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HomeMy WebLinkAbout0080 BRIGANTINE AVENUE - Health "r 80"Brigatine%A A,✓� n ` Marstons.Mift ; i -� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION \y TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A 7 b CERTIFICATION Property Address: 'ice. l ,�,t� /!�f o/I+ L , l Owner's Nam _ / Owner's Address• Date of Inspection: .Name of Inspect: (please print) 'y ;. e C- Company Name'� �' CLP•'� �. Mailing Address: ' lL a� f del Telephone Number: CERTIFICATION STATEMENT 1 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: i/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: — Date: d 00z_ 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 E ; ****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 6/15/2000 page I Page 2 of 11 :j OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A- CERTIFICATION (continued) Property ddress: b *` v C y A Owner: t 1 a 7' ; Date of Inspection: (; I-)00S— Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. /System Passes: V.:. I have not found any.information which indicates that anyof the failure criteria describe&in9 -10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria.not evaluated are indicated below.;, Comments: - J � 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. I Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and.over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of.sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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 I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property,Address: co.)Cc.), Owner:_ Date of fnspection: (-yr� 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. L. System,will pass-urless.Board of Health determines.in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland.or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,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 rank and SAS and the SAS is within a Zoned 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 11 OFFICIAL INSPE CTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Propert, Address: Owner• p / J a 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: Yes N 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 dine 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 V Liquid depth in cesspool is less than 6"below invert or available volume is less than %z 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.frorn.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.] (Yes/No).The system fails.,l 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. x. . zp E: Large Systems: To be considered a large system the system.must serve a facility with a design flow of 10,'000 gpd to 159000 gpd• You must indicate either"ves"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 question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system.has failed. The owner or operator of any large system considered a. significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART B CHECKLIST Property Address: Owner:: -_xIrLf h n Date of Inspection. .Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes 1 '0 Pumping informatior.was provided by the owner, occupant, or Board of Health ,Were any of the system components pumped out in the previous two weeks ? VII-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) ZWas 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 fcr 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 or,: Yes o - Existing information.For example, a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 . Page 6 of 1 I OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Own Address: - _ '' � ��— er: ) 3 A Date of Inspeciion: LOW CONDITIONS RESIDENTIAL Number of bedrooms(design):13 Number of bedrooms(actual):', DESIGN flow based on 310 CM• 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): /C Is laundry on a separate sewage system.�(y . or no): if yes separate inspection required] Laundry system inspected(yes r no):�IV(r Seasonal use: (yes or no): Water meter readings, if avai able(last 2 years usage(gpd)): Last,date of occupancy: Sump Pump (Yes or no): 1� P �f � L �1..