HomeMy WebLinkAbout0033 EVERGREEN DRIVE - Health 33 Evergreen Drive
Marstons Mills
`A-=.103 - 135 M
ERI SULLIVAN ENGINEERING INC.
7 PARKER ROADIP O BOX 659
OSTER VILLE, MA 02655
Peter Sullivan P. E. Mass Registration No. 29733
peter@sullivanengin.com
phone 508-428-3344 fax 508-428-9617
November 2,2012
Thomas A. McKean,R. S. CHO
Director,Public Health Division
Town of Barnstable
200 Main Street
Hyannis,MA 02601
RE: 33 Evergreen Drive,Marstons Mills
Dear Mr.McKean,
As a follow up to our meeting with your staff on November 1,2012,I would like to summarize our
discussion with regard to the above referenced property.
• The property has a Board of Health permit for 3 bedrooms(81-608).
• The property is located only within the Estuaries overlay district.
• The septic system passed a septic inspection in 2008.
• The area of the lot is 43,688 square feet.
• Calculations show that the existing septic system has the capacity for 549 gallons per day.
The owners of the property are proposing an addition to the dwelling that will have a bedroom
bringing the total number of bedrooms to four(4). After our discussion on November 1,2012, it was
decided that present Health Division policy would allow the owner to go forward with adding the
additional bedroom,with no change to the existing septic system,as the existing system has the capacity
to support a 4'h bedroom
I trust this meets your present needs. If you have any questions or require any additional information,
please feel free to call.
truly yours,
Peter Sullivan,P.E.
Sullivan Engineering Inc.
Cc: Stephen&Gail Bunnell
cm
I .
Members of
°' American Society of Civil Engineers,Boston Society of Civil Engineers
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30,00 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 form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
, DATE: -�Z60 Fill in please:
APPLICANT'S YOUR NAME/S: 579 Z,
�,. BUSINESS YOUR HOME ADDRESS: 33 0-dlf)e je t-W 'hK
fi
-53 AM oZty yF
f
TELEPHONE # Home Telephone Number !`I/-333 Z
NAME OF CORPORATION:
NAME OF NEW BUSINESS UN ALL M A*Ata eZ)NS&tr1A16. TYPE OF BUSINESS /LbWAIR- 9U&IekwN6
IS THIS.A HOME OCCUPATION? `v YES NO
ADDRESS OF BUSINESS O OR 3 "/1`ldtIZSTOr1S MI//s M�f- OZGt'/�MAP/PARCEL:N.UMBER /a 3 -/ 35 (Assessing)
When starting a new business there`are several things you must do in order to be in compliance with the rules and regulations o�the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 M,�in St,- (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operat6-"Y r business in tf is town.
BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
r
2. BOARD OF HEALTH
This individual h s ��fogktVhe p ►+rements that pertain to this type of business.
Authorized Signature"
COMMENTS: t
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
r,
r
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Evergreen Dr.
Property Address
P
Estate of Marilyn Cloutier 103 I�
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
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:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
P.O.Box 763
Company Address
Centerville Ma, 02632
�A00 City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
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 5ection,$5.34.0,of
Title 5(310 CMR 15.000). The system:
C-. wY
® Passes ❑ Conditionally Passes ❑ Fail 3
❑ Needs Further Evaluation by the Local Approving Authority G° >
U)
N.
7/15/2008 r °'
Insp tor's Signature Date En rs
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.
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
-
every page. City/Town State Zip Code Date of Inspection
i
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. -
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
33 Evergreen Dr.•03/08 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded .
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/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.
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'' 33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
every page. City/Town State Zip Code Date of Inspection
r
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a,
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or,"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ . the system is within 200 feet of a tributary to a surface drinking water supply
Elthe 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 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
33 Evergreen Dr.-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
i
Commonwealth of Massachusetts
N u Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
El ® this inspection?
® El available
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)]
33 Evergreen Dr.•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is
required for Marstons Mills Ma. 02648 .7/15/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: unknown
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
Seasonaluse? ❑ Yes ® No
l
Water meter readings, if available (last 2 years usage (gpd)): 2006:12,000
2007:6,000
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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):
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
�
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
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:
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 1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
W
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner . Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
every page.. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 14"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: 14"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: 1000 gallon
"Sludge depth: 411. .
