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HomeMy WebLinkAbout0040 ALDER BROOK LANE - Health 40 Alderbrook Lane West Barnstable A= 133-053 , i TOWN OF BARNSTABLE LOCATION - 40 /41 DER RAQOA: L Prn f SEWAGE # VILLAGE LV('S`} l�g�n S /�, i �P ASSESSOR'S MAP & LOT "<J INSTALLER'S NAME&PHONE NO. El�tiS Qr`l°rS CvhS�L, ScS' 3 F9 a' boa / SEPTIC TANK CAPACITY 166 c, 64 . LEACHING FACILITY: (type) P6� fll0� (size) -7 ff lo NO.OF BEDROOMS 3 — BUILDER O OWNER'/ 4 ' - 4—" PERMITDATE: 1 Is COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Al,r.)-cn- f5acom c. W �-3 - 5 i �(d¢0`GdU61c No. 00 ' O 15 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYitation for Mt Foam *pstem Construrtion permit Ap plication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ]]))�/l ��////QQ�� Owner's Name,Address,and Tel.No. Assessor's ap/Pazcel IM ti 13A ri q,� � �„�,®ppJ Installer's Name,Address,and Tel.No.S'oi-3 b-)-(aa3 Designer's Name,Address,and Tel.No. tit i s Paw9� s 3 /''` wig s l A Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/ Other Type of Building /L2-s No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �3 3 c) gpd Design flow provided gpd Plan Date �-- �iy�' Number of sheets t� Revision Date Title -66� JC ' P✓d Size of Septic Tank Typ f S.A.S. Description of Soils ,L,� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Date Application Approved by Of Date Application Disa r v oe PP PP Date for the following reasons Permit No. �l�I ©Zi1 Date Issued 0/l Zl z®f s I T ________-----___--------------------------------------------------------------------__----___________ 3 No. ' Fee O THE_COMMONWEALTH OF MASSACHUSETTS Entered in computer: -PUBLIC HEALJH DIVISION -.TOWN OF BARNSTABLE, MASSACHUSETTS Yes RppYication for Mi posai *pstem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. a Assessor's Map/Parcel Vy ,3-3 eA ti 5 3 134 i L�A&4 , k14,GD O,,,./A tv Installer's Name,Address,and Tel.No.60F 3 44 W 3 7 Designer's Name,Address,and Tel.No. Ittll� S �6aT�t�SConS� Q�c�•$5 �,r��► GTE Cfl s ,�-- i�,pv�� _1aw-�-�" r Type of Building: Dwelling No.of Bedrooms Lot Size �v sq.ft. Garbage Grinder(k)? Other Type of Building /L2_S No.of Persons Showers( ) Cafeteria( ) Other Fixtures r Design Flow(min.required) —3 -3 GD gpd Design flow provided gpd R Plan Date �" ?iy Number of sheets C- Revision Date Title A/ Size of Septic Tank Typ f S.A.S. Description of Soil r s Nature of Repairs or Alterations(Answer when applicable.) i01J h 't� �✓ Date last inspected: Agreement: t:. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H,ea_ '. -•� ' n d � ...E.,.-- �•��� Date Application Approved b Date Z /Z� "5 Application Disapprove ' y / Date for the following reasons -� Permit No. �I Zq Date Issued ZL2l Zo l S ------------------------------------------------------------------------------ -------------------— --------------------------- - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate-of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by y,,,-•;s 5 at L4 p 6 jt.o o/G L h/IC ► 1. &r✓►S J-4 6"been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.'10 15 -C Zi dated 412'Z o l S Installer fy lh S &O-Pv rS Cc-nf f-- Designer T/t S S(4T V/e y -,It +-r )A VC (A VA11, 1�1 #bedrooms 3 Approved design flow �� gpd G i The issuance of thr_lis pe it shall not be construed as a guarantee that the system wi 1 ctibn as d� ned. l Date > i1� Inspector UVV ------------------------------------ ------ -------------------_------- -------- ---------_-----------_---=--------------- �h N04,U Fee . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -Misposal *pstem Construction Permit Permission is hereby granted to Construct(n ) Repair( ) Upgrade( ) Abandon( ) System located at 1jr0 0 I 0 U/L �1 h 1 (41�$}- t 5rn s y i and as described in the above Application for Disposal System Construction Permit. The applicant recognized h�/her d to comply with Title 5 and the following local provisions or special conditions. f i i Provided:Construction must be completed within three years of the date of this permit. — Date//Z� z0 �� Approved by Town of Barnstable Regulatory Services Richard V. Scali,Interim Director sniwsrnste. 9� MASS. ��� Public Health Division iOrEc 39. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 5 - 99- /s Sewage Permit#A 01 ca Assessor's Map\Parcel 13 3 - S3 Designer: 15t+S G L)rz 1{-Cl( i wC. Installer: CC-Z-.r S (5/Z�05 • Qa Address: e,a , 6 o K 1`7 d,� Address: �53Div TEti- Prz r s 5"3W.1e_14 MA 0,kGS`3 AvL.,^00 ra,-cZ; 1t✓1c4 , -7S On I a I /S S 65ie-,0S was issued a permit to install a (date) (installer) JJdd septic system at A/0 AL f j E-A_ 624 o iz L,1•� , based on a design drawn by (address) NAV ko 6 V"416t dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan:revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed'in compliance with the terms of the IAA approval letters (if applicable) OAVID (Installer's Signature) D No, 1211: X /PAY/ , a z tar (Designer's Signa (Affix Des ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc s Town of Barnstable X. Department of Regulatory Services Public Health Division bate - 1 Z- t 4- MAn 200 Main Street,Hyannis MA 02601 rFl)t,M'I� /� Date Scheduled_ �.C�.,.r1. } Time Fee Pd. !DD Soil Su i ability Assessment for ,sewage Disposal Performed By: Witnessed��� J7 �t.