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HomeMy WebLinkAbout0045 SEA ROBIN ROAD - Health 45 Sea'Robir Road Cow �vo) Marstons Mills A= 122-034 TOWN OF BARNSTABLE A LOCATION SEWAGE # I-L 10 VELLAGE M Mgt ,ASSESSOR'S MAP & NS jR;,�jVA E,&�PPHONE NO. •J• V�1O� Y1 '�U. Y1 t( SEPTIC TANK CAPACITY � LEACHING FACILITY: (typeZ (size) 2 x NO.OF BEDROOMS 3 rv► BUILDER OR OWNER Qmi I+-0✓1 140 rfeS PERMITDATE3 I ' 02- COMPLIANCE DATE: Separation Distance Between the: Maximuam 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 j within 300 feet of leaching facility) Feet Furnished by 6 dear of H ou6c, v 2r40' 15 q - eb' s'' S - 661 8" 9 -42' '7 i TOWN OF BARNSTABLE L0CA,T10N � RA SEWAGE # _._ LADE "y M�1 v15 tA t��S ASSESSOR'S MAP &LOT �� ^ �� STALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ksoo ' f �� � LEACHING FACILITY: (type,) `� (size) 10 y Z 3 NO.OF BEDROOMS BUILDER OR OWNER We i Ca+H�� SG M `�/ e N PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility — 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 Feet within 300 feet of leaching facility) Furnished by ECD —TPA—� LEACHING GALLERY o D-BOX O o ` 3 t 2 SEPTIC TANK o LOCATIONS l B A B 1 21.5 FL 21 Ft A 2 28.5 FL 27.5 FE EXISTING # 35 . 3 37 Ft 45.5 Ft z DWELLING J W F ! < � 1 3I ! I f r e 4 SEA ROBIN ROAD NOT TO SCALE i 4 I [ �J Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� < �^M -35�ea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the I ` computer, use 1. Inspector: only the tab key to move your David D. Coughanowr , f cursor-do not use the return Name of Inspector - key. Eco-Tech Environmental Z Company Name <1 �i mb 43 Triangle Circle Company Address c-,, Sandwich MA y102563 - = City/Town State Zip Code--- 508 364-0894 1328 r� Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1w,,k I. � C��/W�.—. October 18, 2007 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is Marstons Mills MA 02648 October 18 2007 required for , every page. City/Town State Zip Code Date of Inspection B. Certification cont. Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5-2800.doc-08106 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 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18, 2007 every page. City/Town State Zip Code Date of Inspection 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page.a e. City/Town State Zip Code Date of Inspection B. Certification Cont. C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate Yes or No to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 3+years. Certificate of Compliance issued 611104(Board of Health permit#2001-610) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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)] t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 262 gpd Sump pump? ❑ Yes ® No Last date of occupancy: undeterminedDate 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): I t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18, 2007 , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5 ft x 5 ft x 5 ft(1500 gallon) Sludge depth: 4 in Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10 in I Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design Plan t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2800.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: El innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leaching gallery. t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18, 2007 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 At outlet inverts Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2800.