�. �✓ . , COMMERCIAL/INDUSTRIAL,�y Type of establishment: C✓ 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: ° I (7 &V'rzz Was system pumped as part of the ins�ection(yes or no): V If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ptic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system (yes or no)(if yes,aaach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Ap roximate age of all components, date installed(if known) and source of information: 16 Were sewage odors detected when arriving at the site(yes or no)' 6 f Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM JNFORMATION(continued) Property Address: Owner. Date of Inspection: ) 0©+� BUILDING SEWER(locate on site plan)/ k Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: , Comments (on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: t�ocate on site plan) 1 Depth below grade: 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: •, �� ,�> Sludge depth: 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: 11 Distance from bottom of scum to bottom of outlet tee or b ffle: 1 How were dimensions determined; Comments(on pumping recommendations,71et and outlettee or baffle condition, structural integrity, liquid levels s related to outlet invert, evidence of leakage, etc.): a /a �z`e � GREASE TRAPAPlocate 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 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.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i Owner 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.): 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 outletsual, any evidence of solids carryover, any evidence of Xeakqge into or out of box, et .): � r \ PUMP CHAMBERi (locate 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.); c 8 Paoe 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' s Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): 41 (locate on site plan,excavation not required) If SAS not located explain why: Type- leaching 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, et. ): ` CESSPOOLS;/ Q (cesspool must be pumped as part of inspection)(lo.,ate 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 constriction: Indication of.groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc:): PRIVY: Llocate'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 Paoe 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propert Address: . � Owner Date of Inspection: ( '9cD.t, , j0 0 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 buildi g. CK, Ion i o lb �. UJ � c) C) 10 Page 11 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property�Address: e, ®• A Owner. Date of Inspection: $ )�4 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to 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: You must describe how you established the high ground water elevation: 11 Per rit Number: Date: _wF Completed by: _h HIGH GROUND-WATER LEVEL COMPUTATION Lot No. Site Location: L�/'J CP�f��L� G� kr<- Owner: Address: :? ®t�" 1��✓ l�Cf�/��/` Address: G�'c, .►'S� Contractor: k - STEP 1 Measure depth to water table / / :. to nearest 1/10 ft. .............................................................................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: y� OA Approp'riate index well..................................rI. .....�.�..... �✓�3 OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... 7 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 ............... ................................................ STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to'water levelat site (STEP 1) ............................................:................................................................ z Figure 13.--Reproducible computation form. 15 i r� 100 MIA IX9 5 I • mow Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is f required for t i A A AA ill I MA 02655 7-8-09 every page. City/ State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector. S I5�b Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 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 C M R 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority jW 7-8-09 Inspector'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 DER.