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0014 JOHNS PATH - Health
14 Johns Path 7f r ASSESSOR'S M'AP NO. PARCEL I �v L6.C,A 1•ION EW A C E PERMIT N0. V.IL' LKCE .IN ST ALL ER'S NAME A ADDAESS Zf6 14 C v � / S Ul L D lF R OR OWNER j-f %ti �S DATE PERMIT ISSUED . . . - 4 4, DAT E COMPLIANCE ISSUED . z ° M t �P i d 17' �R lu t I , r • '" 1 Commonwealth o#Massachusetts Title 5 Officied Inspection Form Not for Voluntary Assess>'nertts Subsurface F Dis Sewage I em 9 pose .Syst Form cr�d�A`r Cc' Inspection results must be subinitt ed on this form or on the official Title 5 lnspecttdn Form dated 6/1S/ M.Inspection forms mail not be alfiered In any MW A. Certification out 1. Property I formatioftme an dw (Cn: i nn PY COMPda.use To A 41 P11-2 only the tab key to ma,►e your ,R dI C airwr-do not Owndfs Nafie IQ owneMe -,, W 10r2r city/rown state �, Zip code Data of Inspection: f LAAM Date 7-j- 2 Ins . !\ Aj Na of � �' I't JCL Cory tic �l�t ems( e d Tetephime Number Certification Statement: I certify that 1 have personally lnspected the sewage disposal system at thfs address anti,that the was pinform reported below is true acxxuate and complete as of the time of the fnspec or.The fr4ecdon my train ing and experience in the proper function and maintenance of on sde sewage disposal systerr s.i am a DEP approved system inspector Pursuant to Section 15.340"of _0 Title 5(310 R 1S.000)..The system: ti-- �-- cj M4 asses 0 Condrtior;W Passes ❑ Falls ❑ F a by the Local.Approving At ortiy j Z4 The system inspector shag submit a cwpy of this Inspection report to the Approving Atrttrority,(Board of Health or DEP)within 30 days of completing this inspection.if the system is a shared system or has a design Clow of 10,0oo gpd or greater,the Inspector and the system owner shall submit the report to the appropriate regfona!otlice of the DEP.The original should be seat to the system owner and copies sent to the buyer,ff applicable.and the approving authority. *"*This report only describes conditions at the time of I at that time.This I Inspection and under the conditions of use the same or diffeThis Inspection on f of address how the system will perform in the future under t5kisp doc•112004 Tilt 5 OBicu Mspec*m Form:Subsume Sewge Dbpwa System. . Page 1 of 16 i ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Volunt ary A►s"ments Subsurface Sewage Disposal System Form A. certificatio (cons) " Addrmry — s owner's tame Deb of ho„ Inspection Summary:Check A,B,C,D or E 1 ahvays complete all of Section D A) System Passes: have not found any Infommation which Indicates that any of the fallure criteria described In 310 CMR 15.303 or in 310 CMR 15.304 exlst Any failure criteria not evaluated are Indicated below. Comments: �%j A�.j lh.-JC , B) Systern Conditlona0y . ❑ One or more system , as described in the"Conditional Pass'section need to be replaced or repaired.Thelsystem,upon completion of the replacement or repair,as approved by the Board of Health,win pass, Answer yes,no or not determined(Y.N.ND)In the[]for the following statements.if°bat determined;please explain. ❑ The septic tank Is metal and over 20 years old"or the septic tank(whether metal or not)is will unsound,exhibits substantial infiltration or or tank Wure is Imminentpass Inspection if the existing tank Is replaced with a cxxrrplying septic tank as approved by the Board of Oealth. metal septic tank w01 pf ss inspection if it is structurally sound,not leaidng and If a Certificate Of Compliance Indk sting that the tank Is kiss than 20 years old is available. ND Explain: i i i i 44I i Mnsp-doc-11 Tdo 5 Offldaf!r»pet n fortrxSWMffftw S WM&Disposal systan- Page 2 of 18 i I 1 I 1 - Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessnwnts Subsurface Sewage Disposal System Form A. Certification (cons) s� — ZIP Code C S' e,Je'e�Z -�j c1413 e/. OWTHAPsteam$ Date of frame B) system Conditionally P (conL): ❑ Observation of sewage backup or break out or high static wafer level In the disinbution box due !"(J to broken or obstructed pipes)or due to a broken,settled or uneven disinbu4on box.Sysfem will Pass inspection if(with approval of Board of Healthy i ❑ broken pipe(s)are replaced ❑ obstruction Is removed I ❑ distribution box isl leveled or replaced ND Explain: j i i i ❑ The system required pumping mxNre than 4 times a year due to broken or obstructed pipe(sy The watern will pass if(with approval of the Board of Healthy ❑ broken tlpe(s)are replaced ❑ obstruction is removed ND Explain: I i I 1 C) Further Evaluation is Required by the Hoard of Health; ❑ Conditions exist Mich regrt further exaltation by the Board of Health in order to determine if the system is failing to pro lent public health.safety or the environment '<1 1. System will pass unless Board of health determines in accordance with 310 CtiAR 15.303(1)(b)that the syst m is not functioning in a manner which win protect public health, safety and the environment ❑ Cesspool or privy is within 50 That of a surface water ❑ Cesspool or privy within 50 feet of a bordering vegetated wetland or a salt marsh i Title 5 official M$Pftdm Form:Subst aws Sewage o Page 3 of 16 i ' s Commonwealth of Massachusetts .Title 5 OfficW. Inspection Form Not for Voluntary Assessments Subsurface Sewage Dispos 31 System Form A. Certification (cunt.) _ l qStaft Tot-4 C e,-j c I zo txae Owmes Nam I pate of hwecum i C) Further Evaluation Is Required by the Board of Health(cont.): i 2. System will fall 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 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. I ❑ 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 won"*. Mefhod used to detemnino distance: 1 **This system passes if the,well water analysis,performed at a DEP c oMed laborafory,for coliforrn bacteria and hrolaU'le organic compounds Indicates that the wen Is free from pollution from that faa'lily and the w user ce of ammonia nitrogen and nitrate nitrrogen is equal to or less than 5 ppm,provided that no othiW failure criteria are WMered.A copy of the analysis must be attached to thts fiDTM. i i 3. Other. 