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18, 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. LEACHING GALLERY 0 D-BOX O o 3 2 SEPTIC TANK o 1 LOCATIONS B A B 1 21.5 FE 21 Ft EXISTING A 2 26.5 Ft 27.5 FL Z DWELLING # 35 3 37 Ft 45.5 Ft J d' W H 3I SEA ROBIN ROAO NOT TO SCALE t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 35 Sea Robin Road Property Address Robert and Cathy Sawyer Owner Owner's Name information is required for Marstons Mills MA 02648 October 18 2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 30+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: 311102 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 30 feet above groundwater table. t5-2800.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BARNSTABLE LOC nj ONE�AA S SEWAGE # VILLAGE 6v►MKS ASSESSOR'S MAP & LOT INSTALLER'S NAaME&PHONE NO. . SEPTIC TANK CAPACITY t S 0 �I LEACHING FACILITY: (type) --"d---=' F (size) �� �` 10 � NO. OF BEDROOMS 3 BUILDER OR OWNER W6"- Se C-4th N1 CDcf 0 Ye e PERMITDATE: COMPLIANCE DATE: 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 Furtiishedby 640 4-TeCh 0%5p`� to/ `'V07 LEACHING GALLERY D=BDX 03 0. 2 11 i SEPTIC TANK Mo L0C:AT10NS l B A B 1 21.5 fE 21 fE A 2 28.5 f E 27.5 fE DWELLING w WELL.I GNG # 3 5 3 37 f E 45.5 F E ? D J I W 3 i SEA ROBIN ROAD NOT TO SCALE TOWN,OF BARNSITABLE 11� LOCATION at.' tic SEWAGE # Ov r=f VILLAGE ' MT ASSESSOR'S MAP fNST�►I.L R 33 4, qP ONE NO. J • V�`O� 1(\� U. Y1 Y SEPTIC TANK CAPACITY LEACHING FACIL=: (type(Z l kah 4 (size) 2, 1 ' x 1 a' NO.OF BEDROOMS 3 BUMDER OR OWNERH 0Lmi +-on 140rfeS PERMITDATE3' 1 " 02- COMPLIANCE DATE: 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 6 dear df Hou5e, ® )4 1 - 31'i" q - eb' s'' .s,_ 66, g„ s" 9 —42' T ' t 'No. ,v THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH OF APPLICATION FOR D SPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( "Repair ( ) Upgrade ( ) Abandon ( ) - Complete System []Individual Components J Z ` + oJ p V �V l 1L�w�ne Name T/Z Map/Parcel# 7? I L #. L I t� 'P V �+ J D Ins U er's N m A7194 Designer's Name Address Telephone# Telephonn9e# Type of Building: 72L�//� i1t- De,l�L.�I IVLot Size ®/ W45Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder 40) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures �7 Design Flow(min.requi ed)�gpd Calculated design flow 1 gp#_Design flow providedy 30 gpd Plan: Date 7 d Number of sheets _ I Revision Date Title V(_o► a c. A-rl P2o Pd-S L-O ►4J-s6- -t s .V&'VAt. Yf: Description of Soil Ss) ��� GofrrN i Soil Evaluator Form No. Name of Soil Evaluator S. h//LS614 Date of Evaluation-9— f 9 DESCRIPTION OF REPAIRS OR ALTERATIONS AIG-kl C-g*JS77Z�' The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu r agppes n9Qto place th system in operation un i. ti of Compliance has been issued by the Board of Health. Signed a v of V v FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Yam. y` �' Y- 3.�-' i'r t'`,ti i ""^rt`M''. 1ti...•.�rr,a.,�..»4ai..r-:+"`.ia~'�rV`4�"/�r�"�».^..,-_tW, # •ry,. �•*1*•.. r v' 5r'4-. ...r ''r t � � r �r t 1_ ✓�p'r r_.'X N-I�I � �V IV r-7HE COMMONWEALTH OF MASSACHUSETTS EE �_ t .: f k BOARD OF HEALTH,- A, 1 O F 16 IT",.S149Q}"Q��� r A APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT A placation for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - Complete'System ❑Individual Components -fZ,7 + f+5- s� Ro3 W R.D. /furs i ra.✓ o;�r S . , Q A f Z , 34 + J�f o ` V �� ! �iwneylS Name ` Map/Pkrcel# es • e Lot# T le hone Des 's Name V Loy, 'In a er's Nam D �� V � 117 /�!'fl r"I 1 �ignerfJr//I'e 7 /rl�r/�C(t�'�' dress 33 A 5-40 a9s, I Telephon # Telephone# Type of Building; n.t?7(DI-'T1ItL`04✓El-I-'I N & Lot Size'4 of LWOSq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder 40) Other.