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. U t5insp official document•03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is Osterville MA 02655 7-8-06 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B System Conditional) Passes: Y Y ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer es, no or not determined Y N ND in the for the followin statements. If"not • 9 determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection.if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: A r a ❑ 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 r ❑ obstruction is removed t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of. Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ ' distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if.(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ ' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System-will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �1 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town. State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ .The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: * This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® 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 '/ 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 orIprivy is below high ground water elevation. ID tributary portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document•03f08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 l f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Diisposal System Form -Not for Voluntary Assessments ,M 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection B. Certification cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliforml 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts F W Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name required for is Clsterville required for MA 02655 7-8-09 every 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 provid ed 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? El ® 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: ❑ E 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)] t5insp official document-03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 330 p gpd x #of bedrooms): Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: _ 6-09 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe):. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` �M 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General information Pumping Records: I Source of information: N/A 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): Approximate age of all components, date installed (if known) and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 10"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000Gal Sludge depth: 10" A Distance from top of sludge to bottom of outlet tee or baffle 22 Scum thickness.. 0. Distance.from top.of scum,to top of outlet tee or baffle 6". Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage.' Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal, ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: concrete El ❑ metal El fiberglass El polyethylene El other(explain): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No i t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „M 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number. 1-1000gal ❑ 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 in good condition and holding 16"of water. Stain line at 36" below inlet invert. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of inspection I D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids le.yer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 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.): t5insp official document•03108 TNe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LB&ck, 34' - �� AT-11:4` i t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 80 Brigatine Ave Property Address Ben Rader Owner Owner's Name information is required for Osterville MA 02655 7-8-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS maps show groundwater at 20'. t5insp official document-03/D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 16 TOWN OF B^ARNST_ABLE 40CATION � � A.p-�_ SEWAGE# VILLAGE (`� � n !