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HomeMy WebLinkAbout1825 SOUTH COUNTY ROAD - Health 1825 South County Road i Marstons.Mills _ A = 098 023004 �I i I ;I Commonwealth of Massachusetts / Q 0a 3--- �'} Title 5 Official Inspection Form ©© V i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments <>� .......... . 1825 South County Rd. r Property Address Peter Bennett -- Owner Owner's Name information is / J MA 02655 6/28/2014 required for every, eryl e S_ ( _ _ _ ----- 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. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �I on the computer, IIY� U use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. _Neighborhood Waste Water raa Company Name 350 Main St Company Address re W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2820 S15016 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 7/7/2014 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. t5ins•3113 Title 5 lInspectio urface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form ( i Subsurface Sewage Disposal System Form Not for Voluntary Assessments ?s 1825 South Count Rd. -----Y--- — ----- - - ----- -- Property Address Peter Bennett_ Owner Owner's Name information is required for every Osterville MA 02655 6/28/2014 - -- ----- 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: System in good working condition. — _----_ 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. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 °. Commonwealth of Massachusetts a} ,s Title 5 Official Inspection Form (i �MIN'jiff .. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is Osterville MA 02655 6/28/2014 required for every _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form (=t I'.i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is required for every Osterville MA 02655 6/28/2014 - ---- - page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less 1 than day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is required for every Osterville MA 02655 6/28/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed plpe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public 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 11 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts } Title 5 Official Inspection Form � i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is required for every Osterville MA 02655 6/28/2014 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 -- Number of bedrooms (actual): 5 - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x5= 550gpd Commonwealth of Massachusetts } __ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1825 South County Rd. _— Property Address Peter Bennett Owner Owner's Name information is Osterville MA 02655 6/28/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 3gpd 2012012=83833gpd Detail: Sump pump? ❑ Yes ® No Current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: - Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): — -- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: -- --- t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 ` . Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c G 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is Osterville MA 02655 6/28/2014 required for every - — page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Truck Sight Glass Reason for Maintenance _ pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3f13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts } _ : Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments E . 