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HomeMy WebLinkAbout0030 CHIPPINGSTONE ROAD - Health c CHIPPINGS TONE R ;'t� A=27 - 42 I � cr,� — Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 30 Chippingstone Road Property Address Wells Fargo Bank ` Owner Owner's Name information is requiled for every -Marston-Mills Ma 02648 6/1-4/-2019 page. City/Town State Zip Code Date of Inspection r r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information ��#i39�� filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane r� Company Address Centerville Ma 02632 City/Town State Zip Code few 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6/14/2019 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owners Name information is required for every . Marstons Mills Ma 02648 6/14/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The dwelling located at 30 Chippingstone Road Marstons Mills is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 5 Hi Cap Infiltrators. The system was found to be in.proper working.condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y- ❑ N ❑ ND (Explain below): . 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Chippingstone Road u Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has-a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityfrown State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every M'arstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No .If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form `! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. . 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: system installed 12/22/1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 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.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc-rev.7/28f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is-required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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: 1500 gallons Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? opened covers and took measurements 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 needs to be pumped soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owners Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5ins .doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 P P 9 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �o 30 Chippingstone Road i u Property Address Wells Fargo Bank Owner Owner's Name information is Marstons Mills Ma 02648 6/14/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5 Hi Cap Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Z Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. was video inspected from vent and found dry with no sign of past overloading. 12. 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.): t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Mlarstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form -t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately 8To Rro ZS- 3- 32' 37.C f sr.3 t5insp.doc•rev.MAIMS Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �V 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ 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: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form l' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Chippingstone Road Property Address Wells Fargo Bank Owner Owner's Name information is required for every Marstons Mills Ma 02648 6/14/2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria),and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holdirg Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 � a ^ Lam" / ` 'VI •i'�V \ `p �c JL C OU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this fori-n at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: (2 1 f Fill in please: ^X , ''a APPLICANT'S YOUR NAM E/S: ✓ - - ti{', BUSINESS YOUR HOME ADDRESS: OV TELEPHONE # Home Telephone Number 77W^ J J E I N OR : 3' 6qC) E-MA I L• �' UwG"_ NAME OF CORPORATION: NAME OF.NEW BUSINESS TYPE OF BUSINESS. 