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Home My WebLink About0024 ACORN DRIVE - Health 24 Acorn Drive W. Barnstable P A = 216 026 0 0 , � o 0 f i a I d Fee S BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicatiou jFor Yell Cott.5tructiou Permit Application is hereby made for a permit to Construct; Alter( ), or Repair( an individual well at: a� ALC�,-c X-) Q1 c c2(=. Location-Address Assessors Map and Parcel Owner I Address Installer-Driller Address Type of Building ✓ Dwelling Other-Type of Building No. of Persons Type of Well i%`1 PV L Capacity \0 Purpose of Well t'�"o J�C" , Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot c on Regulation-The undersigned further agrees not to place the well in operation until a Certificate o pl' n e s een issued by the Board of Health. Signed Date Application Approved By Date Application Disapproved for the following reasons: Date Permit No. C: (L "'00 Issued 36 (p Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well`• Constructed(1, Altered( ), or Repaired( ) by �� Insta er at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot action Regulation as described in the application for Well Construction Permit No.'PO 1� --01Ll Dated '; 6 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector ✓ No.� —©c Fee BOARD OF HEALTH TOWN OF BARNSTABLE 0[ppYicatiou _for Yell Cou5tructiou Permit Application is hereby made for a permit to Construct, Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel C - Owner Address Installer-Driller Address Type of Building ✓ Dwelling Other-Type of Building No. of Persons Type of Well L---t'l Py C, Capacity Purpose of Well Pn�-C',"e_ Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Prot cJ on Regulation-The undersigned further agrees not to place the well in operation until a Certificate o o VI s been issued by the Board of Health. Signed G Date Application Approved By Date Application Disapproved for the following reasons: Date Permit No. (P —00 Issued 311 /- (P Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS'TO CERTIFY,that the individual well Constructed(X, Altered( ), or Repaired( ) by cc � QA\ Insta ler at has been installed in accordance with the provisions of the Town of Barnsta le Board of Health Private Well Pro�j�,ct'on Regulation as described in the application for Well Construction Permit No.�c) I dC?9 Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL.FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE VeYi Cougtructiou perm it No. l�� (p G�y Fee Permission is hereby granted to CC, Installer to Construct`( ),r Alter( ), or Repair( an individual well at: No. Street as shown on the application for a Well Construction Permit No. tiJ � �' _ Dated 3/a Date ! �j Approved Byt, t TOWN OF BARNSTABLE ,LOCATION I C291 U e SEWAGE# VILLAGEPs� / O'e ASSESS 'S MAP/&/LOT 006o DR99AANUM a�l Der 0/7s/ i4 NAME&PHONE N I� SEPTIC TANK CAPACITY . � LEACHING FACILITY: (type) i (size) /DOO C�Q��/> � NO. OF BEDROOMS 3 BUILDER 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 We/!Va. Poa/ //00 ' on site or within 200 feet of leaching facility) �y� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching c lity_)/ Feet Furnished b ,:lS .. ..,,,a y 1� �� `}'h �� ., Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments copy 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information is West Barnstable MA 02668 May 6, 2011 required for y every page. Cityrrown 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 filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name P.O. Box 371 Company Address Sandwich MA 02563 ' City/Town State Zip Code 508-888-6055 SI 12843 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 16.340 of —Title 5 (310 CMR 15.000).The system: : ® Passes ry ❑ Conditionally Passes ❑ Fails c ❑ Nr'�)ds Further Evaluation by the Local Approving Authority U_ May 11, 2011 4' 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 24 Acorn Drive Property Address Jeff& Cheryl Allen Owner Owner's Name information is required for West Barnstable MA 02668 May 6, 2011 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" /N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years of *or the septic tank (whether metal or not) is structurally unsound, exhibits substantial in tration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is yeplaced with.a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspe ion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan is less than 20 years old is available. ❑ Y ❑ N ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts . Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information u red for required West Barnstable MA 02668 May 6, 2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 Heal ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or eplaced ❑ Y ❑ N ❑ ND (Explain below): 7' ❑ 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): i C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require furth evaluation by the Board of Health in order to determine if the system is failing to protect pub is health, safety or the environment. 1. System will pass unless B rd of Health determines in accordance with 310 CMR 15.303(1)(b)that the system i 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M bvbv� 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information is Y required for West Barnstable MA 02668 May 6 2011 every page. City/Town 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: 1. ❑ The system has a septic tank and soil absor ion system (SAS) and the SAS is within 100 feet of a surface water supply or tribut to a surface water supply. ❑ The system has a septic tank and SAS a�} the SAS is within a Zone 1 of a public water supply. / ❑ The system has a septic tank and SA and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS an 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 wXwatalysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent.andeof ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided thailure 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 wafers due to an overloaded or clogged SAS or cesspool El ® 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name r fouired forration West Barnstable MA 02668 May 6, 2011 every page. Citylrown 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 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. ❑ ®! 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 40 feet of a surface drinking water supply ❑ ❑ the system is withi 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is to ated in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) r a mapped Zone II of a public water supply well If you have answered"yes"to an question in Section E the system is considered a significant threat, or answered "yes" in Section D ove the large system has failed. The owner or operator of any large system considered a significan threat under Section E or failed under Section D shall upgrade the system in accordance with 31 CMR 15.304. The system owner should contact the appropriate reninnni nffir . of fhp nenartmPnt. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 f_ T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name required foration West Barnstable MA 02668 May 6, 2011 every page. Cityrrown 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 ❑ 0 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? E ® 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 357.3 GPD p gpd x#of bedrooms): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name e ued for information irts r9 West Barnstable MA 02668 May 6, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Property has a three bedroom deed restriction in place at the Regestry of Deeds. 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 ears usage Private Well 9 ( Y 9 (gpd)}: Detail: Variance granted for distance to existing well in 2002. 116'to edge of SAS. Sump pump? ❑ Yes ® No Last date of occupancy: Nov. 2010Date 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 th Title 5 system? ❑ Yes ❑ No Water meter readings, if availabl t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Acorn Drive . Property Address Jeff&Cheryl Allen Owner Owner's Name information is Y West Barnstable MA 02668 May 6 2011 required for , every page. Cityfrown 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 found Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff& Cheryl Allen Owner Owner's Name r f uired fororation West Barnstable MA 02668 May 6, 2011 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: System installed March 18, 2002. Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 4 p I,Vn Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 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: 1 V X 5'X 4.5' 1500 gallons Sludge depth: 1" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name r f qration uired for West Barnstable MA 02668 May 6, 2011 every page. City/Town 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 39" Scum thickness 011 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape measure and dip tube. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. No leakage.. Risers bring covers within 6"of grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fibe lass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top ioutlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Trtle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information is required for West Barnstable MA 02668 May 6, 2011 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.): 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 El polyethylene El 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information is west Barnstable MA 02668 May 6 2011 required for �_ � T_ every page. Cityrrown 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 a° 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.): One intet, two outlets w/speed levelers in place. Equal flow. No solids carryover. No sign of high water staining over outlet inverts. Riser brings cover within 6" of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pum/amber, ondition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information is required for West Barnstable MA 02668 May 6, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: 2-500 gal ea. w/ ® leaching chambers number: 4'of stone. ❑ 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.): Chambers inspected and located w/camera. Chambers dry at time if inspection. No sign of past hydraulic failure. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of13 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information is West Barnstable MA 02668 May required for Y 6, 2011 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: / j Dimensions Depth of solids Comments (note condition of so' , signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System-Page 14 of 14 I 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M < 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information is required for West Barn Y Barnstable MA 02668 May 6 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water Check cellar ❑ Shallow wells Estimated depth to high ground water: >8feet 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: Dec. 20, 2001 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole to elv= 79.5 found no ground water(2001). Base of SAS at elv= 88.75.Accessed local ground water contours and topo mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins+09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 f Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owners Name infoffrequired adon �s West Barnstable MA 02668 May 6 2011 required for Y. , every page. Cayrrown 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 i c3 L(3�Cr1 qk. � :� O a t5irm-oRM Title 5 Official Inspection Forth:Subsurface Sevrage Disposal System-Page 15 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Acorn Drive Property Address Jeff&Cheryl Allen Owner Owner's Name information is West Barnstable MA 02668 May 6 2011 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 (5) The designing. engineer shall. supervise the construction of the onsite sewage disposal system.and shall certify in writing to the Board. of Health that the. system was installed in. substantial. compliance.with the. submitted. plans.dated December 29,.2001.. This variance. is. granted because the physical. constraints. at the site. severely restrict the location of the soil absorption system due. to the. proximity of wells located at neighboring properties. It is the opinion. of this. Board that the proposed. new soil. absorption. system is designed to. meet the maximum feasible, compliance.standards.contained.within.the State Environmental. Code, Title V. Sincerely yours, �_ I Susan. G. sk. R.S. Chairperson. Cc:Pete McEntee 23 Deer Hollow Road,Forestdale Grossman OF TFIE TOt,. DATE: D FEE: * •ARNS1'AaLE, * � 16 v� i639• ,0� REC. BY Town of Barnstable S CHED. DATE: Board of Health - ZEIVED 200 Main Street, Hyannis MA 02601 ..:.� -' Office: S08F.4,- 644 Susan G.Rask,R.S. FAX: 508 790-6 p 4 - 2002 Sumner Kaufman,M.S.P.H. D Wayne A.Miller,M.D. B,gRNSTABLE VARIANCE REQUEST FORM L .ALTH DEPT. LOCATION Property Address: y 4.C e rr_ je. Gt/e (f 6A/rt. Assessor's Map and Parcel Number: c2/a Size of Lot:.2.3, 9555( Wetlands Within'300 Ft. Yes Business Name: No Subdivision Name: APPLICANT'S NAME: Phone Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON Name:le" , 5�3Arnrr eke/ 6Ya SS mq h Name�ZTe Er-lc M a`'- fj ro S sm---r\ aa - [ 0, Address:c)y A r-o r-h ,Or i ve yl/. barn SA�&Address: a 3 I- -C t 1 G)-u.) �q� T--C]Yq-d j, Phone:3D&--.3 6 o? �� 7 Phone: 07- -Lf-2 :7— GJ 3/3 VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) IN. NATURE OF WORK: House Addition 1100000 House Renovation ❑ Repair of Failed Septic System Checklist(to be completed by office staff-person receiving variance request application) V Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) 14 Full menu submitted(for grease trap variance requests only) Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only],outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) _NL Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Wayne A.Miller,M.D. Q:\HEALTH\WPFILES\VARIREQ.DOC ok r Town of Barnstable Board of Health 200 Main Street,Hyannis MA 02601 Office:-508-862-4644 Susan G.Rask,R.S.. FAX:. . 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D.. February 22, 2002. Ms.. Kimelissa Barnocky-Grossman 24.Acorn Drive West Barnstable, MA RE: 24.Acorn Drive, West Barnstable, Assessors Map 216, parcel 26 Dear Ms. Barnocky-Grossman, You. are granted a. variance. to construct an onsite sewage disposal system at 310 Pine,Street, West Barnstable.. . The.variance granted. is. as follows:. PART XIV SECT.. 2.00:.The soil absorption. system will be. located 116.feet away from.the.onsite. private well used.for drinking.water; in lieu.of • the 150.feet minimum separation.distance required. This.variance is granted.with the following.conditions: (1) The onsite private well water shall. be analyzed by a. certified laboratory annually. (2) No. more than three. (3). bedrooms. maximum are authorized at this property: Dens, study rooms, offices, finished attics,. sleeping. lofts,. and. similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (3) The applicant shall record a. properly worded deed restriction, signed by the owner of the property, at the. Barnstable County Registry of Deeds restricting the property to three. (3) bedrooms. maximum. . A copy of the recorded deed restriction. shall. be submitted to. the. Health. Agent prior to obtaining a disposal works construction. permit. (4). The septic system shall be. installed in strict accordance. with the. engineered.plans dated December 29, 2001. Grossman y -- \ COMMONI�-E, OF :ZL�SSACHUSETTS J d j EXECUTIVE OFFICE OF ENVIRON-MENTTAL AFFAIRS DEPARTAIENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 24 ACORN ROAD,WEST BARNSTABLE Owner's Name: KIM-BARNOCKY Owner's Address: 24 ACORN ROAD,WEST BARNSTABLE Date of Inspection: AUGUST 29,2001 Name of Inspector: (please print) JAMES A.ORPHANOS Company Name: CERTIFIED INSPECTION Mailing Address: 47 CAMERON ROAD NORTH FALMOUTH, MA 02556 Telephone Number: (508)564-5653 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.00). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails /1 Inspector's Signature: male: SE P T EMBER 4.200? The system inspector shall subrot copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days 6 comp) tin this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspect 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. r Notes and Comments The inspection is not designed to determine the remaining life expectancy of the sewage disposal system. Buyers are urged to consult further with an environmental engineer about any part of the inspection they do not understand. ****This report only describes conditions at the time of the inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 I Page 2 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 ACORN DRIVE Owner: KIM BARNOCKY Date of Inspection: AUGUST 2%2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no, or not determined(Y,N, ND) in the ____for the following statements. if"not determined", please explain. _ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 ACORN DRIVE Owner: KIM BARNOCKY .. Date of Inspection: AUGUST 2%2001 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 the 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. 2.1 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 the environment: l The system has a septic tank and soil absorption-system(SAS�and-the SAS"iswithin-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 Zorie 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 rr ' 0Q, Page 4 of I . , OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 24 ACORN DRIVE Owner: KIM BARNOCKY Date of Inspection: AUGUST 29, 2001 D. System Failure Criteria applicable to all systems: you must indicate "yes" or"no" to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _. X Static liquid level in' the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped. X Any portion of the SAS, cesspool or privy is below the high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.l NO (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd- You must indicate either"yes" or "no" as to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply —the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section 'E the system is considered a threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 i Page 5ofII OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B .