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HomeMy WebLinkAbout0032 CHOPTEAGUE LANE - Health 32 Chopteague Lane Marstons Mills P A = 028 073 - --- I I i I I I i TOWN OF BARNSTABLE •y I �l'C��TION .��. G d SEWAGE # ASSESSOR'S MAP & LOT dJ -0 73 ViSTALLER'S NAME&PHONE NO.,-- ;71— SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS s BUILDER OR OWNER ,_ P PERMITDATE: -/3- LE—COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 30 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �J Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ,/U � Feet Furnished by 1 t r y `7 No. Ty- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplication for Migpogal *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components Lo i dd s�t No ��� Owne ' Name,Address and Tel.No. Assessor's Map/Pazce � / /-� r✓ Installer's Nine,Address,and Tel.No. Designer's Name,Address and Tel.No. Ae_ 3v Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) k 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 T' of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued bp thiqB96rd Signed `�� -- Date ""L Application Approved by Date —I Application Disapproved for th ollowing reasons Permit No. Date Issued TOWN OF:BARNSTABLE i LOCATION--",,-�2, SEWAGE #V . �.. VILLAGE`` ASSESSOR'S MAP& LOT d� INSTALLERI&NAME&PHONE NO. SEPTIC TANK CAPACITY 0 �' LEACHING:FAC1LrrY: (type) 77;izj� , (size) NO.OF BEDROOMS :.. BUII.DER'C3I7>(?WNER /lh.t�f Q.a� c:. PERMITDAT : —/3- J COMPLIANCE DATE: SeparationDistaltce Between the: Maximum Ad)tisted Groundwater Table and'Bottom of Leaching Facility �b: Feet `. ; Private Wa ec;Supply Well and Leaching Facility (If any wells exist on site drwlthin 200 feet of leaching facility) �.�� Feet Edge of We'datid-and.Leaching Facility(If any wetlands exist within 300:feet of leaching facility) Feet Furnished 'iy:' .:.:..:... 2— 9 — No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIppricatiou for Digaal *paem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon(-.) ❑Complete System ❑Individuii aComponents Locatio Address gr Lot No Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name, e,Address,and Tel.No. Designer's Name,Address and Tel.No. J " �►, ' dz(- 3v ' Type of Building: ' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 2 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 Ti• of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued t&d of glt/h _ Signed �'�--^r— Date 31- Application Approved by1�67- Date Application Disapproved for th6lo—llowiny reasons a' Permit No._ f ul"'�� p Date Issued THE COMMONWEALTH OF MASSACHUSETTS \ BARNSTABLE, S LE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(x) Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and t Disposal System Construction Permit No. - dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the systemNjill unction as designed. Date 4 - a �7 Inspector s_ ``, _ --------------------------------------- No. -- Fee O THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Digpogar *pgtem Congtruction Permit Permission is hereby granted to Cons uct( epair(�)Upgrade( )Abandon( ) System located at Z C�/�✓ 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. r Provided:Construction must be completed within three years of the date of this permit. Date: Approved by_ 10/97 NOTICE: This Form Is To Be Used For.the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOU DISI'OSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works �construction permit signed by me dated - / •concerning the IN �,, � I1�� / meets all of the property located at U following criteria: There are no wetlands located within 100 feet of the proposed leaching thcility e There are no private wells within 150 feet of the proposed septic system e There is no increase in flow and/or change in use proposed e There are no variances requested or needed. e If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will W be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) B)Observed Groundwater Table Elevation(according to Health Division well map) 2: SIGNED: � DATE: 4 LICENSED 9CSYSTC M INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed systern.Also if the licensed Installer posesses a cetilfled plot plan, this plan should be submi(ted]. q:health folder:cert f�J vl . , . ....._ -- �n.._ _ O� •_ �� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 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 i^ to move your Robert J. Bortolotti cursor-do not use the return Name of Inspector key. Bortolotti Construction, Inc. ?) Company Name P. O. Box 704-45 Industry-Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-771-9399 Telephone Number License Number B. Certification a I certify that I have personally inspected the sewage disposal system at this address and that.th'e F' 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 efion site sewage disposal systems. I am a DEP approved system inspector,pursuant to Section M3,40 of, Title 5 (310 CMR 15.000).The system: ; @Passes ❑ Conditionally Passes ❑ Failsµ ❑ Needs Further Evaluation by the Local Approving Authority Ins6eeturs 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. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Y o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Choptegue Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 every page. City/Town State Zip,Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: - [ d have not found any information which indicates that any of.the failure criteria described. in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 l5insp-08106 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 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. l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 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 ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ El or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool a ❑ Liquid depth in cesspool is-less than 6" below invert or available volume is less than day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)..Number of times pumped: ❑ . ❑ Any portion of the SAS, cesspool or privy is below high groundwater elevation. ❑ El Any portion of cesspool or privy is within 100 feet of a surface water.supply or tributary to a surface water supply. l5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): 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 16,000 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•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form � a o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is Marstons Mills MA 02648 10/18/07 required for 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? M ❑ 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) N. ❑ 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•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of.15 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 every page. CityrTown 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 Number of current residents: 2 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 meterreadings, OS" yl�a 00Z—3�z t if available last 2 ears / Y Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste 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•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 f Commonwealth of.Massachusetts v Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 32 Choptegue Lane Property Address Dale Fornoff: Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 Cit !Town State Zip Code Date of Inspection every page. Y p P D. System Information (cont.) General Information Pumping Records: Source of information: Pumped 4 yrs ago- provided by owner 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: System/Leaching repaired 3/13/98 by J. P. Morin. Were sewage odors detected.when arriving at the site? ❑ Yes ® No l5insp•08106 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 32 Choptegue Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: Meet 1 ' 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.): Septic Tank(locate on site plan): Depth below grade: 12" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years �ls-age confirmed by a-Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8.5'x6'x5' Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle ZU 3" Scum thickness iJ Distance from top of scum to top of outlet tee or baffle Z Distance from bottom of scum to bottom of outlet tee or baffle �l I How were dimensions determined? physical observation 15insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 _' I Commonwealth of Massachusetts `. Title 5. Official Inspection Form Subsurface Sewage Disposal System,Form Not for Voluntary Assessments 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 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.): It's a 1000 gallon precast septic tank with covers and top of tank 12"to grade, it has plastic inlet and cement outlet tees with 3" of scum and 12" sludege at time of inspection-tank was pumped immediately following inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): l5insp•08/06 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 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 every page. Cityfrown 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 working level 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 is 28"to grade and at working level at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 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: 2 -2.5'Wx34' L ® leaching trenches number, length: x 2' D ❑ 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.): There are stone leaching trenches thst.are 2.5'Wx 34' L x 2' D -stone appeared to be dry at ends at time of inspection. 15insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 32 Chopteque Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 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.): t5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 i Commonwealth of Massachusetts _ Inspection Form _ W Title 5 Official ,. Ins ect o p Subsurface Sewage Disposal System Form -.-Not for Voluntary Assessments 32 Cho to ue Lane p q Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 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. e o -c bvl- '( t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Choptegue Lane Property Address Dale Fornoff Owner Owner's Name information is required for Marstons Mills MA 02648 10/18/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells l Estimated depth to ground water: 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: t5insp-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 I Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: ✓ �:u!® �� �G Lot No. Owner: Address: J Contractor: Address: � .�,,� /'' i �. Notes: �,�ssi�I 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: OA Appropriate index well . ....................................... OWater level range zone :.....: STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to waterlevel for index well ......................... 19 7 y month/year 1 . 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.213) determine water-level adjustment ...................................................:.....................................: r STEP . 5 Estimate depth to high water by subtracting the water- level adjustment(STEP 4) Pfrom measured depth to water f level at site (STEP 1) ............. Figure 11--Reproducible computation form. 15 i p fic 7a, / 1.e ' _' S e-5`` i THE Town of Barnstable �pf 1pjY Regulatory Services B,, S,BLE Thomas F. Geiler,Director 9$� 039. •�� Public Health .Division . rED Mp`l A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. FRIECER-F-D ECO-TECH L 3 0 2003 Environmental TOWN OF BARNSTABLE www.eco-tech.us HEALTH DEPT. THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 32 Chopteague Lane Marstons Mills Owner's Name: Jessica O'Leary Owner's Address: 9 Brittany Circle Pembroke,NH 03275 MAP � 2 Date of Inspection: July 29, 2003 PARCEL ® •0 Name of Inspector: (Please Print) David D. Cou:;hanowr,R.S. LOT Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature Date: 13011i 130, 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 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. ****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 1 Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Chopteague Lane Marstons Mills Owner: Jessica O'Leary Date of Inspection: July 29, 2003 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CUR 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B] System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no,or not determined(Y,N,or 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 breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of 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 four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain 2 , Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Chopteague Lane Marstons Mills Owner: Jessica O'Leary Date of Inspection: July 29,2003 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 and 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. 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 by 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 INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Chopteague Lane Marston Mills Owner: Jessica O'Leary Date of Inspection: July 29,2003 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X 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 by 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) No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore,the system fails.The system owner should contact the Board of Health to determine what will be necessary to 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 You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any 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 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 32 Chopteague Lane Marston Mills Owner: Jessica O'Leary Date of Inspection: July 29, 2003 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant or Board of Health. X Were any of the system components pumped out in the last two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available as N/A) X _ Was the facility or dwelling inspected for signs of sewage back-up? X _ Was the site inspected for signs of breakout? X _ Were all system components,excluding the SAS. located on site? X Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum.? X _ Was the facility owner(and occupants,if different from owner) provided with information on the proper maintenance