�► �,94/ �&T/�j,�/Z4!j tnessed By: LOCATION& GENERAL INFORM ION Location Address . _ / Owner's Name Lam/` L41J (lt�L/f Address '5i c$�C.f2f�G�`-�!� Assessor's Map/Parcel: /332 Engineer's Name// � NEW CONSTRRU,MON REPAIR Telephone Land Use. J!139 es p Slo q6 6 �S• SuvdQ c�jt� ( ) ,t',� Surface Stones Distances-from: ft Drinking ater WellJ %%o Gl ! 1371t/�G— /�L4)C-�L �GK IQ Drama a Way / S� ft Property Line ft Other �+�Q' {t �4t A/-114sMti.• SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ids ® ISAAJW 4 s„ VZ I ZO/ Get / - l • 1 Parent material(geologic)e616 lc 64 y o D th to BedmclG Y Q le Depth to Groundwater. Standi-ig Water in Hole: Weeping ft'otrl Pit Face U/� Estimated Seasonal High Oroundwater ��6.16-1 1"'A 3, DETERIYHNATIONIOR SEASONAL HIGH IiATl R TAI3LE Method Used: J2-CXJ/ C C C $v . Depth Observed standing in obs.hole: l� �� Iu, Depth to sail mottles:- . w/4 (n, cw Depth to weeping fnm side of o_bs,hole: Grtundwater AdJustment Index Well# .Reading Date: & �/Andex Well level .�14- Adj..factor .S Adj.Groundwater /o,5- PERCOLATION TEST gate :919—Wrima 1 pLAM F# 77V Z Time at 11 eptof Pere Time at 6" Start Pre-soak Time Q !O� Time(9"-6") � End Pre-soak 1. Rate Min./Inch . Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To.Be Completed on Back------ ***If percolation testis to be conducted within 1009 of wetland,you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:ISEPTICIPERCFORM.DOC J DEEROBSERVATION 1IOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil. Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders. onsistency,%'t3ravel) zj y' loyp- �=ZZ"', . ° a'�1 l oYe. 714 Z -le v,�f z• .� 5a� DEEP OBSERVATION HOLE LOG Hole# 2 % •3 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,`Yo a fay �Acr " snd lvY2 St coos ro7'2 714 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.), (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other ` Surface(in.) (USDA) (Munsell) Mottling (structure,5topes;Boulders. r'.. Consistency. 1.-. a Flood Insurance Rate MaR: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes _ Within 100 year flood boundary No. _ Yes.,.,_,.,,.., Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? .e S . If not,what is the depth of naturally occurring pervious material? Certification I certify that on — 9 5 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trainin ,e ertisee aannd ex eri a described in 10 CMM 15.017. �, Signature �'7 ' ' v Date ¢ Q:\SL-P'riC\PBRCFORM.DOC r - UNITED STATEg'PR 2114 F 9$l l s-CIa F { I a_ a es 12- AUG-2014- PM iI Sender: Please prin t your name , , address, and zIP+4 in this box° ,tea v Q ' Town of Barnstable R Public Health Division oy� 200 Mairj,.Stpip .,, �. HyaARis` ip I i 6 ■ complete items 1,2,and 3.Also complete A.8ignat e item 4 if Restricted Delivery is desired. X gent ■ Print your name and address on the reverse Addressee. so that we can return the card to you. eceived by(Print am e C.,Dateo elivery ■ Attach this card to the back of the mailplece, 60 1 or on the front if space permits. D. Is delivery address diffe,nt m Iiie 1, Article Addressed to: If YES,enter delivery address Barbara:Mcdonald 40 Alerbr"ook Road 3. Service Type West Banstable, MA 02668 ❑CertiU S�5 fied_Mail Q Express Ma ❑Registered ❑Return Receipt for Merchandise r ❑Insured Mail ❑C.O.D. r 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number l�� (Transfer from sendce labeq 7 012 �010 0000 2851 4 211 Ps Form 3811,February 2004 Domestic Return Receipt 102595-02W-1540 pow. y p ryinm W i ru I� L 2:.,v IF ` t; .sue,>• `�.�'g'."• 'k "xs�s� " J♦ j ro Postage $ru A Q Certified Fee 1l Val C7 Rehim Receipt Fee ,✓- stmark SSE I Q (Endorsement Required) :: Here I 'tt`.. Q Restricted Delivery Fee `Nti",7 ass af' Q (Endorsement Required) `� a Q Total Postage&Fees $ Barbara Mcdonald I 40 Alerbrook Road West Banstable, MA 02668 VE Town of Barnstable arnstable Regulatory Services Department HM� I F • A,O�' Public Health Division 200 Main Street, Hyannis MA 02601 2007 Y Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 4211 August 7, 2014 Barbara Mcdonald 40 Alderbrook Road. West Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 40 Alderbrook Road, West Barnstable, MA was last inspected on 7/17/2014, by Trever Kellett, a certified septic inspector for the State of Massachusetts. • The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to overloaded or clogged SAS. • Static liquid level in the distribution box above outlet inver due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER F HE BOARD OF HEALTH vw { Th as McKean, R.6., CH Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\40 Alderbrook Rd W. Barn 2014.doc _. =.._ - ® I PubG_lhssgl2+itrarJlGropd.