-CHECKLIST Property Address: 24 ACORN DRIVE _'_ =''w h`" Owner: KIM BARNOCKY Date of Inspection: AUGUST 29,2001 ':; ' _._ _ _ �, :4 Check if the following have been done You must indicate "yes" or "no" as to each of the following: Yes No X Pumping information was requested of the owner, occupant, or Board of Health. X Were any of the system components pumped out in tiie previous two weeks.? , X Has the system received normal flows in the previous two weeks? X Have large volumes of water been introduced to the system recently or as part of this inspection X _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) X _ Was the facility or dwelling inspected for.signs of sewage backup X z!, :Was the site=inspected,for signs of breakout,,? cl X _-Were'all system components, excluding the SAS,.located.on site_? }r X Were the'septic tank manholes uncovered, opened, and the interior of the septic tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption Sy=,teni (SAS)on the site has been determined based on: Yes no _ X Existing information. For example, a plan at the Board of Health. j X _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] ° •v t' � a (-�. .. .. ,t!. �SC�.. Y .. '.(�$ � r.{)r+� �. rt� �;...r' 5 L Page 6 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 ACORN DRIVE Owner: KI:M BARNOCKY Date of Inspection: AUGUST 29,2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): UNKNOWN,• NO RECORDS Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x of bedrooms): 330 GPQ Number of current residents: 3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no). NO [If yes, separate inspection required] Laundry system inspected (yes or no): N/A Seasonal use(yes or no): NO Water meter readings, if available(last 2 year usage(gpd): HOME IS SERVED BY A PRIVATE WELL Sump Pump(yes or no): NO Last date of occupancy: THE HOME IS CURRENTLY OCCUPIED. COMMERCIALANDUSTRIAL Type of establishment: Design flow: (based on 310 CMR 15.203) Basis of design flow(seat s/person/sgft,etc.): Grease trap present (yes or no)_ Industrial waste holding tank present (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy/use: OTHER: (describe): GENERAL INFORMATION PUMPING RECORDS Source of information: FIRST PIT WAS PUMPED TWO YEARS AGO ACCORDING TO OWNER Was system pumped as part of inspection (yes or no): NO If yes, volume pumped: eallons--How was quantity pumped determined? _ Reason for pumping: _- TYPE OF SYSTEM Septic tank/distribution box/soil absorption system X Single cesspool X Overflow cesspool Privy _Shared system(yes or no) (if yes, attach previous inspection records, if any) _Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from the system owner) Tight tank Attach a copy of the DEP approval Other(describe): _ Approximate age of all comp6nents;date`installed ('if known) and-source of information UNKNOWN Were sewage odors detected when arriving at the site (yes or no): NO 6 Page 7 of I I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION{continued) Property Address: 24 ACORN DRIVE Owner: KIM BARNOCKY Date of Inspection: AUGUST 24,2001 �, F BUILDING SEWER(locate on site plan) N/A Depth below grade: Material of construction: cast iron 40 PVC _ other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) N/A Depth below grade: Material of construction: concrete metal Fiberglass Polyethylene other(explain) If tank is metal, list age: _Is age confirmed by certificate of Compliance.,(yes or no): .(attach a copy of certificate) , Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: s ' Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction: concrete_meta_Fiberglass_Polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition structural integrity;'tliquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 ACORN DRIVE Owner: KIM BARNOCKY Date of Inspection: AUGUST 24, 2001 t TIGHT OR HOLDING TANK. N/A (Tank must be pumped at time of mspection)(loca e on site plan) ) Depth below grade: Material of construction: —co ncrete_metal_Fiberglass_Polyethylene_other(explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order: (yes or no): _ Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: N/A (locate on site plan) Pumps in working order: (yes or no): Alarms in working order: (yes or no): Comments(note condition, of pump chamber, condition of pc?mps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 ACORN DRIVE Owner: KIM BARNOCKY Date of Inspection: AUGUST 24,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: ONE: 6'DIAM.X 6'DEEP leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:. innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.).- THE BOTTOM OD THE SAS IS 9'BELOW GRADE, THE DISTANCE BETWEEN THE INLET INVERT AND THE LIQUID LEVEL IS 7". _ CESSPOOLS: Y� (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: ONE: 6'DIAM.X S'DEEP Depth-top of liquid to inlet invert: NIA CESSPOOL ACTM AS SEPTIC TANK Depth of solids layer: 6" Depth of scum layer: 3" Dimensions of cesspool: 6'DIAM.X 8'DEEP r Materials of construction: BARREL BLOCK Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) NO ADVERSE INDICATORS. PRIVY: N/A (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.) 9 Page 10 of 1 1 1 '{: • . V OFFICIAL INSPECTION,.FORM�-.NO"S' FOR,,VOLUNTARY,ASSESSMENTS t SUBSURFACE SE.WAGE.DISPOS.AL,,SYS.'t:EM INSPECT ION:I•�ORM !PART L _ _ fiYSTEMIi�'FC)RryIA,•rION;E(conttnued) Property Address: 24 ACORN DRIVE Owner: KIM >iARNOCKI' c t Date of Inspection: AUGUST 24, 2001 SKETCH OF SEWAGE DISPOSAL SYSTEM ,. .. . Provide a sketch of sewage disposal system including ties to a t least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. locate where. public water supply enters the building. ,: t 2 ACORN DRIVE. ,:r 1� . ,'t,1 � •5 , s5,; �a r:;i.>•/�..�L:., F,!,..� u:�rr'D �9 3�r� .,k�„a a , 7 3' 3 5' 96' 10 Page 1 1 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOIZIVIATI:ON(con.tinued) Property Address: 24 ACORN DRIVE Owner: KIM BARNOCKY Date of Inspection: AUGUST 24,2001 SITE EXAM Slope GENTLE SLOPE FRONT TO REAR Surface water NONE OBSERVED Check cellar NO SUMP OBSERVED Shallow wells NONE OBSERVED Estimated depth to ground water >9 feet Please indicate(check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed Site(abutting property/observation hole within 150 feet of SAS Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high groundwater elevation: PROPERTY IS APPROXIMATELY 40' IN ELEVATION'HIGHER THAN NEARBY GARRET POND. II TOWN OF BARNSTABLE LOCATION At0ls J 72� . SEWAGE # VILLAGE �N _ /�!J IZ Q S i M,l ASSESSOR'S MAP& LOT o IC& INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �� (size) NO. OF BEDROOMS BUILDER OR OWNER /TLI= ,S /AkI Pace t c d ►J 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) "7 /� Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 fe t of leaching facility) /Vi A Feet Furnished by J.r)/7PAA 1• 0 C TOW_ _ N OF BARNSTABLE £ _ 1 � T>�iCATION, Q 4 Q C D 6YL JJ 6 . SEWAGE # D i E W , �^•-�yv� L� ASSESSOR'S MAP & LOT 21( ~02,15 INSTALLER'S NAME&PHONE NO.�ZZ NS A A 541-2t,r3'( -2;V V 2'4 g H SEPTIC TANK CAPACITY lSGD Cs�-f'� LEACHING FACILITY: (type) �� 611'lu- d&m,,m p(size) NO. OF BEDROOMS BUILDER OR OWNER7� — PERMIT DATE: -U, COMPLIANCE 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 Wed within 3(�'dd and Leachin Facility(If any wetlands exist et hi of leac i ) Feet Furnished b u LID 3G o " TOWN OF BARNSTABLE LOCATION L� O T'-r` 'Q)r , SEWAGE# VILLAGE �J, �r.n. ASSESSOR'S MAP&PARCEL INS-I '4 NAME&PHONE NO. Z� SEPTIC TANK CAPACITY S C)© LEACHING FACILITY.(type) ,�oo G.+,`\c, (size) Y'K l a is NO.OF BEDROOMS OWNER S��d- �' �,`.. r��► I �\\z�y� PERMIT DATE: �'�a 6 COMPLIANCE DATE: 3 J Q 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 ACC fic ® �t ®-�:_, 1 C�O° -cA sue• O a � ' No. U� ! VrArtwce- FEE COMMONWEALTR OF MASSAC14US ETTS � ✓ � Board of Health, � N$TN�(� MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( tAbandon( ) - .Complete System ❑Individual Components Location 2/4' Acorti D W i l b Owner's Name Map/Parcel# 21(P" Address �.9- /{G�•/1 �� C IDOL �j Lot# ( .Z Telephone# XInstaller's Nam S a Ste-`/� Designer's Name �'� f �� ✓ I,, Address .�0 �'J Cc�,-t V Address �3 d Cl LV Lc) Telephone#S S -14- -0 _ C11" -4—1 Telephone# +7-7-53) 3 R&17Z� Type of Building s i /--la wi; /�-Si�G(�✓Lk( Lot Size 7i3 �- sq.ft. r Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building N j A No.of persons Showers ( ),Cafeteria ( ) Other Fixtures /N/g Design Flow(min.required) gpd Calculated design flow 33b Design flow provided 357 3 gpd Plan: Date 2�U l Number of sheets Z. Revision Date AVA Title Sfeb'C SvJ ggg�u,r /004 nil Z� Acorn Or , W, dl4re%S)-e0bLP yl-y4 Description of Soil(s)0-6" A ; S( do -Z 4"6:Jsw-,24 C J; C�� 66 =-/08"L 2 o job�� PS6C3: $7,,F/* Soil Evaluator Form No. Name of Soil Evaluator IqW / Gc$;j [P Date of Evaluation 1420161 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fur agrees to not to place the em in operation until a Certificate of Compliance has been issued by the Board of Health. �( Signed % Date r }� D —v 2 DESIGNING ENGINEER MUST SUPERVISE Inspections INSTALLATION AND CERTIFY IN WRITING THE SYSTEM WAS INSTALLED IN STRICT PLAN.ACCORDANCE TO r'• V v .?' ;J ""y�� (/r f ( ^� V / ` ,I «.,.