2 �\�Q I DATE: SEp7EMBEl2 2.4, '1999 a DUPLEX RECEPT. W/ 112 SWITCH - WHERE SWITCHES, RECEPTACLES, AND FIXTURES l ARE NOTED IN SAME LOCATION, ALIGN 6GFI GROUND FAULT INTERUPT OUTLET VERTICALLY. �E ® TELEPHONE JACK - COORDINATE WITH CABINET MAKERS ON REVISIONS DATE ,9 CABINET-MOUNTED RECEPTACLES. THREE-POLE SWITCH - ALL RIGHT-HAND OUTLETS TO BE PERMANENTLY 2X8 H SWITCHED TO LAMPS. I ---- - - I - SINGLE-POLE SWITCH _ - REFER TO SECURITY/ALARM LAYOUT. VERIFY TYP.) p DIMMER SWITCH ALL LOCATIONS WITH ARCHITECT. (.3) 2X - HDR. L ------ - LOCATE CENTERLINE OF SWITCHES 42 1/2" JAMB SWITCH FIXTURE A.F.F. LOCATE CENTERLINE OF THERMOSTATS 49" A.F.F. 1 LE EXHAUST FAN - LOCATE EXTERIOR SCONCES AS INDICATED ON GUEST HOUSE FLANS WALL MTD. EXHAUST FAN - LOCATIONAOIFGELECTRICAL- OUTLETS TO BE VERIFIED FOLLOWING SHOP DRAWINGS. 6 GH t EL M I � o ROOF FRAMING PLAN SCALE: 1/4" = -o" GHI—g 40 9 E3 / l)EMIIIMA / III.SI1)IJN(]l" \ 41 \ / GRAND ISLAND DRIVE 4 46 / / OYSTER OSTERYILLEHARBORS A " GENERAL NOTES: 0" ^" 4' / ® / / THE DRAWING AND ALL OF THE IDEAS 3'' q,.^^2 2 49`S" / / ARRANGEMENTS, DESIGNS AND PLANS INDICATED THEREON OR REPRESENTED THEREBY ARE OWNED BY AND REMAIN THE PROPERTY OF DOREVE NICHOLAEFF, 8" O ac ARCHITECT INC. NO PART THEREOF Z' 8' 9,_p / SHALL BE UTILIZED BY ANY PERSON, FIRM 3/4" T Q� � / 3/4 ��,4 OR CORPORATION FOR ANY PURPOSE: EXCEPT WITH SPECIFIC WRITTEN PERMISSION OF THE FIRM DOREVE NICHOLAEFF ARCHITECT, INC. S ANY ERRORS OR DISCREPANCIES ON ER\OR pLA�� nIA^ / EQ(�q` 4 THE DRAWINGS, SHOP DRAWINGS AND 2A 11/q � 3 „/ a^ SQ�� `6 3/4" DETAILS ARE TO BE BROUGHT TO THE 3 ^/A R 2 P• Oy,✓R •O14S I 2x6 L ,�.ti 1 L ATTENTION OF THE ARCHITECT BEFORE 3 014 �M�C2 P, OyER �VqL nl� / THE WORK HAS COMMENCED. M v��'� �6" Y / 3pDd Zx^p OM MPN GAY 1 �. 3 / /` DIMENSIONS ARE TO BE USED AND NO CL�pt; / 34 \ DRAWINGS ARE TO BE SCALED. P a � / G 'S 3 ABOVE a \ < P ABOVE x az \ l / \ S �i2" " A 21� B�DR i t 4 I,— c�oaf / 214 0 �4 J A8 / / /� s �/2" �. / BED �v 21 V.. Q l R° er °M 12'- w 9 — \ / 6 "7/ A 2 �1N��GEU,-^ G"A/A" G� 23 ABOVE 3 lb J4 %u AB VE A9 30 UP J u c � a 04 9 w A8 \\ 23 S A ��R — D $ / \ 5 l U. \ M P�R�pM \ , — \ ,; , " \ 0 0 / \ ��" 213 / to rq AI TYp AA 32 T� l ,�� Y M N sN 3 � OV�RA�'/OGA/�y DECK: O J \ \ N N l l ', 208 / Rp Zp2x p.7' pL J ABOVE / �A" " >> \ / / ,� 3/4" M rc b B� / repD M RS VTAp RE S W pLRW"E �E oM �L 5 y 5 0 / L ? A v / SYSSEM 0 N A��/ \\ 58 4_s 3/� Tc?"