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? measured
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
wM 33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
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.):
Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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):
33 Evergreen Dr.•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15.
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
every page. City/Town State Zip Code. Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required).is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008 y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number:
1-1000 gl. LP
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Leaching pit was dry at time of inspection.Stain line is 46"
below invert pipe.
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
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.):
I
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
33 Evergreen Dr.
Property Address
Estate of Marilyn Cloutier -
Owner Owner's Name
information is required for Marstons Mills Ma. 02648 7/15/2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 55'
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:
As-Built Card
El Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data. USED:Technical Bulletin 92-000-01 Plate#2 Annual ranges of
groundwater elevations.
33 Evergreen Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
P` o Regulatory Services
r ,►
IARNSrAB[.E. : Thomas F. Geiler,Director
MA
3 Public Health Division
prEp Mp'l A
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
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 or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations 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 Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTICADisclaimer Private Septic Inspections.DOC
(4��3-33'
4 tbe, e.t - /,o
LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME i ADDRESS
6UILDDER OR OWNER
Lp
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
2
O
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Low d
R ee{�
01
No. ®_ ._. .. ss . ... ..........
THE COMMONWEALTH OF MASSACHUSETTS '9 .
BOAR® OF HEALTH
lvkq !� ! /..._.fN-,.ov..........OF..... / lL/�lST.. :/.7 ...........................
Appliration for Disposal Works Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ') or Repair ( ) an Individual Sewage Disposal
System at
Addr s -or Lot No.
'------------------------------------ ---------------------------- ----------------------•------------................
Owner Address
Installer Address
Type of Building Size Lot...43,-74G.....Sq. feet
U Dwelling—No. of Bedrooms.........3...............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures BE.al1o'arr�
W Design Flow............ . a gallons per er da Total daily flow...........3-3Ggallons.
WSeptic Tank—Liquid capacity,/O gallons Length_Pi_..'.6.... Width.'¢-:'A�. Diameter................ Depth.. =..-#_"
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......../.......... Diameter..../.0......... Depth below inlet...6.......... Total leaching area..Z�Z...sq. ft.
Z Other Distribution box (X) Dosin tank (
Percolation Test Results Performed by. —.. . �.__...................... Date.... ............
,aa Test Pit No. 1....G z..minutes per inch Depth of Test Pit..... 5_6..... Depth to ground water......._.-............
Test Pit No. 2.. _ Z...minutes per inch Depth of Test Pit-_/.a- ...... Depth to ground water._.....--........___.
----------------------------------.................I------------------------------ ------------
Description of Soil.... 3.6..........7.0 _..jug Sci •...---•--
------- ------
W ------------•----------------------------------------------•--- GAO!4 .s?'..........�-.. D...---..............-------•------------------------------------........-----------------
UNature of Repairs or Alterations—Answer when applicable..............................................................................................
.........................................-..............................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT:Z 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 boar of health.
Signed•--•-- ....... • --•--- --•--•-•--•--•-----....... -•.••.........
Date
Application Approved BY �1r/�. v, L�---------------•--------- Cry _
Date
Application Disapproved for the following reasons-------------------------•-----------•------------------•----......-------------•----------------•••......._.....
........................................................................................................................................................................................................
Date
PermitNo.......:................................................. Issued--------•---•-----------------...... -
Date
,t
�. ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1
../._.�_)IV_A ............OF.... ,�! .��. ! " r.:. .�. ........,t'.
Appliratiun for Uiipuiial Workii Tomit /utiun Vrrmit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
...- t1/ .��._��/� `/ •/ �/v/= ...................................................
Location-Address or Lot No.
W } -7I Address
(/ -----•--•-•-----•- -•----•--.-----•--••---•--------------•---------------.--.----.--`---.---------------..---•------
/�i7 T?. 0X le S' Address
Type of Building Size Lot.43.�.�2.. .....Sq. feet
U Dwelling—No. of Bedrooms___........_._..... Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
a YP g ---------•---------•-------• P ( ) — Cafeteria ( )
Other fixtures -------------------------•..-_.�r s %rrelm''+
W Design Flow............11_.r�.._ ......................gallons per--son per day. Total daily flow...........-►...-3.��......................gallons.
04 Septic Tank—Liquid capacity/a gallons Length,-^.'-c-..... Width-�'C-� .. Diameter________________ Depth...~.
Disposal Trench—No..................... Width..................... Total Length.................... Total leaching krea....................sq. ft.
