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HomeMy WebLinkAbout0028 BLACKBIRD ROAD - Health 28 Black Bird Rcl (Marstons Mills) e No, Fee THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21ppYieation for Misposai *pstem Construction permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.Z f Of c_c U n/ Owner's Name,Address,and Tel.No.,5ke,r o, Lk 6c , Assessor'sMap/Parcel f Dt"S /`// 29' Q/&t [?',/ 1�0 �J'1ultfoslS /h�"��r Installer's Name,Address,an Tel.No. �{ ,^ t Designer's Name,Address,and Tel.No. D,L era o S�✓.xr ,�` j o,4,S Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �7 Design Flow(min.required) 3 3� gpd Design flow provided 3 3—0 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) g 64_ v l`e a 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 Certificate of Compliance has been issued by this Board cf Heal Signed ate Application Approved by Date 6 ' r?—(4E> Application Disapproved by Date for the following reasons Permit No O Date Issued — No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Nplication for -Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.Zt L3(e_((4 &AIIJ 90 Owner's Name,Address,and Tel.No. 5k&j o G4h be- i Assessor's Map/Parcel ^" G rS L Co 2 . /IS (,�� -21 f'&c V� Installer's Name,Address,an Tel.No. t Designer's Name,Address,and Tel.No. Diar wa.,o St./-ef `' eck 15 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3� gpd Design flow provided 3 3 a gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 12 ex-, v v-e D� d /�^C/''1G C-C a 7C 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 Certificate of Compliance has been issued by this Board of Signed Date 9 /�'JO f Application Approved by Date G "1?—f 6 Application Disapproved by Date for the following reasons Permit No. VLl Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS T BARNSTABLE, MASSACHUSETTS -- Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by D Is GCS L~ d n 0 c/ C.L r• ✓l (p(24 o.t at Z b /M C u & 1`./a !� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 12016 -)o q dated J `A/ Installer Designer #bedrooms �ZletApproved design flow gpd The issuance of this permit shall not be con rued as a guarantee that the system will functio d si ed. Date 4 (P Inspector �-� ----- -------------------------------------------------------------------------------------------------------- ------------------- No. (� Fee— 5 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Misposal 6pstrut Construction Vermit Permission is hereby granted to Construct( ) Repair( kl?;, Upgrade( ) Abandon( ) System located at 13 "IA 99 and as described in the above Application fo-Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constru tiqji must be completed within three years of the date of this permit. Date —"� Approved b PP Y AsBuilt Page 1 of 1 � , To OF BARNSTALE d LOCATION _SEWAGE #86- g�/✓r VILLAGE&L6�z"i ASSESSOR'S MAP & LOT #o� l i.S/- Clog-OR-0 NAME 6 PHONE NO.�C.cr✓ ( ostS��CM_znC SEPTIC TANK CAPACITY 1070 LEACHING FACILITY.-(type) (size) A 00 NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER L, Z DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: l�✓<� � / 7 VARIANCE GRANTED: Yes No Cx qc 0 C-t S� http://issgl2/intranet/propdata/prebuilt.aspx?mappar=151008020&seq=2 6/20/2016 Commonwealth of Massachusetts W Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments�� �p 28 Black Bird rd Property Address Sharon Sanocki Owner f-+ Owner's Name Q'} information is required for every Barnstable M M Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection GD dD W Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms Y A. General Information l/_ 5 W on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name 8 Johns path Company Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/15/16 1 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Yb t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner—' . Owner's Name information is required',for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) J_ Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Dbox is rotted and in need of replacement. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken ,pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd M Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. CitylTown State Zip Code Date of Inspection D. System Information Description: System is in good working order. Dbox is rotted. Dbox needs to be replaced. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 179 Gpd g ( Y 9 (9p ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste hoAing tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Occupied Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection,records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented through the roof Septic Tank (locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Dbox is rotted and in need of replacement. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was dry at time of inspection. Stainline indicates level has not been within 20" of invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and conficuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7/31/86 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: . You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 6/16/2016 Assessing As-Built Cards � cry O OF BARNSTA�LE LOCATION SEWAGE r86- Sy✓r VILLAGE ASSESSOR'S MAP& LOT #Rb F1 �' psi- oos-0ao INSTALL 6i INSTALLER'S NAME PHONE NO. �� P,� o,t. f rn ?dr SEPTIC TANK CAPACITY_1000 LEACHING FACILITY:(type) (sie) A00 NO.OF BEDROOMS___3_PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER LN �/—S'o%t✓s DATE PERMIT ISSUED: DATE COMPLIANCE ISSUEDz^T,/ VARIANCE GRANTED: Yes No i4 cx^n`9e po ct,5 e- F7- http://www.townofbarnstabl e.us/Assessing/H M display.asp?mappar=151008020&seq=1 1/2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 28 Black Bird rd M Property Address Sharon Sanocki Owner Owner's Name information is required for every Barnstable Ma 02668 5/12/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION �.1/��'�f e�/OP3 IP 2> SEWAGE # VILLAGE 127 ' d1'✓ L L S ASSESSOR'S MAP & LOT lNffA&bg= NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY S��T/ L //LS�f e /oIt,, LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE ARN1119F DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ®tip 974 l o TO OF BARNSTA L LOCATIOL.? SEWAGE #SG VILLAGE ; ASSESSOR'S MAP Cr LOT � /s/_ ooff-oozo INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY IWO LEACHING FACILITY:(type) (size) A 00 NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER L,L,Z DATE PERMIT ISSUED: ?, 7 ~ DATE COLiPLIANCE ISSUED: �✓ VARIANCE GRANTED: Yes No 9e _ d ca S . t t a� ScGF7^ 4 1 No .". .... Fps. . ... n THE COMMONWEALTH OF"MASSACHUSETTS BOARD OF HEALTH .............................................. Applira#iou for Disposal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct (1/`)or Repair ( ) an Individual Sewage Disposal System at: ................._!---------------------------' t • Location-Atldres<— ...........................or Lot No. - ............ . _ ._..�._.` ....>. ..... J ...--...... yl'. �............................................................ . Owner Address r.:.. ........................s Installer Address U f / Q Type of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms.........`- -��..............................Expansion Attic-(- ) Garbage Grinder (—) Other—Type of Building ................-A.^�_:.!r_ No. of persons...... ................... Showers ( - ) — Cafeteria-(- ) Otherfixtures ........................................................................ --•--•--••-------••---------`--••......................................... WDesign Flow.......................�:?.__.............gallons per person per day. Total daily flow..._.... _: ...........................gallons. WSeptic Tank—Liquid capacity.._L _gallons Length_�_..5!. Width.`4..