1,� J S I i 1 i Tie 5 OWOM InspecGon FomL Sulst,rfaoa sew8ge Dbpwd system► Pap aof,1s i I i i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont) ' C�Is1 l y Ow mes Naw Dare at pectic n f D)System Failure Criteriaplicable to All Systems; You must indicate"Yes"or"No"to each of the following for all Inspections: Yes No ❑ Badarp of sewage into fad{ity or system component due to overloaded or SAS cesspool ❑ Disdmrge ogged or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool ❑ Static Qquid level in the distribution box above outlet invert due to an overloaded or d SAS or cesspool ❑ than Uqu cesspool rs less bran 0'°below invert or available volume is less ❑ Required pumping more than 4 times in the last year NOT due to dogged or obstructed ph*s).Number of times pumped: ❑ 1 Any poi ion of the SAS,vesspoOi or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any poition of a cesspool or privy Is within a Zone 1 of a public well. ❑ Anyportion of a cesspool or privy is within 50 feet of a private water supply ❑ Any portion of a cesspool or privy is less than 1 W feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis,IThis m�P N tlhe well water analysis,performed at a DEP certified rY,I COMM bacteria and volatile organic compounds iBtu icates that ifs well Is tree from pollution from that facility and the Pes, ce ofammonia nitrogen and nitrate nitrogen Is equal to or less ppm,Provided that no other fallure criteria are triggered A copy of the a Is must be attached to this form.] Yes No - ❑ The system fails.I have determined that one or more of the above failure criteria exmst as described in 310-CMR 15.303,therefore the system farts.The system i mner should contact the Board of Health to determine what wig be necessary to correct the failure. .doc•1112N TWO 5 FWW Subsurface SewageDkPoSdsydW pages of 16 i Commonwealth of Massachusetts Title 5 Offici ' l Inspection Form Not for Voluntaq Assessments Subsurface Sewage Disposal System Form . A. Cerrtifi`cation Pont) Address OAR 7r/o CA -w CP,!j VZC-)Z owners Na Dana of lnspecton 1 E) Lard Systems: To lbe;conskkred a merge system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"Yes"or are to each of the Wowing,in addition to the questions in Section D. YES NO ❑ ❑ the system Is within 400 feet of a surface drinking water supply i ❑ the sysi-tem is within 200 feet of a tributary to a surface drinking water supply the m is located in a ❑ sy�te nitrogen sensitive area(interim Wellhead Protection Area;IWPA)or a mapped Zone If of a public water supply well If you have answered eyes'to any question in Section E the system is considered a significant threes, or answered'yres"in Sedior D above the Large system has failed The owner or operaW of any large system considered a significant threat under Section E or failed under Section D shall upgrade tare system in accordance with 3C 0 CMR 15.3044.The system owner should contact the appropriate regional office of the Do I f i I `t I i I i I - i I " I rSutsp doc•1 t/2004 Tile 5 Orr kM)eCUM Fam&ftu face 1 Page6 i I i i I Commonwealth of Massachusetts Title 5 official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal'System Form B. Checklist .ell 2 c rraw — ZfP coda Owns NameDatealkipecodn Check if the following have been done.You must indicate W or W as to each of the fdbwing: 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? 0 Have large volumes of water been introduced to the system recently or as part of this inspection? fq+� Were as',bunt plans of the s❑ system obtained and examined?(!f they were fiat available none as WA) ❑ Was the'fadRy or dwelling inspect for signs of sewage back up? ❑ Was the site Insp ected 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 flees,material of construction, d'anensions,depth of Hquid,depth of sludge and depth of scum? ❑ Was the facmy owner(and oocuparmts if different from owner)provided with information on the primer maintenance of subsumfaoe sewage disposal systems? The sizeand 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 aPPraxfmation of distance is unacceptable)[310 CMR 15.302(3)(b)j LgnW doc-1 MAN rite 5 Official 1 nsn Form:Subsurface Sewage DeposW Sysmem. r Page 7 of 16 Cominonweaft of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information z� stme zo coae 7r�e dwmWs NWW Deft kMeCUM r Residential Flew Conditions: Number of bedrooms(design): Number of bedrooms(attualx DESIGN flow based on 310 CMR 15203(for example:110 gpd x#of bedrooms): =z Number of current residents: Does residence have a garbage grinder? ❑ Yes [ No Is laundry on a separate sewage system7 fif yes#separate inspection required] ❑ Yes No i Laundry system inspected? Yes ❑ No Seasonal use? ❑ Yes No Water meter readings,if available(Nast 2 years usage(gpd)y Sump pump? ❑ Yes [ ��No t / Last date of occupancy. Comore tlaUtndustrial Flow Conditions: Type of Establishment: j f Design flow(based on 310 CHAR 15.203): Gebw Per day Wd) Basis of design flow(seaW sq.fL,etc.): Grease trap per? I ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if avalll ble: Last date of occupancy/use: Date Other(describe): i Mnsp doc•MAN AN Title 5 OMdai ingmdon Fonir . ePage58d16 i� f fz k f . Commonwealth