�ta/Parcei�cai a>P,:'T� d4,9 It]jlf&X UU•ie Sparch ._a.�..T. --. .... Application Center(2) ',l http--www,town.barnstable... 91 Application Center ®Suggested Sites &,lieb 3I1ce Geilery;- Favorites o- - 11ppi p cation Center ��Parcel Detail _ X t �= •. a F fit,� \'xj,ti., ;'":+ • G • Parcel Info �V Parcel ID,t33-Or— 53 ( Developer LOT Lot Pri Location d0 ALDER BROOK LANE _I 160 Frontage Seci Sec C Road' I Frontage Fire Village WEST BARNSTABLE District'W BARNSTABLE V. Town sewer exists at this - ` --- -_---- Road Index 10016 t: address;No Asbuilt Septic Scan: Interactive �F ll 133053_1 Map I r I r Owner Info , Owner!MCDONALD,BARBARA J I Co-Owner l Streetl 140 A`_DERIBROOK LANE Street2' I city'WEST BARNSTABLE State jMA Zip�02668 Country 4 # Land Info ' anet d5tart y _ 12:39 P i . QS TuesdayParc I Detau-Window I.. 1_ �° �' S�� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal-System Form-Not-for Voluntary Assessments 40.Alderbrook.Rd Property Address .Barbara Mcdonald Owner Owner's Name information is required.for every West Barnstable MA 02668 7/17/2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered-in-any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on-the computer, use only the tab 1. Inspector: key to move your r cursor-do not Trevor Kellett use the return key. Name of Inspector , -� Aardvark Environmental Inspections 4 I Company Name PO BOX 896 r Company Address East Dennis MA 02641 City/Town state Zip Code y-;y 508-292-1056 S113744 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.1.5 340.of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 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 10,060 gpd or greater,the inspector and the system owner shall submit the -reportto 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 136 l H Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Wcdonald Owner Owner's Name information is required'for every West Barnstable. MA 026% 7/17/2014- page. City/Town• State Zip Code Date of Inspection R. Certification (cone.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310-C MR 1-5.303 or in°31 G 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" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,-exhibits substantial.infiltration-or.exfiltration.or.tank failure is.imminent..System will.pass. inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating thatthetank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(.Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Enspectfon Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald Owner Owner's.Narne information is required for every West Barnstable MA 02668 7/17/2014 ,page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The _system will.pass inspection-if(with-approval.of the Board-of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title 5 Offidal Insped9on Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection-Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald' Owner Owner's Name information is required'for every West Barnstable MA 02666 7/1:7/2014 page. City/Town State Zip Code Date of Inspection R Certification (cost.)- 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑` The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. El The system has'a septictank and SAS and the SAS is'less than 100 feet but 50 feet-or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this farm. 3. Othec D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or ® ❑ clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid'level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than%day flow t5ins•3113 ,. Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4'of-17 I Commonwea-th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald Owner Owner's Name information is required for every West'Bamstable MA 02668 7/1712014 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year RIOT 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 col iform.bacteria indicates_absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a_design flow-of 2000gpd- 10,000gpd. ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E.) Large Systems: To be considered a large system the system must serve a.facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered'"yes" in Section'D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304: The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 rn � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w ,0 40 Alderbrook Rd Property Address Barbara Mcdonald Owner Owner's Name information is required for every West Barnstable MA .02668 7/17/2014- page. City/Town state Zip Code Date of Inspection C. Ghecklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not El available note as'NYA) .