HomeMy WebLinkAbout0022 CAMERON LANE - Health 22 Cameron Lane
Marstons Mills
064006
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is Marstons MillsMA 02648 April 2007
required for h ,
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your David D. Coughanowr
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name
raE 43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 Pending
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: =rt
® Passes ❑ Conditionally Passes ❑ Fails
-7
El Needs Further Evaluation by the Local Approving Authority ) =-
#Aa �J w April9, 2007
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 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.
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is
required for Marstons Mills MA 02648 April 9, 2007
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:
® 1 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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5-2596.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is Marstons Mills MA 02648 April 2007
required for P ,
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.
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
l
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is required for Marstons Mills MA 02648 April 9, 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
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 '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the 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.
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is required for P Marstons Mills MA 02648 April 9, 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (corl
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
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.
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
I
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is Marstons Mills MA 02648 April 9 2007
required for P ,
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 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?
D-box—no
SAS—yes ❑ ® Were all system components, excluding the SAS, located on site?
Inlet only ® ❑ 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)]
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is Marstons MillsMA 02648 April 9 2007
required for P ,
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310.CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
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 ears usage-(gpd)): 460 gpd
9 ( Y
Sump pump? ❑ Yes ® No
Last date of occupancy: neverDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is Marstons Mills MA 02648 April 9 2007
required for P ,
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Owner's agent
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Age: 2+years. Certificate of Compliance issued 9124104 (Board of Health permit#2004-103)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-2596-doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is required for Marstons Mills MA 02648 April 9 2007
every page. CityiTown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2feet
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.):
Sewer appears structurally sound with no evidence of backup or leakage into dwelling
Septic Tank (locate on site plan):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10.5 ft x 5 ft x 5 ft(1500 gallon)
Sludge depth:
none
Distance from top of sludge to bottom of outlet tee or baffle 34 in
Scum thickness 0 in
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined?
As built card.
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is Marstons Mills MA 02648 April 9
required for p , 2007
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.):
Pumping not required at this time, but maintenance pumping is recommended every two years.
Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or
out was observed. Outlet end of tank was under paved driveway and inaccessible. Design plan calls
for H-20 unit.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
required on is Marstons Mills MA 02646 April 9 2007
required for p ,
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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was under a paved driveway and not accessible for inspection. System was instead evaluated
on condition of leaching gallery(see page 12). Design plan calls for H-20 components.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is Marstons Mills MA 02648 April 2007
required for p ,
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:
❑ leaching chambers number:
® leaching galleries number:
1
❑ 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.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Leaching gallery was opened and
found to be dry.
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is required for Marstons Mills MA 02648 April 9 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is required for Marstons Mills MA 02648 April 9, 2007
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.
LOCATIONS
A B
1 33 FL 14 FE
2 33 Ft 42 f t
EXISTING
DWELLING
n
# 22
SEPTIC 6
TANK
w
z
J
2 ❑ D-BDX
w
r
3
LEACHING
GALLERY
CAMERON LANE NOT TO SCALE
t5-2596.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 22 Cameron Lane
Property Address
Harvey Solomon
Owner Owner's Name
information is required for Marstons Mills MA 02648 April 9, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water: 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:
Approved design plan on file with the Board of Health shows bottom of system to be over 20 feet
above adjacent lake.
t5-2596.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
TOWN OF BARNSTABLE
. ._ 1
LOCATION �iZ ���" [ C SEWAGE #
VILLAGE�Af`/'��7U/� S ASSESSOR'S MAP& LOT0o�I
INSTALLER'S NAME&PHONE NO. > s �
SEPTIC TANK CAPACITY ,, !! ��AA .
LEACHING FACILITY: (type�3 C/' (ggQA, (size)
NO.OF BEDROOMS
OWNER M40486itf.7
....•ERMITDATE: G" COMPLIANCE DATE: ���y
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
oce 541w
�3 del . 5
TOWN OF BARNSTABLE,
.
LOCAnOtN 7i2 �✓1Qdv C-G /C Y SEWAGE # 9 l3C rC
VILLAGE /v*`IlS ASSESSOR'S MAP & LOT
Jii�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK°CAPACITY
LEACHING FACII,TTY: (type 1'ZO Ay4qk4size)
NO.4OF BEDROOMS
OWNER ..