60 6; c iS IS THIS A HOME OCCUPATION? YES NO �r '� Uan`f ^� ADDRESS OF BUSINESS 3O C�� a fw�►- 1?I��; �ti MAP/PARCEL NUMBER a— [Assessing) . When starting a new business there are several things you must do in order to be in compliance with the rules and regulations.of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to Legally�oe)rate your business in this town. 1. BUILDING COMM ISSIONE S OFFIC MUST COMPLY WITH HOME ME OCCUPATION This individual has be inf ed of an mit requirements that pertain to this type of business. RULES AND REGULATIONS. FAILURE TO Lu COMPLY MAY RESULT IN FINES Auth rized Si ature** OMMENTS. 2. BOARD OF HEALTH This individual has been XP7 ed of the pe it equirem is that pertain to this type of business. -iz' ign re** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. ti Authorized Signature** COMMENTS: PP.ONT EL.EVN-TION �v �" 1� EJ' PI R91 78 P� u's l- ` � 0.eo crnk0...c..t..waor�os 1✓V/ r L zv' EXI JT IN6 HO1)9� NFw dAZGE "ID"TION MR. P, m.RS. mq-cT• 38-ot4so*) 4 •IFmr "P�pO"°O wuwnn 7 i.3 oS •svpm - CHi�'PIN6 SgDUE' 1 "'A'—sqva.9 MA- Fpoor 7°.(.(�/ OMWII 17 nor i..nmo�.a aomwwr�m. .h-R'1StJ � plc (� L'e7T FLEVA'fl.ornl Rkmif CROSS SCUMM) �T� Rezt,Eo R�o6¢ V� GDx 7 L�%LS. 44 2b t_ x GoLh2rtZ. ae. z 2x{o Rm°'TNt 6"a c, Tr FIO. 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Ho°�SF NEW G A414r r I 24 i BGlBi APPPOVBJBY{ DMWY BV OAr1[I PmrYeb 1DU&OAn AI PL4yj, ?,%6tyf ELEV, JIJ OPAMNO!WYBBP L{ `3i +c'c'iy �a�NonY L L LNING RoorA NEW 6,✓r[.e6C 2vxt4 I ten, o�6 � I a�rn NCW 5117 Md / - c�ser NEw'�XM �NDaw t�7O 1 u �, ` a�Aaew J 241 NVV M*ST7;7. 2T.V-M PA V7 S o� MR�'MRS MAIM 7Dhgu% • ccels! w'. � vmovl ' wn! b eS muvm w leav�o CHIPP1 Nd SfDME IZa StOALi MIL{.S MA, ` [x�gT- 2ND Fi.aa it 'PI.A'aJ onnwru rareu �-- U ;-_ o ;o I� i I n IN "J 1 • f I i I 4di NG I�cbly� U�/Yi NG I f 1 z19mOlzU:) 10 -3zu aril loi »6.O.JA qd zluovsl bn5 znsiq \(lsnimil-jl9 //00 r 1 V t -. ...--_....... T—. 10 I sgd At Af o 1 n w TOWN OF BARNSTABLE � N LOCATION - Ctil ���� s �a y� eAd SEWAGE# ��rr��J — GC?, VII,LAGE n��T=��c i(l.s- ASSESSOR'S MAP & LO'F�J7 INSTALLER'S NAME&PHONE NO. V k y SEPTIC TANK CAPACITY /So© 6;. I- LEACHING FACILITY: (type) rL r�iQ j,j EgZUd (size) //may -79 k / NO.OF BEDROOMS _3 BUILDER OR OWNER MA-r T �O L so�J PERMTTDATE: I Z- /3- 9a COMPLIANCE DATE: /Z-ZZ-9 9 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 � o II �T-o - Z?.3 3- 3Z 3 6 z � v�•,,�. . No. �� !�la� Fee 2CZ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: , Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for Wgpogar *pgtem Comaruction Vertu Appl cat r P ' to onstmctjf�Repair( )Upgrade( )Abandon( ) CC.4?6mplete System O Individual Components Location ddress or Lot No. La's- Owner's Name,Address and Tel.No. Assessor's Map/Parcel M t4 'c `�7 �r�t o i P a-7 ® 5- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Ist Yq# e s 0-CPP_ ( CC)NSUGfi`4,v�rs M�t1.3 yo�3yHi)•s�f !'1i�4RS7nNS L R /''�a9. LIo1S—obS� Aq- Type of Building: Dwelling No.of