of Mafsachusetts .Title 5 official Inspection Form Not for Voluntary Assessments . Subsurface Sewage Disposal System Form C. System 19fo►un `on (cons) Y j r Code owners to t»CN k"ecrm General information Pumping Records: Source of irrforrrtation: Was system pumped as part of the inspection? Yes ❑ No If yes,volume pumped: gaBOM 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)Cif yes,attach previous inspection records,if any) ❑ lnnova#%WAftemaWe technology.Attach a copy of the current operation and maintenance Onhad(to be obtained from system owner) ❑ Tight tank Attach a copy of the DEP approval. ❑ Other(desca'le): Approximate age of all cpmponents,date instal!pd im)vm)and source of information: Were sewage odors detected when arriving at the site? ❑ YesX ] No tftsp doc•1 MAN Me 5 ofr"kmxcrion Fom Substnr Sewage Dbposa systm. Page 9 of 16 Commonwealth of Massachusetts Title 5 Official. Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (coat.) PIC AP A dd S Zip Code OwnesNwv paW of ikon Building Sewer(bate on site plan): Depth below grade: n j �(f 'mac Material of construction: ❑cast iron ❑40 PVC ❑other(expialn) Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,eta): Septic Tank(locate on site planx y�1 Depth below grade: feet Material of construction: Qt-oncete O metal O fiberglass O polyethylene ❑other(e)plain) If tank is metal,list age: Is years certificate) by a Certificate of Compliance?(attach a copy of o,y,� Ho r� es O Dimensions: z L� Sludge depth: Distance from top of sludge to'bottom of outlet tee or baffle L/ Scum thickness 3�< Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum tD bottom of outlet tee or baffle l i How were dimensions determined? d�� tWzp.dm-11120D4 Title 5 OWxW kapectlm Form Subsurface Sewap pbPWW stem Pape 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form h C. System Information (cons. R�� Zip cone ow vies Dare of fps Comments(on pumping recommendations,inlet and outlet tee or baffle condign.structural integrity. liquid levels as related to outlet invert.evidence of leakage.etc.): Grease Trap(locate on site plan)k/ Depth below grade. feet (r Material of construction: concrete ❑metal D fiberglass ❑polyethylene other(explain): i Dimensions: Scum thickness Distance from top of scum to top of outlet flee or baffle Distance from bottom of scum to bottom of outlet flee or baffle Date of last pumping: Date Comments(on pumping recommendations,inlet and outlet tee or baffle condition,struc kiral integrity, liquid levels as related to outlet invert evidence of leakage,etc.): Tight or Holding Tank(tank OW at time of Inspection)(locate on site plan): Depth below grade: " Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): t5tnsp doe-1112004 Tice 5 Offtdat Inspection Fume Submsface sere Dbposaj SySWM- Page 11 of 16 r commonwealth of Mask chusetts .Title. 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disp i sal System Form C. System lnformapdri Cont c Zo code Date cff Mspecom Tight or Holding Tank Dimensions: capacity: Design Flow: ( gaum per day s Mann present: i ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes❑ No Date of last pumpkng: Date Comments(condition of alarm and float switches,etc): j� I DWbution Box(if �must be opened)(locate on Re plan): Depth of 1'rgted level above outlet invert Comments(note If box Is"I and distribution to outlets equal.any evidence of soft carryover,any evidence of leakage Into or out of box,etc.): �? y � jam, I s I Pump Cumber{locate on s!W plan): Pumps in working order. i ❑ Yes ❑ No i Alarms In working order. [Q Yes ❑ No I { tsmA,.ax•ttt2ooa ! IWe 5 OMcm kWpectton Farr Subsurlaw SevW9 Dbposd syrsWm- Page 12 of 18 { I i i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Inf9irmation (co Q //S' l 6 --2 4C AY yRn � State_J Zip Code Owner's Name V Date of Inspection Comments(note condition of pump chamber,condition of pumps and appurtenances,eta): 1� Soil Absorption Sy stem(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: 3 S S % I UW Type: ,❑ leaching pit I number. LLY leaching chambers number. ❑ leaching galleries number. f ❑ f leaching trenches number,length: ❑ leaching fields number,dimensions: overflow cesspool number ❑ innovative/altemative system Typetname of technology. Comments(note condition of'soii,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): i S/tom i 1 t}k 4 t5nsp.doc•11/2004 k Title 6 Official inspection Form:Subsurface Sewage Disposal System. i Pap 13 of 16 i i i i Commonwealth of Massachusetts Title 5 4#ficial Ins ection Form p Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt. -MPWYAOftW A `h - -- Wrom Owns Deb of hen Cesspools(cesspool must be pumped as part of Inspection)(locate on SRO plan): 'Number and configuration j Depth—top of liquid to inlet invert Depth of layer Depth of scum r Dimensions of Materials of construction i Indication of groundwater inflow ❑ Yes ❑ No Comments(note condtion of soil, f hydraulic failure,level of ondi condition of etc.): D ng. veetation, t f 1 1 t 141Privy pocate on site plan): 4 Materials of construcfi t Dimensions Depth of solids Comments(note condfb'on of 101,signs of h failure,level of ponding condition of vegetation, i { t t i i 15 M doc-11/2004 Tdle 5 oflic is lnwoc ron Form:8obsu"age Disposal 3Ys Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection F arm { Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 1I ,, Properly dress 1 �ti s City/row s III t — Zip Code Owner's Name j Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water. Please indicate all methods used to determine the high ground water elevation: Lam' Obtained from system design plans on record 1 If checked,date{of design plan reviewed: pate i 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: i You mW describe how you establis the high ground water eleva ' n: . c- — t !