HomeMy WebLinkAbout0245 CEDAR STREET - Health 24.5 Cedar Street
131-002 West Bamstab(
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TOWN OF BARNSTABLE
LOCATION oP V S C cd a r c5"'r•cc'} SEWAGE # aoO 7- q
VILLAGE_ � 8?qeJYO—� L a ASSESSOR'S MAP & LOT 3 Z,2
INSTALLER'S NAME&PHONE NO. Q 6xgay(x4 i on , 4/77-OGS3
SEPTIC TANK CAPACITY /SOO ///O
LEACHING FACILITY: (type) Soo ctia.HS C 3) (size) 13 X 30 X P.
NO. OF BEDROOMS 3
BUILDER OR OWNER-KarcrN Cooper
P 6 a9 0
ERMIT DATE: ' COMPLIANCE DATE: GT G.1 O-7
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
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INSTALLER'S NAME dt PHONE NO._ OLD Excraya3 i or-, 5/77-OG53
SEPTIC TANK CAPACITY lSoo N/a
LEACHING FACILITY: (type) Soo cl%*mS r 3) (size) 13 x 3o x V-
NO.OF BEDROOMS 3
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BUILDER OR OWNER KarcrN C�noccr
PERMTTDATE: 5 9 f O' COMPLIANCE DATE: GT G.10v7
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
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TOWN OF BARNSTABLE
LOCATION Z 9-S SEWAGE #
VILLAGE W` 3S1"2-" ASSESSOR'S MAP & LOT 13> ®Z
INSTALLER'S NAME&PHONE NO. FAiLEO INSPECTION
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
f NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within.100 f t of I Ching f ' 'ty) Feet
Furnished by ,
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Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �-
245 Cedar Street "'
Property Address '
John Cooper ow
Owner Owners Name
information is
required for every West Barnstable Ma 02668 10-15-18
page. City/Town State Zip Code Date of Inspection p'
1
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. Inspector Information 514- (33e&
on the computer,
use only the tab Brett Hickey
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
Co Route
130
� Company Address
Sandwich Ma 02563
a At
City/Town State Zip Code
(508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ■❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
°Bare BBB B-°Brett Hickey
10-15-18
;:ON:m=BrenNde.o.aua e'nBm�B MBe�vaem.M.<.US
Azle:M1B.18.1888:18.%LBVp
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
r
Commonwealth of Massachusetts
�o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
v
Property Address
John Cooper'
Owner Owner's Name
information is west Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
■❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2013 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
r
Commonwealth of Massachusetts
�e ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
U
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
v
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) 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
❑ a Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ O Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ [E] Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ 0 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ El 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.
5) 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 CA.
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c� Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
El ❑ 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?
❑ 0 Has the system received normal flows in the previous two week period?
❑ a 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)
❑ E] Was the facility or dwelling inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
Q ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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?
El a 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:
0 ❑ 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)]
t5insp.doc-rev.7J2612018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 18
cam, Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is required for every west Barnstable Ma 02668 10-15-18
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 2
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330/gpd
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes [j] No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonaluse? ❑ Yes E No
See below
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
.—WELL WATER—
Sump pump? ❑ Yes ❑Q No
Last date of occupancy: 3 1/2 years ago
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
�v
Property Address
John Cooper
Owner Owner's Name
information is west Barnstable Ma 02668 10-15-18
required for every
St
page. City/Town ate Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- last pumped in '13 or'14
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/j 245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is west Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El 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):
Approximate age of all components, date installed (if known)and source of information:
6-6-07 per COC
Were sewage odors detected when arriving at the site? ❑ Yes X No
5. Building Sewer(locate on site plan):
21
Depth below grade: feet
Material of construction:
❑cast iron H 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7126.2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: 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: 1500 gallons
Orr
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Orr
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
measured
How were dimensions 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.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
Property Address
John Cooper
Owner Owners Name
information is required for every West Barnstable Ma 02668 10-15-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
cam, Commonwealth of Massachusetts
1 , Title 5 official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
v
Property Address
John Cooper
Owner Owner's Name
information is west Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
0"
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.):
The d-box was in working order at the time of inspection.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.):
NA
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
(3)500 gallon chambers
0 leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number: I
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c Commonwealth of Massachusetts
�m Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
�v
Property Address
John Cooper
Owner Owner's Name
information is west Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leaching was in working order and was dry with no high staining at time of inspection.
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
�= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate of site plan):
Materials of construction: NA
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
l
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Y Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments
245 Cedar Street
V
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
Asbuilt Ground water profile
Well
3'
SAS
>100'
>156"
Al-96'
B1.93'
A2.91'
B2.94'
A3.155'
83.153' O O A4-160' >51
84.156'
A5.150'
B5.149'
3❑
Ground water
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` Cv 245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is Test Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
X Surface water
■❑ Check cellar
0 Shallow wells
Estimated depth to high ground water: No GW @ 156"
feet
Please indicate all methods used to determine the high ground water elevation:
n Obtained from system design plans on record
Mar-7-07
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:
A plan on file with the Board of Health was used.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
+n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
245 Cedar Street
Property Address
John Cooper
Owner Owner's Name
information is West Barnstable Ma 02668 10-15-18
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
■❑ A. Inspector Information: Complete all fields in this section.