��\1 ASSESSOR`'`S MAP&PARCEI-011 X INSTALLER'S NAME&PHONE NO. SC 6 R �,r c,,-\L szu X �7a u �U 61 SEPTIC.TANK CAPACITY ��C(��.,4 r n 0 'Z 0 Q4 N ...LEACHING FACILITY:(type) '�6 Qc (, (size) /� �( 'C NO.-OF BEDROOMS S � OWNER PERMIT DATE: 1 q \�o COMPLIANCE DATE. N. Separation Distance Between the: r 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) 4 r ,,,- .. �. Feet s FURNISHED BY /A3 7. 7 � 8o f �1 TOWN OF BARNSTABLE LOCA-_TjoN Oy [8r;,a�, e Aue SEWAGE # ------- VILLAGIE � L,A-411 ASSESSOR'S MAP& LOT_ INSTAL.EWS NAME&PHONE NO. 5EP11C TANK CAPACITY /D o 0 9�--_ XACHJVG FACILITY: (type)Pi f- (size) _/— /yoo 9 l 40,OF BEDROOMS -2 BUILDER OR OWNER, ?ERMIT®ATE:. COMTLIANCE DATE:.,.. separation Distance Between the; qaximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching f,:aciiity (If any wells exist on site or within 2W feet of leaching facility) Edge of Wedand and leaching Facility(if any wetlands exist within 300 f e of leaching fa,c�il/acy} ^ec ?unVshed by �n 114—` Z1,0 a �� -6cG _. -Q-c- qq A-D-341 it No. �' V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliLatlon for Bisposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(v�Upgrade( ) Abandon( ) ❑Complete System VIndividual Components Location Address or Lot No. � \ � wner's Name,Address,and Tel.No. Assessor's Map/Parcel 09 M�,rs�0 6�V k- � � w Installer's Name,Address,and Tel.No Designersame,Address,�' N Add Tel..No. •t7 (36x I.6 c�'tA►�•�n'�t 3 rJ4or'1 - fit*-•r�S 6 a rM Type of Building: ��; �4 ell( 3 Dwelling No.of Bedrooms 9-S 7 Lo iz� .,C�, y O t) sq.ft. Garbage Grinder Y' Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 320 gpd Design flow provided gpd Plan Date t� i t (D Number of sheets Revision Date Title Size of Septic Tank C'Xk vj� IQ-) Type of S.A.S. Lp,(-. t✓ l /S Description of Soil C4 p j C,6 Cr S-e_ `T14, tie CSC Nature of Repairs or Alterations(Answer when applicable) we- l) &,L 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 Health. Si pp Date l Application Approved by A;: k Date � Application Disapproved by Date for the following reasons Permit No. 2.0 Date Issued oo ,. No. Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 9pplicatlon for -Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(%,� Upgrade( ) Abandon( ) ❑Complete System W Individual Components Location Address or Lot No. �� 1Jr\G)Geri_V C wner's Name,Address,and Tel.No. n C 6cr� rndc,tl Assessor's Map/Parcel C9 Mrrs�o n Kc1�) Installer's Name,Address,and Tel.No. K � Designer's Name,Address, d Tel.No. v�� Xc•��o�` p•U 06x1.6So`+� �11� o Uc��ic�c •�S 3 a I� Type of Building: Dwelling No.of Bedrooms - $ LotAize o[Q 0 0sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) } Other Fixtures y; Design Flow(min.required`) 3 y gpd Design flow provided - y f gpd II` Plan Date ,� (5 1 (p Number of sheets Revision Date Title Size of Septic Tank eS t t]0 Q Type of S.A.S. 3 G.` LAK, Description of Soil C v S �,� y� ° P M o y G.1 �t ��-+�u Nature of Repairs or Alterations(Answer when applicable) z) c,Qjx u 6 cL U3 M�S—i c3-CZ- ^e 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 Health. Si • Date 6I b Application Approved b PP PP y Date .) h�/14 Application Disapproved by Date for the following reasons ~ Permit No. 2.U (L - G 5 Date Issued ' - ��-& - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by S(o M 7CL^\4. k at �a �v�i C4 CAJ A A\Q--�_ MU S�Ue-\ Nk Mas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Noc 2 4/ 0 3t dated �.- /�/ -l 6 Installer 5 co7 \ cr\ ���� Designer y�� `\Gl G\� #bedrooms Approved deIrgn flow �L/� gpd i The issuance oft is pe it shall not be construed as a guarantee that the system wi f ii ctioh�gas designed. Date I ( Inspector ----------------/----------------------------------------------------------------------------------------------------------------------- No. G 16 ' () Ci Fee 0 THE COMMONWEALTH OF MASSACHUSETTS T PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon'( ) System located at— and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. d Provided:Cons ction /ust be completed within three years of the date of this permit. Date j / Approved by Town of Barnstable Regulatory Services t Richard V.Scali,Interim Director 'ARNSTANIA M Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: alavl 16 Sewage Permit# 0messor s Map\Parcel_a2.L( Designer: S'CEl� i� X. k A A.