>�.-7 1 t5insp.doc-1112004 { Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 l Commonwealth of Massachusetts Title 5 Official Inspection Form Asses ments Not for VoluntaryInspection Subsurface Sewage Disp8sal System Form C. SYStem hformation q vL� S� 7 ZiOCOde Or.,,er s rvame i o Data Of hqMCGOn Sketch Of Sewage Dtsposal System;Provide a sketch of the sewage disposal system Wuding ties to at least two permanent reference landmarks or berrchrnarks.Locate all wells within 100 feet Locate where public water suppiy enters the building. S j �7 t l I � 1 I s I I t5�spaoc•i�r�a f �4 Ttti e 5 OMCW kwPOWM Fonm Su p bpww ii Page of io I z TOWN/OF BARNSTABLE oo ° C k LOC'►AnON IVI' Ja J 7`� SEWAGE # VILLAt � r Z` a ASSESSOR'S MAP & LOT lV - 116 INSTALLER'S NAME&PHONE NO. r�aY���T�i /Ow3��� ��S-�1�G SEPTIC TANK CAPACITY DOD GAG coo LEACHING FACILITY: (type) 3—c.0 GeL tflmA� 63) (size) NO. OF BEDROOMS C� BUILDER O OWNER Ye PERMITDATE: G S"'O COMPLIANCE DATE: 02 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f Feet Private Water Supply-Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �s6 Feet Edge of Wetland and Leaching Facility (If any wetlands exist i within 300 feet of leaching facility) Feet Fumished by /I vy 6 iw� a� 366 " I 7�6 COO THE COMMONEALTH OF MA1IS�-S_ACHUSETTS Entered in computer. W Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Dtgogal bpgtem Comaructton Vermit Application for a Permit to Construct( )Repair( )Upgrade(P Abandon( ) ❑Complete System Pndividual Components Location Address or Lot No. / Owner's Name,Address and Tel.No. Assessor'sMap/Parcel Installer's Name,Address,and Tel.Nog Ic O tU Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 7 Lot Size Z l>Zsq.ft. Garbage Grinder( � Other Type of Building r YZIFNo.of Persons Showers( ) Cafeteria( ) Other Fixtures �f Design Flow gallons per day. Calculated daily flow gallons. Plan Date ZS— e Z Numbe} of sheets Revis on Da e Title 71/ 5 v�L° !R'r'I ® f .S )0? Size of Septic Tank levlo Type of S.A.S. Description of Soil �3 3 S X/Z• f`J��'� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b his Bo d o ealth. Signed Date Application Approved by /I✓- `i�_ Date d Application Disapproved for the following reasons Permit No. Date Issued 6 'a— _VNo. _ ,� MONWEALTH OF MASSACHUSE �...-� :��� � �f"`" " � ,�.��*'-f•'' Fee THE COMTS Entered in computer: tom/ Yes 4 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpprtcation for Mtgpozal *pztem Cott 5" 'Citofi i3ermit Application for a Permit to Construct( )Repair( )Upgrade( P Abandon( ) El Complete System I [individual Components Location Address or Lot No. Owner's Name,Address and.Tel.No.. Assessor's Map/Parcel Installer's Name,Address,and Tel.No, C U _ A' Designer's Name,Address and Tel.No. -7��- Type of Building: A,�.� Dwelling No.of Bedrooms Lot Size 2-1©1Z sq.ft. Garbage Grinder(_7 - Other Type of Building ) CPetln'-No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �`7 gallons. Plan Date A—Al Z Nurnbe5 of sheets Revis on Date Title 7-1 71f' 5 ✓lt� / �>`'� Size of Septic Tank f QD O Type of S.A.S. /3'— Q09�/ C' Description of Soil 1 3r- Nature of Repairs or Alterations(Answer when applicable) Date last inspected., Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is o d of ealth. /Z �QZ Signed a Date Application Approved by Date &S d 7 Application Disapproved for the following reasons r Permit No. Date Issued 67 S T 'x- t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certtftrate of (Compliance THIS IS TO CE, , that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(4--1 Abandoned )by at at l ✓d 5 Q� A/� �®/11� /�l S has been constructed inf ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2/J —07 6 dated :2.�/� a Installer Designer r The issuance o this permit shall not be construed as a guarantee that the syste ill tion as desi. nle�d-. Date 3S �l U�- Inspector_ � ..�✓��;l 1 i - fu - --------------------------------------- No. POUj — Fee, r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS lotgaal *pgtem Con.5 ru tton Vermctt Permission is hereby granted to Construct( Repair )Upgrade(✓)Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Con truction must be completed within three years of the date of thisgermit. Date: Approved by � TOWN/OF BARNSTABLE LOCATION /y �d�✓.t T�i SEWAGE # / � G, �ZL/ :e AP & LOT -ASSESSOR'S MQz I� VILLAGE / INSTALLER'S NAME&PHONE NO. �aY)e�7��� SEPTIC TANK CAPACITY J,DOO GAL � O LEACHING FACILITY: (type) 5-ao (size) /3 �33,f �9• NO. OF BEDROOMS BUILDER O OWNER A PERMITDATE: COMPLIANCE DATE: U 2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply-Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by / ovy I , 366" - /3 s S✓ , ilk Crocker, Sharon From: Crocker, Sharon Sent: Wednesday, September 26, 2018 4:19 PM To: Bellaire, Dianna; Flynn, Judith; Soto, Kathryn; Sousa, Vanessa Subject: 14 John's Path, MM - Accessory Affordable Apt.Applic. The owners will be bringing their floor plans in—hopefully, Monday, Oct 1, 2018. Their original application is in the Holding Tank. —Tom has signed it BUT he needs to see Floor Plan before releasing application. Once it arrives, please pull street folder and give to Tom. (copy of application will be in street folder) Thank you. Sharon I Health Department Drop-Off Hours:-800 AM — 4:30 P.M Town of Barnstable Received by Health �T"E, Regulatory Services Department on BARNSMBIE, Richard V.Scali,Director � s MASS. Public Health Division 039. FDMAr� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE Property Address: /T-" �,T 1_)n ` Assessor's Map/Parcel Number: b a 7 - // 4'- 2=00 COO d Applicant(s) Name: t- TO-Ines sperweore- Phone: SW&V ,5 E-Mail: . P47. 