of subsurface disposal systems. For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: X _ Existing information.For example,Plan at the Board of Health. X 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 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 32 Chopteague Lane Marstons Mills Owner: Jessica O'LeM Date of Inspection: July 29,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CUR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan on file at Health Dept. Number of current residents 0 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection requiredl Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two year's usage(gpd): 164 gpd Sump Pump(yes or no): no Last date of occupancy: July 1, 2003 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sqft/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: System not pumped in recent past(Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: X 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/Altemate 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: 5+years Certificate of Compliance issued 3/13/98 (BOH permit#98-155) Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Chopteague Lane Marston Mills Owner: Jessica O'Leary_ Date of Inspection: July 29, 2003 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:_cast iron X 40 PVC other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting,evidence of leakage,etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling__ SEPTIC TANK: X (locate on site plan) Depth below grade: 10 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 8 in Distance from top of sludge to bottom of outlet tee or baffle: 26 in Scum thickness: 4 in Distance from top of scum to top of outlet tee or baffle: 8 in Distance from bottom of scum to bottom of outlet tee or baffle: 12 in How dimensions were determined: Probe to top of tank 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 recommended within 1 year,and maintenance pMing is recommended ever 2 years. Li uid level at outlet invert.Tank and tees appear structurally sound and functioning as intended No evidence of leakage in or out GREASE TRAP: none (locate 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 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Chopteague Lane Marstons Mills Owner: Jessica O'Leary Date of Inspection: July 29,2003 TIGHT OR HOLDING TANK: none (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 inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: at outlet inverts Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.) D-box appears structurally sound with no evidence of leakage in or out Effluent level at outlet inverts Few solids in tank. PUMP CHAMBER: none (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Chopteague Lane Marstons Mills Owner: Jessica,O'Leary Date of Inspection: July 29,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan;excavation not required) If SAS not located, explain why: Type: X leaching pits,number 1 _leaching chambers,number X leaching galleries,number 1 _leaching trenches,number,length _leaching fields,number,dimensions _overflow cesspool,number —innovative/alternate 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 leach pit and gallery ppeared unsaturated. No evidence of surface ponding,breakout,lush vegetation Or other evidence of hydraulic failure was observed. CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PL1 ate 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 I Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Chopteague Lane Marstons Mills Owner: Jessica O'Leary Date of Inspection: July 29,2003 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'(Locate where public water supply enters the building) LEPTH LOCATIONS O � 3 LEACHING TRENCHES A g D-BOX ❑ 11 1 3 6 f t 14.5 f t Z❑ D-BOX 2 72.5 f t 59.5 f t 3 88.5 ft 75 Ft 4 99 f t 86 f t SEPTIC a TANK o I --r B A EXISTING DWELLING # 32 J Z_ J W H Q CHOPTEAGUE LANE NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Chopteague Lane Marston Mills Owner: Jessica O'Leary Date of Inspection: July 29,2003 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater: 35+ feet Please indicate(check)all methods used to determine 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 local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Town of Barnstable GIS Department records indicate that the groundwater table lies over 35 feet below the surface of the lot. 11 �i C A TIM, SEWAGE PERMIT N OOVILLAGE 401,5 INSTALLER'S NAME i ADDR SS 73 2*4er Sty BUILDER OR OWNER v ad& 023501 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �f/ / L X J � ® Sty s ce No. I..aZ�.�...� F c...-1. .....' THE COMMONWEALTH OF. MASSACHUSETTS BOARD OF HEALTH -rCDw. OF.................`�-R N5T_A..SLE.,..._._.._...