—Type of afeteria;Building No.of persons Showers ( )� ( )C Other fixtures s' Design Flow(min.requi ed) 330 gpd Calculated design flow gp*Design flow provided3;o gpd Plan: Date 7 !� Number of sheets Revision Date Title Lo C Ar/ PRo Pd 5 go v S E S va 1-04 Fy1C E SJ-UACA,r &S6/o Jj t_ S y� Description of Soil(s) Q"/6 Lv�lti. �z �d Z8 L evt � Z^8��3 2 S ,0 ' S'oil Evvaluator Form No.9 4 �9 Name'of Soil Evaluator--5, A//L.SO4 Date of Evaluation 9-13" 79 1 DESCRIPTION OFREPAIRS OR ALTERATIONS Ale CW STD r't d nI t The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu r, s no to place thq system in operation un ee ifi2a of Compliance has been issued by the Board of Health. sr Signed at Z,13- f \t f FORM 1.-(APPLICATION FOR'DSCP DEP APPROVED FORM 5/96 NO.v ,0`V— THE COMMONWEALTH OF MASSACHUSETTS` ___ FEE �`�V��� �—J _ BOARD OF HEALTH CERTIFICATE OF COIVPLIANCE Description of Work: ❑ Individual Component(s) BKomplete System The undersi ned hereby certify that the Sewage Disposal System;C struct (1-<A5e ai. d ), pgraded( ),Abandoned( ) by: 'at ,,-�' ,;n + * y5 ..CA, ` r: %t1 �, has been installed in accordance with the provisions of 310 C R 15.00 (Title 5) and the approve! -ess gn plans/as-built - plans relating to application No dUdated 1 (� Approved Des `n FloW�1 f""(gpd)r t C:lrr Installer 3 A Designer: Inspect r ate Yf � The issuance of this certificate shall not be construed as a guarantee th t�t e system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 1 iz No qL. k lc,I V THE COMMONWEALTH OF MASSACHUSETTS FEE ' BOARD OF H E A LT H DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to.Construct (1/�Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at +_*f Hc,- CD C. 12tN,6 r) 9-1 te�r cf,—k V1 lu as described in the application for Disposal S stem Construction Permit No. A�\- G I Q ,dated 'I 111 1�1 Provided: Constructi n all bcomp�et d within three years of the date of this per it� Lloeal co 9t tf o s mus be Date Board of Health 1 FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV-5L96,1_ . H&W HOBBS&WARREN TM PUBLISHERS- BOSTON FROM :R.J. BEU I LaCQUR CONSTRUCTION FAX NO. :503—B33-6359 Jun. 02 2004 09:57RM P1 Town of Barnstable Regulatory Services Thomas F.Ceiler,Director Public Health Division Thomas McKean,Director ZOO MAn Street,Hyannis,MA 02601 Office; 508-862.4644 Fax: 5t78-790.6304 lu r&DesiaaerCertific4tion Form Date: Designer: Installer: Address: ��? . L,-�•�i Address: MA 0 7-7 was:issued,a permit to install a instal � t le a r e= ``' °based on_adesgii dt'a�nii ii l?y septic system at � �� � . - . (address) `N-G. dated esigaer � I certify that the septic system referenced above was installed substantially according to the desisn, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Ucal Regulations. Plan revision or certified as-built by designer to follow, le sSignature) � 2 � g><ter Si a er S Desagns tamp Here PL tp BARNS LE'` IBLIC:HIirALT13I'b S101dt" =CENT' CATS p C WILL T,.B ISSUE OT11 TIII FORM AS- KC6F.,. E P B SAL D1C'YI IO . D: Y TIE; Q:HWtb/SepddDesiper Certif ntioo Form _ TOWN OF BARNSTABLE 1 LOCATION Z 4- SEWAGE # Ov I VILLAGE lJ Q rV� �e- �c _ASSESSOR'S MAP INS R' AME 8c PHONE NO. •� F �(U. . . 3 y$°1o1 SEPTIC TANK CAPACITY k LEACHING FACILITY: (type MrA (size) 2 NO.OF BEDROOMS 3 BUILDER OR OWNER 0.mi �"�'o✓� 0 S ' PERMITDATE3- I . O2 COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by 1/ Rtox NauSe. 