-s,'pC Installer: 5dC7M 1 A. ��=-P►tJ6�-' Address: ` '' �• tDk �� Address: It's oW �AP..1-�or3i�-1 Rb O UP&O On C SC°�T- ►4- F-a-AO K was issued a permit to install a date) (installer) septic system at nQ ��t J based on a design drawn by )(address)' `&Th:P R-6,3 k P-AjA'&J dated �O (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. ` I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils Ia were found satisfactory. I certify that the system referenced above was constructed ' laance with the terms of the INA approval letters (if applicable) �f a x (Installer's Signature) (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc A:� a' Town of Barnstable P# Department of Regulatory Services 1 a Public Health Division Date*qh 42 MAIM 200 Main Street,Hyannis MA 02601 • rfo►,tX�" �-+ Date Scheduled �° Time i '^ Fee Pd.— acv Soil Suitability Assessment for Sew e Disposal w Performed By: � ?��r • i"" �� . � Witnessed By: vi �M LOCATION&.GENERAL INFORMATION Location Address n Owner's Nam. ` 2* 'r vrt`T ✓k Address ''0 Assessor's Map/Parcel: ` ' 1 Engineer's Name � tx-� / NEW CONSTRUCTION REPAIR Y Telephone# Land Use Slopes(96) Surface Stones / C� Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Draihage Way i ft Property Une �� "f ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands in proximity to holes) 1 V" ,�v Parent material(geologic) GSz'�" �' Depth to Bedrock Zc Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater JA DETE�NATION FOR SEASONAL�HIGH WATER TABLE Method Used: /U/ 4- Depth Observed standing in obs.hole: ___- In, Depth to Boll mottles: In. Depth to weeping from side of obs.hole: ____ In, Groundwater Adjustment ft. Index Well-0 Rending Date: Index Well Icvol � Ad),-fhetor, ,_.' Adj.(lruutrdwaterlxval , PERCOLATION TEST Date 16/Tbna L/°'� Observation Hole# Time at 9" Depth of Pere Time at 6" �•'' Start Pre-soak Time® Time(911•61, ) End Pre-soak . Rate Min./Inch �'^Z <1�•%jc> ��:�/ O�Siu.v� �c,c. 7�,sr- �v�3G`8 f � . Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original-. Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Shcl Color Soil• Other Surface(in.) (USDA) (Munsell Mottling (Stnucture,Stones;Boulders. asistency.96 Unveil ''7/3 DEEP OBSERVATION HOLE LOG Hole# z. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, o �• L U 3 z ✓" 1-5 U : Y/.� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole#. Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. 1 Flood Insurance Rate Man: Above 500 year flood boundary No— Yes Within 500 year boundary No�` Yes Within 100 year flood boundary No. Yes ..,._ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? .._-. Certification `/ I certify that on It !V f (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trainin rP rtise and experience described in 10 CMR 15.017. Signature Date Q:\SBP11C\PRRCPORM.DOC No.21_ 25 .... ....... ~THE COMMONW�EALTH OF MASSACHUSETTS r BOARD OF HEALTH .......... d u.N............OF........I�IY19 s.Wf 4 L........------------------------------- Appliratinn for Uiipniittl Workii Tnnitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -- Location-Address or �n s f}�2 Q, MO Ow er Address Installer Address U Type of Building Size Lot...A8 f._D:®.52.._Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p., Other—Type of Building ...YK.).4�........ No. of persons............6........... Showers ( ) — Cafeteria ( ) Q, Other fixtures -------------------------------- - W Design Flow..........5S.$. .......................gallons per person per day. Total daily pow............... 13.n..............gallons. a' Septic Tank—Liquid'capacityJ4W gallons Lengthl_LQ.-_-l®-... Width.......3....... Diameter________________ Depth................ W Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by...l_UQ�'?t7 ....���d-��!¢�.._._.... Date....l. ....... Test Pit No. 1. .........minutes per inch Depth of Test Pit-__--�. ____. Depth to ground water---AIA G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-___--_-:-_.--_____- R+ -------------- -----------------•-•---------------•-----------...........-----•----•-------•------•... --••--------..................-•----•-----......---- O Description of Soil-------- r......S`U-/3-50/ -- ---�°� .'J........ .tt11 x = - -----------------------------------------------------------------------------------------------------------------------------------------------------------------•--•-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•--------------------------•-..._....---------------------•------------------------....----.....------------------------------------------------...----------------....-------------------•------.•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance,with the provisions of iITI I-E 5 of the State Sanitary Code—The u dersigned further agrees not to place t e syste in operation until a Certificate of Compliance has b issued by and healt Si.ned. ............. i ._..... Da Application Approved By----------- ......... ............................... f. .............. Date Application Disapproved for the following reasons--------------------------------------------------------------------------------------------- ----------•-•-•---. ....-•-------------------------------•--............---------------------------------------•-----•----------------------------------------•------------------------------------------------------------- Date PermitNo--------------------------------------------------------- Issued_....................................................... Date No.. �:.5_� •.. ,� Fx$:�.. ......._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........7'�a40ti.............OF...-....& er ;'W 6 L Appliraation for Dispoii al Works Tonstrnrtion 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....•�D T .....:......:Q!%? .....L: �E . tion ...........................••-•-•---•--•---•-••-••......----••••-------• '.. .� 'A.D, S >1i9"e oll Owner Address W �/oE/�0 % -/E O,��f•..�/JI.i Installer Address UType of Building Size Lot.... �/.-a .a_.-Sq. feet Dwelling—No. of Bedrooms....... _________ ............Expansion Axtic ( ) Garbage Grinder ( ) Other—Type of Building __ ................... No. of persons..........._______............ Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow........... _______________________gallons per person per day. Total dail flow___.__.__.__.__3__...__O___............gallons. W Septic Tank—Liquid capacity/M gallons Length/0_ l4____ Width.... Diameter________________ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area. ................... ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by... `�4 '�I !v._.%? 'II I I� to �� O .......................... Date ---•.............. --•--. Test Pit No. 1_ :-..........minutes per inch Depth of Test Pit____e z,-___.. Depth to round water...�O v�.__. (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... W Description of Soil....... S`U 6S0/ G uN9 S? U •---•-----------------------•------._.._.....-----.....--..---------...---------••--------..._----•----•----•-••------•- ANS W x -•-------------------------------------•----------••----------------•----------••---------••---•--.._..----••----------------------------•-----•-----•--------------••---•--•-------••----•____....._._. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --•----•-•--------•--------•----------•............................•-•----------------------------------------•-•-------•--••----------•-•-----•---•--•-------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITT,E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed............. ---••-----•••--•------•---.....---•...----•..._.....---••-•-----_..... .......................... D e Application Approved By...........- ! y � + ' ------------------••••-••-----• .---------_.. Date Application Disapproved for the following reasons---------------------•---------------•------------------•------------------•------------.._.._..---•---...--•-•- ------------------------------------------------------------•------------•--•---------••----•------•---•---------•-•---•------------------............................................................ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................w.....................OF.....-.