Bedrooms Lot Size ® a sq.ft. Garbage Grinder(/�o Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33® gallons per day. Calculated daily flow -3 3 gallons. Plan Date Cr_ 1-/— 1 Of Number of sheets Revision Date Title s 1-e -t Se,p' 4 N Size of Septic Tank 1, S 000 Type of S.A.S. 1)X S l N)c L7R A d ILS Description of Soil $-e e /A/V Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is this Poard of Health.sue Signed a Date — 01 Application Approved by Date Application Disapproved for"iAe fo wing reasons Permit No. C/— Date Issued TOWN OF BARNSTABLE LOCATION C — 0 SEWAGE #_9+g_ Gam_ VII LAGE__ n� /Z.. ASSESSOR'S MAP & LOT_ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /Sov LEACHING FACILITY: (type) �' �d (size) NO.OF BEDROOMS_ _3 BUILDER OR OWNER wn,a-r-r" PERMITDATE: /Z- /3__T COMPLIANCE DATE:_te-z z i Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and LeachingFacility ty (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet ------------------ 9'62 -h -9 f2 o f� I .t r1V0. `f C(f 1^ �=.o+o► -` / Feed •l. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppYication for Migpogar *pgtem Congtruction Permit Application for a Permit to Construct(VRepair( )Upgrade( )Abandon( ) Tki'4plete System El Individual Components Location Address or Lot No. ��'j- 01 e 1 S Owner's Name,Address and Tel.No. Assessor's Map/Parcel W,I/!411'i Fa-R P, On A.) MAP a- o L� 77- ® IS'© Installer's Name,Address,and Tel.No. Designer's Name,Address and M A R S Ta N S R A. 4ia8- 00 Type of Building: Dwelling No.of Bedrooms Lot Size �o� sq.ft. Garbage Grinder(/IVO Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow 3 3 O gallons. Plan Date 4- ''/- '1 9 Number of sheets Revision Date Title S i11 t &eet*c l,q. IV Size of Septic Tank Type o'f S.A.S. I) X 38 - 5 1 N I✓,&JZ 4 T-a I-S ' Description of,Soil S l A /V Nature of Repairs or Alterations(Answer when applicable) 1 ✓., Date last inspected: t Agreement: i 01 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 pl ce the system in operation until a Certifi- cate of Compliance has been issued by this Poard of Health. R Signed ` Date__LZ- - Application Approved by Date 4,, _6 Application Disapproved for e fo wing reasons Permit No. y- Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS . z BARNSTABLE, MASSACHUSE17S (tertificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(l/jRepaired ( )Upgraded( ) Abandoned( )by at LoT L/a C Ff t PP I Al&- STOP 6 Rl'; has been constructed in accordance with the;provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer VA Nkfe 5-/Ve1 C`o/nSUCTI N7S The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date I -? ti _ 1 ' Inspector -�c--� No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS .t PUBLIC HEALTH DIVISION,-BARNSTABLE, MASSACHUSETTS, Migogar *pgtem Congtruction Permit _ Permission is hereby granted to Construct( repair Upgrade( )Abandon(' ) ' System located at ' L_674,a C N l PP/NCr S 1yN& ' ow_ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction Viust be c'm leted within three years of the date of r Date: / Approved by 'a 0/ P r DOC:7 S 1,0 0 10-06-99 111:I It I"�w f BRRNSTABLE LAHO COURT REGISTR DEED RESTRICTION WHEREAS, Richard W. Onenzi a/k/a Richard W. Ortenzi and Patricia M. Onenzi a/k/a Patrica M. Ortenzi ("Owners") of 318 North Central Street, East Bridgewater, MA, are the owners of Lot 49, Chippingstone Road, Marstons Mills, MA 02648 (hereinafter referred to as the lot) and being shown on a plan entitled "Subdivision of Land in Barnstable, Charles