6 2 r40' 5'► i q ^ (vb, Sit IS - bb' g� SA -- 21#�',► S„ 9 -42' 1 Town.. of tarnstable 99 Depnrtnlent of 1lealth,Safety,and Environmental Scrilices ,oFTPMA�r,� Public Health Division Date 1U � G� o� 167 Main Street,llynnnis MA 02601 r °rE059. " Date Scheduled w s 3. : 'Time /0,,ey Fee Ind. Soil Suitability Assessme»t.foie Selvage Disposal Perhmned 13y: $, A ,lJ�i l5vr fit^. Wilnesse'd 13y: l7 I�arans�(r LOCA'I ION G E N 'RAL INI{0104ATION Localion Address � b l;vc,.c� Owner's Naine �ll� - Address .lcv' Gacsc,rs Wa. Assessor's Mn 1/Parcel: ` 2 9a 1 ji7a1� /Z2 �c l .�$ linginccr's Nanlc NEW CONS'1'RUC'I'ION REPAIR 'I'ciclihonc Il Land Use _V2c r-Qp--t e4 Slopes -;:1 'It, SuifnceStones t — Distmlees froth: OpcnWnter tlody 11 Possible Wcl Arca n DrinkhT 1Vita Well n Drninnge Way Il Properfy Line . 11 Other n SKETCH:(Street nmne,dinic lions orlo(,exact localions of test hoics R perc Icsls,locale wcllands in proximity to holes) ♦.y riper>P vj P �Z ZspE4 ti y,j, f9_ .Go.00 S 1'arenl material(geologic) ltor-la t r^.it7wYtit;wl Depth to Bedrock Depth to Grotindwnter: Slandhlg Water in I tole: Weeping from 114 Face Estimated Sensonnl I ligh Groundwater U1!� Cl2MXiv 1,`ZXC IV X+UZt SEASONAL 1lIG1I wA`1'LI ,.I A13Ut Method Used: Depth Observed slnnding in obs.hole: Depth to loll iiiolllcs: Denlh to weeping froth side ofobs.hole: in.' Groumkh iter Adjus(tncol (1, - Index Well N_ RrndinR Unle: Index Well level Adj.rnclor Adj.tiroundwsllcr i,cecl - -- -- • i T ri �y�y try -rr,. ' .`'.. i; .1�A�1�\ V �'AV.N Jllus�1 I)t11Cr I'flffC Observation .. . . . I ole ll Hole M 9.�; Depth of Perc ( Ir ''Fin ic Slant Pre-soak-rink End Pre-conk u��5a }o :c�t}tAz 9ti Rnte Min./Itch 2 v+.rn�lvl I (VI Site Suitability Assessment. Site Paeserl Site hulled: Addilioonl`Testing Needed(YIN) Original: Public Ilealth Division Observation Hole Da(t to Be Completed on 131cl( j VJ Copy: Applicmlt }fit Yy. t y�c y. r *T + Ll{,1rF V< L�,it;Y. `1101`I rA�'1,1r 1,OVr i1�1.�# Depth from Soil Horizon Soil Texlore .` Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulderes. to ° O- 4�� u �" "� ' $uncG� t eaw� l0 ` a rsh 9� - 2 L u u ,g " $awQ t-•oast ' l o.ti'12 5�(0 C l i. I.a�✓„� SunOt I o nEEP` B ERS�ATI0 HOLE LOG : Hole# Z ..... . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell).. Mottling (Structure,Stones,Boulderes. c ° Gravel) O ^,3 94 ., „ N u 5 0. ".""n to,?to 3 io "�3 � io 2g ,, �k•u2� Lv�►u to 5-M0 6 a 90 Y2 6 C �St1 ' ' ON HOLE L.OG dote Depth from Soil Horizon Soil Texture Soil Color,, , Soil , Other _ Surface(in.) (USDA)! (Munsell) Mottling (Structure,Stones,Boulderes. r Consistency.° Gravel) :< AE+EF O�SERVATO]'V SOLE+ :LOG Hate:#` '' :':` Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.). (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. • e oGravel) Flood Insurance Rate,Map• ,1 Above 500 year flood boundary No— Yes ,. Within 500 year boundary' No t% Yes Within 100 year flood boundary No l� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material,exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I : I certify that on _4 1 S (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with 1ti'VequiMre'red t"raining,expertise and experience described in 310 CMR 15.017. Signature Date ...... :...... .....:: is2.:..;,.,.:•....;...,,.i....:.......:........:.......:.:.:'..:.:,:.....,,,....:.:..;::..,.....:...,:.,.:. ::''asi::: i?;;i;`:: ...."t::'::;;i. i"ii:i;i:i i'i;';i5i'i'i::':>'i i?; %,;;<1;{ii iiy �:��� ������.��rY�� c������. . : :: big� �;:::::::..