�W�,� FEE. �L COMAIWEA ell Board of Health t N APPLICATION. FOP DISPOSAL SYSTE 'l[ C@h RK(TION PERMIT Application for a Permit to Construct( ) Repair( Upgrade(A Abandon( - OXomplete System ❑Individual Components Location '��"' A'wor r's Name � ,✓y ,9Gl -10 GGw c Map/Parcel# v(V Anl-ee t Add`reg. Lot# ./,,, .Z, Te14 one# Installer's Name .�s, y� A Ste-•`/�. Designer's Name Address - o (')a -)C 732 coot V t-L Address 2-:3 DEC✓ 140 110IV Telephone#SO 6 -14l o _ "j � 1 \ Telephone# �06) 4-7-7-53/ '3 du tjl Type of Building 5�n► i k i ,,, LoOize 73 -q ± sq.ft. Dwelling-No.'of Bedrooms Garbage grinder ( ) Other-Type of Building W/A No.of persons Showers ( ),Cafeteria O *^ Other Fixtures &/A Design Flow (min.required) gpd Calculated design flow �y�i'L) Design flow provided 3.S 7,---?_gpd Plan: Date 1 2-1 20 O 1 Number of sheet.^ 1' Revision Date AVA Title v Description of Soil(s)a"6" A ; St , (0 29 °'13;S#f2.4"-W`C f i Cl� d 66=/08 "G Z: Sa,a,//5i If 101E`- 1Slo�'C3: R Soil Evaluator Form No. „ r 1i �iYde. Name of Soil Evaluator ✓ P� FrrL1.�P Date of Evaluation 1 Z/2�1- i DESCRIPTION OF REPAIRS OR ALTERATIONS 1 _ The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fume agrees to not to place the ,stem m operation until a Certificate of Compliance has been issued by the Board of Health. Signed: C Date Inspections .No. Uo -u6� FEE CO9[MONW ALT14 OF MASSAC14USETTS Board of Health, Fki'1 y_s* ^e L E MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) 0 Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by. at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. ?�d Z' �'I dated? -:7) Approved Design Flow 3 3d (gpd) Installer A d.A Sdv .of Designer: Inspector: b q N - Date: '3-iQ,:,m The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. n UO 2 VW4 FEE COMMONWEALTH OF MASSAC14USETTS Board of Health; l zlU JS TA•rat 6,- MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permisstioon is hereby granted to; Construct( ) Repair( epair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at 1 ff r C"') D r . In/. !9 fi'nYfk Ra as described in the application for Disposal System Construction Permit No. 061 ,dated 2 Provided: Construction shall be completed within three years of the'date of this permit. All local conditions must be met. Form 1255 Rev.5i96 A.M.Sulkin Co.Boston,MA Date :2 Board of Health { alp = I TOWN OF BARNSTABLE L LOCATION a aCOC �6 . SEWAGE # VILLAGE W - T ASSESSOR'S MAP & LOT 21�-0.2ti INSTALLER'S NAME& PHONE NOV'KSM V.10 -cl 4� SEPTIC TANK CAPACITY b I LEACHING.FACILITY: (type) C-2)_W 60)/,, C1�AM^419 £(size) NO.OF BEDROOMS A BUILDER OR OWNER .��-C- ��S.57� PERMITDATE: a COMPLIANCE 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 Wetl d and Leachin Facility (If any wetlands exist within 300 et of leachi i ) Feet Furnished b 16L 41 � 50 _ SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signatur item 4 if Restricted Delivery is desired. ent ■ Print your name and address on the reverse X Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on the front if space permits. L '' -0-7-0 0— D. Is delivery address different from item 1? ❑Yes i 1. Article Addressed to: If YES,enter delivery address below: ❑ No C ` 2 P, Abe dz 4. 1 6 U, /"a--1 3. Service Type Q lAc ❑Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) 0 0 d O S Q D��Z �( U Z-7 3 PS Form 3811,August 2001, ,Domestic Return Receipt 102595-01-M-2509 UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • `A �� SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. a ❑Agent ■ Print your name and address on the reverse X �V ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, J4APAfir. or on the front if space permits. D. Is delivery address different from item 1? El Yes 1. Article Addressed to: 1 If YES,enter delivery address below: ❑ No 10 40xuL'a0 AlA/j 3. Service Type ❑Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (Transfer from service label) tl U UQ S Z O O o ZZ2 �{U 2,7 2 1 PS Form 3811,August 2001 Domestic Return Receipt 102595-01-M-2509 r. UNITED STATES POSTAL SERVICE., --. First-Class Mail I \ Postage&Fees Paid USPS a NA Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • 9@.P1DC � � ar.n � r CA I «• '"� ...'.'.�. !{[!t?!fl}{?��?!?f.{lf�f?�I??!{{l}�}?t:e{�{f?f{?f!?If�?!{f??li,( SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete ' at item 4 if Restricted Delivery is desired. ent ■ Print your name and address on the reverse ❑Addressee so that we'Can return the card to you. a eived by(P Hied Name) Dat f Delivery ■ Attach this card to the back of the mailpiece, � J1-7 or on the front if space permits. , ll C/ .D✓)s deliv ddress different from item 1? ❑Yes 1. Article Addressed to: �+�// If YES,enter delivery address below: ❑ No - C(�t2 Vnn �lJ z�zi L L( , :U — 1' Service Type c f i . 1 A (� E Certified Mail ❑ Express Mail V �l V 1 ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number q :/ (Transfer from service label) PS Form 3811,August 2001 Domestic Return Receipt 102595-01-M-2509 UNITED STATES POSTAL SERVICE First-Class Mail LISPS e&Fees Paid Permit No.GIT0 • Sender: Please print y u`r narne�address, and-ZtP44-M-th s_B6 I 2c�n0C�� I I k4 Cnf-A l I I I • k SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. ature item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. R c ived by(Printed Name) C. at�f D 'very ■ Attach this card to the back of the mailpiece, or on the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No AA 3.4�S�ervi �ype t Certified Mail El Express Mail C) a\V ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number -7G�D G.�-Z� Y- G 2- 73(�� (Transfer from service label) �C Z PS Form 3811,August 2001 Domestic Return Receipt 102595-01-M-2509 UNITED STATES POSTAL SERVICE First-Glass„Mail _ F R Postage&Fees Paid USPS. p rV{ Permit No.G-10 -" n - • Sender: Please print yo,ur..name, address, and ZIP+4 in this box • q % y 0 rA �Ch t � 77 - Engineering Works Civil Engineers 23 Deer Hollow Road, Forestdale, MA 02644 (508)477-5313 March 18, 2002 Mr. Thomas McKean - Health Director Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Re: Certificate of Compliance Lot 2 -#24 Acorn Drive, West Barnstable (Map 216, Parcel 26) Dear Mr. McKean, As per your request and in accordance with 310 CMR 15.021(3) of the State Environmental Code-Title 5, an as-built review of the septic system at the subject site has been conducted as well as frequent inspections during construction. I hereby certify that the existing Sanitary Subsurface Disposal System has been installed in substantial compliance with the Design Plan by Engineering Works/Terry A. Warner, PLS, dated December 29,2001. Should you have any questions, please do not hesitate to call. Sincerely, Peter McEntee P.E. cc. Kim Bamocky-Grossman Tow n of13arnstable P# /°f Department of Health,Safety,and Environmental Services Public Health Division Date I 167,Main Street,I lyannis MA 02601 f eAwrareara A)re�y.L� pate Scheduled ! a Time �' U Fee Pd. fC sF Soil Suitability Assess>,Zent for• Sewage Disposal n nA Witnessed By: Performed By: :.. .. ••,..:•::•:•::.::;>r •::: . :: :: .....:::::. :.::'< ss>:» :::<z:i s>.»^>;::;::,::;;:•;>;:<:>::>;:;:•:::•: Owner's Name i"en 13 ev-no G y Location Address e� hc.or.A I Address -7-+ A-corn N" BaMd��•t'. lt.?,�da�rn 5)-4�l.c�� ►1f3' �^�i h��•;� j/��(,CS Assessor's Map/Parcel: /Y1 g"o 2/1Q A/Ge Engineer's Name REPAIR X Telephone N L Soo) 477—S31.3 NEW CONSTRUCTION nn � •2 —�' Surface Stones �e� 6 Land Use /_ts a Slopes(/.) 7 R ' Drinking Water Well f 3a= n Distances from: ft Possible Wet Area Open Water Body � 3 - t! AJ ft Property Line Oilier ft Drainage Way SKETCH:(Street name,dimensions of lot,exact locations of lest holes&Pere tests,locate wetlands in proximity to holes) • Y , P 141 _ P A CO 21U /j ps �. Depth to Bedrock 3 Parent material(geologic) v � Depth to Groundwater. Standing Water in Hole: AJ�A- Weeping from Pit Face Estimated Seasonal High Groundwater 13i :.........:.•....,,..., .....::.......,:......::.;......... y� �}t 'Method Use In. Depth to soil mottles: ft. Depth Observed standing In obs.hole: in Groundwater Adjustment Depth to weeping from side of obs.hole: Adi,factor AdJ.Groundwater Level Reacting Dato:�._�_ Index Well level .•Index Well/!_�_._._ � Observation Time At 9" Hole 0 'time:at 6" _--� - Depth of Pete Time(9"-6") — -- Slant Pre-soak Time® _---- End Pre-soak ------- � 2 h �s�r�� U✓15��-� � /E'erc ��- 7J�8. � t Rate Min./inch mil Mac Additional Testing Needed(YIN) - ` Site Suitability Assessment: Site Passed _ Site Failed: "rit__,...:."I:nn ►-Inle Data To Be Completed on Back i1 :ijl.yy.�■ nw�t'+fti• V.K �;T.:: .... rT;'!;y.; .•\•• Other .... S oil ..:....... ..:.:...::......:. Depth Crom 5011 Ilorizon Soil Texture Soil Co or Mottling (Structure,Stones,Boulderes. Surface(in.) (USDA) (Munseil) n 4 5 L is Y2 "- ZY`► 5`l l �� 2's Y CI Cca, y 5-Y `/3 �I-1 a9 CZ sari d . 2,5.y /,� laasG T6 �t(�M 6 ors s, !�- C 3 n e S�� S,-5 I.caas e ..�-•1::.:.:.::...:.:.:..... ... .:.<:. . :>IlH P:::QBSE. :L, . . ......... Other .::.>:.>.<.<:.;:.::::..::�:>:.�..::.>::•>::,>;::;:;�;:.�>:;:;:;>;;�:::.::.:.::...::::::.: soil • Depth from Soil Horizon Soil Texture Soli Color Mottling Structure,Stones,Boulderes. Surface(in.) (USDA) (Munsell) ( • � 1 :< .. ------------ a'' ................ .. .. ........... ...... .{yHHy�,' [c:. .Dry` lt;•::+•. . .�... ..:...::.......:.:.::::..:.:....::•:::::�:::..�:..:. .. ... :::i:•i2<t::''t�::;;:;:; :3:::::i::;:::S:::a:::::2:::5:; ; :..........;.. : ...