_,F7—.RMTTDATE: COMPLIANCE DATE: . Z y(o _
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility - Feet it
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) t
Feet
Edge of Wetland and Leaching Facility(If any wetlands exist •'
within 300 feet of leaching facility)
Furnished by Feet
�4?
1
ki -- _�_.
.. __.____... _.
r
A
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No. < C00 03 THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components
Location Owner's
Owner's Name
1 &74/
Map arcel# Address
7
L t# �. Telephone#
v �� A�'6!� v /�✓�
� taller's Name esigner'sfl
Iyame
✓�_1� ''3eJ� � / �d�s �� �� �S�� Ad e
Telephone# Telephone#
Type of Building: ,��5����� Lot Size '��(`/ Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(mi req fired) gPd Calculated design flow gPd Design flow provided 3 gpd
Plan: Date 3 Number of sheets Revision Date
Title 'Jia
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator O.� Date of Evaluation o 3o r1
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLES and further agrees-not to place the sys m in operation until a Certificate of Compliance has been issued by the Board of Health.
5.4_ gig I
� RRne• `� Date
1Ffisp�ti
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
j�. .. .. ..se,.T. ..�,.�!.-� -.:,.a :-t.l� '*,.;^'F-,-- .y.+•..;y'ti'-d'+ -h'` .. .', .{f,�,.,'.�' i"'ii+id++r1"' ..�....i'a.^Y -az}.f*:"
i No. �L — '/0 3 TT ` E COMMONWEATH OF MASSACHUETTS-wF E � t
x ! O ad, HEALTH �
of :l T 11-4 .
t
APP iIOAXION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Perm�toConstruct Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components
Z2 C-A�t�`YLe.�I Z_A/ /Yl..
Location Owner's Name
Map arcel Address,
i \ '7
Lot If Telephone#
F
Installer's Name I Designer's me
T o cN 4S1 3 `tt dY-
4
dress
Ad e
Telephone# v,y Telephone#
'h Type of Building: ��s���( ,, Lot Size Y�(9'66 Sq.feet
Dwelling jNo.of Bedrooms �. Garbage Grinder
Other=Type of Building No.of persons Showers ( '), Cafeteria ( ) ,-e
t
Other fixtures t.•
z Design Flow(mi required) gpd Calculated design flow 3 So gpd Design flow provided � pd
Plan: Date 3 ! �'f Number of sheets Revision Date /t
Title
Description of Soils) .
~`"*Soil Evaluator Form No. Name of Soil Evaluator 4W Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
� s 1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
!TITLE 5 and further agrees not to place the sys m in operation until a Certificate of Compliance has been issued by the Board of Health.
1
t � ----- 2
s '
Stgned 1 Date . �
Auction
f FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
—No. �CUL - THE COMMONWEALTH OFMASSACHUSETTS FEE ) J�-
f ,�; F � BOARD OF HEALTH -
F CERTIFICATE. OF COMPLIANCE
Description of Work: ❑ Individual Componetit(s) Complete System
- The undersigned hereby certify that the Sewage Disposal System;Constructed NX Repaired( ),Upgraded( ),Abandoned( )
by: n/� /
at c�� (6"Mrro"' Lfndl9 imt^Irt JJ I)^r
has been installed in accordance with,the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. Z)'J0 -/'Uj dated Z q Approved Design Flow (gpd)
Installer 2 1 1
Designer: InspectorPrantZ
- k i. je�PeSDate L /
r
The issuance of this certificate shall not be construed as a g that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. uU .-l'o THECOMMONWEALTH OF MASSACHUSETTS FEE ( U
&f �,. p ' BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
t
Permission is hereby granted to Construct ( ) Repair.( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at r nn al n n r ,: - /vt, lr♦f as described
_ ,
in the application for Disposal System Construction Permit No. a0t)L/' /03 dated
Provided: T struction shall be completed within three years of the date of this rmi .Aw 1 1 cal coedit ons must be met.
Date 6) Board of Health
t
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WARREN rM PUBLISHERS- BOSTON
I
TOW�Ni,OF BARNSTABLE.
LOCATION �Z Q/IQ6R./ "" SEWAGE# 9 00 LL
VILLAGE / �/� ��5 ASSESSOR'S MAP&LOTAQV
/
INSTALLER'S NAME&PHONE NO.D%l �_��� lt
SEPTIC TANWCAPACITY
LEACHING FACILITY: (type a—zo size)
NO.OF BEDROOMS
OWNER
'�.MTTDATE: COMPLIANCE DATE: I/Z YII(p
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of teaching facility)
Edge of Wetland and Leaching Facility(If any wetlands.exist Feet
within 300 feet of leaching facility)
Furnished by
f N r
y e
SEP-29-2004 07 :03 AM DOWN CAPE ENGINEERING 508 362 9880 P. 01 .