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is O_steryille MA 02655 6/28/2014 required for every --- — ----- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 14 Years per plan on file at BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): --- -- Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.).- Line inspected with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): 2'1" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 2000 Gal. H-20 tank. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gal 5,Sludge depth: -- — - t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1825 South County Rd. Property Address Peter Bennett _ Owner Owner's Name information is required for every Osterville MA 02655 6/28/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 88' ---- Distance from bottom of scum to bottom of outlet tee or baffle 1711 —_ How were dimensions determined? Sludge Judge/Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 2000 Gal H-20 Tank in good condition. Tees clean and in place. Level is normal. Tank pumped for maintenance. 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 t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 ... ....... Commonwealth of Massachusetts al --r Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 1825 South County Rd. Property Address Peter Bennett _ Owner Owner's Name information is required for every Osterville MA 02655 6/28/2014 -- ------------ — 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: ---- — Capacity: gallons Design Flow: gallons per day 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 ?Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 <LN, Commonwealth of Massachusetts Title 5 Official Inspection Form f ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �� 9 P Y rY 1825 South County Rd. r Property Address Peter Bennett _ Owner Owner's Name information is required for every Cisterville MA 02655 6/28/2014 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): H-20 DB-3 in good condition. Box was level and clean with no sign of solid carryover. 2 -Lines out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): - If SAS not located, explain why: t5ins•3/13 Title 5 Officia!Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N _ 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is Osterville MA 02655 6/28/2014 required for every -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: --- -- ® leaching chambers number: 7-5009al ❑ leaching galleries number: ------ ❑ leaching trenches number, length: - -- ❑ leaching fields number, dimensions: --- ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 7-500 Gal Leaching chambers in a 12'x44' configuration. 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ., Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments : ,..__. 1825 South County Rd. Property Address Peter Bennett _ Owner Owner's Name information is Osteryille MA 02655 6/28/2014 required for every - . page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form iR' ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 P Y rY _- 1825 South County Rd. Property Address Peter Bennett _ Owner Owner's Name information is required for every Osterville MA 02655 6/28/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts a Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.e,j 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is required for every Osterville MA 02655 6/28/2014 -- -- ----- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +12' _ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12/14/2000 _ Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain.- You must describe how you established the high ground water elevation: Test hole data per plan on file at BOH dated 12/14/2000. Test hole to 12'with no water encountered. Bottom of leaching at 69". Minimum of 4'3"groundwater separation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts -_�` Title 5 Official Inspection Form t. l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _ 1825 South County Rd. Property Address Peter Bennett Owner Owner's Name information is Osterville MA 02655 6/28/2014 required for every — — — page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Coco Property Address Owner Owner's Name information ieSro^,rl ' required for every �-O V �► page. Cityfrown State Zip Code Date of D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separate) 0 C 3 I 6 366 ►7� a 7 C? 3 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 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 r TOWN OF BARNSTABLE CC_ LOCATIONCO- W SEWAGE #.7MD` 9YQ VILLAGE c 4 ASSESSOR'S MAP & LOT ®R?'0 3'�.71y INSTALLER'S NAME&PHONE NO.. 211 C� C./I Sc.Jt$ SEPTIC TANK CAPACITY Q4600 6&1 — ""2220 LEACHING FACILITY: (type) "7'5'00010)/Cy-9 M1:11 (size).1A �X'g ' NO. OF BEDROOMS S BUILDER OR OWNER t`�7er? 6nr�e77;" PERMIT DATE: ,02—19—4Oo e COMPLIANCE DATE: 7-7-0 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by, n� 0 F's P:e � c � Sy r -n v/ le. 7- /"S-'6 r6er 10. Dine 1 i 9'6 a a�s k No. ' v r Fee 166 t000 THE COMMONWEALTH"OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for ;Bigo5af *pgtem Construction Permit Application for a Permit to Construct(K )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1&'Z S ,.Cps �( QQ Owner's Name,Address and Tel.No. Assessor's Ma /Pazcel �� �2 C ` }��, �1 p 23,bo� 11\Gus-Hl 1511T t �]Y �/��M Installer's N e.,Addre s,and Tel.No. Desi ner's Name,Address and Tel.No. ®� ���... ��� �A.. 4�8 �7a�wee �c� �I u.0 M A Type of Building: .` Dwelling No.of Bedrooms Lot Size S%Q- sq. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow <<0 @ S: SSp gallons per day. Calculated daily flow SSCd gallons. Plan Date�� 2[`M Number of sheets I ZI Revision Date l46Ia E. Title Size of Septic Tank 5 Type of S.A.S. X !d -4,e,.j,., Description of Soil e - 6Q�•6.I��cL A "—v? -75A1-* t� . 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 bee ' ued this B and of h. Signe 4 Date t Application-Approved by U Date 00 Application Disapproved for the following reaso s Permit No. Date Issued Im -.- ---t No. —Fee No. r THE COMMONW'h'&'LTWOF MASSACHU;SETTS Entered in computer: } S� sa:-. Yes - PUBLIC HEALTH DIVISION -TOWN-OF-BARNSTABLE., MASSACHUSETTS 2pprication for Mi000l *pgtem Construction Permit Application for a Permit to Construct(K )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ' Location Address or Lot No. l 6Z S C'j ,C-p„ Owner's Name,Address and Tel.No. �t p Assessor's Map/Parcel \? C �VEr.► I Installer's N e,Address and Tel.No. Designer's Name,Address and Tel.No. AL'� S r 1 (,1\Aft.iC.a(� "-\7 �.1�_�I1 CL'•�. \•` 17 'Type of Building: Dwelling No.of Bedrooms J Lot Size \OZ sq.f--� Garbage Grinder(� Other Type of Building No.of Persons I Showers( ) Cafeteria( ) } Other Fixtures r / Design Flow �OC�S' SSCa gallons per day. Calculated daily flow gallons. Plan Date's?—j` Number of sheets 1/1 Revision Date ►Idti r_ Title ? S2Tl C L cd4 lo Size of Septic Tank 1 Sb/C�� G& r)),a 5 Type of S.A.S. 1?.X 4 Description of Soil b-2" 1 — 62C"ems\L r l,� �t�d?