�................................................... (9rrtifiratr of ftont:rliztnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by... 5%`7 -_---•-•----------------------•----------------------•----•-----•---------••-•-------___-____-_______-___---_-_-________-___-•-------_________-•---•---••-•-•--••-•••----•-•- Installer _____----•--•------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-----g�'_._'_.M�. r ......... dated_._.-_____.-._________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS GUARANTEE THAT THE 1N�SYSTEM FUNCTION SATISFACTORY. DATE.....2 . Z f•%3• Inspector........ �- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i� 5�5 ............... _..----..... No.......:................. FEE--- .................... Disposal Works Tonstrnrtion ramit Permission is hereby granted__.__ � E�U rx/e")//X A9/ -b /S to Construct or Repai ( ) an Individual Sewag Disposal System at No.... T __....._ �9.t/ -7 ,VF "dam , 7nV I'-�ToN.S !TjIZIS /� 4SS, ...._.------ --------------------•---------•----------.-----..--------•----------.,................. Street as shown on the application for Disposal Works Construction Permit No____________________ Dated.......................................... fi r' ... DATE. L`` oard of Healtli 7 - ---- -------------•--- ............ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS t N ,ION 9 SEW A G E PERMIT NO. ILLAGE INSTALL R'S NAME i AD PRESS f7 en 2. e U I L D E R OR OWNER DATE PERMIT ISSUED ` IkDATE COMPLIANCE ISSUED 2— O I nu -S DRFV why g z Al 0CAT10N_ V _ 110. DATE = / I LLAG E ,--e- PLI 77�f_& ��/� � i FEEA-Ko ,r1 HONE NO. n-refundablt .DDRESS `� �r2 411 PD� IJ �� Y ,fr; -Y NGINEER T:;EFAp NO. - ATE SCHEDULED 2 _ � P�nt• s signature) . . . . . . . . . . . . . . . . . . . . . . . . . . . SOIL LOG UB-DIVISION NAME DATE ;XPANSION AREA: YES. NO _ /t/� LIdLOS !'J'IS ,?��/ ENGINEER . COWN WATER KPRIVATE WELL �pti/ BOARD OF HEAL' EXCAVATOR KETCH: (Street name, etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: �e7 -7 0 0 v PERCOLATION RATE TEST HOLE NO: ELEVATION: TEST HOLE NO: ELEVATION: 2• .SC/,B.SolL 2 3 36 Or3 4 5 5 3y " 6 -6 7 7 `1'd�1}/�/�y► 8 8 9 9 10 10 11 11 - - 12 13 12 13 14 - 14 1 - 15 5 16 16 SUITABLE FOR .SUB-SURFACE SEWAGE": LEACHING .LEACHING FIEND- L,EACHIN :PITS UNSUITABLE FOR SUB-SURFACE SEWAGE . REASONS: ;TOTE : ENGINEERING PLANS 1`IUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: CO:IPLETED TN MITTRETY By P A`10 RETURNED TO BOARD OF IiFALTH 71 v r ... ow w �TF t rw\/GL- �' � ---- - - ---- t3a�E'� c>..i U. S.C � G .5 [�t+cs'v►� 'C�J.�.1 tE ^ -�• -�-� Z — Pt Tc r 1 ,4 t t t..t►J E5 A 1� +J t M v of _ ` J~� ! ' V' A�. P t�s o ►. 744Z`5 STEM S N A,- �,; QI ( 1 r< 1 _ -" ne CACST tiLollj c SC�i vv�.E AO PAJ•C . ALL - EPTtC TAti1V-S C�tSTc2�8UTto►J E,ox Ar.�o 2,0 t _ —— _ _ _-- _- �--- t2.E MC>✓� A t,.a... Ur.15U t TA c��-•E MATE r2 t A t...� ��►J E�.Tt-t • a 0 �_ � OF fit? A 3c) 5 .1C-Pk t_L_ W,lTN c A.`J F72G oo • i _ _ ---7- I (�� 8c�,ar2C) ot~ �_ L-T-A "UST `�' `'' C w 1C` t-4� (f-tEI� Wt�E:►.� TEFE �ySTE►.j �S NEAP - iv �'} COt..{PLETtbrJ Aw1tJ Q t�_taTE'U, ALL N� Z to• Q �. G = SAO-1I-rAL'� "" c��Pca�ltGc.i �Ha►c _� , tasra.��.�v �t.1 T-Ec Z 1'1 y a a o c Taff C�i2��.+ iC� ur'iTN TY F C A L D ST�1 byT-i t� co o x_ — G A T iJOR"E �t�TiZ+ac.'f+cZ� ! 8aK Pk..iP ipoo t��►...Fo+�L.Pv 5£'.PT"',G T�k- Eby 1�tE2ic�.,s F�Ec..�ST h1C�T_ "T"O ��.�.� ��l�T T'o �C,A-�.-E C32 EG,c_�p.t.. . �r� : Taw.iKS ctE� ..t�ocGEv TN-2C�caGr-�0.� WCT'N E�.€�Tzkc wELO�ZD �t�(Z� u i� 1 ,�� OTE_ ACES{� M�+,►al-��t ES Tc� ,s �o�� p� �-r 5e�-(c -r�s� o.��� Lca�..µ�►.�c„ Pt� _�.� BE "T t�i 'P -T i2 tti�CH t?S 8fcti>�� � t `�t-1 CcP_AC�F ,yctii'33'd�x. } P�.STd;�� w f , r i, • ;G�t�C',� � ' �'ttEZ�run � �:. _ -.y _ __ ' � ° 1 n:�'r d ° ► 3 z'1'.�'' ,Jy' _ � � � � t'J � ;�1 '�yy% �': _ �y' �•o ' { � �J ® �, ND ,' rJ C_ �iGAL SEA•' L,� tit~ F EV-CC�A � x t � �t � � Dp.�SE�UATt©►..J S `v`� � -a NAB�---��F-Q�� Q iL:)A TIE `�' _c.. ... .... t __ -- -_ �k, r- «►� e PROP05ED 5eiA*,E fl S,POS A►t�. SYS'T'E?"'� � :�xH.. __._..' �-A i✓t..,��,..1 S P�t2 ��E�c'.,So►J Pam- D�4�;' �. ` � PEQ.cc>L.A T tt��_1 a ,GT ASS► P� H i tJ Fa P ' 1�tJ� p �\ � Z.aP -5 E�7 t EAG t �lC-T P 5 C S 4 _ - _/ -- ^`` - ,/vo ~� _. .. _ ._: NOPMAN �3 U TT4/`f j o G ?27 ' �aoz; ..^ �r Q/ �rc�a� - i +EtJC�c r.