C��SJ)GZ-- PAD
Tow
n of Barnstable
Py�p TH[
H
$ Regulatory Services4 W a sce
V:RNffA Thomas F. Geiler,Director
y MAC
Public Health Division
rFc M Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
---' ---..
%8-862-4644 ,
ter,_
Fax: 508-790.6304
Installer& Designer Certification Form -- _
/ Installer: Pf40v 0e,
Address:
--zy - � was issued a permit to install a
(date (installleer)
Ystem at s�.riC� i�.4
based on a design drawn by
(address)
.
dated
.... (d ise gner)
d, I le
certify that the septic system referenced above was installed substantially according to
i•lie design, which may include minor approved changes such as lateral relocation of the
11stribution box and/or septic tank.
certify that the septic system referenced above was installed with major changes (i.e.
:treater than 10' lateral relocation of the SAS or any vertical relocation of any component
o 1:-the septic system) but in accordance with State & Local Regulations. Plan revision or
CeIrtified as-built by designer to follow.
017st er's ig a e
ARNE M
OJALA
CIVIL
I.),-,igner's Sign e) Af x
( a Here
1'I= -k 1 __ TO I&ARNRTAB E PUBI. C HE TH D sI CER
T BE I SUED UNTIL HOit Cim M.
T THIS AND A
BY THE RNSIABL rULIC HEALTH DIVISION.
YQVL
..'i>tic/Designer Certification Fotm
7To
Town of Barnstable `��?
P�owt"E' Regulatory Services (Wee Sc e
Thomas F. Geiler,Director
* BKRNSFA WY. •
9 MASS. Public Health Division
s6.. .
39
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 =508-790-6304
Installer & Designer Certification Form
Date: 7 of
c
Designer: 47W /1)00W-� Installer:
Address: / - aC� ' U y Address:
On �y o f����� was issued a permit to install a
(date) (installer)
septic system at �� based on a design drawn by
(address)
dated y
(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.
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.
HOFAfgss
( st ler's Signa re �o�� ARNE H �ctic
o OJALA `
CIVIL v
No. 30792
(Designer's Signa e) (Affix Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
'OF COMPLIANCE WILL NOT BE _ISSUED UNTIL BOTIR THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
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FOUNDATION
ro'3arMrues 4'+rr i
x 2'x O"orwyS fn- o
'CD`n-p`N1O
TOP FNDN AT EL. 77.0' SYSTEM PROFILE TEST HOLE LOGS
PROVIDE INSPECTION PORT
: ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) TO FINISH GRADE
Accfss COVER (WATERTIGHT) To ENGINEER: AH OJALA, PE 2
76.0' MINIMUM .75' OF COVER OVER PRECAST FIN. GRADE I H
2% SLOPE REQUIRED OVER SYSTEM 76.0' WITNESS: SAM WHITE, IRS
74.0' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE DATE: 10/30/03 Vi �
1500 FOR FIRST 2' l' < 2 MIN/INCHPROPOSED H-203' MAX. PERC. RATE =GALLON SEPTiC 73.50 H-2 CHAMBERS 73.83'73.75' TANK (H- 20 ) GAg CLASS ISOILS p# 10611BAFFLE 73.27' : 73.10'MIN cg � mmm 0 OOmm73.0' Doom m Do2 % SLOPE) �6" CRUSHED STONE OR MECHANICAL m a m m m m m m OCOMPACTION. (15.221 [2]) 5� 2' ED O m O m m ED m a 71.0' ELEV. ELEV.