® ❑ 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 Solt 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 El 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 gpd x#of bedrooms): 330 thins-3113 Title 5 Offic al Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald Owner Owner's Name inforniation is required for every West`Barnstable MA 02668 7/17/2014 page. CityfTown State Zip Code Date of Inspection D. System Information Description: This system consists of a septic tank d box and leaching feild Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/scI t., etc.): Grease trap present? ❑ Yes -❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Tile 5 Ofidal Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 40 Alderbrook Rd Property Address Barbara Mcdonaid' Owner Owner's Name information is required for every West.Barnstable- MA 02668 7/17/2014 page. City/Town state Zip Code Date of Inspection M System Information (aunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of.Massachusetts Title 5 Official Inspection Form 9,` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald Owner Owner's Name information is required for every West'Barnstable MA 02668 7/17/20 t4 page. Cityrrown State Zip Code Date of Inspection D. 'System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 9/23/77 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.1 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction.- concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is-metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 4" t5ins-3113 Title 5 Official inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald' Owner Owner's Name information is required'for every West Barnstable. MA 02668 7/17/2014 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 28 Scum thickness 2 1. Distance from top of scum to top of outlet tee or baffle 9 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were--dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic Tank is water tight has staining common with back up and a large ammount of solids outlet cover is-a°4"xi ' block Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Mrs•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald Owner Owner's Name information is required for every West Barnstable MA 02668 7/17/2014 page City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.).- Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: -Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts > Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s; 40 Alderbrook Rd Property Address Barbara M'cdonald` Owner Owner's Name information is required'for every West.Barnstable- MA 02668 7/17/2014= page. City/Town 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 flooded Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is completely flooded and backed up Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald Owner Owner's Name ,information a West Barnstable MA 02668 7/17/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Type: 0 leaching pits number.- El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 3 ❑ 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.): water is present 6"inches above the stones and over d box cover new system is a must Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Tile 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald� Owner Owner's Name information is required`for every West Barnstable. MA 02668- 7/17/.201.4 page. City/Town State Zip Code Date of Inspection D. System Information (cont.)- Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara Mcdonald Owner owner's Name information is West'Barnstable -MA 02668 7/17/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt:) 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 A g 0 e A1)21.5' A2)22.5' A3)68' °61 j29' B2)27.5' B3)28.5' t5ins•3113 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd Property Address Barbara M'cdonald' Owner Owner's Name information is required for every West Barnstable. MA 02668: 7/17/2014: page. City/Town State Zip Code Date of Inspection D. System Information(coat.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 10+ Estimated-depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Maps show ground water between 10 and 20 feet Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Ofidal Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Alderbrook Rd -Property Address Barbara Mcdonald Owner Owner's:Name information is required for every I West Barnstable MA 02668 7/17/2014 :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•W13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 LOCATION SEWAGE PERMIT NO. VI L L A G E :ON 133WJ Olt ;ON dYW SdOSS3SSd I N S T A LLER'S NAME & ADDRESS 114/1 AA s ill- Xe BUILDER OR OWNER y� &,F657;tis 4 115 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED a �_ 77 f 11 lj� Fim.zV................... THE COMMONWEALTH-sQF MASSACHUSETTS BOARD OF HEALTH r tJ-N .... 