__ Diameter________________ Depth-`A_._..t. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------j----------- Diameter....L._?-......... Depth below inlet...3_..S.1... Total leaching area•-?..l ?__-:- .sq. ft. Z Other Distribution box (�)' Dosing tank.(-^")- Percolation Test Results Performed by.. - . '?/,_C!'�F.S_.: � .r /!`Date... ?� . ...- ,`�a Test Pit No. L. __. ?-..minutes per inch Depth of Test Pit ?..z_......... Depth to ground water.....I__?....... Test Pit No. 2..._ n...minutes per inch Depth of Test Pit..... ...... Depth to ground water..... - -Description of Soil.... f ...................... xf................................... VNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ .---•-----•••---------•-•---•------•--- -- ---•----•-•-•--•-••----•-•-----------------------------••----•---------•---•----•----•-•••-••-•-•----•••------------•-•--•-••......--•-----------••-- Agreement•.: The un�rsigt.,,'re s to install the aforedescribed Individual S wage Disposal System in accordance with the provisions of TIT 5 of the State Sanitary Code, The undersi wage ur er agrees not to place the system in operation until a Certificate of Compliance has been isu b thepoa of 1 /te Signed._ .... .......... -•-•-------..A lication A roved B 1ri�_..._..._. ._ 1'� ' _ .....•..... ._PP PP Y -� ...----- -- � Application Disapproved for the following reasons--------------------------------•-----------------------•-----------------------•----------------------•-----•--- -----------------•••-------...--•-•------.....-•••---•-•------•--•--•-•---------.......--------......•-•-I-•-•-•-•-----••-••--•----••-------••---•-•---•--•-•-----------•------••----•----••----•----•--- Date PermitNo......................................................... IssuedL------------------------------------------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7_­�a .......0F.1�.t .l? 3.1.�...---... .................. ........................ . Tntifiratr of Tlautplianrr THIS I T/��. CER Y� ha�te Indivi ewage Disposal System constructed (—)nor Repaired ( ) by .. - `. �' ----------•--•-------- .......----•---------------------------------------••----•-•---------•------- Installer at--- J v---� •�) 0-/..j..�../� , y G,<? /L, --=- ------- -------- -• --------- - --------- --- --- ---•------ --- ---- has been instilled in accordance with the provisions of ?17TLU 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........... .... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... ....................•-------•-- ....................................... Inspector.-----------.....-=- .............................................. THE COMMONWEALTH OF MASSACHUSETTS -• --- BOARD OF HEALTH ....'c3�.,..vt/...oF..... �` .-? !1/`a , y,�3 L t No......................... FEE -S..... ------ Rapo . t� Permission is hereby granted...Va •------- ----- •-------••' f# r--•-------------------------------------••-------.....--••--••-------- to Construct (I-)or-Repair ( ) an Individual Sewage Disposal System _ ,/ � at No... •--.... •---- }/0 f j,ti-: /G� i � � R I�x !/V �_a �Z , ----..••--- ------. --- ---------------------------•-------------•-------------•---------------------••------ Street pp�� as shown on the application for Disposal Works Construction ermit Nol(X.......--Dated.....•.................................... -•----. �q-1X-tit, . . ... ........•--. _...... DATE. 2 Z v Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON Fps.. . .. C,Y THE COMMONWEALTH OF MASSACHUSETTS �Q BOARD OF HEALTH ...----..-- -- �------. OF... ✓!/1JJS f'�.-------•--- ` A13;i irFatilan for BiopnsFal Works Tonstrurtinn 1hrmit Application is herebyade forte�ermi to Const c or Repair Individua�Se�Disposal System at: g .s% p U✓1.C1 ........Z 1 - - - ----------------- --- - oc -A dpvQi s(— or Lot No. Grpf ` e._ ,rr . ................................ Owner ddress t— a ... ...... ...... ..