DEPTH OF FLOW = 4 MIN MIN o0?5$% SLOPE) ( 1 % SLOPE) ocO" 76.0' O" 78.4'
TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE A I
INLET DEPTH = 10" A
OUTLET DEPTH = 14'> - LS LS LOCATION MAP NOT TO SCALE
6" 10YR 3/2 6" 10YR 3/2
LEACHING S' 2s't BW BW ASSESSORS MAP 64 PARCEL 6
1
FOUNDATION- 12' SEPTIC TANK 19' D' BOX 12'
FACILITY
MCLS MCLS
YARD SETBACKS:
BOTTOM TH 1 EL. 66.0' 24" 10YR 5/6 74 0' 24" 1 OYR 5/6 76.4' FRONT = 30'
GROUNDWATER EST. AT EL. 43.0' - 44.0'
SIDE = 15'
- REAR = 15'
SEPTIC DESIGN: (GARBAGE DISPOSER is NOT ALLOWED )
PERC COS PERC COS FLOOD ZONE: C
DESIGN FLOW: _3_ BEDROOMS ( 1 10 GPD) = 330 GPD
USE A 330 GPD DESIGN FLOW
SEPTIC TANK: 330 GPD ( 2 ) = 660
2.5Y 6/4 2.5Y 6/4
USE A 1500 GALLON SEPTIC TANK
LEACHING:
SIDES: 2(30 + 9.83) 2 (.74) = 117
,I
BOTTOM: 30 x 9.83 (.74) = 218 120" 66.0' 120" 68.4'
TOTAL: 452 S.F. 335 GPD
NO WATER ENCOUNTERED
USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR
E:OUAL) WITH 2.5' STONE AT SIDES AND 2.25' AT i
ENDS }
I � .
_1
BOARD OF HEALTH
MA
APPROVED BATE
R NOTES:
qC�
1 . DATUM IS APPROX. NGVD
/ 2. MUNICIPAL WATER IS AVAILABLE
3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 20
5. PIPE JOINTS TO BE MADE WATERTIGHT.
6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
/ ENVIRONMENTAL CODE TITLE V.
�ti.. 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
ON USED FOR LOT LINE STAKING.
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
/ Q 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
�' I INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
� �w FROM BOARD OF HEALTH.
i
/ 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE
6 LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR
TO COMMENCEMENT OF WORK.
11. WETLAND FLAGGED BY AM WILSON ASSOCIATES 2003
12. NO KNOWN POTABLE WELLS WITHIN 150' OF PROP. SAS
PROP. VENT WITH CHARCOAL FILTER /
AND BUGSCREEN (FINAL PLACEMENT BY /
CONTRACTOR WITH HOMEOWNER
CONSULTATION) / 61
62 �,
64
TOWN WATER
----66 +
6 g
68 S E2
6
�-70 7 LEGEND
8 100.0 PROPOSED SPOT ELEVATION
ti 9 BENCH MARK - TOP OF CONC.
0.4 BOUND ELEVATION = 72.9 100x0 EXISTING SPOT ELEVATION
1 F, 4.
>> 100 EXISTING CONTOUR
a\ ` 5
o � ���?� 1 pp PROP. CONTOUR
.EXIST. WELL j o 717' '�`��4 5� fl 71.8
Al
C / GAR SLAB I 5� 6 45.3
R=30. \ �9 H ° 1 g
/ + 74.2 0. ' A/446.0
t_ 79. PROP. DWELL. /+ i. 0
TF = 77.0'
/ 4 7:0
+ 74.1 4 A3
'1 y, 71 i
+ .6 49.1
A4
7 .6 69 1 OT 7
8
6 4, 8 F MYSTIC LAKE I
/ 67. Vol '
I 4A5
�)h + 60.
+ 5.
a A66 4 TITLE S SITE PLAN
OF
22 CAMERON LANE
+ 6T +
I&cr
46.1 IN THE TOWN OF:
PROP. WORK LIMIT LINE OF o
A7 ( MARSTONS MILLS) BARN STABLE
� -
STAKED SILT FENCE, AT 100'
OFF RESOURCE AREA 6 •9 PREPARED FOR: HARVEY SOLOMON
+ 69.3 J
45.9
�
+ 2. A8 30 0 30 60 90
�
i
45.6 SCALE: 1" = 30' DATE: MARCH 14, 2004
co - _
64.1 A9 REV 3/16/04
62 /
6 b �V� �zH �OF�
6 ss9c OF
ARNE H.
At0 45.6 I� OJALA
5
CIVIL H-
57 / No. 30 92
5��� • ,���s��f 26
a/�46.d ARNE H. OJALA, �}., P.L.S. __-DATE
1 -
i
Al2 -
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off 508-362-4541
fax 508 362-9580
I
down cape engineering, inc.
CIVIL ENGINEERS
LAND SURVEYORS -
939 main st. yarmouth, ma 02675
04-070