'MST}3.L.�................................. i Ui trnrtinn rrntit ,���Itrttttnn fnr �t,��u��t1 nrk� Cann � Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal System at: l:L�Z Doi<---4-,,9AI ty�.Si 1s i9 e s i��3t�C N,915, 1. 9 T �'--------------- ------------------------ Location•Address or Lot No. ............................. Owner Address -•-------• ..✓GAS .....�3i...& S V... 4=:_ /''1' zq..----•-- ,� Installer Address Type of Building Size Lot.-Y../_________C.......Sq. feet U Dwelling—No. of Bedrooms_.__-.._. ----•__--------------------Expansion Attic (x) Garbage Grinder M .-I Other—Type of Building __________________________ No. of persons..-____4____............ Showers ( ) — Cafeteria Q' Other fixtures -------------------------------•. _ W Design Flow---_-___--- �70________________________gallons per person per day. Total daily flow.........L3 �.........................gallons. C4 Septic Tank—Liquid capacity/----------gallons Length................:Width---------------- Diameter---------------- Depth..--_-----.__--. xDisposal Trench—No..................... Width.................... Total Length__-_____•--_----.- Total leaching area--_-----__...___--_-sq. ft. Seepage Pit No..................... Diameter.................... Depth below 'nlet..... _____ i'.. Total leaching area---_.--_.____----sq. ft. Other Distribution box Dosm k � ( ) y ,'( ,� 1 77, Percolation Test Results Performed b ... __ Date___.._. _..__ -__________________. =----------------- Test Pit No. 1................minutes per inch Dept of "Pest Pit.._.________..______ Depth to ground water.._.________...__..... rZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground , e - water--.__ .__--.-------- •-------------- -• -3------- ._.. x ` y� .. t�------------ i oO Dpi f Soil - ------------ U ------------1. . .... ----- G --------- ----------•---- ---------------------------------------------- - W ---------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable.__.•------------------------------------------------------------------------------------------ -------------- ----------------------------------------- ---•--------------------------------•---•-----•------------------------------..............I--------------------- --------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the bo of health. C ' l the . . ....... ' ' Da e Application Approved By-------- -,/ ......... --. =......... -----•------------ 7 R=,4--.77----- Date Application Disapproved for the following reasons-------------------------------------------------------------------------------=-----------------•-----•--...... --------•-----------------------------------•----------------•--•-----••----•-----------------------------------------•--••----•----•-•--------••-•---••......-----------_...._.. Date Permit No......................................................... �.,�— ?. Issued. --- Date -——————-—— No.� .......1.11", FizE .................... 4J THE COMMONWEALTH',PF MASSACHUSETTS BOARD OF HEALTH ............. . ...........OF................................---- ................................................... ApVtkation -for Uhipoiial Works Towilrudion Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewag e Disposal System at: ................................................................................................. ................................................................................................. Location-Address or Lot No. .................................................................................................. ............................................. ................. .............................. Owner Address ...............................................Instal.I.er......................................... .............................................Ad'dres's------------------------------------------- Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms______________________________ __ .Expansion Attic Garbage Grinder per, Other—Type of Building ---------------------------- No. of persons_-------------------------- Showers Cafeteria Otherfixtures ..... ------------•------------------------------- -------------------------------------------------------------------------------------------------- Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity_.-__-_'-__gallons Length...............:.Width..___......._.. Diameter_----_..._-._.._ Depth-._____-_.-._. Disposal Trench—No- -------------------- Width_____.--_______-_-__ Total Length--_-_____-_______--- Total leaching area....................sq. f t. Seepage Pit No_____________________ Diameter_________--______--_ Depth below inlet......t_ ... Total leaching area------------------sq.,,.j it. Z Other Distribution box Dosing lc r4l / —77o: . . .................................... ----------------------- .4 1 Percolation Test Results Performed by.