4040 IF Size of Lot: 2a. How many bedrooms exist at your property now? �` 2b. How many bedroom are you planning to add as part of the Accessory Affordable Apartment Program application? 2c. How many bedrooms total are proposed at this property (including the Accessory unit)? 2e. Is the proposed Accessory Apartment contained within: the main house; OR a detached structure 2f. Submit floor plans for all buildings on the entire property. Show all existing rooms in the dwelling and the proposed accessory apartment. Label each room clearly. Label measured width of all open doorways. Use straight edge for hand drawn plans a d e sure all label' g is legible. Signed- Date: f do 1 t ► ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE FOR STAFF USE ONLY 1. Is the dwelling connected to Town sewer? ❑ Yes ❑ No 2. Dwelling located ❑ INSIDE ❑ OUTSIDE the Saltwater Estuary Protection Zone 3. Dwelling located ❑ INSIDE ❑ OUTSIDE public supply well Zone of Contribution 4. Dwelling is connected to ❑ ON-SITE WELL ❑ PUBLIC WATER 5. Disposal works construction permit on file? ❑Yes ❑ No 6. If yes, how many bedrooms were allowed by this permit: bedrooms 7. Were building permits obtained for additional bedrooms? ❑Yes ❑ No 8. Engineered septic system plan: a. On file at the Health Division? ❑Yes ❑ No b. If proposed accessory unit is detached from principal dwelling, is that plan on file? ❑Yes ❑ No 9. Existing septic system capacity is bedrooms For the accessory unit to receive approval from the Health Department the following action must occur: ❑ Existing system accommodates proposed additional bedroom(s) ❑ Upgrade existing system to accommodate additional bedroom(s) ❑ Must remove a bedroom from the main house ❑Must connect detached structure to the existing septic system ❑Must install septic system for the detached structure 29 Othe 61AJ �,a �,,o,,�� L`°4 17�j: 1x ro4� � �U rew�aee 'C1� YU � �o��f b � Signed Date � 2 Health Department Drop-Off Hours,-8:00 AM - 4:30 P.M Town of Barnstable Received by Health 7 oIMEQn Regulatory Services Department on Richard V.Scali,Director RAMgrABM " Public Health Division Fo +" Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE Property Address: Assessor's Map/Parcel Number: 0OZ 7 - /'® 4pXZVC700 Applicant(s) Name: 94%elle- Phone: SaPido 6244 E-Mail: Size of Lot: 2a. How many bedrooms exist at your property now? 2b. How many bedroom are you planning to add as part of he Accessory Affordable Apartment Program application? ar e 2c. How many bedrooms total are proposed at this property (including the Accessory unit)? C 2e. Is the proposed Accessory Apartment contained within:, the main house; OR a detached structure 2f. Submit floor plans for all buildings on the entire property. Show all existing rooms in the dwelling and the proposed accessory apartment. Label each room clearly. Label measured width of all open doorways. Use straight edge for hand drawn plans a d e sure all label'pg is legible. Signed- Date: _fZ71 l ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE FOR STAFF USE ONLY 1. Is the dwelling connected to Town sewer? ❑ Yes t No 2. Dwelling located D1 S,IDE ❑ OUTSIDE the Saltwater Estuary Protection Zone 3. Dwelling located INSIDE ❑ OUTSIDE public supply well Zone of Contribution 4. Dwelling is connected to ❑ ON-SITE WELL B-171 BLIC WATER 5. Disposal works construction permit on file? es ❑ No hp-.Z a® 60� 6. If yes, how many bedrooms were allowed by this permit: —[ bedrooms 7. Were building permits obtained for additional bedrooms? ❑ Yes ❑ No 8. Engineered septic system plan: a. On file at the Health Division? ales ❑ No b. If proposed accessory unit is detached from principal dwelling, is that plan on file? ❑Yes ❑ No 9. Existing septic system capacity is bedrooms For the accessory unit to receive approval from the Health Department the following action must occur: ❑ Existing system accommodates proposed additional bedroom(s) ❑ Upgrade existing system to accommodate additional bedroom(s) ❑ Must remove a bedroom from the main house ❑Must connect detached structure to the existing septic system ❑Must install septic system for the detached structure Other P` "1e ISV6" � � �-• � ,notj1 1�►®.� -z"' �e fo0 a^ 1,3 iU S Tlccr. — Signe Date �L 2 Qy - - - - -- - - WEI U PLO J ' 'T li LL u - v f cacEf — — � M� �Thr7s N 1 � I i _ G7 Ono 1 � � 40,: - -- - - u 77 ----------------- a I 4 i- - - -- - 'r5�- MA I L 0 oil � c7 U w o r �,,,. .. • . ..�,� _ _.,cam ..�,,., .� �. _�,.,,•��.�»=.��- id TPO-KN OF BARNSTABLE LOCATION•I` , �S SEWAGE # SESSOR'S MAP& LO INSTALLER'S NAME&PHONE NO. �dh JC,( a�bl l�/POa�b I! lTt6 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ni 1 r. (size) NO.OF BEDROOMS `(� BUILDER OR OWNER QS® OW' Ci PERMIT DATE: —1 � D COMPLIANCE DATE: SS Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 4- Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) J rJ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility, nCAR-J Feet Furnished by arl \\��� 7/•�E�/`1� v qPT' a g RA 3-7a Be qa . 1 . ASSESSORS MAP N0: - �^_ � - PARf�I NO a_ � � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... 1N...N.........OF.......... R.N57Qblrn-&................................... Appli-ration for Diipoott1 Workii Tontrur#ion Permit Application is ereby made for a Permit to Construct ( t1,6r Repair ( ) an Individual Sewage Disposal System at: O H NkS PAT Address or o. .