N. Savery, Inc., Surveyors, April 4, 1969", which said lot is shown as Lot 49 on Land Court Plan 34846-C. WHEREAS, Richard W. Ontenzi and Patricia M. Onenzi as the owners of said lot have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a variance from the Town of Barnstable Board of Health "330 Regulation" and to obtaining a building permit for this lot-, WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting the variance from the 930 Regulation" and authorizing the issuance of a building permit for the construction of a single family home on this lot is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE, the said Owners do hereby place the following restrictions on the above- referenced land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title:. 1. Lot 49,Land Court Plan 34846-C, Chippingstone Road, may have constructed upon the lot a house containing no more than three (3)bedrooms. Said Owners agree that this shall be a permanent deed restriction affecting Lot 49, Chippingstone Road, Marstons Mills (Barnstable), Barnstable County, MA, and being shown on the plan recorded on Land Court Plan 34846-C. For title see deed from John F. Hamblin and Jeanette M. Hamblin dated July 6, 1977 recorded as Land Court Document No. 222,845. Also see Certificate of Title No. 71109. r s EXEDUTED as a sealed instrument this day of October, 1999. chard W. Ontenzi a/k/a Richard W. Ortenzi Patricia M. Ontenzi a Patricia M. Ortenzi COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. Octobers", 1999 Then personally appeared the above-named Richard W. Ontenzi a/k/a Richard W. Ortenzi and Patricia M. Ontenzi a/k/a/Patricia M. Ortenzi and acknowledged the foregoing to be their free act and deed, before me NOTARY PUBLIC My commission expires:0—: y:\work\dtkt8\winword\bank\farrington-deed restriction.doc BARNSTABLE COUNTY REGISTRY OF DEEDS ATRTRUUE COPY,ATTEST JOHN F.MEADE,REGISTER PAWTARIT WISTRY of nFF11S z is Q 111 � I •7•• I°, l+ Dt �� I2'O 3••�'.. i Q•6-� I I ITG i t 1 P ul - ► � N� I w LA I l I A N • tA,Q 1 s.�, a'e � N I I t pi S'2 3's i t a I iy t O' I � r- p Z• 1 �C.�. - b t 1 ' 1 j `I 1 < !_c.nt-4c,QooNA, o I 1 wn;CAP ON - � __: � o , I I t -- _ -`7 0 i Preliminary plans and layouts by p.C.O.are for the use of their customers only . Any other use is strictly f -� MARSTONS MILLS A.M. 27/39 TOWN WATER Cl A.M 27/40 L C PLAN 34B46c 9 PATTYS (FNo)\ 1 I j II \\ \ \ \\ I TOWN WATER (1G t� POND 85 \ \ \ 1 \ \ 3 0 / SPUR LANE CN cb AM. 27/42 \ms��� I I i I 0 q c� h ; / ) A.M. 27/4I IWAYRLY AREA=20,592 SQ. FT J I I 96 TOWN WATER 90 /./ / / f 'ol / loi—\ e9 LOCUS MAP NC c. 91 �_ 92--- �� A.M. 27 43 93 —� 4/ %; WELL o < —— 95 �94 �'9 �� PLAN REF. 34846C 150 `_f ,i o %4�c�/' \�'� ,-' ZONING: RF O ——— 97— 0 3 0. �cis� /F'// / / 0 sz. - se— / �/�/' � ONE lag.0 FLOOD ZONE. „C.. 14 SITE & SEWAGE' PLAN 10092°°I W "" G�'�p C� E ' ,-'A L\�f RO �\�So r ''Lk g8.0 ,pn EN GRA . 8 �(E A.M. 27 25 VON, .�� NE TELE p"E ,''n s r(`Q 1�1 WELL • PROJECT LOCH T/ON � —� ---- • �71 F S 1 AS/MAP 27 LOT 42 CHIPPINGSTONE RD. i �g�` 53 D G E ,� MARSTONS MILLS / i °� E 1 p\ (BARNSTABLE), MA. �� �i r° °ti ° t j(p �g ''so APPLICANT- BENCHMARK --� f WILLIAM E. FARRINGTON EL=100.0 (ASSUMED) - ON CATCH BASIN U.POLE YANKEE SUR VEY CONSUL TANTS P.O. BOX 265 �s! 27/24 UNIT 5, 40B INDUSTRY ROAD WELL MARSTONS MILLS, MA. 02648 A.M. 27/35 PH.(508)428-0055 — FAX(508)420-5553 WELL IN REARar SEPTIC IN FRONTG. SCALE. 1'=30' DA TE.• 914199 REV. REV. A.M. 27/36 --- = -•':'� _F��� =s7t!•3i8' HOUSE WELL IN REAR JOB NO. 52060 SHEET I OF 2 SEPTIC IN FRONT $ , cL.