__ Date.... Test Pit No. 1----------------minutes per inch Delpwtr"r Test it......._____..__.._ Depth to ground water_____--._-_.-_.-__.-__. G14 Test Pit No. 2................minutesper inch Depth of Test Pit....._.._.__.______. Depth to ground water-------------------- ------- ------ - ?;�a ";, 7 --------x--- Soil 7At � 0 - --------------------------- escript* �4------/ ............. ;a�/ D Lon of ........ ---­---------- --- - --------------------------------------------------------- U .............0 . ----------- X�_ ----------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or'Alterations—Answer when applicable.__------------------------- ------- ------------------------- --------------------------------------------------------------------- ............. ----------- ............... ........................... ------------------- Agreement: The imd'ersigned",agrees to install the aforedek-ribed Individual Sewage Dispoiil Systern-in accordance with the provisions of Article XI of the State Sanitary Cod,e—The I un'd&rsign*ed fuirth'e r agreeg'n'ot to h place-,tie system in operation until a.Certificate of Compliance has been issued by theboard of health., ...,�Jgned --- ----------------............................. ............................ ................................ Date Application Approved By. - - ------ ......... ------------------ ... ------- ------- Date Application Disapproved for the following reasons:............................7/.......................................I.,-------------------- ............................ ... .......................................................................................................................................................................................................... Dale PermitNo......................................................... Issued......... ------- 7............. Date THE COMMONWEALTH OF MASSACHUSETTS -,"BOARD OF HEALTH ...........................................OF...... ....... .............. .................................................. w1rdifirate of Vm;thattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by---------------------------------------------------------------------------------------------------------:.......................................................................................... Installer at------------------------------------------------------------------------------------------------------ -------------------------------------- ........................................................ has been installed in accordance with the provisions of < � XI Q The State Sanitary Co de as described in the application for Disposal Works Construction Permit Nc -------------X-Y--------- dated__7-__2_/-_7.7............. THE ISSUANCE OF THIS CERTIFICATE.SHALL NOT BE CON/STPIF.,D AS A GUARANTEE THAT THE SYSTEM WILL FUCTION SATISFACTORY. -./ DATE................... 7 1� 4�7.7.............. ------------ ............ .•........................ .. ...................... ...... ... inspector ......................... THE COMMONWEALTH OF MASSACHUSETTS C7 BOARD OF HEALTH )-1 ......................................... OF---- .......................................................................... o N ...... FEE.../X............. MnVviial Mlark ii Permissionis hereby granted....................................................9---------------------------------------------- ----------------------------------- to Construct or Repair an Individual Sewage Disposal System at No. :=.......................... ...................................................7-------------------------------------------------------------------------------------------------------- Street as shownion the application for Disposal Works Construction Permivlqb�.................... Dated_?—,9_/—.77............. ---------- ----- --------- .................... - -----------CAI /Iul .. ------------- ------- ------- ------------ DATE--------- ................................... B card bf Health FORM 1255 HOBBS &.-WARREN. INC.. PUBLISHERS .!N. No. ------- -- -- Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2[pplication-*rVelr Con5truction3permit Application is hereby made for a permit to Construct (s/T Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address S ----------------- `��' 4,161 s,�iv :�- �Z, /I�-_® ------ ------------------------- Installer — Driller Address Type of Building Dwelling------—----- - - --------------------------- Other - Type of Building ------ No. of Persons----------- ------------------------------ Sl �gLCrn�; c irl,i�✓r� Typeof Well--------------------------------------------------- Capacity----------------------------- - - Purpose of Well------�''� E� - -- -- --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. f f Signed- — - - =- - - -- — --------- -— j`-- d Application Approved By — �"= -- ------- ----- -- `� �?