---` ...: " ddress........................................... a Installer Address d Type of Building - Size Lot.CZQ ...Sq. feet U Dwelling—No. of Bedrooms........ -Expansion Attic Ava Garbage Grinder,(Vo per., Other—Type of Building ........... ��t.... No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ------------------------------•• - W Design Flow.......................S.L:!5..........gallons per personer day. Total daily flow__..Jam. .........................gallons. WSeptic Tank—Liquid capacit}��.�` _.gallons Length- :.q..... Width.y'........... Diameter................ Depth.-._._.......... x Disposal Trench—No. .................... Width..........::........ Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..j!!5W,6----_ Diameter......../..e5...... Depth below inlet................. Total leaching area.2.49-5..sq. ft. Z Other Distribution box ( ) Dosing t nk �I ) `, /// 7 //aJJ��,, '� Percolation Test Results Performed by...... :. Date..........l:_.....1.._.Ul......... a Test Pit No. 1.........-_-minutes per inch Depth of Test Pit..... _• ._ Depth to ground water_ ... Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ --••----------------------------------------------------------------------------•-•----•--------......-•---..............---------------................----- O Description of Soil............... . -----• . ---- ---- •--------------------------------------- ----.----- Ay x --------------- - �l- 1�1 - ! ------------------------------------------------------------............--•-- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------•-------------------------------------------•---•--•------------......------....._..........----•----------•------------••••--•-------•-------•-•---•---•----•--•----------•---•.....-•••------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is y the and of health. -- . ..... ...... . ........ ........................................... --- . ......... . Date Application Approved By-----•-- ............... ......• ........ .. ....... ............................. ..._ ..... Date Application Disapproved for the following reasons--------------------------------------------------------•----...-•-----------•--•--•---------------•--••••..... .................................•---................._...-----•-•----------------------.................---------------•-------....---------------------------•------------------------•---•--••------- Date PermitNo....... ... --. Issued....................................................... Date — -- - - - - --- No. ?..�.�.....:5... l Fss.. 1 j THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............:....OFII.t ! .. lr .17..................................... Appliration for Disposal Works Tonstrurtion rrrutit Application is hereby made for a Permit to Construct (a or Repair ( ) an Individual Sewage Disposal System at: +-i NS .., T 2 ..-- . . ........�..�.. L.1.�. ....•--- ••---...... .......................... ........ adres5 -- ...... l.S�.[l(!.. lt'7f ..1.:..1..--- Y------------------------- Address .... "` ..../ �..... fn .� .�. y {�:.... .... Y......... ................ I staff ller `7n c�;���d0ress ding 3 zb Lo ......... . ..Sq. feet aDwelling—No. of Bedroom ........ .1�-------------------------Expansion Attic Garbage Grinder aOther—Type of Building ----------- No. of persons............................ Showers ktleL— Cafeteria" dOther fixtures .-------•----------------------•-----------••-•-----------------------------------------------------.-•- Design Flow............... ,5................gallons per pegrson�er day. Total daill,Y�flow.... .._.........._...... Ions. Septic Tank—Liquid ca.paci allons Length.' Width_ <..... Diameter................ Depth............... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area... sq. ft. 3 Seepage Pit No..I�l(1�.. Diameter.................... Depth below inlet....... :........... Total leaching area..-�O ft. z Other Distribution box Dosing tj�nk ( i '-" Percolation Test Result Performed bY.._�.,!-. .._L./ Q �:...... ......................... Date �2JRa....:.. a ,..1 Test Pit No. 1................minutes per inch Depth of Test Pit& .u,5.. Depth to ground water.. l . fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit................... Depth to ground water........................ 9 ............................................................... ................ ------ D Description of Soil................ :..-•-- --.- : ............... /, ..... -:::�::: --:_.. ....... ....................... W .............................. ..............-----••-••---- V Nature of Repairs or Alterations—Answer when applicable.......................................................................:...._.................. Agreement: a.. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 5 of the State Sanitary Code— e unOrsigned rther agrees not to place the system in operation until a Certificate of Compliance bee d lby th .boa Zlt R V Date Application Approved By......................i ..... --- ,.... ::_ -- Application Disapproved for the following reasons:............................................................................................................ -•-•...................................••-----•-----.......------.............--•-----...............................................................................................................- Date Permit No...... Issued-..................Date ............................._ . Date THE COMMONWEALTH OF MASSACHUSETTS _ /�, BOARD OF HEALTH ......1 4.4401.fl..........OF.... ........................... Trrtif utttr of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) by.............................. ..... .... ----..........