Seepage Pit No-------/........... Diameter..,/.r.2. ........ Depth below inlet..6............. Total leaching area. Z....sq. ft.
Z Other Distribution box Coe ) Dosing tank )
`-' Percolation Test Results Performed b . . Date f
y� d ............. '
Test Pit No. I..........Z....minutes per inch Depth of Test ...... Depth to ground water........................
(s, Test Pit No. 2.55L-. .....minutes per inch Depth of Test Pit./.,$_.6...... Depth td ground water---_•-- ..............
...................................................-................................4... ................. ';.--------------------
O Description of Soil_........2 G'...•......�1r�sOi �G.. � ..
U ...-----•.. -'°��:�e ....-���--•-•-•-----... . `ice
�-
W ------------•.-----------rl.4c l' J.�.----'r-'-�-'-I-n�`a• .....
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TTTL: y g g p y
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed --- ....• ............
j Date
Application Approved By... ..... ........... .. ....... e.
Application Disapproved for the following reasons:-•------------•--•------- ......................................................................................
Date
PermitNo......................................................... Issued....................................... ...............
Date }
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........��wr.,�...............OF.......... .. ........�..............................................
(9rdifirtt#r unt �i�anrr
THIS IS TO CERTIFY, That the Individual.,Sewage Disposal System constructed (✓j or Repaired ( )
b -71 .....=z-es
.'--•----•--•----.....-•----nstaller...----•--•----..................................................•--.Installerat-----•--•••.... a ............... -••-•-------•••.._..hhas been i ed m a coe p ovi ons of T ?'o I: >of e State SanitaryCode as described in the
application for Disposal Works Construction Permit 1' ,f _4::�6tq................ dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE C TR AS A G RANTEE THAT THE
SYSTEM WIL FI! CTION SATISFACTORY.
DATE..,a. .L
r1.1kj......... Inspector fL` •-•----------------------•--•-..........----•---........
THE COMMONWEALTH CHUSETTS \
BOARD OF HEALTH
.... ..... ..............................OF..... ....
N FEE......
�i��ruu�� urk� �un��rnr#iun �i�
~� 1
Permission is hereby granted •-- --------------•--•-•----. --......••--•......---•.......•••......---......
to Construct ( .)/or Repair ( ) a drvi u ewag > al ystem
atNo. f. ----------------------------•-----------------•-•-•-------•-••--•------.--.---
as shown on the application for Disposal Works,Construction Permit N-?5_r' Q -- Dated---rQ- `l- '....1.........
/ - ----------------------------------------
-
ealth
DATE.......................................................................
..-
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS `
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F OIL -,T . ' / ,,,,. ,•. ,.<:.. . _._ : V __-*,. .AT .B 98 . ; ALL WORKMANSHIP _A:ND MATERIALS .
QATE 0 S EST "a FNVE UIL.DLN,G FT.
,. �, =,• , z:. ,, •"; 9., 7� :SWALL CONFORM TO D:E:`Q.E. TITLE
WITNESSED BY . ` -... .., ._ f INLET.,,SEP,.TIC ..TANK,; _Z. FT 5
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. . . ... .. _OUTLETr. :BI:ST.R:IBUTI0 ,- .BOX . 6 S. FT D _
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. _ , . NUMBER `OF: BE-DR .^ _
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G,AR-GAGE D5PO-SAL tJNT'I'... .� 1..,,. . . . NoNf =,;
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OTA.L ES.TiMA'I'ED FLOW (1L GAL/BR/DAY x 3 BR.): 330 GAL
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r. �' .. .. ,Ta 0oA-es�:�` E.OULRED SEPTIC TANK CA .CITY., 49 _ :GAL.
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_L'EACH,ING AREA REQUIREMENTS
/ GAL
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». <. PROFILE OF: X. �: ; G:ROUND WAT,E:R TABLE
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DECK
................
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71
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FAMILY
MASTER BDRM
DINING/KITCHEN -UPI
....... 20'-3"
II
LF
IL
ILIVING
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t
OFFICE/DEN
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10._9" BEDROOM
co CID.