� �" date Application Disapproved for the following reasons:-------------------------------------------------------------- - ---- ----—- __ - —_-----— ---- — - - --- —---------—------------— -- — - —---- �j date Permit No. -��"l�_`�a � m- � ----- Issued--- -------------------- ------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate (Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( Altered ( ), or Repaired ( ) Installer at----------— has been installed in accordance with the pr visions of the Town of Barnstable Board of HHeealtth�Private Well Protection Regulation as described in the application for Well Construction Permit No��"f-�—'-�7�ated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- --- --——-- ---- - — —--- Inspector-----------------------------------------— -- --— . - ,, .s..- .`�.r �'7'^.w„�Pst�eT wt�}�"��bnr�� �,-! �"'i,J +++•'"`t�l'tiF3. ,mom. -�r�ikiCT.���.��`Z s�,..j '�.t e..,.�'+�, • , 3" � •_p a•.�z ram..`` .f/ '-'h � �� x , V 4- - No. /M�-------- ------ Fee-------,-- --- - { e BOARD OF HEALTH + -; TOWN OF BARNSrTABLE ; ` Applicat ion-for Well.Co''otruction 3permit Application is Hereby made for a permit to Construct (l/1' Alter ( ), ors Repair ( )an'individual Well at:' Location - Address ` Assessors Map and Parcel Owner. Address _ vfL i w =L C- ----------- ----------------- G_mild,in. .i.�s � / _` Installer - Driller 1 Address��• �-17 Type of Building Dwelling -- ----------------- Other - 7 e of Buildin ------ No. of Persons---=-_____ ________________—______________ YP g --- - TYPe of Well— - - ,I- ---- - -=------------- Capacity=- >: - C�9- LCows _ /Ylii�✓r� Purpose of Well E�- -- --- Agreement: The undersigned agrees to install the aforedescribed.individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well.Protection Regulation The undersigned further agrees not to place the well in operation until a Certificate :of Compliance has been issued by the Board of Health. Signed— �ate'=X- Application Approved By — - ------ --- _ ' R=�!/, date Application Disapproved for the following reasons:------------------------------------------------------------= — —-- ---_--- - — --- — - -- - —---------------— - - -- -- ------- - date —-- Issued--- — - —`- ---------------- Permit No. '� date �ar w.�.�e.a�..r.c��..�...��-�o,�vr m.�nt �a�o wa�..��.Anne else:�.r..s�.��o�..o..w.a sris�..ao......r.r+iiwr®.�a.nn.�sa..Y.�►a....asr�rers�r:. f` BOARD OF HEALTH TOWN OF BARNSTABLE Certifirate Of Compliance a.. THIS IS TO CERTIFY, That the Individual Well Constructed ( Altered ( ), or Repaired ( ) Installer - a � � - -= `�'--ems' sTfc�------------ — - - - -- at-- ---------- has been installed in accordance with the pr visions of the Town of Barnstable Board of��Heealth,Private Well Protection C Regulation as described in the application for Well Construction Permit No lf' -=-Y.l�bated:-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE ---- ---- -- -- ---- — - Inspector------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Ivell Con5trurt ion permit -� � No. -- Fee�----�— Permission is hereby granted-- --!X-' - - -- -—- - -- - to Construct (jam, Alter ( ), or Repair ( ) an Individual Well at: 0. Street as shown on the application for a Well Construction Permit , i' !` ---- - --- - �y / t - -� —f------------------ No. - — -- — Dated--- -- ,, J/✓,,. !� - Board of Health DATE-----------------?-----� ---- - I EL=20.81 TOP OF FOUNDATION (EXISTING HOUSE) I PROFILE OF 4" SCHEDULE 40 P.V.C. (10' MIN.) MIN. PITCH 1/8" PER FOOT (2) OBSERVATION PIPES SEWAGE DISPOSAL SYSTEM FILTER TO GRADE W/SCREWCAPS (NOT TO SCALE) FABRIC AT EACH END EL=19.2 5 ,...,,_,,....,.. .. . .......�:... EL= 18.9 ::� :..............::� ;.............,, ., EL= 18.5 6 MAX.' ,,, :: tr i :::::;;;;;;; .% " . 9" MIN. COVER RISER & ::;:;r::a :;;;: :::;::. ,.,..,,,.. ,••• ..... :.....,,.,.:i� "CLEAN` SAND"FILL" " ,`' .OF.. EXISTING PIPE EL= 17.80 (ASONE D.) LEVEL PER 310 CMR 15.255 - 9 TIE ENDS MIN LINES TO REMAIN 8' s= .015 FOR 4'(LONGEST RUN) S=.01 EL= 16.55 (2) DIRECTIONS 32' 0 S=.005 FLOW LINE EL= 16.4 ,. ,° INV= 16.06 110" 14" INVERT INVERT I��ER o 1° °pO 8" :o 1 oo�b°o 08 oozy°8�v o`m° oo� °000 0`� 6.. BOT. EL= 15.56 MIN. ADD EL= 16.55 EL=16.43 6" SUMP 6 INVERT 4' c,as r EL= 16.22 SOIL ABSORBTION SYSTEM (FIELD) BAFFLE 6" BASE OF MECHANICALLY > ' EXISTING EL=16.72 (IF NECC) COMPACTED SAND I 7.0' X 65.0 INVERT INVERT PROP. DB6 3/4" TO 1-1/2" 65.0' EXISTING DISTRIBUTION WASHED SE 6" BASE OF MECHANICALLY WASHED STONE FILTER ci COMPACTED SAND BOX 2.0' 3.0' FABRIC 2.0' O EXISTING a w USGS ADJUSTMENT ° oo- TIE ENDS OF IJNE$o �° �A o END VIEW 1 ,000 GALLON TANK WELL - SDW 252 °°°°°�°° ° ° �'° � ° �° °� 0 o (TO REMAIN) ZONE "A" INDEX 47.40 7.0' o i1' NOTE: DATUM BASE NAVD GIS NOTIFY: EAS SURVEY INC. 48 HOURS PRIOR TO ADJ. = 1 .5' - BACKFILLING SYSTEM FOR INSPECTION. AUG. 2014 ADJUSTED GROUND WATER ELEV.- 10.5' GENERAL NOTES GROUND WATER IN TEST HOLE ELEV.