-----••----- ApplirFation for Uhipos al Works Tonstrnr#iun ramit Application is hereby made for a Permit to Construct ( ) or Reidair ,( ) an Individual Sewage Disposal System at: S µ� d AF ITLocation-Address or Lot No. ..... - ._......Wit_L.G4............................ ...W u._C4'L-,/-........_... ......................... wner Address _....._••--••-.... .- ................... ... ......M� (,5......I...1?55.............. Installer Address , Type of Building . Size Lot��..._��... ft U Dwelling __.__Expansion Attic ( ) Garbage Grinder (�No. of Bedrooms---•-•----------- ---------------•--- — Other—Type of BuildingNo. of ersons____________________________ Showers Cafeteria dOther fixture-----------------------------•-----------•----...-----••------------------------------------------••--------...--•------------.........._..__-----• Design Flow.._.: .......5!;1 ..............gallons per person peri ay. Total daily flow...............3®..................gallons. WSeptic Tank—Liquid capacity_LQP�.gallons Length____.K__.____ Width._.___.___ Diameter................ Depth..... x Disposal Trench—No. ........I.......... Width...... Total Length_____10..........Total leaching area___A.%_Z_......sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z �% Other Distribution box ( ) Dosing tank ( ) r� ,•� N i s Percolation Test Results Performed by.R�FA..(. ,_P _____. _._._.___i....................... Date._.�_1_� � .._�._____..___.... n Test Pit No. l.__..__ minutes per inch Depth of Test Pit__.__L3__.__._.. Depth to ground water_._.^!_ P P P (s, Test Pit No. 2..__... ...__._m nutes per inc D pth of„ st Pit___ L____.__. Depth to ground water.MK° _ -_..... ............................................................... 0 Description of Soil........MlY2--1&0 �-........5A N. %`----=3---....................................................................... U __--- ------- ^..-•--------------------- . -• -• ------• --- -2 ------- ... �£ UNature of Repairs or Al rations—Answer when applicable—' _____________________________________________________________________________'�..______. ••-------------------------•------------------------------•---•-••-----------------•-•--...........----.....-------------••---•---••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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. tgn _._._... - • - - -•---•._.....•• ................................ Date Application Approved By-•"...... f1tLM....... .. .. ..1... - 1� � ............ Date Application Disapproved for the following reasons-------------•----•---------•-----•------•---•---------•---------------------••-•----------------._.....--•-•-••- --•.....----•-•----------•-•-•---•-----------------------------•-•---•-----••------------....---=------•-•--•-•--•----•--•---------------•--•--•----•••--------•----•••-----•----------•-•-•-•-.._....._ Date Permit No......................................................... Issued....................................................... ' Date r 04) No.......... �.'...... FEs... ................... .�-..-/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF................. ��R N ) A0�L;Z.......................... Applirattion for Diopoii al Works Tonotrur#ion umi# Application is hereby made for a Permit to Construct ( ) or Re air;(r� ) an Individual Sewage Disposal System at: ... .... .. - --. ---...... ...--•- Location-Address ' or Lot No. ....... .v r\1_... W 4 L 1 ? V.1 A _ ':'` E>'t A'T E 5 •-• -•- ..._ .__... -- ------ --------------------------•••--•--- Address W ner, S M ILLI7 "ASS a 1z - ------------------------- �... ....,:................ Installer Address d Type of Building Size Lot---_-_..1..........0...sq. f t U Dwelling 3.......................Expansion Attic ( ) Garbage Grinder 44 �, �NO. of Bedrooms____________________ `4 Other—Type e of-Buildin .............. No. of ersons......................_..... Showers — Cafeteria W YP g -------------- P ( ) ( ) QIOther fixtures...-•----------------•-...------•---•----•-•---.... ....--- W Design Flow___ . .... ._ ?..................gallons per person periday. Total daily flow..............33.�...................gallons. Ri Septic Tank—Liquid'capacity �oU gallons Length.__`�_."._._ Width-_-�a�.. Diameter................ De�th..._.+.......... Disposal Trench—No........�._._....... Width..._..��............. Total Length___-•1.0_......... Total leaching area-__�`l .......sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by. L.:F .. .. .'r..... ...... ......1...._..__._......__.._. Date_.y_�_�`t__� __�._.___...._..... Test Pit No. 1......` ._minutes per inch Depth of Test Pit..... _________.. Depth to ground water.._ IA- .................... CL, Test Pit No. 2..... _minutes per inc D, pth of st Pit ,....�.,'a.�........ Depth to ground water. ....... O Description of Soil tit .! c' °...4.jtz �A .. +. - •-----------------------------------------•••••-•--••---•-•.••--- x - ----------------------•-----------------------.