-----.........-- .•........ -•---•---..... ....... ...... ._...._ { /,- at.......... ��::E........•- �/�� ..... Tel .... has been installed in accordance with the provisions of TIT 5 of. to Sanitary Cod de r in the application for Disposal Works Construction Permit No......... _.-_ dated.............. 2. -• .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... -...... ............. Inspector......_... ...............................--•........_................. 2.Z THE COMMONWEALTH OF MASSACHUSETTS J BOARD OF-- EALTH s-!5A 1..�-1..1�1!'.jdV�..............OF.. No........ ....... � �--............ F .. .•....... Disposal Works Tonotrnrtion rrrutit Permission is hereby granted.__-.-...-.,.::: to Construct ( ) r $ppair ( ) an'I Sl�i` System �'j at No... ............. ....... 15 .•. ----•-..._•--..............-_. •-•------•--•---.....-•---••-------...................--........:......... Street as shown on tv appl' tion for Disposal Works Construction� Permrt�o j..;�^�t ated..........................................a �� -----------------•--------------=•.......... ..............--------..............------................._ Board of Health DATE.......................•--•-----••---........................................... FORM 1255 A. M. SULKIN, INC.. BOSTON I - �E� } John Grad D.E.P. Title V Septic Inspector ._: 564-6813 1/ ' o v ' - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK f Address of property J ocw' owner's name Date of Inspecti PART A - - -- CHECKLIST - Check if the following have been done: Pumping information was requested of. the owner, occupant, and Board or Health. i----None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. ""The facility or dwelling was inspected for signs of sewage back-up. i� The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The site and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. { The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. . . SUBSURFACE SEWAGE- DISPOSAL SYSTEM. IINSPECTION FORM PART B.. 'SYSTEM INFORMATION, J - FLOW CONDITIONS If `residential number -of bedrooms number of current residents garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no - If nonresidential, calculated flow: Water meter readings, if available: wet\ Last date of occupancy GENERAL INFORMATION Pumping records and source of information: e7 M ae �S System pumped as part of inspection, yes or no if yes, volume pumped _ I (�00 S; 0_1�_ Reason for pumping: Type of system i/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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arriving at the site, yes or no t ^r r f tr x- nwr^eM.b.Y1p`tY�2,••sw.dh r 9 SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM - { PART B - SYSTEM INFORMATION continued SEPTIC TANK: 1/ (locate on site plan} depth below grade:_ - material of -construction: concrete metal_ FRP- other(explain) dimensions:_ _ � � � -- �Ji '� +► �� L� ' 1.011 sludge depth '+distance- from top of sludge to bottom of outlet tee or baffle +' scum thickness- i°' distance from top of scum to top of outlet tee or -baffle-- distance from bottom of scum to bottom of outlet tee or -baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in:-relation to outlet invert, structural integrity, evidence of leakage recommendations for repairs, etc. ) SQ-Z>� nnc-)��g �ic_( k-A t6z DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, dence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: - (locate on site�plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances;-: recommendations for maintenance or repairs,etc. ) :W.�.W.........w.»,->:.,.:.».:,,.;. ,..u.......,,rx.a. ,.,w«.weea+a,.....,,.....«.„...:,,.o.«,...,.-arc .....,,.;..,-...w. .,.......... ...:.............-..-_.._..«.:... ... . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B . SYSTEM INFORMATION continued SOIL ABSORPTION- SYSTEM (SAS) : - - (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type _- leaching pits and -number leaching chambers- and number leaching galleries and number leaching trenches, number, length- leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, con4ition of vegetation, recoQmmendations for maintenance or repairs,etc. ) j 13 CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: � 1 (locate on site plan) IV materials of construction � . dimensions' depth of solids Comments: (note -condition of soil, signs of hydraulic failure, level of ponding, condition: of vegetation," recommendations for maintenance or repairs,etc. ) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B _ SYSTEM INFORMATION continued SKETCH OF 'SEWAGE DISPOSAL SYSTEM: include ties. to at least -two permanent references landmarks or benchmarks locate all wells within -100 ' i-7'3" o B 6oq 3�' o � , DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation:MS ►�S , } a t t 12 y' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` _. FAILURE CRITERIA Indicate yes, no, or not determined (Y N, .or ND) . Describe basis of determination in all instances.-- If "not determined", e;:plain why not) -. Backup of sewage into facility? �. Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? � V Liquid depth in cesspool <6" below invert or available volume< 1/2 day ^ ( flow? - Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? ,[\ Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? J�J within 50 feet of a surface water? within 100 feet of a surfac e water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply ,well? less than 100 feet .but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analy: _.for—coliform -bacteria, volatile organic -compounds, ammonia nitrogen -,and -nitrate.