■❑ B. Certification: Signed&Dated and 1, 2, 3, or 4 checked
F C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
■❑ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System"drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
H I...`..Ir. ;c _wog i cape engineering i n c . �AX NO. :15083629880 Jun. 07 2007 11:48RM F1
Town of Barnstable
Regulatory Services
it t'iiN - `i- Thomas F. Geiler,Director
Public Health Division
1�V'I� Slari�3 ��
;,;�;t.,;�•�,• Thomas McKean, Director
200 Mitin Street, Hyannis, MA 02601
Fat: 509-790-6.,041
s i c.i t: :'()1462-4644
Installer & Designer Certification Form
/-7/0'7 Sewaare Permit# �0�7' Assessor's MapTarcel -3�
Installer: �
r'3 cJ L� Address: I e
was issued a permit to install a
_.m(duel (installer) V
CP�( based on a designa drawn by
o,.1:f Li..: �.si:e,.n at !•.�r
(address)
.11
: dated
(des er)
certify that the septic system referenced above was installed substantially according to
-.v._ the design; which may include minor approved changes such as lateral relocation of the
iis�tcibution box and/or septic tank..
( ck q-ify that the septic system referenced above was installed with major changes (i.e.
�re.3.ter than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance Mth State & Local Regulations. Plan revision or
c,--r. ified as-built by designer to follow.
LZH OF A4A&�n
DANIELA.6W
��
11er's Sign r ) oJALft
CIVIL
__.... ..... C 4 No.45502 Q
. 6
/7 ®7 fey %T G/S-r-L
..- ONAI _ —
'--- --- (Affix s Stamp Here) -
(Dcstgner's Signature.)
s,c, —" TURN T RARNSTABL}? _PUBLIC HEALTH DIVISION. CERTII~ICATF OF
wiLL NOT BE ISSUED UNTIL B(�Tli THIS FORM AND AS-Bt11LT CARb ARF
lf))'BY THE BARNSTABLE PUBLIC HEALTH D1''1SiUN. THANK YOU.
c,:1' :i;1ah/Srptic,,/Dcsigncr Cenification Fomi 3-26-04.doc
EY.
No. � � °' � r .. Fee ..�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Zipplication for ntgo al *patent Comaruction Vermtt
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 4,yS 6c d o r S t Owner's Name,lydress,and Tel.No. -S 08 ` V a-7— 4713
W- Bnrnsttable Sohn t knfPn, Coo�e/
""T—
Assessor's Map/Parcel ,�� .3 I�UrCe.1 a 2,fs ccaar S f W •(3gr%f,-,_hLA_
Installer's Name,Address,and Tel.No. Designer's Name Address and Tel.No. `50 9.36 Z — Af5 y
Robear 67li-Foy- ,QtC3 E><COVO fjon Down L4i� £n7oeerin
e Soar-�� _0 43 A'IQrnSt' 4rrnout� opt
1
Type of Building:
Dwelling No.of Bedrooms v Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330gpd Design flow provided gpd
Plan Date a 13 to_] Number of sheets Revision Date 7 10 7
Title T tie S C SI l�lc,n
Size of Septic Tank 15 o o Type of S.A.S.
Description of Soil
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 Health.
Signe P Date Jr �I1O
Application Approved by C Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
_,*
No. l'
,Qa 1 f . + ) Fee
THEJQ AMO�VWEALTH OF:�VIASSACHUSETTS Entered in computer.
PUBLIC HEALT , DIVISION - TOWN:OF BARNSTABLE, MASSACHUSETTS Yes
Z[Ppricatiori for Mizpoza' 6p5terit'Zow6truction Permit-
`Application for a Permit to Construct O Repair( j Upgrade O Abandon( °)''❑ Complete System ❑Individual Components
Locatiop Address or Lot No. 45 C e an r S 1'' Owner's Name Address,and Tel.No. -5 G& ' L/9 7 L 7 13
w Bnrn6fab►e TOhn + 71�cr61n. (4.)Cne/
Assessor's Map/Parcel ap 131 'PU<C e 1 2y5 (e ClCt r S+ W ' 13(1(,)_5 bL L .
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
-So& 3L2. - M5 `l1
7/U'berer C-rli-Foy - 43re C)(uiv6 Dior) Down (ap-d
114 reab rvdn� 7ure5f lol Sub °r77-4)(, -3 939 ti1nr,,5h /<�rrllu�� h(�U+ t
TI pe of Building:
Dwelling No.of Bedrooms \3 Lot Size sq.ft. Garbage Grinder ( ) r
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided gpd
' Plan Date a'13 It,7 Number of sheets Revision Date - 7 10 7
Title Ti i le ,5 5l/L PICi n
R. Size of Septic Tank (} Type of S.A.S.
Description of Soil
f
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: <"'� l i.ln.