•:::' .. : . ' :.:....:: :::: Depth from Soil Horizon Soil Texture' Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoncs,Boulderes.., a Q— 4 N u 011 , C . Fdi Not S a..0 10 `e t2 6/4 ..::::.;:>::: :FR .L Tto.. ;n PCBS :2. ....:.:.::. Depth from izo Sbi1 Horn Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % to Y2 4/6 Mine- .......... S;f..: .:......:..::..:.....y,::,•;...,.:..,...,_:....,..:....:.,...:.:.r.....•,:;..:;:: :::...::...;>::;:ii:.:::i: ....:.. _,..:;::::i .>::::.1..::. .. :'....:. ( ) )re Soil Color. Soil : Other Surfalcerom Soil Horizon S(USDA). 0 DA). (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.%Gravel) :::< V.- ; 1. :..:> e;.#::..<..•;.,.::::.:.::..:..:, :..:::...: EEP..:.:.C......TL01!!I, :.>:....:: >::.::::: :..I .:::.•.::::::: Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % ! ml: Flood Insurance RateMao� Above 500 year flood boundary No— Yes !� Within 500 year boundary No t/ Yes Within 100 year,flood boundary No ✓ Yes Depth of NaWrally Occurring Pervious Material Does at least four feet of naturally occtrring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? y If not,what is the depth of naturally occurring pervious material? Certification I : I certify that on 4 ji 5 (date)I have passed the.soil evaluator examination approved by the Department of Environmental Protection and that the.above analysis was performed by me consistent with IM flR46iRd train"►ng,expertise and experience described in 310.CMR 15.017. SMOKE DETECTORS O.K. B T�F LE BUILDING DEPT. I --- \ I 1 i EIFI f ai i G� j�.vlSs->F�.gCge4 _'2naw��.. UH _ - -- -- - -- _—:._.krT .. - ..-p - i - 508.428.6191 M1Un- Fh r Il c.light rM copyright f " LfS':tXroRCaCJCP Ia-O-mC79.—=>�---- I it ►' - - F � -��� _ ' 1 - Preliminary plans and layouts by D.C,D.are for the use of their customers only.Any other use ii strictly Prohibited 1 N .4 VITHIC CONC_SLAB_ ' ' 0 .. .. ... ....... 26 X 2'X t°THK.Ff G-FOR 7 1/2•. - Q.CONC.FILLED LALLY COL. - 0 0 _ LE, DiTE- .508.428.6191 i + a-DIX COUC.FILLED 50!'O TUBES N2 X2 X10THK.FTQ [Re eviin Ustom oesigns ZP All Rights s rued . . --- - 2.4.o`: 7r� ' C. Al .. to o` _..: ,..._.146 _. _ __ S'THK.WALLS ONt-VX8 —_ "p THK.KEYED IFTO. i g • � - 5 Preliminary plans and layouts by OC.D.are for the use of their customers only.Any other use is strictly Prohi Dite ,T qyo e - i i< IO.te .. IO:ce .9 O' S.Q.. -. � 0. r— a ; O .0 i 7G. L2Z., DE=C.z: _.i s i of CD. 4 .. ., L1y F3FAtioc�e� '. b v m -- d t . r 4 i s -  -- - - j��� 6 -S• y� 44 5_to' 1 t I t I O i to " t -- . . ss�_stuue�� 508.428.6191 �levlin . o Custom 0Si signs :. .. 5/8'F.C..60 SHEETROCI( l O 10 I 8 - _ — - Copyright 02002 rj -- - Wa1S CEWKG _ - 11 Rights Reserved bit 14 ..S.o.. 5_e.. I' I zo:o.. 7 s A4 eC Preliminary plans and layouts by D.C.D.are for the use of their customers only:Any other use is strictly Prohi Dite z _ .� r 5b i 1 i . i. INW ji r I r (lr I 1 I. I' 11. I I - � � �� � - • SCALE DATE r -r. i 508,-428.6191 .......... ----...� a evlin Custom I o esigns copyright 02002 �3) - • All Rights. 'Reserved i ,e e ClS " -- -ter " r _ Preliminary plans and-layouts by DC.D.are for the use of their customers only.Any other use is srricfly Prohibite f 1 - .. to. .. I L A - - l2 - Q --- - ,t,� 3T4S4ct SG 10�clOo�lA _ _ — 12 �s I • L II - irt•.YY..�.��. fL 1'S I�.15lJ1 —�.- -1. 3:'SltiT"➢PnJCt,-. —- � I - I. `.;— � scuE DATE 508.428.6791 I d ev i n ' N W - - ..: I�EFSILZSaFiC- r -�� -- aST�6Q-'LSi�c rt- I Custom i !, --- 44o esigns \ - c . copyright 0 2002 - nISt>✓� _ All Rights Reserved L. - i 5 Preliminary plans and layouts Dy I?c.0-are for the use of their customers only-Any other use is strictly P10hi Dlle .