-nitrogen. -. ... y. IN „ t F, f. 13 SUBSURFACE- SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART D CERTIFICATION Name of Inspector " - Company Name -JOHN GRACI "- - — - Titielinspector - -Company Address P.O. Box 2119 Teaticket, MA 02536 Certification Statement I certify that I have personally inspected the sewage disposal -system at this address and that the information- reported is true, accurate .and - complete as-of the` time- of inspection. The inspection was. performed and any recommendations regarding upgrade, maintenance and repair are - consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Ch� one I have not found any information which indicates .that the system fails to adequately protect public health or the environment as defined in 310 CMR ,15. 303 . Any failure criteria .not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority iia 0,a t4 fi a,` � •' g � r �z S*r Jyw.1��1` �^ x^y„ h A eyfi '+Yf z. "✓ �: 3 ;FYX+rv ,k9` �,vfi, "e,vrkh4Z ' AN 'k5 'Y a` ;i sf. Fth-rw' Mie # "+'F{v '4 r 1'.�' �!' �"'-F �+2: t-�:'#}�'y3Ma'.> '�; #r "` .!•!R�''A�" + t�` '#* �.t '�4 �$�',s ��4e�`f r�ck' a"'`t,-b X y,;i�n "i t "_;�*�.}'y,•a,`,"� � 7;.�2 "7,{, �, � :,yy,�.��„-"'rg�y�NK�g���` <l�` Za.:'. 4a ,,�.:a�' 7 .fir ;-t''.st„Fs' fit{ - . ,dQ, a _ TOWN OF '��(—-�I�C1`(�1��S BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM - PART D - CERTIFICATION .. .......... - -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS ASSESSORS MAP, BLOCK AND PARCEL OWNER' S NAME - PART D CERTIFICATION- NAME OF- INSPECTOR COMPANY NAME JOHN GRACI - _Title-Vlnspector COMPANY ADDRESS P0. Box io Town or City State LIP Street aaticket, MA C?o�S COMPANY TELEPHONE O C�y- FAX CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one , System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspe do form. 'F Inspector Signature - Date One copy of this certification must be provided to the OWNER, the BUYER (where applicable) and the BOARD OF HEALTH. * If the ' inspection FAILED, the owner ors perator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required ,otherwise,as provided in 310 CMR 15 . 305 . - �x � tl ` � `Ymart {t �53� xi r partd.doc SYSTEM PROF- IL. E TEST HOLE LOGS � TOP FNDN Et_. 96.0' (NOT To SCALE) _ ACCESS COVER TO WITHIN 6' OF FIN. GRADE ACCESS COVER (WATERTIGHT) TO ENGINEER: J. JACOBI WITHIN 6' OF FIN, GRADE WITNESS: BARNSTABLE HEALTH DEPT. MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 95.0' u 9 .6' RUN PIPE LEVEL 2' DOUBLE WASHED PEASTONE DATE L86 ( 4SPUR z FOR FIRST 2' z ExlsT_. OQQ_ 3' MAX. PERC. RATE _ < 2 MIN,LIN�H P E... 4 580 . ,GALLON SEPTICF t A DI S P# 1 C!_ SS S L 92 92.0 W TANK H- 10 ) GAS 9 2 <,0 A F EE B r L91.44' C 0 d CJ L� C�7 Cl CJ C� I -� o ' 4 AROUND - -`1 91.17 [� C3 (� CD � Q C� [� C_. ELEV.6' CRUSHED STONE OR MECHANICAL [� [� [] CI Q L} (� [� [� rMPACTION. (15.221 121) cab 94.5 cO ;Q�� 2 C700E EJ C_1EDCD [-1 � 89.17' DEPTH OF" FLOW _ 4' 1( 1% SLOPE) ( "/. SLOPE) r r _" WASHED - / W S ED/4 T DOUBLE TEE SIZES 3 0 1 1 2 Dp B 10, TOP/LOAM/SUE INLET DEPTH = _ OUTLET DEPTH = 14' 36 LOCATION MAP NOT TO SCALE FOUNDATION- EXIST SEPTIC TANK-- 66' D' BOX 12 LEACHING ' FACT'ITY ASSESSORS MAP 27 PAC,CEL 115 MED. SAND 7.67' O V O r- o 81.5' F-- BENCH MARK TOP OF G�NC. BOUND. ELEV. = 95.8 + 90. 5 5 f 65.00 I� � 3 o, 86' 156 81.5 NO WATER ENCOUNTERED SHED 95. � �- 95.7 Nil TES°° 94.0 SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED > 1. DATUM IS ASSUMED 951 DESIGN FLOW: 4 BEDROOM; C ' 10 GPO) _ -40 GI 1 ^, L-^ " �T c . IW: w. uL"r1L 'w�, , x)STINr USE A 440 GPD DESIGN FLOW 3. NI-NIMUM PIPE PITCP, TO BE 1/8r PER FGOT. Y 0 T T H H-10 . 2 88 4, I'ESLLGN LOADING FOR ALL PRECAST UNITS T❑ BE AAS 0 r _ 440 92.1 PT K:SEPTIC TAN P )GPD i + 95.1 5° PIPE JOINTS TO BE MADE WATERTIGHT. rn USE A 1 GALLON SEPTIC TANK (RE-USE EXIST,) ABOVE APPROX. TH AREA _ 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE ITH MAS S, ENVIRONMENTAL CODE TITLE V. PLAN)(PER PREVIOUS SITE L ) LEACHING: R 94.2 -- G GROUND FOR PROPOSED W RK ONLY AND NO";'- TO BE 7 = 7. THIS PLAN IS D D OO 2 33.5 + 12.83 2 4 137 93.8 L ( .%� SIDES ) / + 95.9 USED FOR LOT LINE STAKING. 33.5 x 12.83 (.74) = 318 7 P BOTTOM: 8. PIPE FOR SEPTIC SYSTEM o D SOH. 40-4 VC. TOTAL: 615 S,F, 455 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT LOT 90 + .4 I CHAMBERS ACME OR INSPECTION BY BOARD ❑F HEALTH AND PERMISSI'DN OBTAINED 95 USE 3 500 GAL. LEACHING C BE ( ) ( FROM BOARD OF HEALTH. 21,072t SO. FT. AROUND E A 'EQUAL) WITH 4 STONE / 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) FAILED LEACH PIT _ / 11. WATER TEST D BOX FOR LEVELNESS l EXIST. ST (RE SE) ZD i rn : n 1 93.0 op 30 O N LEGEND + .6 3 cp 95.7 100A PROPOSED SPOT ELEVATION OF , T JO 14 HN S PAIH r- Q 100x0 95.5 EXI STING TING SPOT ELEVATION I 95.6 IN THE TOWN OF. 0 • 1 0 C 1 PROPOSED CONTOUR R TA MI S BA N �.. BLE ( MARSTONS LL 95.2 1 � l I Sp. ro 100 EXISTING CONTOUR PREPARED FOR: BOR TOLOTTI CONSTRUCTION /H OPPE EXIST. DWELL TF = 96.0' GRAVEL I �� DRIVE I N I 20 0 20 40 60 1 � 9g.4 BOARD OF HEALTH L �`* MA J 1 1' - 20' AT JUNE 5 2002 , DATE: , �9 APPROVED DATE SCALE EXIST WELL (PER + 91.5 i 97 -9 \ � 93,7 / �� off 508-352-4541 0 \ \ 93.4 / fax 508 362-9880k�A Of \ / / ARNEi• & 8 -.--� '- s� - �_\ -- dOWn cape engineering, Inc. � AflN' H. Gam, � H. �. �T 92.1 d OJALA r1, v OJALA t „ \ '-_ _-/ �. CIVIL ENGINEERS ct4L �.2ss4a 8> 1 =1�-25, 0 F�'�532.00 No.31792 .4 90. ?U 9 t� , LAND SURVEYORS� tSt - ,. � � --�- • " _,.. , ._... ..._ _.._ 1 ,��. � r���- 1 91.2 D2 12,� JD N'.S' d' Tl� 939 vain st, yarrnouth, rya 02675 H. QJALA, P.E., Q.L.S. 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