� :h+.. ..� MQ. ..:. .. .... •:,t:r, ::1--i..:;�:?•....:;%:'::;•:.•;.�::::::::;•:::%::::>:;:;�>:•>:>:•>:.�• 5::::•::::::;�»:•:<^;•::x•::e•;::•::+:•:::•:•::::.�::::::::..:........ Soil ...Diller " `''''l Soil Horizon Soil Texture Soil Color Depth from Mottling Structure,Stones,Boulderes. Surface(in.) (USDA)' (Munsell) g i i :.:::...::::.:::::...::::.::..�.;:.;:. : : :•::D�S�1�?PATIO]!�<�:+(J:L..:..:•::.:.:.......�::::::.:..., •'• Other •>:::r•:::::::::.:•.:.:•::.:••:<.:.::. ...:. ...:...�:.....:.:.::.:•.:•: .:.:....,..:;.;:..;::•.: Soil Depth from Soil Horizon Soil Texture Soil Goior Mottling (St;vcturo,Stones,Boulderes. Surface(in.) (USDA) (Munsell) a LGMYdL- Floor! ins rmRa Rate IYIm ; Yes Above'500 year flood boundary No___ ... . �_-f BUILDING SKETCH Borrower/Client Barn ock ,Ian/Kimelissa Address 24:Acorn Drive City West Barnstable County Barnstable state MA zip code 02664 Lender/Client River Mortgage, Inc. • ;. .. ._:.__.......9... ..... _�_ - _._M . . . ............:.....i.- ......_ ' _ _ � . : r , . �.....:........... I , F11t :. I � I _. ° ' . I : ! I , _.._. ... p - - I } ; I ., i i .1.. I .t , . i ___,_ I I.... _ _. . : , : -_ . I ..... .: ,..., ,.. .. , F, i f ,..., ,. I t .... .....:... _... ' ..... I.; : i i , ..... ;. . . 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I a_._. ,__ ....' f .. i i .., .. ...! 1 " t . 11 i .... i + i I —_. .... .. 1. ,.., I.t. 1 ...i ., I — _ i _ '... ...... i . r T . .,. . ; /� j.' I r -. i I ..I �///� 1 r,,,. I _ , . . t .........._._. :o .._. ,.,,...._ : . . ....._.,, } j ._.,...r.. _.... t.. ..I...., :... .._...r. ..I .. I '...I ` 1 14 , - : ..: I ... I 1 I - {...I ! .. 1:.., : . { j .._.;__}.4. ' ....I. i : i . : __ ... : . _..__ ....., f ;. i.1� ~I I. I �. «..... ..........t ,. ;.... l 1. i ..... ._. . 1 { ..; .;.. . ,._.....,...I �.....,._L. ..1 i..,..f.. _. .....__. �_«.... L.., �7 I . .. a r—� .......:..: i j i.. I. : : : ; : 1 4 .. II I I _._;... .. I. ..... ' P. I "{ .:.. t 7 I . 1. I .....I. j".... I. .. I• ...,. `I1. .. ....i. .., .«. I r I r I ...:. .. ...._...., .....:.. : i ...., .. ....., { : �- . ..t 1_.:. _f-_.. ....i....1.- f . .....-...... I I I „{, -: _ i ;... • : 1 . ..I i. j . I , } _,�.�_ ,.. r--- - I. I .. -•! a ,.... 1 } - .. .,. l 1.1 I 1.. I... 1. __ ." 1. , j ' I '- I.. - - - -I + a� j. _. .,..., j... Oaj I 1 I t i 4 ,j I _{ I I if ' , ...:...........I.....; : ;:L. i I„ . 1. .._. ; ' I t. �... ,....,-...;....'. { j... t L. f ,, BORTOLOTTI CONSTRUCTION INC. ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop �T h/�-/--�--a--_---- --- ---- ---- ----- - ------ ---------------- -------- Date of Inspec} M arce Owner PART A — CHECKLIST CHECK IF THE FOLLOWING HAVE BEEN DONE: ( PUMPING INFORMATION WAS REQUESTED OF THE OWNER,OCCUPANT,AND BOARD OF HEALTH. 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 COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. SAS-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. (r THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. BALL 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 IN FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID, DEPTH OF SCUM. 12 &-THE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING I MATIO OR�t APPROXIMATED BY NON-INTRUSIVE METHODS. VOO ft �rHE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH 1 0 MAt4kO�'N��CCTiirrFJ�PROPER MAINTENANCE OF SSDS. - -__ -_ _ _ Ion, N PART B — SYSTEM INFORMATION RESIDENTIAL FLOW CONDITIONS � - - - - No of Bedrooms No of Current Residents Laundry Connected to System ____Seasonal Use NON RESIDENTIAL: — --- -- -"— - ----------- Calculated flow) WATER METER READINGS,IF AVAILABLE: GALLONS Pum 'ng Records and Source of Information: -..- / lc' SYSTEM PUMPED AS PART OF INSPECTION?/L Q IF YES,V�XU��tUMPED = GALS Reason for Pumping: -:- ----- ------- --- TYPE OF SYSTEM: -- - -- --- l Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes,attach previous I spection records, if an Other(explain) /._ C), I✓ Appr 7ximate age of all components. Date installed,if known. Source of information. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade: Dimensions: Material of construction: Concrete Metal FRP Other} Sludge Depth Distance from top of sludge to bottom of outlet tee or baffle 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 Comments: DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: PUMP CHAMBER: Pum sinworkingorder. Comments: SOIL ABSORPTION SYSTEM (SAS): IF NOT PRESENT,EXPLAIN: TYPE: Comments: CESSPOOLS: Number and configuration ' ,Y Depth-top of liquid to inlet invert I Depth of solids layer Depth of scum layer Dimension of cesspool g>',() ,e Materials of construction (� � �' Indica tion of groundwater inflow(cesspool must be pumped) Comments: gel i ' ! VA 6,1- w% PRIVY: Materials of construction Dimensions 7 Depth of solids Comments: 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 I qu t18� q3 Veo �h L P� DEPTH TO GROUNDWATER: DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? �Z Static liquid level in the districution box above outlet invert? zV 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? Within 50 feet of a surface water? I Within 100 feet of a,surface water supply or tributary to a surface water supply? I Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools&privies only, not the SAS)? i Less than 100 feet gut 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 analysis for coflform bacteria,volatile organic compounds,amonia nitrogen and nitrate nitrogen. I' PART D CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY- BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONAL_Y INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION I REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION, THE INSPECTION WAS PERFORMED AND ANY I RECOMMENDATION 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 ONES- V I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 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: /AA& DATE: ? p�� ORIGINAL TO SYSTEM OWNER,COTES:BUYER(if applicable),APPROVING AUTHORITY r G1c 14$ 3 P:947 �1Es36 . 0 2—2 1—2 01212' a 12 a 32P DEED RESTRICTION WHEREAS, Kimelissa Barnocky-Grossman & Eric M. Grossman of 24 Acorn Drive located in West Barnstable, MA, are the owners of 24 Acorn Drive, West Barnstable, Ma and being shown as Lot No. 2 on a plan entitled "Plan of Land in West Barnstable and Commonwealth of Massachusetts, Property of Marion A. Hannigan, July 6, 1955, Charles N. Savery Company, Engineers & Surveyors", duly recorded at the Barnstable County Registry of Deeds in Plan Book 122 Page 141. WHEREAS, Kimelissa Barnocky-Grossman and Eric M. Grossman as owners of said lot have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included on any home built on said lot as a pre- condition of obtaining a variance from the Town Local Board of Health Regulation which restricts the placement of a Soil Absorption System within 150 feet of a drinking water well. I WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting said variance, and authorizing the issuance of a Disposal System Construction Permit, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on said lot be put on record with the Barnstable County Registry of Deeds by recording'this document. NOW THEREFORE, Kimelissa Sarnpcky-Grossman and Eric M. Grossman do hereby place the following restriction on their'qpove referenced land in accordance with their agreement with the Town-of Barnstable,5oard of Health and only to be lifted upon receipt of written permission granted by the To" of Barnstable Board of Health, which restriction shall run with the land and be binding upon'all,successors in title: 1. 24 Acorn Drive may have constructed 4pp11 it a house containing no more than three (3) bedrooms. Kimelissa Barnocky-Grossman and Eric M. Grossman agree that this shall be a permanent deed restriction affecting the dwelling located at 24 Acorn Drive, West Barnstable, MA and being shown as Lot 2 in Plan Book 122 Page 141. Page 1 i i • Sk 14843 P948 :1f�34S8 For title of Kimelissa Bamocky-Grossman and Eric M. Grossman see the following Deed: Book 11633 Page 13. Executed as a sealed instrument this 41 _day of , 2002. COMMONWEALTH OF MASSACHUSETTS ss ` -41t - Date , 2002 Then personally appeared the above named 7 l�wc known to me to be the person/s who ex a following instru ecuted men and ea. e,,,. acknowledged the same to be their free act and deed, before me. .. r �aaaqrril�, • off.-••••• ' otary Public 9< My commission expires: Z BARNSTABLE COUNTY REGISTRY OI:DEEDS A TRUE COPY,ATTEST BAMSIBLE REGISTRY Of DEEDS Page 2 2 I 1 LOCATION,� SEWAGE PERMIT NO. L/ �`YE,o, A-- vI L G E I.N ST A LLER'S NAME i AOOREAS d -- 8VILOUR OR OWN R GATE PERMIT ISSYEO /�� '2 2 DATE COMPLIANCE ISSUEDIc;21 s i.[�!�;` �, j�� !� -r. fi ;:, �, l /j �`Fl. �� i �� 1 1 �\L.+� r �\i�Y j, '\ /�, \ � \/ � b �� ,� \`�__� o / `� / f J e `)h.`. Yi NO 70:.. Fus._.. .5 0_.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... .T own...-....OF...a4;cnst.a.ble............................................................ Appliratiun for Di-qpu.5Fal Worke Tonfitrurtiun umi# Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: .......?4... ornhDx:,a-�Ie .. xi a 27.e.--.4266$---... - • ................. Location Address or Lot No. M. Su � l.-•-•----•--------••-----...---•---•-•-•----•---.._..-................ ....--- Owner Address A &_B- Cesspool_Service 128--Bishops_Terrace,__Hyannis,.-•02601 -•------•.............•••-•••••----........----•-- Installer Address dType of Building Size Lot.... ......... .........Sq. feet Dwelling—No, of Bedrooms...........3...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons...................2...... Showers ( ) — Cafeteria ( ) a Other fixtures --------------------------•--- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_----------------- Diameter__________:_________ Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ") Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date....................................... aTest Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water.....................__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__________________...... a •--•------------•-•------------•----------•--•-•--•---.._..--•..................••--••-••-•--••----•----...-•--...__......--•-•--•---•--------.:.....-----. 0 Description of Soil.................Sand x W -----•-----------------------•-•-•-•---------------....•-•-----------•-----------------•---------------------------•--------------•-------•-•••-------------•-•••-------------------------•----.....-•-- UNature of Repairs or Alterations—Answer when applicable--------Installation__of._s.... ne___thQusand(l,_Q9Q) ......ga.11Qn__stone--packed-,---pre 7cast_.1each••pi...................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with •-� the provisions of l^IT/'1'7 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed,/ ..... - ---=.1- •------.-�•l-5/'�9_.... 10 •....................•--------•-...........-----•-----•• � . : ll D to Application Approved By.................................................................................................. ----•--._._.__ -5/79------ Date Application Disapproved for the following reasons________________•_-___-_-____________________________---•----____-_--------------_---------------------..__.._..- -•--------•---__...---•-------•----•----------•-----••--•-----------•..............•.._........----------.._---------•---•---••---------•--------•----------------•---•------•---.... -------------- Date PermitNo........79•-.......................................... Issued_.............. 11- 5179...................... Date -1. n n No.7�- �_--'Z. YzE.....hr._^n......._ ,........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ow'n.......O F....Fs.MRtOl..1 e........................................................... Allp iratiou f v' r Uhipoii al Works Tome rnr#inn Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal t System at -•-•• .................................................. -- --- ,L66agpn ' ddre54 or Lot No. .... ...... .. Owner Address ......A_A.B.CesepgQj Service :.-•-•-•-•-••--------------------• --•12$._�?1 sb�?s.__T_? ,X. Installer Address �'+ d Type of Building : Size Lot................. .........Sq. feet U Dwelling No. of Bedrooms_............3................ .....Expansion Attic Garbage Grinder j p,, Other—Type of .Building .................... No. of persons.................... _..... Showers ( ) — Cafeteria Q, Other fixtures ---------------------- :_. d 1 W Design Flow______ ...............; ..__gallons per person per day. Total daily flow...................................:..•....._gallons. WSeptic Tank—Liquid;capacity gallons Length................ Width................ Diameter................ Depth.... x Disposal Trench No, `.`° Width....:............... Total Length.................... Total leaching area........_.._...__ .sq. ft. .` Seepage Pit No -. `,, 4 Diameter.................... Depth below inlet.................... Total leaching`area..................sq. ft. Z Other Distribution box,( )';° I Dosing tank ( ) Percolation Test Results ;Performed by---------------------------------------------•••-•---•-•••-••-••-•--••---- Date.................. ,� Test Pit No. i._..._ _mmutes per inch Depth of Test Pit.................... Depth to ground water--_____-_-_-_-_____-.__ f� Test Pit NTo. 2 £ •� �.nunutes per Inch Depth of Test Pit____________________ Depth to ground water.__________.____._._____ ` b ..-e Descriptionof Soil --------------------------------------------------------------------------------------------------=---------.............................. x t U W 4 UNature of Repairs or Alterations `Answer when applicable_______-Tnet.Ile. i—on.._of-_- LIP-0.) ....... a$t..leaCh.J3_ft------------------------------------ Agreement: t ; The undersigned.,agrees,to install the aforedescribed Individual Sewage Disposal System in accordance with f'1 T/'..i� .1.- the provisions of 5 at the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed {t.r -��6: `G� r� £ = 4 17�---- / `i to Application Approved..By,.-------------=-------------------------------------•--•----....-•-----•-•....-----•-------•-- ...............11D 'V7_9..... Date Application Disapproved for the,following reasons--------------------------------•-----------------------------------------------•----------------------------- ..--------•-----------------•--------••� -` -=--••--••----•------•----....-•---------•-----•-••-----------------•------•----•---•---•---------------...---•-•----•'Date Permit No.•---_.79-=--•----------•-•••••-•-•-••••---••-••••-- Issued-..............111_--5` 79 Date 4.1 -THE COMMONWEALTH OF-MASSACHUSETTS .: BOARD °,OF.. HEALTHT ow ... r-... C�ra~iifiratt,oaf TompliFanrr THIS IS TO CERTIFY, That the IndividuaN.Se•age Disposal System constructed ( ) or Repaired ( X) by.,.A. _B..Cesspool ........v ......1:28_-Bishcvs- errace,,-Hyanr��s-,._MA.........................75-6.2E�.. Installer Z4 Acorn Dr., .West Barnstablet 0266$ `=' Susich :. ------- ----- -- -----• - has been installed in accordance with the provisions of TIT13 j of The State Sanitary Code as described in the application for Disposal Works Constructlon Permit No..? ....�,7.jj.....___.._.. dated-----------11,....`?._7Q:................ THVISSUANCE OF THIS'CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .-._.. DATI:.::'�,>_----- �•..�_:.--• ,---��,rr�f:�--•----•-�y-.l�,�.r,�.. Inspector. -- �-�-•'y,,�='===?'-' .-----...---•-----•------•---- THE COMMONWEALTH OF MASSA�HUSETTS•` BOARD OF HEALTH € 79- ... own.....0F....._!'�nstable r5.00 ......................... .... .................................................... No............��+_� FEE........................ � ��untt1 nrk� �nnn�n�inn �erntt# _ Permission is hereby.graitted__._A_.`�_.B_Cesspool Service, 128 Bishops "errace, Uvanriis 02601 to Cons ruct (' ) or Repair (X ) an Individual Se ,g e Disposal System f !14 Acorn Dr., iMeet r'arnst�,ble, 02 ,, -- 1K. Susg.ch atNo.............................................................•-----:..:::...._.._.....--------.-------- .--------------------•----------------------------------------------------•-•--_------ Street as shown on the application for Disposal Works Construction P t No79;-___ ]1 .......................79 __ Dated �.. _: _. ----•--..--•-•:-_--- ll/ 5/79 Board f Health DATE.......................----------------•-....................................... .._. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS Finc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �I _--fo-W 0 .............. .fi.R.N.S�TR...�3.L. ........................................... Appliration for Dhipoii al Workii Tonstrnr ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( Zan Individual Sewage Disposal System at X.C.Aletl ..... ..... .._._. _._... ..... --------------•-----. "------------- Location- dress or Lot No. --•----------------- --------------------------------------= --.....---------------•-------•------••---•••-•---- Owne Address ------------------------------/3::—_7-�.----- �..r-pin..----------------- ----------- Installer Address ,g, dType of Building Size Lot............................Sr'-feet Dwelling—No. of Bedrooms___: 7___________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ZiWk_____________ No. of persons........../_............... Showers ( ) — Cafeteria ( ) Q' Other fixtures ...........I.-7.7�?'.�_................................................................... W Design Flow............................................gallons per person per day. Total dailyflow........................________._..________ ions. WSeptic Tank—Liquid capacity............gallons p Length___. _.__..__.. Width................ Diameter______ ________ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area_____._-___________sq. ft. Seepage Pit No_____________________ Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water-----_.................. fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ -------------------------------•---•-----•-•-------•--......---••-------•---.................__..__.......................................................... 0 Description of Soil...................................................................................................-----------------•-•----•-•----------------------------------_-•-•- x W •-••------------------------•----•--....•-------------••-•---------••---•--•---.._..-•----•-------•-------------• ------------------r r U Natt^re of Repairs or Alterations—Answer when applicable._____—.gip q �.. __ `'d----zl'�?..__h _.___.__. •--•-----------------------------•-••----------------------•-----------------------.._..