\Aa t_ '"—\? " — S,�►s i�Y 1_[ tM Z,5-�le 4 Z 12"-Z4'` - L CAM -5kt`xp 2.4 �= 1�i \7' Si�1�17 1()`(r (��),Ln \c t.a77=2 E�1Lout 1,i TL�EZ� Nature of Repairs or Alterations(Answer when applicable) i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system din 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 be ' ued this Boardof h. Signer, Date :3 U Application Approved by Date �Q Application Disapproved for the following reaso s Permit No. Date Issued -----�= -------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( K )Repaired( )Upgraded( ) Abandoned( )by at _ S u CU 1 L.,t- = has nstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N d t -11 Installer I 5�-"C c Designer The issuance of this permit shall not be construed as a guarantee that the syst will,f nction as 1des'gned. Date ) z7- o 2, Inspector_ �1- =,1 --------------------------------------- Fee j6v_x� / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopogat *pztem Con0truction Permit Permission is hereby granted to Construct(Y, )Repair( )Upgrade( )Abandon( ) System located at ! R2S ':50u171-\ -mac 6L-Kc -/ O.0 7P Q !1 L LC and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t e Date: � Approved by f ` i TOWN OF BARNSTABLE EL LOCATION Vic, SEWAGE VILLAGE—If ASSESSOR'S MAP & LOT 017-023-09 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY '2 000 6&1 020 r � LEACHING FACILITY: (type) "7—5-0 0 6n CI19 A4 z" (size) NO. OF BEDROOMS S I BUILDER OR OAR PERMIT DATE: COMPLIANCE DATE: ;P--a`7—o Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 n i 0 Gc�P(A�e ,6,, ,t ��7, eT C � a_ TOWN OF BARNSTABLE GL LOCATION ii7-5a� SEWAGE VILLAGE - c Iy1< <—�5 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. l`'I&CCL11,1 cr 1-1 a 8' Oro SEPTIC TANK CAPACITY cQi6OD G5'I " /�;20 LEACHING FACILITY: (type) �—SO 0 CA,I UY9 MR7'1� (Size) la �X 6 , NO. OF BEDROOMS BUILDER OR OWNER Pr--,7e-'? --B&Welt PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 0 36`6`' ou�e% 19`6 Town of Barnstable P# Department of Health,Safety,and Environmental Services Public Health Division Date ` : -23 -2 367 Main Street,Hyannis MA 02601 RARNMOM MAIM Date Scheduled �-�/ 'r17 Time. .3 0 Fee Pd. CEO— Y Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: )�A--f D�Nr-' n2. �►+ '' LOCATION & GENERAL INFORIVIATI01�1 '; Location Address � ,Z,,j S �-��„ __ Owner's Name wA-D E z- . ,A-r- �g`.�"..'.�� �, , .(Sox ?tZ Ir` Address GbMGO12-D , M A •,o i-14;L Assessor's Map/Parcel: q S 3 - Engineer's Name A APL AL r.�•�s, �+c NEW CONSTRUCTION ✓ REPAIR Telephone# 5o 6- 41-6 Land Use (Ao�Jn Slopes(%) O - Zo 7o Surface Stones ,,7onG Distances from: Open Water Body ZSO ft Possible Wet Area 2OID ft Drinking Water Well — ft Drainage Way ft Property Line So ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) Cq LP P ►. ♦ +TTP•2 J t B Parent material(geologic) G lac i a l no+L�4 S h Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH TA9M. Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. in. Groundwater Adjustment ft. Depth to weeping from side of obs.hole: Index Well# Reading.Date:_ Index Well level- Adj.factor Adj.Groundwater Level PERCOLATION TEST'' l)tite 6 9 Time Observation # 1 Time at 9" Hole# Depth of Perc 4$' Time at 6" Start Pre-soak Time cQf 1 1;"fig Time(9"-6") End Pre-soak 11155 Sec! Z4 Rate Min./Inch �+ Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YN) Or iginal: Public Health Division Observation Hole Data To Be Completed on Back—� Copy: Applicant .:P r DEEP.OBSERVATION HOLE LOG Hole# . 1. Depth from Soil Horizon Soil Texture Soil Color • Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % 0_2 v ayazz Vl;Z 4 4 ./2"-2�4 � foam Sang{ 7,S YR S16 y/1' DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % p _ 3 " O /o Y/2 ?