� OF l �(`� G 0 I O 4 �� ��Y CL l / N 4 M �}/r)ABOVE \ 4 // \ ABOVE ��'6 qu A 0) 2 , � n to01 (J) oil t / 02 FLAT CL 0 , I-10IR b / p \0. w 2pg p o �aw ABOVE ABOVE ABOVE /C❑2M� U T\E 0(7 /��----�� W❑ \❑\N S zoo INSIDE LINE 48 it N a O. V V> �N GN�MHp�GX' GsWti 6 A/2 BALCONY OF MONITOR Ceto � 21 w / Oq � I QTV/PLAYR❑❑M y qNA w WJ \ / l r��� ^O-6 �/2 W 2p1 A-3A 36 x 7_5 �i2" -� \�O 6 q 4LG. a FLAT CEILING ' e� \ \ / A/2 ABOVE in r{` � W� M t'1 A S }C / 2 / l5a ABOVE to 49 ABOVE ABOVE 18 CLTT Cam' 90ABOY OPEN TO Y 51 � SELO it 'COY / ABOVE , DOREVE NICHOLAEFF yew ARCHITECT INC. ,ro 812 MAIN STREET 6PEN TO OSTERVILLE,MA 02655 T .508a o 223 BELOW FAX w A8 0 �> 0 M BOVE LB ABO �� ;t V I � � M � W_ I A9 C Q ,EQUAL 3'-3" 3'-3" �QvgL FILE NUMBED: ,12.0 �2�O" 3_3" 3_6" PROJECT NUMBER: 9804 T, v 5,.6" 6,.0" 6'-p" S_6" SCALE: 11411 = ,ti_O" DATE: SEPTEMBER 24, 1999 40'•p. 5'_S4 2 REVISIONS DATE A8 W h h T1TLE 4 2 3 A7 A5 A7 SECOND FLOOR PLAN E SECOND FLOOR PLAT T SCALE: 114" — -O" 1)l4j' NI R elIAN II14 SI1)fil N("A1J GRAND ISLAND DRIVE OYSTER HARBORS OSTERVILLE, MA 4 A6 2 T A6 G7 A B GENERAL NOTES: ° '\N THE DRAWING AND ALL OF THE IDEAS ED THEREON ARRANGEMENTS, DESIGNS INDICATED REPRESENTED 5-A4/\ Z THEREBY ARE OWNED BY AND REMAIN u THE PROPERTY OF DOREVE NICHOLAEFF, ARCHITECT INC. NO PART THEREOF SHALL BE UTILIZED BY ANY PERSON, FIRM 32 ��NEi Q Q 6' B 7b OR CORPORATION FOR ANY PURPOSE: Z �RpM�1��" �\ 7Q 2 EXCEPT WITH SPECIFIC WRITTEN PERMISSION OUG�A / I \ \� ' EQUAL ftj OF THE FIR INC. DOREVE NICHOLAEFF 6' gb Z �J P�' QV,gL OGNPpS GO V NS w U' ANY ERRORS OR DISCREPANCIES ON 'p\p. ONE �� N\� JPV THE DRAWINGS, SHOP DRAWINGS AND �Z \2O\ 51 , 0 �( , DETAILS ARE TO BE BROUGHT TO THE 32 AS ATTENTION OF THE ARCHITECT BEFORE A8 ER��NE \ t0 UZ THE WORK HAS COMMENCED. G0�'vMN 2U A OVE 110 Q DIMENSIONS ARE TO BE USED AND NO 11 3 ABOVE Q DRAWINGS ARE TO BE SCALED. i \ I MAR E H 1 ABOV �p N E5�°NECD °1�P VRE P°RGN � PIP 14 It 10 Q 110 0 q 4 ABOVE Ag \ > / 2 J4 URROU 4 '6 ,�Oq G RE p�1� V� I 4'-6 ja / M �ro'`Y Nro © sjoNW jog F�REP\ pGe 1 3 ' " sa p° p�OvE 4' A9 A' 9 2 IV -*Ij s �J YE \ 10 nw' '� v 10 "' �8 3 rn \ c eB 4 o w o 5�ON� o 5�N �FNN�M�NE 10 �`; C / O, NEpRE pETE \ DER O GE1 E� �i w �o s 13p F�°oGPNYA�� wY��s \ 7B �\w 10 v ® l (r P Y TON�bSINOR�, , , STAIR o� n„ �N OO MpNE��NG w0 11 CO4- C A$O ANT A$LATV N ��N \ s \ 10 0 \ 0p1 / \ 3-B^q 32 3�b l B�8 N \\ \ LZBRPR \ 4' a ® // TO b w 4C 0 \ ^N 3 ,4' p 1 4 3 ,4- i�N CONC. N 36 X 96 IVSH-�'6" 1 3_B�" CH 114\ `° F 101 ;U -T_�N ro HALL M % / / 1p l 26 to N � LINE OF BALCONY 0 0 �\ ABOVE flu 104 � 119 11 2 52 CLOSET I FL 40 0, iYry � 14 a ?' 3., ;,� 117 / !Y O 100 3-" C FOYER J ? 6'_Op �, w 16 w �= I 3" DOREVE NICHOLAEFF Lo sz N ARCHITECT INC. 812 MAIN ET t0 OSTERVIL ESMA 0 655 N b�, i� TEL.508-420-5298 3 03 \> 6, , $�L` FAX 508-420-2240 w. AS T I R �9 ° , [_q y 7. p 0QEQ 1 6 C SAC T/ (rD 36 b 1200 Sp�C 0 1B A OVE oV Sr0 C'7' AB VE m v Cl4 �� w \A5.OV45.Op/ �7"r YSTONq Sw A9 0 P J i`lE EQU �' EQV'4l. // CO FILE NUMBER: 3-6„ ^A''O" 3_3b 3_6b PROJECT NUMBER: 9504 '"0" 1 SCALE: 11411 _ 11_011 5,6N " 25,-0" DATE: SEPTEMBER 2.4, '999 5'_5N REVIS10NS DATE AS S_7N A u? 3' BN 1'_Zb J a M T1TLE 4 2 3 A7 A5 A7 FIRST FLOOR PLAN d FIRST FLOOR FLAN SCALE: 114" _ -CY