•----•-•----•••--•----••----------------•-•---L._----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of-health. Signed---- '� ... ---- ............ Date ApplicationApproved By.................................................................................................. ---•----•---•-•••••-•-•-............... Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•-•-•••••-•••--•--•----._....._ .............................................•-•-----•---•-----•---------...----•------------•---...--•--'•------------------•-•-------------••-••-------•-----------------•-••---... -••-••----•--- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..�..^1..............of..........1 �4 .!�t.:S./'.. .�3.�.L-~.._.................... Trrtif iratr of Toutpliatta NO THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed � or Repaired by............^-- JR------------.C.6rSS.'PQD'C.--------------------------------------------------------------------------------------------------------------------------- ll Installer at.2..y.....�r ae-�...�.a............. -------•-•------------•-•---- has been installed-in accordance with the provisions of 5 o/ff The.Mate Sanitary Code as described in the application for Disposal Works Construction Permit N ._____�__ .....�` off.__ dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SFIAL OT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH Z9 �- ...../Q.60..N...........OF....... �.� �1�. _ v.................. No..._.._... � FEE....Ir............ Disposal Vorkg TwOnstrnrtion rranit Permission is hereby granted A �s .p��- to Construct ( ) or Repair (1�an Individual Sewage Disposal System at No. 2._;t4/....... x.j._..._..1)a............6Q. ......_FA&N.S774.1,)t4.45........................................................... Street as shown on the application for Disposal Works Construction Permit No_____________________ Dated.......................................... •.......................•--......---•-•------•---------••-•-•---••----•-•••-•---•••••----•••-•-•--••---- Board of Health DATE................................................................................. FORM 1255 Hoess & WARREN, INC.. PUBLISHERS s j;, s .. -� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'r0k _4---------------OF..... :r, . `1'�c.8.[ ~---------------------------------....----- Appliration• fitr., Disposal Works Tons rnr iun rPrmd# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at ... ... .. ai ,t�l... . ... � . �CC `rc'.. =m � ............... ... Location-Ajdress or Lot No. ....MIU ••_ X.V.Ay.-•-•--. Chl...:...............•• -•-...•--•---•••--•••------•••••-•••-••------••.......------••--••.........--•-----•-..._•••...._.I Own Address 1.4 Installer Address �... Type of Building Size Lot..l! ''_': _: eet Dwelling—No. of Bedrooms...... _.2...........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building p,l yp g r°g............. No, of persons.........f................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............"'.V!7.-Y....................................................... W Design Flow............................................gallons per person per day.- Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity_...._.._...gallons Length................ Width................ Diameter------_......... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( .) Percolation Test Results Performed by.......................................................................... Date......................................... aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------•--•--.....-----..........._.__.._....----.....----•-............................................................... 0 Description of Soil........................................................................................................................................................................ J x' W -----------•-------------------•------------------------------------•---------------•---------------•------------ ----. ..................................... ,r Nature of Repairs or Alterations—Answer when applicable �»_ ._. / U: P PP -------- ----------------------------•-•-----------------•--•------------------------.._............._..------------------ 7.............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by th board oL44th. � y Signed..... -••- ..-• •- ------------ ............ .: - - -- _... Date ApplicationApproved By................................................................................................ ------------------- ................... Date Application Disapproved for the following reasons_____________________________________________________________________________________•__.-_........._......____ .....-•-•-•------------------------------------------------•..............-•----------.....•---•-........._..._........----------••--------------...-•-•----------------------------------------••------- Date PermitNo...................................•--•----------....... Issued..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ...............OF........ ........................ Tntif iratr of Toutpliattrr NO THIS IS TO CERTIFY, That_the Individual Sewage Disposal System constructed or Repaired by............ ............. oz.pare A............................... Installer at ._. ......-- -------------------------------------------------•------.._..------------------. has been installed in accordance with the provisions of 5 of The tate Sanitary Code as described in the application for Disposal z, Works Construction Permit N _. __._ __ ± ____ da.ted................................................ THE. ISSUANCE OF THIS CERTIFICATE SHAL OT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 1All1l FUNCTION SATISFACTORY. DATE....................... Inspector THE COMMONWEALTH OF MASSACHUSETTS~ BOARD OF HEALTH .....Z0"` .N............OF......� �J1+'. �d�_ �:.. ..................... No._:..................... FEE.... ................. Dispos tl arks TUanstrnrtion rn'of w Permission is hereby granted............_!:"" -- ............... ! u�.Pm_i........:____- Y to Construct ( +) or Repair (Lean Individual Sewage Disposal System at Na. ----._2.C�._...-- - :.tit....... lx_x_......_.(r_).!..�'.A&NS7W4�.e---- ------------------- Street as shown on the application for Disposal Works Construction Permit No....................... Dated.......................................... .......................................................................................................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ' Gt� , 4 , i BBENCHMARKi Bay Colony Railroad LEGEND 03 NAIL IN 24" OAK EL:96.60(Assumed) �b o 99 PROPOSED CONTOUR ati 99 S 49°l9 ' E PROPOSED SPOT GRADE o°a �fl I r 31 � ll i 171,87, f —110 --- EXISTING CONTOUR Water a 110 EXISTING SPOT GRADE � 1 t r� q3 TEST PIT �oUte 6 �O(jte W 1 1 ra g t S _� _ --- - EXISTING WATER SERVICE 6,q ` LOCUS ~J \t ttt " EXIST. CESSPOOLSSTRIP s "' a _ - To q � - e p 3 (see n l) tt (6�lk yt1' " filled with sand t3 okw D ''c 0 0 ooa� �4 Grr 4 �� tl t +lei``ems -• 9p� _�--__..,.____...__..._.._ o��o` ��or is� LOCUS MAP N.T.S. G) I t �' ✓ GENERAL NOTES: Proposed ✓n °i Septic Tank ✓ ° O 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. �-- TPA r° i --- - _ Ix�� 3 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS �22 i 15, 13.2' EL r 9�5 a q Gµ ---. __ / OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE ai r . i 2 a o I � LOCAL RULES AND REGULATIONS EXCEPT AS RE UESTED BELOW:Q 1 I 'ti CS LOCAL VARIANCE FROM WELL SETBACK: It0 O :; rop, PARC t2f 1) A 34' variance to the owners well, for a separation of 116'. I ro I J D} oX �r EXIS ti 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 3 1 u! I:. '�' , �� TINGG TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 3—BEDRpp/y f DESIGN ENGINEER. 1 1 �f 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING NDUSE #Z4� �'� FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 39, TDF=96 40 far a r�' ENGINEER BEFORE CONSTRUCTION CONTINUES. ca \ �� 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. �, qG� 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF � a e 96 �, �, THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 2� a ^ y Up'�� 116' _ � � q��o -' l HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. `c i Exist. 7. WATER SUPPLY PROVIDED BY PRIVATE WELL. �� f well r� 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 100' OF THE S.A.S. a 4-1L�T 2 J, 9. ALL AREAS CLEARED FOR CONSTRUCTION ARE TO BE RESTORED TO v' /� ' i A CONDITION AGREED UPON BY THE OWNER AND CONTRACTOR. to a MAP ->�16 �� q,�q 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE ° ' r q THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING i PARCrL 26 r CONSTRUCTION. c I Exist, 11 WHERE REQUIRED CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS ?3,?54±S.F. � Well a I5o' well radius -N IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. a AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). Parcel 10 � 00 136.01' a _ � pF Myff9r , St 53°35'40' E P�1 PETEFZ T. �� SEPTIC SYSTEM REPAIR/UPGRADE q�2 Edge of�raver�en#' c�� !