�E.F 80` ' NoW. Le?J5 �l 11 42-7 G 7' �� i ACCESS COVERS MUST BE WITHIN 9" MINIMUM. INVERT ELEVATIONS : DES,I GN CR I TER I A : GENERAL NO TES : 6" OF FINISH GRADE 3' MAXIMUM COVER 101.2 FIRST 2' TO INVERT OUT SEPTIC TANK: DESIGN FLOW: 2 BEDROOMS. DESIGN FOR MIN 2" OF PEASTONE INVERT IN DIST. BOX: 100.97 3 BEDROOMS MINIMUM AT 1/0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION BE LEVEL OR F!L TER FABR!C /00.8 BEDROOM EQUALS 330 G.P.D. US A OF THE SEWAGE D l SPOSAL SYSTEM ONLY. INVERT OUT D 1ST. BOX: �p 4' DIAM PIPE 3/4- - 1 1/2- DIA INVERT IN LEACH CHAMBER: !00.3 �" o�r DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER: 96.3 NO GARBAGE GRINDER u ���� 2. VERTICAL DATUM l S ASSUMED. FOR BENCH MARKS 100.8 r� ���^` SET. SEE SITE PLAN. j 101.2 2' �o GAS o o .� 98.3 ADJUSTED GROUND WA TER: N/A BAFFLE 100.9 .p iD 100.3 SEPTIC TANK REQUIRED: U OBSERVED GROUND WATER: N/A 3 OUTLET 2-500 GAL LEACHING GHAMBERS 330 G.P.D. X 20OX - 660 GAL. j��(3• ALL CONSTRUCTION METHODS AND MATERIALS AND EXISTING D-BOX W/4' STONE AROUND. 12.8's x 25'1 x 2'd BOTTOM OF TEST HOLE #!: 92 3 SEPTIC TANK PROVIDED: 1000 GAL. EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1000 GAL H-20 CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6" CRUSHED STONE OR H SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DESIGN .PERC RATE C 5 MIN/INCH SOIL TEXTURAL CLASS - ! 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER PROFILE : NOT TO SCALE EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: 2-500 GAL LEACHING CHAMBERS W/4' STONE AROUND. A-471 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 471 S.F. x 0.74 - 346 G.P.D. APPROVED EQUAL. N 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED -6- SOIL TEST PIT T DA TA & PRECAST CONCRETE OR APPROVED POLYETHYLENE. • i� BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER �J INDICATES INDICATES PERCOLATION = OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE I TEST = GROUNDWATER OUTLET. Par/ TP #l 4940 TP #2 7. BEFORE CONSTRUCTION CALL "D 1 G-SAFE'. r' O" HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. 102'.3 0' 102.3 FOR LOCATION OF UNDERGROUND UTIL I TIES. A LOAMY IOYR A LOAMY IOYR SAND 3/3 SAND 3/3 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE 8 - - - - - - - - - - - - - - - - - - - 101 .6 /0" - - - - - - - - - - - - - - - - - - - - 101.5 DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION LOAMY IOYR LOAMY IOYR B OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE SAND 4/6 SAND 4/6 24" - - - - - - - - - - - - - - - - 10013 24" - - - - - - - - - - - - - - - - - - - - 100.3 CONSTRUCTION INSPECTIONS. 0� o / POCKETS OF IOYR POCKETS OF IOYR 'per l `r C� C� 9. EXISTING LEACH PIT TO BE PUMPED DRY AND hp 6p h. So" SILT LOAM 7/3 - - - -SILT-LOAM- 7/3 09' 48" - - - - - - - - - - - - - - - - - - - - 98. 3 60" - - - - - - - - 97.3 BACKFILLED. C2 MED-COURSE IOYR C2 MED-COURSE IOYR SANG AND 6/8 SANG AND 6/8 /0. ALL UNSU I TABLE MA TER/AL (A. B A C I) 104--- f ��� GRA VEL GRA VEL ENCOUNTERED BELOW THE INVERT OF THE L EACH 1 NG FACILITY TO*BE REMOVED FOR A DISTANCE OF 5* Y 6 F AROUND AND`REPLACED WITH SAND IN ACCORDANCE - --WITH TITLE-5. TP•2 NO WATER NO WATER l 1. EXISTING SEPTIC TANK TO BE PUMPED AND CLEANED. 1 l20" 92. 3 120" 92.3 INSPECT AND REPLACE INLET TEE IF REQUIRED. DATE: JANUARY 19. 2016 l j `�� if / TEST BY: STEPHEN HAAS +\c3l T �� TP.I WITNESSED BY: DAVID STANTON 99 103.6 • PERC RATE: 6 2 MIN/INCH EXISTING I 102.3 SEPTIC TANK I ti� 102.4 sU, p« w Mr \ ` D-BOX// G is\ SOIL REMOVAL ti X Q '$ v SEE NOTE 10. VZ ' 12'PINE SM. CORNER BH ds, �/ :.._ ,. s w," > , r \,,EL-104.52 02:9 \ 2-500 GALLON " LEACHING CHAMBERS W/4 STONE AROUND IO2.5 +103.2 l S E P T I C S Y S T E M DE S / G N tihhp 80 BR I CANT 1 NE A VENUE . MAP 98 , PARCEL 28 102.9 + LOT 7 B' ARNS TABL E . ( MARSTONS MI LLS ) MA 20. 000+ S.F. o PREPARED FOR : LEGEND ROUTE 28 R O B E R T L Y N N T Y N D A L L soar ■ CB CONCRETE BOUND ti�bLtir -W WATER L I NE SCALE : l 20 F"EBRUARY l .S 2016 y RO L OC S V HYDRANT / -G GAS LINE STEPHEN A . HAAS / OHW-- OVER HEAD WIRES LIGHT POST _ ENGINEERING , INC --£- UNDERGROUND ELECTRIC LINE .� �+ y P . (D . Box 1 6 /, � �T� � �� o u t h D i ann s , MA 02660 -T- UNDERGROUND TELEPHONE LINE � ''-� S /�1 i -CTV- UNDERGROUND CABLEVISION LINE �� � ( SO8 ) 362-8 1 32 +40.4 SPOT ELEVATION .--•-40....... EXISTING CONTOUR LOCUS MAP 0 /0 20 40 40 - PROPOSED CONTOUR JOB NO: 16-007 p,