------. ---•------- ...L.l�.1�� --- Installer Address Q Type of Building Size Lot.... ----Sq. feet Dwelling—No. of Bedrooms............................................Expansion AttiQ-t--f Garbage Grinder k--}-- aOther—Type of Building No. of persons.......jCc>_............... Showers-.(----)—=Cafeteria-(--)- Otherfixtures ................................................................................................................................................. Design Flaw...................6' ..........gallons per person per da'y. Total daily flow____--- 3 3. .........__.__._...gallons. WSeptic Tank—Liquid capacityl a9q.gallons Length__ ... ._.. Width__-._.kq!"Diameter______________- Depth `..e."' Disposal sposal Trench—No..................... Width.._._.i............ Total Length.................... Total leaching area-___-_..---`-.------sq. ft. Seepage Pit No---------i.______--- Diameter----)...Z..._._._ Depth below inlet___s..� .___ Total leaching area.._Z` _sq. ft. Z Other Distribution box Dosing pikk °-' Percolation Test Results Performed by._ ate___ ,1 �/ ._�.. aTest Pit No. 1._G Zminutes per inch Depth of Test Pit... Depth to ground water.....1_z fz, Test Pit No. 2...1k_Z-._minutes per inch Depth of Test Pit----- ----- Depth to ground water-____l.l..`_. '.- _-- --- -- •--..... - - ------.---- -----._... Description of Soil — u`" �''� ` - ----- ram" V --------------------------------------------------- •--•----------- ---------- ----------------------------------------------------------------------...........................-----------•----•---•--------•...--•••••-----------------------••----••-•-•-----•--------------------------•--••----------••--•••------•-----------------......-----•..------ UNature of Repairs or Alterations—Answer when applicable................................................................................................ ---------------------------------------- --------------------------------........-•------------------------------------------------------------•---------. ....... ----------------=----- Agreemen The tin si re s to install the aforedescribed Individual S wage.Disposal System in accordance with the provisions of iITIU 5 of the State Sanitary Code The undersi d r er agrees not to place the system in operation until a Certificate of Compliance has been is the ar of Signed.. ---•• ••----•----•--- -----•-•-•-••-----•-------•- ..... .... ..... ..� at Application Approved BY t?-- . --�---- D to Application Disapproved for the following easons--------------•--••-----••-•-----••---------•----•---------------------------------- -- ---•--•---------•-•--•••-------•---........•-•-••-----•-----------••-•---•••------•--......•------•----•..................••-------------•--•---------------•---•-•-•------------••---------•-•--------- / Date PermitNo........... -------------- Issued....................................................... Date RECE 'ED JUL �, 51986 holmes and mcgrath, inc.-, r civil engineers and land surveyors 200 main street, room 201 falmouth, ma. 02540 548 -3564 July 3, 1986 Mr. Douglas Lebel Lebel-Sollows Corp. 131 Old Route 132 Hyannis, MA 02601 Dear Mr. Lebel: Re Fieldstone Estates Our Job No. 85,310 Enclosed please find the following: 1. . Topographic Plan of Land; Dated July 30, 1985 2. Subdivision Plan of Land (3 sheets) ; Revised June .26,1986 3. Subdivision Plan of Land (Sheet 2 of 3) ; Revised May 12, 1986 4. Results of Percolation Tests witnessed by Barnstable Board of Health. The Subdivision Plan of Land; Revised. June 26,. 