�� - --- ;Y__...91� MC VILE _ 24 ACORN DRIVE, WEST BARNSTABLE, MA q q E q� `' No. 35109 Prepared for: Kim Barnocky, 24 Acorn Drive, West Barnstable, MA ACDRN DRIVE �° Ell$ZE Engineering b Surveying b DRAWN JOB. NO. SCALE/ 1'=20' f j 9°FFSs EGA EngineeringWorb TEA.by: SCALE sc1LE 20' P.T.M. 126-01 23 Deer Hollow Road 22 Long Road s J � I CHECKED SHEET N0. Forestdole, MA 02644 Harwich MA 02645 DATE 0 PO 40 �aU (508) 477-5313 (508) 432-8309 1 2/29/01 P.T.M. 1 of 2 r 4 1 NOTE: TO PREVENT BREAKOUT, THE PROPOSED TOP OF FOUNDATION F.G. EL: 94.5(MAX.) FINISH GRADE SHALL NOT BE < EL:91.25 EL: 96.40 _'N� FOR A DISTANCE. OF 15' AROUND THE F.G. EL: 95.2 F.G. EL: 93.0t F.G. EL: 94.2 PERIMETER OF THE S.A.S. MAINTAIN 2% MIN SLOPE OVER S.A.SA MAX. COVER = 36' INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D-BOX TO 2-500 GALLON LEACHING CHAMBERS IN SERIES INSTALL RISER OVER CHAMBER/S WITH 4 STONE ALL SIDES SHOWN ON PLAN AND SET COVER/S �:• TO WITHIN 6" OF FINISH GRADE WITHIN 6' OF FINISH GRADE 'L =15' WITHIN 6' OF FINISH GRADE ` 4" 0 V L =55' L =14'(MAX) 4" SCH 40 PVC 4" SCH 40 PVC S= 2% (MIND INV.EL: 93.45f�T- ILN 10' 14� @ S= 17. (MIN.) s eaa as PROPOSED @ S= 1% (MIN.) ®aa0BB® (EXISTING) V.EL: 91.86 1500 GALLON INV. ELEV.=91.06 INV. ELEV.=90.89 2' EFF, DEPTH:[ ®eaB�®a Y:..' SEPTIC TANK 4' 5,2' 4' INV.EL: 91.61 FFECTIVE WIDTH = 13.2' INSTALL INLET & OUTLET TEES INV. ELEV.=90.75 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY —BREAKOUT ELEV.=91.25 TUF-TITE, ZABEL, OR EQUAL TOP CONC, ELEV.=91.5 INV. ELEV.=90.75 g66a ®®aaa 6aa66a®1 011 SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND TRUE TO aeoaaaaaa®a GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED BOTTOM ELEV.=88:75 STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 4' 2 x 8.5' = 17' 4' SEPTIC SYSTEM PROFILE 4' MIN. ABOVE BOTTOM ❑F EFFECTIVE LENGTH = 25.0' T.P, EXCAVATION OR G.W. 11 N❑ G,W. ENCOUNTERED LEACHING SYSTEM SECTION N.T.S. BOTTOM OF TP ELF 79.5 (3) 5' DIA.OUTLETS 1 DESIGN CRITERIA y�N °F N'rr/ T NUMBER OF BEDROOMS: 3 BEDROOMS McENRTEE a� H-10 LOADING o CIVIL. '10-6 SOIL LOG SOIL TYPE: CLASS I s.,;� No. 35109 D-BOX _ DESIGN PERCOLATION RATE: 2 MIN./IN. �£G/SZE`�� 3 - 20" Dic. Covers DATE:- DEC. 20, 2001(Ref#P10,139) DAILY FLOW: 330 G.P.D. FSSlONAI J SOIL EVALUATOR: PETER MCENTEE DESIGN FLOW: 330 G.P.D. INSPECTOR: DAVID STANTON GARBAGE GRINDER: NO 5'-8" 0 BARNSTABLE B.O.H. 4" KNOCKOUT I LEACHING AREA REQUIRED: (330) = 445.9 S.F. COVER Elev. TP Depth .74 ' KNOCKOUT 0 4' KNOCKOUT 82' _ 92.5 A SANDY LOAM 0" SEPTIC TANK PROVIDED: 1500 GALLON (MIN. REQ'D) 4' KNOCKOUT Top View 92.0 10YR 4/3 6„ USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 6" Dia. Outlets B SILT LOAM 6" Dia. Inlets 2.5Y 5/6 SIDEWALL AREA: 2(13.2' + 25.0') X 2 = 152.8 S.F. Top Vlew 4„ 90.5 C1 CLAY 24" BOTTOM AREA: 13.2' x 25.0' = 330.0 S.F. O 5Y 6/3 TOTAL AREA: 482.8 S.F. 87A �C2 66° ®®®® 0 ®E3®® FINE SAND W/ DESIGN FLOW PROVIDED: 0.74(482.8) = 357.3 G.P.D. ®®�1®®®®®Ii�0ER 33" POCKETS OF SILT ®®®®®®®®®®® 5'-8" 4'-7' 48° Liquid Level 4'-4" (UNSUITABLE) SEPTIC SYSTEM REPAIR/UPGRADE N ®Q ®®®®®�®® 4" 3" .. 2.5Y 8/4 1oa• •.. 83.5 C3 1oa" 24 ACORN DRIVE, - . WEST BARNSTABLE, MA FINE SAND Prepared for: Kim Barnock , 24 Acorn Drive, West Barnstable, MA Section Section 2.5Y 5/4 P Y 500 GALLON CAPACITY, H-10 LOADING 1500 GALLON CAPACITY, H-10 LOADING 79'S 156" Engineering by: Surveying by: SCALE DRAWN JOB. NO. NO G.W. ENCOUNTERED Engineering Works Terry A. Warner P.L.S. N.T.S. P.T.M. 126-01 CHAMBERS SEPTIC TANK 23 Deer Hollow Road 22 Long Rood PERC RATE: <5 MIN/IN. Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. nca• N.T.S. ALL "C3" HORIZON (508) 477-5313 (508) 432-8309 12/29/01 P.T.M. 2 Of 2 i e , Ali ' Bay Colony Railroad LL I J 1 I i I BENCHMARK LEGEND 0 NAIL IN 24" OAK o EL:96.60(Assumed) 00 99 PROPOSED CONTOUR �o °a 99 PROPOSED SPOT GRADE N � I S 49°19'31' E Water o 171,87' �� —110 EXISTING CONTOUR Lr ' 110 EXISTING SPOT GRADE fq TEST PIT ROUte Root S8- W EXISTING WATER SERVICE ; LOCUS 6q EXIST CESS-aX �� a° o o\ To be \ D1' Csee n� fi i l) \\ `o-ab�%go------ -- --`-- lled hp sand o� q� �-F LOCUS MAP N.T.S. °\ \ 9 92_ GENERAL NOTES: Proposed \� Se tic To nk O p 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ro BOARD OF HEALTH AND THE DESIGN ENGINEER. �g ��_ 3 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 2,�,i� TPA ��. ----� OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 13 15, EL, 9?. �� Zo �e�� , LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: _ LOCAL VARIANCE FROM WELL SETBACK: 1 I f� • ,I � � o,� °v � PARCEL 27 1) ,A 34' variance to the owners well, fora separation of 1 16'. I� Q :.. . rap, . 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR > I ro I7a ;I D�ox /�� EXISTING �' TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE II • I 1 9 3-BEDROOM - DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING Imo. 1 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN HOUSE (#24) ENGINEER BEFORE CONSTRUCTION CONTINUES. 39' T-EF=96,40 Gauge _f 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF o r 1� 116' 96 �� `�,}�' � � HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. i +1 �' y"o PROVIDED BY PRIVATE WELL.Exist. 7. WATER SUPPLY PROV D a - C) i 3 /// Well 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 100' OF THE S.A.S. blo // 9. ALL AREAS CLEARED FOR CONSTRUCTION ARE TO BE RESTORED TO o LOT 2,' � ' ' // A CONDITION AGREED UPON BY THE OWNER AND CONTRACTOR. MAP �16 I` g°`� 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE / ®� . PARC�'L 26 \� THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING i w / Exist, CONSTRUCTION. a ?> a � 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 23.9 F 54+S. Well o a 150' well radius ) IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). Parcel to 4 0p1 1116.11 5153°35'40' E ® SEPTIC SYSTEM REPAIR/UPGRADE Edge of paver,ent �� l WEST BARN STABLE, MA� ,�- �,fig`' �o 24 ACORN DRIVE, t Prepared for: Kim Barnocky, 24 Acorn Drive, West Barnstable, MA '13 ACORN DR'I VE �� ESTONA` ErS Engineering by: Surveying by: SCALE DRAWN JOB. NO. Engineering Works Terry A. Way7wP.L.S 1"=20' P.T.M. 126-01 SCALE, 1'-20' Call: Kim Barnocky 23 Deer Hollow Road 22 Long Road Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. (508) 362-5224 (508) 477-5313 (508) 432-8309 12/29/01 P.T.M. 1 of 2 0 20 40 3� t f MINES NOTE: TO PREVENT BREAKOUT, THE PROPOSED TOP of FOUNDATION F.G. EL: 94.5(MAX.) FINISH GRADE SHALL NOT BE < EL:91.25 EL: 96.40 -� F.G. FOR A EL: 94.2 PEERIMETERTOFCTHEE S A S AROUND THE F.G. EL: 95.2 F.G. EL: 93.0t MAINTAIN 29. MIN SLOPE OVER S.A.SA MAX. COVER = 36" INSTALL RISERS OVER INLET & OUTLET INSTALL RISER ❑VER D-BOX T❑ 2-500 GALLON l CACHING CHAMBERS IN SFRIFC INSTALL RISER OVER CHAMBER/S TO WITHIN 6" OF FINISH GRADE WITHIN 6' OF FINISH GRADE WITH 4' STONE ALL SIDES WITHISHOWN ON PLAN AND SET C❑VER/S L =15'' WITHIN 6' OF FINISH GRADE ` 4' SCH 40 PVC L =55' L =14'(MAX) 'ig, 4" SCH 40 PVC 4" SCH 40 PVC T.- INV.:EL: S= 2% (MIN.) INV.EL: 93.45f� 1O' 14- @ S= IV (MIN.) U ®a as PROPOSED @ S= IV (MIN.)(EXISTING) 1500 GALLON INV. ELEV.=91.06 INV. ELEV.=90.892' EFF. DEPTH �aa®Bea 91.86 r " SEPTIC TANK 4' 5.2' 4' INV.EL: 91.61 FFECTIVE WIDTH = 13.2' AM Aft M AN INSTALL INLET & OUTLET TEES INV. ELEV.=90.75 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY TUF-TITS, ZABEL, OR EQUAL TOP CONC. ELEV.=91.5 -BREAKOUT ELEV.=91.25 INV. ELEV.=90.75 !063 eseSEPTIC TANK & D-BOX SHALL BE SET LEVEL AND TRUE TO law a aa10 63aBlaaaa GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED BOTTOM ELEV.=88.75 STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 4' 2 x 8,5' = 17' 4� SEPTIC SYSTEM PROFILE 4' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 25.0' T.P. EXCAVATI❑N OR G.W. NO G.W. ENCOUNTERED LEACHING SYSTEM SECTION N.T.S. BOTTOM OF TP EL, 79.5 (3) 5' DIA.OUTLETS 15_ 5' F•-- 16, ("2• i �� <� �' • DESIGN CRITERIA 15.s• 6' NUMBER OF BEDROOMS: 3 BEDROOMS H-10 LOADING 2' 10'-6" SOIL LOG SOIL TYPE: CLASS I D-BOX "TA DESIGN PERCOLATION RATE: 2 MIN./IN. IITS 3 - 20" Dia. Covers DATE: DEC. 20, 2001(Ref#P10,139) DAILY FLOW: 330 G.P.D. SOIL EVALUATOR: PETER MCENTEE DESIGN FLOW: 330 G.P.D. INSPECTOR: DAVID STANTON GARBAGE GRINDER: NO 5,-8" O CI BARNSTABLE B.O.H. a'KNOCKOUT LEACHING AREA REQUIRED: (330) = 445.9 S.F. 20' Dw. COVER Elev. TP Depth .74 +•KNocKOUT /a° KNOCKOUT g2' _ _ 0" O 92.5 A SANDY LOAM SEPTIC TANK PROVIDED: 1500 GALLON (MIN. REQ'D) 4' KNOCKOUT Top View 92.0 10YR 4/3 6„ USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 6" Dia. Outlets B SILT LOAM 6" Dia. Inlets 2.5Y 5/6 SIDEWALL AREA: 2(13.2' + 25.0') X 2 = 152.8 S.F. Top View 4" 90.5 24• •'•' C� BOTTOM AREA: 13.2' x 25.0' = 330.0 S.F. CLAY 0 5Y 6/3 TOTAL AREA: 482.8 S.F. 87.0 C2 66" 6@®E30 O ®®®® - FINE SAND W/ DESIGN FLOW PROVIDED: 0.74(482.8) = 357.3 G.P.D. E3 E3®E3 E3 la®E3 E3 I®E3 33" POCKETS OF SILT N _ ®�®®®®®®®® 5'-8" 4'-7 4" Liquid Level 4'-4" (UNSUITABLE) SEPTIC SYSTEM REPAIR/UPGRADE 2.5Y 8/4 4" 3.. 83.5 C3 108�I 24 ACORN DRIVE, WEST BARNSTABLE, MA 102" FINE SAND Section Section 2.5Y 5/4 Prepared for: Kim Barnocky, 24 Acorn Drive, West Barnstable, MA 500 GALLON CAPACITY, H-10 LOADING 795' 156" Engineering by: Surveying by: SCALE DRAWN JOB. N0. 500 GALLON CAPACITY, H-10 LOADING I Engineering Works Terry A. WarnerP.L•S. N.T.S. P.T.M. 126-01 SEPTIC TANK NO' G.W. ENCOUNTERED 23 Deer Hollow Road 22 Long Road CHAMBERS PERC RATE: <5 MIN/IN. Forestdole, MA 02644 Harwich. MA 02645 DATE CHECKED SHEET NO. wTa N.T.S. ALL "C3" HORIZON (508) 477-5313 (508) 432-8309 12/29/01 P.T.M. 2 Of 2