----------------•------•---- U Nature of Repairs or A erations—Answer when appliEabler.............................................................................................. --------------------------------------------------------•-•--.......................................................----------------------------------------•----------------------------•-•------•-- Agreement: The undersigned agrees; to install the aforedescribed Individual Sewage Disposal,System in accordance with the provisions of TITI:E 't 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. lg •--•-•. -•------.•-'------------------------••---_--------------•----•--------•---- --------- .--•-----------•-- / Date t - ----------- ' Application Approved BY...: ...... ------------------------------------------------------------------- ......._._.� Application Disapproved for the following re Date a,sons_____________________•. --------•..............................r....---------------... -----------------------------•--------------------------------------------------------------------------------------------------•--- Date PermitNo.....................................................L. Issued........................................................ Date a THE COMMONWEALTH OF MASSACHUSETTS y BOARD OF• HEALTH ........... 1�/'�...............OF.............. .. .....: ........ ................. Trrfifirttfr of TontpliFanrr THIS IS TO CERTIFY at the Individ 1 S age D�sal System constructed ( ) or Repaired by:.......... ........ - . • ................................. ---------------•-- ----- staller at:: ..... L / -�T'-..-- rt . has been installed in accordance with the provisions of F 5 f he State Sanitary Code as describe in the application for Disposal Works Construction Permit N _l�'yT.............. dated.....v!!__�`_. .....--....._........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SY TEM WILL FUNCTION SATISFACTORY. t GlitfiriDATE..... :.:.............. Inspector �./. � � ------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTHY . ' //� OF.......... `... ..:. ........... .�x✓�-'..... ••................... No...... l..._ FEE-. ................. Disposal rhB i n n rrntii Permission is hereb ranted.........--•.....----••....... ........ to Cons t t (l rW' io( ) a i ,ual_S . , is os .j ystem at No... Street / as shown on the application for Disposal Works Constpruction Wit No_____________ __ Dated.._.____�Z /' G �--------------------- Y / Board of Health : DATE (p.....-�.............................•-•---- f � . FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS S - - SECTION - SEWAGE � o /l I I - SEPTIC TANK - "D" BOX - LEACH-_GA< LEY ICS.Z I I IP nF F IN ^. / � 2 V N5L1= •WASH2"OFEDSTTONE Q NOTE: REMOVE ANY U 150;TA8LE MATERIAL FOR A DISTANCE I , \ V I OF 10 FT.AROUND ENTIRE LEACH p AND REPLACE WITH CLEAN COARSE SAND. j r i p-, 01,, N 1 ,� P --- - -- OUT 4 N Ul;i IN I i'-y' fir~ J� / O4 / .L (' ta7. SO /r sEariCG — D .� o e TANK �O� tos-,G ELEV. -J / .� ELEV. ELEV. r ELEV. I Y _ _ _ - 3�29 ELEV. ELEV. 10 .5`i I1 d' Cr i lOr:•9/ R. 3HR NOTE: le `/ - ?i o u_ f tooc� eo q BRING ALL COVERS TO WITHIN WASHED STONE J`�� `� ,A L_ 1 FT,OF FINISH GRADE. TA fJ yL , TEST HOLE LOG # 33�t ;F TEST BY k, � A1TzV,At-kK k(' N C-1I IF:K7RI to TH it WITNESS -- TEST DATE 14 181 DE N _ _._...BEDROOM HOUSE _-beT ELEV. _ ELEV. I! : .; ` Ir7l3.(0 ` ,� �. ba NO A /6fl. 10-1.C - o't Co PERC RATE .__2____.-MIN/IN. DISPOSER DISPOSER `Q SAN�,v lL1Y _ - t`1G �c� (GAL./DAY ) v, O ~� /o C_LA Y - , c FLOW RATE 3. _. .I►.v L y SEPTIC TANK 3ja 11'51= 95• _ REQ'D SEPTIC TANK SIZE IGnv p MEQIIV*A C. EA lI,-t co E, LEACH FACILITY \ i ,1_. SIDE WALL !12 1,Q) �_'�` �_,�.5 I = 29�. I _ G/D. LCT" 2 '1 " BOTTOM tc - 6 =- ®U I I..0 1 fiQ _. G/D - TOTAL ►g8.�{ F AL-�Cr I ' L _.. �15. �� USE _._WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) 1. DATUM (MSL) 'TAKEN FR�QM_--.G_©TU I --------------QUADRANGLE MAP 2.MUNICIPAL WATER-----------I _r_-_...................AVAILABLE 3. PIPE PITCH: 1/4"PER FOOT *� 4. DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO- (d ___-44 DISTANCE AS CERTIFIED 5. MIN.GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. j {{- -- 6.PIPE JOINTS SHALL BE MADE WATER TIGHT ( �j>iryN 7.CONSTRUCTION DETAILS TO BE ACCORP4NCE WITH COMM.OF MASS. F I HEREBY CERTIFY THAT THE BUILDING SITE PLAN STATE ENVIRONMENTAL CODE TITLE (�10 GF+ p 1r 1 + 1� a�:.. 1y SHOWN ON THIS PLAN IS LOCATED ON THE 2 7 ra / Y l '' `1L�. GROUND AS SHOWN HEREON& THAT IT LOCUS: LOB CONFORM TO THE ZONING BY LAWS OF THE C/� K E$Y E T A S-E -- TOWN OF — -- - REG.PROFESSIONAL ENGINEER WHEN CONSTRUCTED. DATE REF: _A.►, F3C�OK 2-1 2- down cope engineerhy PREPARED FOR: Nor?M,A)1 `JI,/4r!-S ' CIVIL ENGIN--ERS LAND SURVEYORS ------------ - BOARD OF HEALTH I REG. LAND SURVEYOR CONTOURS (EXISTING)---------- SCALE (PROPOSED) --O-O-O--O- APPROVED _____.. _.DATE MA Yarmouth & Orleans,MA - DATE