1986 (enclosure 2) is the plan approved by the Barnstable Planning Board on June 30, 1986. The Planning Board is in possession of .the signed copy of the plans. I have enclosed the Subdivision Plan of Land (sheet 2 of 3) ; Revised May 12, 1986 (enclosure 3) , because the test holes were located according to this plan. (Lot 1 on this plan corresponds to Lot 1 on the test report and Lot 2 on this plan corresponds to Lot IA on the test report) . Due to the redesign. of the lots during the testing procedure, the test reports .themselves do not accurately reflect the final lot numbering. Adjustments should be made according to the attached sheet. If you have any questions, please call or write. Yours truly, HOLMES AND MCGRAT.H, INC. Hobert A. /urgmanit Vice Prep'L ent RAB/dcl cc: William Haney A TEST REPORT FINAL SUBDIVISION PLAN Lot 1 Lot lA Combined into Lot 1 Lot 2 Lot 2 Lot 3 Lot, 3 Lot 4 Lot 4 Lot 5 Lot 5 Lot 6 Lot 6 Lot 7 S Lot 7 Lot 8 Lot 8 Lot 9 Lot 9 Lot 10 Lot 10 Lot 12 Lot 11 Lot 13 Lot 12 Lot 14 Lot 13 Lot 15 Lot 14 Lot 16 Lot 15 Lot 17 Lot 16 Lot 18 Lot 17 Lot 19 Lot 18 Lot 20 Lot 19 Lot 21 Lot 20 Lot 22 Lot 21 Lot 23 Lot 22 BENCH MARK 19 v. 133. 7Z yG, v,o. TEST HOLE RESULTS P#,f 4 ," DATE WITNESSED BY a 3, (am. . 7- ►-1 % 'r-; ./ .5 z_"),F ` fry ' /�-/ C7 L E�aS ` 1 s r J"t-a • vvc I�u •:%vts.Sc�rG L Ji.S� / 2i, 013 C.7 CL /J \ P / ,S 7-0 A3 ZF* R ,;=r'i 0 / o ' �=-� v sir 1� 1 �,�cr-t ,c)VEL T ° W I T H 00 r,.. \ � { 'rf� , _.,.� l %' `r//3 O F' . TON. ,y dr - !"' s ►2► Off-. T C r2.v7--j2t c �'cr2 : r'�/ �� s, ✓ w' .� , _ T". '!' y~ .... L�- / ,._ ` � II ��`' , 1- � '``•�� T'-OV ATrvn! 7-c7 0 MANHOLES AND COVER TO BE BUILT TO .� ELEV. TOP OF JN WITHIN 12 OF FINISHED GRADE FOUNDATION Ion C!- \� � 9 � o- ` {� 3% ., _ FINISHED GRADE MIN. 2% SLOPE e7 �"" ` `+ 4i DIA. _ .T-r- q" DIA. PIPE FIRS -- - - / �qc� GA o k.. 1 -PI P E N+� .: -- MIN. 2 LAYER OF. 1 T!C p o�'rn ow. (' M I N.PI TCH FT. 2 LEVE J� f i � - '�� 5• 1 .Y. .-•. y F'ik 4, PIL MIN. PITCH /e'»an,w 14�' �8-"Y2� PEASTONE -r-•� � � ��1. , G � _ 1 /�,oyn , :• ; A FT /oc�C? '`'`uv. 113.25 ® • ` �-- 0. y,-. � �--- �•» ; . ,., INVERT .. GALL 0 N INVERT CG swHP INVERT �� m ; t, rcPTID TANS' = � DIST, / �, -, d [� ..y � I � DIA. -_- d .-:: . - - .__. ,1.._...al✓/ �T. ......: � '.. - :...�C . '- , s -T—.}•r �•�r, .—r- -'� r�'�I: RT , /-.1..,_ 0�r 5 J • , �S�r" " �` .,s INVERT -s=•- -- - 1. BUX WU �• WASHED STONE V� �. LE'sCJt.-� -_ I , PLACE ON a INVERT ��, d '� ALL AROUND � Cc , - � l.. � // 2 � � 10� MIN.) '; n. � `���• BOTTOM A EV.'/aa3.0a _._._ R r4 gV6. E 0 GARBAGE 0, M I 3,(_ r 3, r'"_' • _ ( 2 N•) •/ 4 2.©O' �►: = GRINDER � 2 /3© T. AFT, r�oL � ELEV. /04. 0 PROF I. '- E OF GROUND WATER TABLE I3aLati. SANITA.RY DISPOSAL SYST-E M ( NOT To . cscALE ) DESIGN DATA r f • CONSTRUCTION OF SANITARY DISPOSAL BEDROOMS SYSTEM ' SHALL CONFORM TO THE MASS. DESIGN FLOW 33© GAL./DAY ENVI RON M E N TA'L CODE- TITLE UC G (REVISED . 7- 1-77) AND T-HE ' TOWN OF LEACH RATE — MIN. INCH I3�RnlSTz3L HEALTH REGULATIONS. REQUIRED LEACHING CAPACITY :OLD STAG E IR 0 A 0 33 ' SEPTIC TANK DISTRIBUTION BGX AND LEACH PROPOSED " ` -4, GAL/DAY ING UNIT TO BE OF REINFORCED CONCRETE : MIN. CONCRETE STRENGTH = 3000PS.1. / t� ®cam REQUIRED SEPTIC TANK MIN. STEEL STRENGTH * 209000 PS. 1. MIN. DESIGN LOADING : H-_ eH,2Q LOOS) PROPOSED SEPTIC TANK SGOP�- .�` c�. 1� �►�'. = --tcT • DRIVEWAYS NOT TO BE LOCATED OVER SYSTEM UNLESS H2O DESIGN LOADING IS USED �4-0 �5e> • ALL PIPES AND , FITTINGS TO 3E WATERTIGH-T - II 2+� // a (o� AND TO BE OF CAST IRON OR ,APPROVED P.V.C. HEALTH AGENT APPROVAL- DATE ELEV' � 10 - _ . - SITE PLAN SHOWING PROPOSED CONSTRUCTION Z0NrNG , DATA LEG END LQCAT10N : 3 a'az 'r - 14., ' ( �1 � `r6 �s nm, .,. . FOR .) 4, ) 0_ I. Z r . . DATE z23i j8 TEST HOLE LOCATION REQUIRED ^ AREA . �1354U) Ivt �l�" EXISTING SPOT ELEVATION 17•6 � Q� REFERENCE 0- ' t �6 : HOvllv co REVISIONS REQUIRED FRONTAGE :— _, /50) 67»J EXISTING CONTOUR 16 REQUIRED FRONT SETBACK : (.3 /81 ,* PROPOSED CONTOUR P Ifi • (/S /da4 PROPOSED SCALE *- J 1. 0 ' REQUIRED SIDE SETBACK S WATER SERVICE W--- r, I 15 P R O P O S E: D GAS SERVICE G----- L ENS REQUIRED: REAR SETBACK : C _ r t L.A�/n//n/4� r3aAr2.� v'c�T r `)4,147 PRO,P0S_ RD ELEC. a > TELE .'—E a CRAIG R . SHORT , P. E . PROFESSIONAL CIVIL ENGINEER BU I L D I NG INSPECTOR APPROVAL DAT E 1' 31 ' OLD ROUTE 132 •, HYANN IS , 1NA. 02601 FILENO. / -58 ( T-,F 4,5' < Via) 3 2 - -r ., ; SHEET 1 OF l -