= 101'_ TOP OF FFdNDAT/ON 20' MIN. 10 MIN. CONCRETE COVERS 4"SCHEDULE 40 P.VC MIN. MYCH 1/8 PER FT 27 A YER OF EL=100' 1/B"-1/2" VENT CONCRETE COVER\ / EL=101.5 EL=101.W HED S719 EL=101.5 / / ,6"KAX / , , , , , / / i / , , 4' CAST IRON PIPE P0I7C /4�PERMINVUM FT CLEAN SAND 9" FLOW LINE ,3' MIN EL=97.0 INVERT 0 1M,N 14" `2O EL.-_-- -- cAs INVERT LEVEL BAFFLE _98_0' /NVERT�6 SUM INVERT 0 INVERT EL.-__ EL.= 9B.25' EL.= 97.75' EL.= 97.50' ° =95.5 (7O BE PLACED ON FIRM BASE) DISTRIBUTION MECHANICALLY COMPACTED OR 6" OF SMNE BOX EL.=96 5' GALLONS TO BE WATER TESTED 11' X 38' TRENCH FORMATION SEPTIC TANK IF MORE THAN ONE OUTLET PLACE ON 6" STONE 3/4. ,_,/2. SOIL ABSORPTION r PROFILE OF DOUBLE WASHED sm" SYSTEM (SAS) H-20 SEWAGE DISPOSAL SYSTEM BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV.=_89.5_ NOT TO SCALE NO OBSERVED WATER TABLE (8127199) ELEV.=_8_9 5_ OBSERVATION HOLE 1 ELEV.=_101_5' PERCOLATION RATE c2 MIN./ INCH AT _4,2f_ INCHES OBSERVATION HOLE 2 EL V=_101_5' DEPTH HORIZ TEXTURE COLOR MOTT OTHER DEPTH ORIZ TEXTURE COLOR MOTT OTHER 0-10" A SANDY LOAM IOYR 4-4 0-10" A SANDY LOAM IOYR 4-4 10"-48" B FINE SILTY SAND IOYR 6-8 10"-48" B FINE SILTY SANDIOYR 6-8 GENERAL NOTES 46"-14 " Cl MEDIUM SAND IOYR 7-4 PERK. 48"-144' Cl MEDIUM SAND IOYI? 7-4 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN OF BIRNSLIBLE_--_ RULES AND NO WATER ENCOUNTERED NO WATER ENCOUNTERED ? REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2) ONE COVER ON.SEPTIC TANK SHALL BE BRO UCHT TO SOIL TEST WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" DATE OF SOIL TEST 8127/99 SOIL TEST DONE BY BRUCE C. MURPHY, RS. 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITNESSED BY. EDWARD BARRY WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE DESIGN CAL CULA TIONS' USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. NUMBER OF BEDROOMS . 3 4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL GARBAGE DISPOSAL . NO BE MORTERED IN PLACE. 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH TOTAL ESTIMATED FLOW DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO TOP LOAD ( -11--0--GAL/BR./DAY x 3___ BR) 330 GAL/DAY OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 5 INFILTRATORS (H-20) WITH REQUIRED SEPTIC TANK CAPACITY 1500 GAL 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VATION CONTRACTOR 4' STONE SIDES AND ENDS iS TO CALL DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS Il' X 38' SOIL CLASSIFICATION . 1 PRIOR TO COMMENCING WORK ON SITE. DESIGN PERCOLATION RATE . MIN. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS EFFLUENT LOADING RATE . . . . . . 74 CAL/DAY/S.F. BITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. LEACHING CAPACITY (AREA X RATE) 381 GAL/DAY 8) PARCEL IS IN FLOOD ZONE___"('"__--_. RESERVE LEACHING CAPACITY . . . 381 GAL/DAY 9). LOT IS SHOWN ON ASSESSORS MAP -_-27 AS PARCEL _42___. (38X11X 74)+(38+38+II+IIX 74) JOB NUMBER _ 52060 _____ TOWN OF BARNSTABLE THE TO w OFFICE OF BAH39TdSL : BOARD OF HEALTH NAdR p �oe�'630' \gym 367 MAIN STREET HYANNIS, MASS. 02601 September 30, 1999 William Farrington 54 Jones Road Mashpee, MA 02649 RE: Lot 49 Chippingstone Road, Marstons Mills, A=27-42 Dear Mr. Farrington: You are granted variances from the State .Environmental Code, 310 CMR 15.214, restricting sewage flows to 440 gallons per acre per day in zones of contribution to public water supply wells and from the Board of Health Regulation restricting sewage flows where parcels are located