/z 3 =/2" Leay 2.sY/I4/3 As 25 ✓� S 24"- 144 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % :DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Flood Insurance Rate Ma_ Above 500 year flood boundary No_ Yes l/ Within 500 year boundary No w/ Yes Within 100 year flood boundary No t/ Yes Depth of Naturally Oc ri Pervious Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? f��s If not,what is the'depth of naturally occurring pervious material? Certification I certify that on 4�ys (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature __-- Date 6/4�7 2' CIO -O' ,• O Y WA L4 .�iN• .. V. .f. Q VA n 1` I - - Y _ o � v {' I I .•} r- -— I i _ _ —------ - — - L • I I' =1G p,G�•W 9'$ WWb �. N � ts3 I lu I i vAPoF Ati< .I>iR i8Q'D�. . N n ' Rilu< y,oN YAM Y Z - I_ 6 1 I I - - l— — _ -- -- x 2 WD B6. W• � - q D5• IG I - - 7(ti i I �I • � Imo, Id Dom. J�To • I Owl V>/IIJ17 � I 0 Ntpu L_ • j ,�,�� NEG� I B a�•LTAI!a. � e I►df Ll1kD 8ac/tFaN�r.WG4lL. rm rAolow L v l. . 1 '� L---- -- - , — $ 4 ANRPKA , . i,/RisA/�ra'o �/ f. 9 I 2• � [NvCtJL°('.p.. � - I � • �i-FFii - /lMl(i W' •fU A�4 / �� i •M1 -._ -._ �.T I �! YW`�A�OI.I�J' �/, • I -� , . - �- - �t d,A�f,AV f All, �1 j- W, a' V, q; kU. 71M bIONt bkOW ' LJ , x 7� •'2}IRbG I I ��^' '� I'it t� r � I I � (\/I}'�/1 O � � �• JET ��H I►J f To#h �.:. gyp. . I I. I I G I • 'REVISIONS �^` ' _� I I I •I of. , T. ---- _--- - _- — - - � �• I 12' YP . 2• �! � . \ PROJECT ; 12` , A(iMtJE7 NUMBER-470 5 7 7-L 1 DATE: S o SCAM ]- I6'-6. I 23, 27 i 0' DRAWN-% CHECK_, '�. i DRAWING•NUTAaER r - ���� � � � l.D_W� ��'�� 'PION � � � �• -_.- G" o yjous Vkcti .� /t YNB .S 'y(O►JY.. y�Nf .'¢ O Q I fi ys i�P• 1 f ly WAU, 5 I 4•(0 wp, #pip#•I6'O.A v _ .. ._. _.._....... — — i U - WAIN Wit Jd 0 DAD, = Z G. L) 1O . g I F I�h:2 UNWf. LAP U-. .Q N) G 2YWD. 411p 3?x 7° Cx(� i ; !o"a. Y( �f �'A� W Z 1 VIj , La fQ'' V) Jius�tu �A+7Zj]�JQy INDAV ai ~Ibis, ,..wh..•.: I ��•� - i o --- .G 1AW* OF TT Y w� 1' •Y'�1 I i I �.:.;,,c, --�-- t- \\C�,1+G, � �� _ Q I I' RJ •y�hf� tN '%�� or� �I;•- / •..f .. R• - y Afa: ION 4N�WN Z. STIA�Nt Ap$ .E 1 1 UYIa1Gt t oPGa •to�,E.vE :I I eyr -� . . WlIJ7O4J IAANU�q�(U S psco luny 2;I _ •„ 5. f a s f .r I ` b L( Itfr�h(�11G(f1�AL ' ywuESWEE �� R. Ic— I• ` ,O 5' I VI.F. 'i=G' S , /j. �. . . . l� I �P ) -S 61 T 6' wwDA� 6' wwD AGod� - — ¢ h`• 1 a -— - - ! I A N "� Q : . 14 �\I ( 1 REVISIONS: PROJECT I' NUMBER: ..70 7 f r�:p• (�' 'P DATE:. 2S o ' Y 1 - - 1 I \ - - • 61.6' 25-0' I6.6 29- G 16.0 \ DRA9'I1L• . wl J >rSl DRAWING NUMBER: .. ... ._.--- ---- ---- — — i, . i ��c� �wQ_..� ups• _ � . _ - — pRRw uX�FtNzr tO °a - --- ——.. --- - -- -- c -- - - - F41 UJ Z D A. 2 - - - — 2 ?. 1 0 ¢ N o j J _ < LIN �2 i 1vo I II g'-B• At �� All.✓ �. � o tof„i E1V"s�O .r \ L. j I ED s ` V --------- -- ----- 19stisco rail►1a ----- ----- - v ` O V WINDOW O i.+ 1 1 1 4=p• . ` 1 I' . � 1 1 1 a•cF 1 1 1 WaVcl � WG REVISIONS.: . —- --- -- 1 ----- 1 7177 �" 16, 1 ww. NUMBER; B' .97OS7 . J _ DATE: 2 s SCALE: s - , DRAWN:. Z'.. CHECK DRAWING NUMBER ?f 4, . 6e11, v'�1-0" FEB262001 Assessors Map 98 �� v Parcel23-4 -- — Zoning RF •f g Setbacks Front 30' °e Side 15i �i Rear 15 r� ._ p 10 Overlay Districts: GPB,AP r '} (0C o/ 3 US ��'j o N N v O _ _ _ ' = A-/ - p N I t ° o a_ D J 9yA WI/Ham a Ruth N oT e N/F W// f ' o N -i ` I �, Cu/c/iff 1 N=-BCTlEO I �� O _ � _ POOL TO Bit OZ.ONit ly C�efiberLV i � Q LOCUS PLAN -Sr>cA Pit 0 WAL 1 Q' I i EL.3a.o-38.0 '.