= 9.0, 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. I CERTIFY THAT I AM CURRENTLY APPROVED BY THE DEPARTMENT OF TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS ENVIRONMENTAL PROTECTION PURSUANT TO 310 CMR 15.017 TO CONDUCT FOR SUBSURFACE DISPOSAL OF SEWERAGE. SOIL EVALUATIONS AND THAT THE ABOVE ANALYSIS HAS BEEN PERFORMED 2. ALL ACCESS PORTS OVER TANK TEES SHALL BE DESIGN DATA: ACCESSIBLE WITHIN 6" OF FINISH GRADE, WITH ANY REMAINING BY ME CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE " DESCRIBED IN 310 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY ACCESS PORTS BROUGHT TO WITHIN 6 OF FINISH GRADE. 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE SOIL EVALUATION AS INDICATED 0 THE ATTACHED SOIL EVALUATION FORM, CAPABLE of WITHSTANDING H-10 LOADING UNLESS THEY ARE ARE AC E ND IN AC DA E WITH 310 CMR 15.100 THROUGH 15.107. NUMBER OF BEDROOMS........._- NO UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEN THEY GARBAGE DISPOSAL................._______ MUST WITHSTAND H-20 LOADING. 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION TOTAL ESTIMATED FLOW OF ALL UTILITIES PRIOR TO ANY EXCAVATION. EDW A. STONE, ERTIFIED SOIL EVALUATOR (110 GAL./BR./DAY X 3 BR.) 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE 330GPD X 200% = 66O GAL OR WITHIN 6' OF GRADE SHALL BE MORTARED IN PLACE. 6. FINISH GRADE SHALL HAVE A MINIMUM OF 2% GRADE TEST PIT RESULTS. P 14472 USE EXIST. 1000 GAL. TANK OVER THE S.A.S. AND DISTRIBUTION Box. INSTALL: 7' X 65' FIELD (W/6" CRUSHED STONE UNDERNEATH) 7. SEPTIC TANK SANITARY TEES SHALL BE CONSTRUCTED OF SOIL TEST DATE: AUG. 28, 2014 SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE REPLACE WITH CLEAN SAND PER 310 CMR 15.255 THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND B.O.H. AGENT: DON DESMARAIS SOIL CLASSIFICATION................ LOCATED DIRECTLY UNDER THE CLEANOUT MANHOLES. --- 8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN SOIL EVALUATOR: EDWARD A. STONE, PLS I DESIGN PERCOLATION RATE..... <2 M1N 1�1. 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT EFFLUENT LOADING RATE.........__74_-- ELEVATION OF THE OUTLET PIPE. BACKHOE: RODNEY FISHER, REQUIRED LEACHING CAPACITY.....330 GALZDAY s. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 wcHEs' LEACHING CAPACITY PROVIDED.....33_6_GALDAY 10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS ELEv. TEST PIT #1 BAFFLE, 4 INCHES IN DIAMETER AND CONTRUCTED OF 4" PVC. 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND 18.8 DEPTH IN. HORIZON TEXTURE COLOR MOTT. OTHER BOTTOM: (7' x 65')(.74)= 336 GPD FIRST TWO FEET OUT OF THE DISTRIBUTION BOX SHALL 18.3 0-6" A/E LOAMY SAND 10YR5 1 BE LEVEL. 17.0 6-22" B LOAMY SAND 0YR7 6 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION TO EAS SURVEY INC. FOR B.O.H. AND DESIGN 15.6 22-38" Cl COARSE SAND IOYR6/6 10%GR. ENGINEERS REVIEW AND APPROVAL. - 8,8 38-120" C2 MEDIUM SAND 2.5Y7 1A 336 GPD PROVIDED - 330 GPD REQUIRED = 6 GPD RESERVE GROUNDWATER ENCOUNTERED ® 118" ELEV.= 9.0 \tH OF MASS CONSTRUCTION NOTES: ELEV. TEST PIT #2 PERCOLATION RATE <2 MIN./IN. BOT ® 42" aa�``A '�ti� �� N t °F1`1Assy SEPTIC SYSTEM DETAIL PAGE 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND 18.3 DEPTH IN.) HORIZO TEXTURE COLOR MOTT. OTHER a DA D o=� EDWARD cyG� ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING p -' c� #40 ALDER BROOK LANE WORK ON THE SITE. 18.1 0-8 A E LOAMY SAND OYR5 1 F6A E JR o A. 2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE 16.0 8-28" B LOAMY SAND OYR7 6 0 2 ST WEST BARNSTABLE, MA. WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT 14.6 28-44" C1 COARSE SAND OYR6/6 10%GR. FcisTER�c �' 0 SEPTEMBER 26, 2014 IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. - 7.8 44-126" C2 MEDIUM SAND 2.5Y7 4 PERC SA ITAR\'' s J 3. ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING ,. A L SHEET 2 OF 2 J# 1696 TAPE OR A COMPARABLE MEANS. GROUNDWATER ENCOUNTERED ® 112 ELEV.= 9.0 POL� WELL WEST BARNSTABLE 1ro \ LOCUS CBAS I � oz 1 •v \ � O'er o LOCUS MAP 1 \ / ' F LOT 4 LOCUS INFORMATION UPOLE LOT 5 \ 11 PLAN REF: 273/51 ip TITLE REF: 11006/99 AREA=40,000t S.F. ABANDON OLD FIELD PARCEL ID: MAP 133 PAR. 53 WELL W ZONING: "RF" GARAGE FLOOD ZONE: "X" COMMUNITY PANEL: 25001CO534J DATED:07/16/14 73 W / Sys // SEPTIC SYSTEM REPAIR PLAN TOF=20.81 _ _ �� LOCATED AT: ATI�o� BS �$ 40 ALDER BROOK LANE s� �� WEST BARNSTABLE, MA. 1 , o- 1S �, � / PREPARED FOR LOT 6 BARBARA J. McDO �g. 6 Q N ALD �, fo P , o � coo BS 1�QI / �h SEPTEMBER 26, 2014 O / / BENCHMARK: / / / ���OF Ass COR. BULKHEAD 55 / / �� DAVI qc� �SH oY�u`�S9 20.00 (GI O �j s c ELEV ( R C) EDWARD �O LAa t A. SAVE 1000 GALLON /, F P� / �� / STO E SEPTIC TANK o 2 $ / 100' z 0.5 E. A. S. PARCEL I: SURVEY, INC. GRAPHIC SCALE / / ��� 133/ 141 ROUTE 6A / �/ ,�y SALT POND BUILDING 30 0 15 30 60 120 / / �6� P.O. 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