adjacent to homes served by private wells. These variances are granted with the following conditions: (1) No more than three (3) bedrooms total are authorized at this parcel. Dens, study rooms, finished attics, sleeping lofts, and similar type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The applicant shall record a deed restriction at the Barnstable County- Registry of Deeds, signed by the parcel owner, in regards to the maximum number of bedrooms allowed at this property (three bedrooms maximum allowed). (3) The engineered septic system plan shall be revised to show a complete listing of variances requested. (4) The septic system shall be installed in strict accordance with the revised plan. (5) The dwelling shall be connected to the public water supply prior to occupancy. chip r a (6) The designing engineer shall supervise the construction of the septic system and shall certify in writing to the Board that the system was installed in strict accordance with the revised plan that the dwelling was connected to town water. These variances are granted because it is the Board's policy to approve three bedroom dwellings on parcels of 18,000 square feet or greater in size. This parcel is 20, 592 square feet. As a matter of right, without a variance a two bedroom dwelling could have been constructed on this parcel. It is the Board's opinion that one additional bedroom, totaling three, would not significantly alter the poor quality of the groundwater in this area. Sincerely yours, Susan G.4sk, R.S. Chairperson Board of Health Town of Barnstable SGR/bcs chip CF THE)per DATE: ~O FEE: PCs ✓� • snxxscnat.>E, v MASS. i639• REC. BY �0 AlE° �° �, � � � � SCHED. DATE: Town of Barnstable J v «< 411" N * ;1 Board of Health J�EC�IVEO �dVO 367 Main Street, Hyannis MA 02601 Office: 50-790-UP 9 1999 Susan G.Rask,R.S. FAX: 5 8- 630 Ey Sumner Kaufman,M.S.P.H. TMQgq Ralph A.Murphy,M.D. oe '- VARIANCE REQUEST FORM LOCATI Property Address: Assessor's Map and Parcel Number: Size of Lot: Wetlands Within 300 Ft. Yes Subdivision Name: No� Business Name: APPLICANT CONTACT PERSON Name: G,/Gf9 Name: C- Address: t5 )ZJCS° 42r' I�2 Address: Phone: �{'J�/�4� Phone: FAX: vim-6&Je FAX: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) a Checklist(to be completed by office staff-person receiving variance request application) Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/leasee only],outside dining variance renewals[same owner/lessee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G. Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman, M.S.P.H. REASON FOR DISAPPROVAL Ralph A. Murphy, M.D. Q:/WP/VARIREQ ------------------- MARSTONS MILLS A.M. 27/39 TOWN WATER / , I II I I \ \\ 11 1\ 1\ 1 ``` A.M. 27/40 4 C PLAN 39a96c ���2c� �}� PATTY'S (PND) \ 1 I II I \ \ \ \ \ ��� TOWN WATER O~ O (�G w POND \ lr LANE CS N A.M. 27/42 dam, / ► I i °� �� �� ,� / KIMBERLY \ AREA=20,592 SQ. FT. I c6 6. ) A.M 27 41 J / / WA Y rG . \ / I p`� 719WN WATER 999 ioi — 8,9 / FE LOCUS MAP 91 A.M. 27/43 92 —-_ y6� u� •4-i / -_9' yy / coy WELL __- 93 = Z �\ GQj� / �p� - c ' ,'Y�" 94 ,/, / �•�, X ''' — 96 --- j o/� ' ' \� PLAN REF 34846C I50 01 --- 97 - 90 F'9k° �� ������, ` ti4�,�,'/ 0' ZONING: »RF» ., �- FLOOD ZONE. C 998 - 9 N ° rl SITE & SE WA GE' PLAN �100 G��p c° �,0 �fro I r / - w_N - 38•0 TP0'IE ELEGRA Y A.M. 27/25 101 vE , .�� P TE. + E A s WELL PROJECT L OCA T/ON i � - / & ' q71� .