�"_ a fo Scale: 1 = 2000 - 1 1 l , TERRACE C-L,31 g A-4 � cc)-[fox I V A-3 // / I // / //�/// ///\/►�� / // �//. l43�p� 2o'x4o GARgGE 1 �!' old A-5 ffO// 0 V/Fb HILLIN& 0V4a � l l l 41) POOL EGLUIP, 9 , C- to o TP-1® 12, 1ize M toP p yV DRYWELI.. TP-Z _ F ALL ` A-7 �I9RKLIMIr EL,yO,p SEPTIC / / w•— 1 eytLT'FF3NGE`r % TgNy� \ DRtVEu/A'�TO SOUTH HAY B►,L>~s�- \ \ _ J / / / COUNT`( ROAD r \ In r Z ` \ ` J / J U f / \ ��� •-c_ \ \ I/ ju ! LOT AREA 0 5 17 ACRES ry A-10 (� N/F Michael B Lisa Pajo/ek t \\ ��•,_/ / i / � ____�-�-/6 A-/B\\ � A-// • / i A-/5 A-/9D\ -/4 A-20\ A-/2 PLAN VIEW A-2/ ' ��C \ '° I „ _ T, ® Note: For landscaping details see BVW Flagged by A-/3 Scale : I = 40 - Field Data by Baxter a Nye A-22 plan by Thomas Wirth Associates FUGRO EAST,INC Inc.for the Bennett Residence dated Dec.10,2000 O TEST 1-IOLE 1 EL. 4c.6' O ORGANIC MATERIAL- NOTES DESIGN DATA I O YR Single'2./Z. Wi h no Garbage Grinder m I.Water SupplyForThis Lot is Municipal Water. SANDY LOAM Dail Flow=110x5=550GPD A 2 Location of Utilities Shown on This Plan Are Approx. Y 2,S Y R y/y At Least 72 Hours Prior to Any Excavation ForThis Septic Tank:550 GPD x 200%=1100GPD I2 B LOAKAY SANO Project The ContractorShall Make The Required Use 1500 Gallon Septic Tank -7,5 YR. Sl6 Notification to Dig Safe(1-800-322-4844) LEACHING AREA �y M H DI uM SA ND a The Contractor is Required to Secure Appropriate 550 GPD/0.74=744 SF Required _ C. Permits From Town Agencies For Construction Sidewall=2(12'+44')2=224S.F. 10 Y IZ G/�/ Defined by This Plan. I y 4' Bottom Area.=12'x44= 528 S.F. PERCOLATION TstST 4• Install Risers as Requiredto Within 12"of 752 S.F.TotalProvided Finished Grade. LEACHING CHAMBER DESIGN 21 C aswxarwisuae ffAL = CLASS I MA-r•E R u.L 5.All Structures Bu}fed Four Feet or More or Subject All Pipes to be Schedule 40. Use DGPTH', 4e INCHNS MIN 1 NCN to Vehicular Traffic lobe H-20 Loading. 5-500 Gal.Leaching Chambers Ina ZEM KA l_ 1 NOfsRoutAOWATRR13N000NTEM & Septic System tobe Installed in Accordance With 12x44WashedStoneFieldasShown (_�, s,y DATE: 6/Q/Q-7 310 CMR 15.00 Latest Revision And The Town of No• : P- 8RS4 Barnstable Board of Health Regulations ���t' r Or At, y (� '�' rx01BGTLOCATIatk W ITNLSS',Z,PUIININCii T.o,C3, 13.0•N 7 All Piping tobe Sch.40 PVC. �r ` I a x`�� w l M 1 F�b `0f`� 0`>1 �l f=NGINEER: BAYTER e-NYE PI:T:R 1Lt� r�l«,e..DI[ndx hoealiaird a•Order otCoodld•m JEST HOLE 2 ELEV, 34.0 , A10. Cj�L33 - OR �O� O Otz6-moc M>•TERIAL f.G.40.5 6I " , .�+ r; aaeorcmatrloo, ❑ 10 V R �/2 FG.39.0 ' aE¢�.. 'y. . 3 SANt�Y LOAM `�vl a! • _s Tbleplenw�llbmotldsedm n n I Zr •2,5 Y R 4/3 38.2 35 3 1 �y Dab 6 LOAMY SAND 1500 Gallon Top El.36.3 'S• V 7.S Yl< C/$ 38.0 Septic Tank 37 S Bot-EI.33.3 z y" C MC-DILIM s1.Np ,•r�.;:4_-,:._Yj,.•: 35.7 35.5 l 1 44- 1 O YR 1/4 6.3! Beddingas Bottom Test Hole El. No C-Rou"DWATER F-trcouNTI=D Per Title 5 27.0 No Groundwater Observed Directions: from Hyannis take Route 28 towards Osterville, Take a left onto South DELVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM County Road and the lot is on the right# 1825 Not to Scale Finish Graf .. >< Flits d Fobrie Compact FIII ■ i stem eN r®posed Septic �� Ile-ile hea 810" AT ceenhe.° 3/�•-II/:• 1825 SOUTH COUNTY ROAD N SDoubleWa*.W The septic system is to be built in accordance with all provisions of Title 5 OSTERVILLE , MASS. I 310CMR15.00 Latest Revision and the Town of Barnstable Board of Health Regulations. This includes complying with all performance and material specifications FOR PETER C. T CROSS SECTION of CHAMBER not specifically noted on this plan. B E N N E SCALE: AS SHOWN DATE DEC. 14, 2000 '4040T TO SCALE SULLIVAN ENGINEERING INC. OSTERVILLE I MASS, ATTArHMF_NT A aond