1 31/16"
F
T-8"
7...........I
DECK
...... 88'-5"
LIVING AREA
1502 sq ft
PROPOSED ADDITION
22-p" N
\
S EP
N 3 9 1/2I LVL NOR45
S
7V
c' v YIOB 1 r
30 V16k54 7/IO CATHEDR4 CEILING r(�
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KITCHENETTE
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-- --- _'--- --- UTE ---
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KITCHEN EXISTING '
FAMILY ROOM N
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EXISTING
GARAGE
EXISTING V/
RESIDENCE
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FIRST FLOOR PLAN
1. SCALE: 1/4" it-O" ,✓�-a2
1
1 11
JOB: 1301
DRAWN BY= KW
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.�•� 22'-0' Y,
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1 •v SPACED 32' O.C. I c
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JOB: 1301
DRAWN BY: KW
DATE: 2/25/13
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DOUBLE ROW iV
STAGGER NAILIN °
INTO BOTH PLATES
2.6 DBL TOP PLATE lT/w'� (,`vy,)■
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RAFTER TO PLATE CONNECTION STAGGER NAILIN
SCALE:N T.5. INTO BOX AND SILL
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JOINT DESCRIPTION Nur1BER of NLIMBER OF NAIL SPACING
COMMON NAILS BOX NAILS
ROOF FRAMING N
Z
BLOCKING TO RAFTER(TOE NAILED) 2-Sd < 2-I06 EACH END O
RIM BOARD TO RAFTER(END NAILED 2-lid 3-16d EACH END
WALL FRAMING V�
SHEAR WALL COMPLIANCE=
TOP PLATES 4T INTERSECTIONS(FACE NAILED) 4-I6d B-Ibd AT JOINTS !L Q
STUD TO STUD(FACE NAILED) 2-16d 2-16d 24'O.C. W. Bm OF EACH WALL RUN
HEADER TO HEADER(FACE NAILED) 16d I6d 24'O.C.ALONG EDGES VERTICAL SHEATHING WITH 4 w
FLOOR FRAMING Bd NAILS 3' EDGE/12'FIELD L
(4)16d NAILS PER FT H(T TOM PLATE Q
JOIST TO BILL, TOP PLATE OR GIRDER(TOE NAILED) 4-Sd 4-IOd PER JOIST L� 15% OF EACH WALL RUN Z
BLOCKING TO JOIST(TOE NAILED) 2-Bd 2-IOd EACH END
BLOCKING TO SILL OR TOP PLATE(TOE NAILED) 3-Iid 4-16d EACH BLOCK VERTICAL SHEATHING WITH LLI
8d NAILS 3' EDGEAV FIELD w
LEDGER STRIP TO BEAM OR GIRDER(FACE NAILED) 9-16d 4-I6d EACH JOIST (4)I6d NAILS PER FT HpTTOM PLATE
JOIST ON LEDGER TO BEAM(TOE NAILED) 3-Sd 3-IOd PER JOIST LL
BAND JOIST TO JDIBT (END NAILED) 3-16d 4-I6d PER JOIST UI
BAND JOIST TO SILL OR TOP PLATE(TOE NAILED) 2-160 3-I6d PER FOOT
ROOF SHEATHING
Lu
WOOD STRUCTURAL PANELS >
RAFTERS OR TRUSSES SPACED UP TO 16'O.C. ad IOd 6'EDGE/6'FIELD W
RAFTERS OR TRUSSES SPACED OVER 16'O.C. Sd IOd 4°EDGE/6'FIELD
GABLE ENDWALL RAKE OR RAKE TRUSS w/o GABLE OVERHANG Sd IOd 6'EDGE/6'FIELD m
GABLE ENDWALL RAKE OR RAKE TRUSS w/STRUCTURAL Bd IOd 6'EDGE/6'FIELD
OUTLOOKERS
GABLE ENDWALL RAKE OR RAKE TRUSS w/LOOKOUT BLOCKS Bd IOd 4'EDGE/4'FIELD
CEILING SHEATHING — OF
GYPSUM WALLBOARD 3d COOLERS - 7°EDGE/10'MELD
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WALL SHEATHING
WOOD STRUCTURAL PANELS \.
STUDS SPACED VP TO 24'O.C. Bd IOd i'EDGE/12'FIELD
s
Y'AND-V FIBERBOARD PANELS Sd - 3'EDGE/V FIELD
GYPSUM WALLBOARD Sd COOLERS - 7'EDGEAO'FIELD
FLOOR SHEATHING
WORD STRUCTURAL PANELS
P OR LESS Dd IOd 6'EDGE/1'FIELD
t GREATER THAN I' IOd I6d 6'EDGE/&'FIELD
JOB: 1301
DRAWN BY: KW
DATE: 2/25/13