-'o F T 0 AS/MAP 27 LOT 42 CHIPPINGSTONE RD.MARSTONS MILLS i 0`. x E V C( MA. �� �� 1° tio ° '� IVAPPLICANT. BENCHYARK --� WILLIAM K FARRINGTON � EL=100.0 (ASSUMED) U.POLE ON CATCH BAS1.7V YANKEE SURVEY CONSUL TAN TS P. O. BOX 265 A.M. 27/24 UNIT 5, 40B INDUSTRY ROAD MARS TONS MILLS, MA. 02648 y A.;� z7/35 � '� _ PH. (508)428-0055 - FA X(508)420-5553 �, qyu . WELL IN REAR 41. SEP71C IN FRONT DA TE. 9[ 14199 __ MURPHY �SCALE.• 1"=30' \7 No.749 ,F5s9 y mat _ _ �.t'7 A R V.E • RE V.• A.M. 27/36 =- HO U:SE S' WELL IN REAR B NO. 52060 - SHEET 1 OF 2 JJOSEPTIC IN FRONT "" r - } 101' _ TOP OF FOUNDATION 20' MIN. 10' MIN. CONCRETE COVERS 4" SCHEDULE 40 P. VC MIN. PITCH 118 PER FT. 2"LA YER OF EL=100' 118,-112" VENT CONCRETE CO VER WASHED STONE 6" MAX ' " ' / / , , , , , / / / El,=101.5 EL=101.0 EL=101.5 4" CAST IRON PIPE (OR EQUAL MINIMUM ,S PITCH 114 PER FT. CLEAN SAND M N FLOW LINE 3' INVERT 1 10" EL=97.0 MIN. 14" EL.= 98_5 __ GAS INVERT �6 SUM LEVEL c o °° ° INVERT BAFFLE EL.= 98.0 INVERT INVERT, ° o° ° ° EL.= 98.25' EL.= 97. 75 EL.= 97 50_ °°° °° ° ° EL.=95.5 (TO BE PLACED ON FIRM BASE) DISTRIBUTION MECHANICALLY COMPACTED OR 6" OF SMNE BOX EL.=96.5 _1500 --GALLONS TO BE WATER TESTED 11 X 38 TRENCH FORMATIONto SEPTIC TANK IF MORE THAN ONE OUTLET PLACE ON 6" STONE 3/4" M 1-1/2" SOIL ABSORPTION PROFILE OF DOUBLE WASHED STONE SYSTEM (SAS H-20 SEWAGE DISPOSAL SYSTEM BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV. =_89.5__ NOT TO SCALE NO OBSERVED WATER TABLE (8127199) ELEV. =_ 8_9.5_ OBSERVATION HOLE I ELEV.=_ 101.5' PERCOLATION RATE MIN./ INCH AT _4&'_ INCHES OBSERVATION HOLE 2 ELEV.=_ 101.5' r DEPTH HORIZ TEXTURE COLOR MOTT. OTHER DEPTH HORIZ TEXTURE COLOR MOTT. OTHER 0-10" A SANDY LOAM IOYR 4-4 0-10" A SANDY LOAM IOYR 4-4 10"48" B FINE SILTY SAND IOYR 6-8 10"— 0"—48" B FINE SILTY SAND 10YR 6-8 GENERAL NOTES 48"-14 " Cl MEDIUM SAND 10 YR 7-4 PERK. 48"-144 ' Cl MEDIUM SAND 10 YR 7-4 x 1) ALL WORKMANSHIP AND MA TERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN OF _BE4RNSTARLE____ RULES AND NO WATER ENCOUNTERED NO WATER ENCOUNTERED REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2) ONE COVER ON SEPTIC TANK SHALL BE BRO LIGHT TO SOIL TEST WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" DATE OF SOIL, TEST 8127199 SOIL TEST DONE BY BRUCE G. MURPHY, R.S. 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITNESSED BY: EDWARD BARRY WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE DESIGN CALCULA TIONS: USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 3 4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL NUMBER OF BEDROOMS . BE MORTERED IN PLACE. GARBAGE DISPOSAL . . . . . . . . . NO 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH TOTAL ESTIMATED FLOW DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO TOP .LOAD ( 110__GAL/BR./DAY x 3___ BR.) 330 GAL/DA Y OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 5 INFILTRATORS (H-20) WITH REQUIRED SEPTIC TANK CAPACITY 1500 GAL s 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR 4' STONE SIDES AND ENDS IS TO CALL "DIG— SAFE" AT 1—800—322—4844 AT LEAST 72 HOURS 11' X 38' SOIL CLASSIFICATION . 1 PRIOR TO COMMENCING WORK ON SITE. DESIGN PERCOLATION RATE . . . . . < 2 MIN./IN. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS EFFLUENT LOADING RATE . . . . . . . 74 CAL/DAY/S.F. SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. LEACHING CAPACITY (AREA X RATE) 381 GAL/DA Y 8) PARCEL IS IN FLOOD ZONE___"C"_____. RESERVE LEACHING CAPACITY . . . 381 GAL/DAY 27 (38XIIX 74)+(38+38+11+IIX 74) 9 LOT IS SHOWN ON ASSESSORS MAP __ AS PARCEL _42___, t. SHEET 2 OF 2 JOB NUMBER 52060 ______ i