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 Health. '
Signej 2�1L1 `/ n, /1n Date Jr 1 16 7
Application Approved by
/�3 d Date O
Application Disapproved by: ` r Date _
for the following'reasons
Permit No. Date Issued ! rl
——————————————— —————————————————= —————————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned O by i Q E X L I V 6 4 1 Ca l, ) T.�J L.
at a Ll S ctcC r1 r S+ .i>1j .B A r n c i r_t_b'�P has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. [ dated
Installer(..}22 eT?— —' (T I L I'0\4 Designer T)D V\,I V C f1 C I n e 'Lt (�
#bedrooms V Approved design flow 3 3b gpd
The issuance of this permit hal not b const ued as a guarantee that the syste ill function as designed. (/ —'
Date Inspector, / � ) +
——----------- -------- (Z-- .- 1 /---
No. �.U�� �_r�f L�, — ,--———--— Fee
I 1 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
1wigpogal *p5tem Con.5truction Permit
Permission is hereby granted to Construct ( ) Repair (X ) . Upgrade ( ) Abandon ( )
System located at
y � Tint-nsi<�_hle
E ,
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions. a
Provided: Constructio must be completed within three years of the date of tf- ermit..
Date Iry 1191 Approved by v �
Town of Barnstable P# 01 —
�pF SHE
y�P p Department of Regulatory Services
RAruvsrAar.E.
' PubTie Health Division Date
v "'ACLq-
9. 200 Main Street,m,Hyannis MA 02601
f•'-, :x. �plfD MA't Aim , ,
Fee Pd.
Date Scheduled± 7 'U' �" ' Time 14�!
Soil Suitability Assessment for Sewage Disposal
a0w►N CaP a eN I ti ��
AN; O)�IrLA ?L5 GI7'
Performed By: B S%sse�d;Dya q'r`� s
LOCATION r& GENERAL INFORMATION
Location Address ay s- &dmr A� { Owner's Name 61'h4r1e f `
Ir Address y�y�" coOPe1C)
V12Jt gG.rn f 4 r 1LA.f sN,
Assessor's Map/Parcel:
Engineer's Names` a0W h Ci+� 2►'�S�h+}!"�
T 362 4-
NEW CONSTRUCTION REPAIR Telephone#`
n_ i T- -
Land Use ' ' Slopes(%) ' I Surface Stones
i 1YL
�- ft Drinking Water Well Zt� ft
Distances from: Open Water Body ft Possible Wet Area g
,ft. Property4Line 5 �; ft Other.. ft
Drainage Way !
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
C�
o
N
0 r-A IL
75 l well/
�Z Jl
�- papp•,SS. ,
Ov t r
Parent material(geologic) yY�OY`f`A�h e- y Depth to Bedrock
from
Depth to Groundwater: Standing Water in Hole: Weeping Pit Face
Estimated Seasonal High Groundwater 2' �kCW lD� i%;t r tJ-L
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: r0.&; �
Depth Observed standing in obs.hole: n�� 7 m. "bepth to soil mottles:
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level—
PERCOLATION TEST Date 1 Time
Observation
�J 1' Time at 9"
Hole#
Depth of Perc v -7 t l Time at 6"
Start Pre-soak Time cr
t15m"v+ I✓!C`ow �Q�/ Time(9"-6")
M/G 5AN1J
End Pre-soak
_ „ �rY -
RateMin./Inch ( ho
Site Suitability Assessment: Site Passed' Y Site Failed:
Additional Testing Needed.(Y/N) nOt�p C Vt�aG
Original: Public Health Division Observation Hole Data To Be Completed on Back----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:HEALTH/W P/PERCFORM
,DEEP OBSERVATION HOLE LOG Hole# 71'
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in,) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
r�nnsistencv °i°Gravell..._�
o H CIA 5� o Y�- �/�
Li 3CD c 5 s 10 `/(1- &A.
L. 2.5y 7/1 ocltets st�T CAM
M�•���-
71+1
DEEP OBSERVATION HOLE LOG
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel
3 0, I�
l2p -:,1`t4 G2 M/c SANS' . 2•5y7/ 5 Gi¢wv, - sV, )-*.bk
C o►%� 1ooljvrv�
ferch.�.� W�-I-�,r a 7•0 � Sw, cc�'.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency %Gravel)
}
� r ,
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil
Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistene.%Gravel
a P
Flood Insurance Rate Map:
Above 500 year flood boundary ,No_ Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes
Depth of Naturally Otirrins?Pervious Material
cc
pervious
material exist in all areas observed throughout the
Does at least four feet of naturally occurring p ;, ,t
area proposed for the soil absorption system? yC 5
If not,what is the depth of naturally occurring pervious material? L
Certification
I certify that on NOV by� (date)I have passed the soil evaluator examination approved by the
Department of Enviromnental Protection and that the above analysis was performed by me.consistent with
the required training,expertise and experience described.i... .. C' 4., 1.5.01`7.F s
ivy-- Date.
Signature
Q:HEALT} /WP/PERCFORM
i
P�°FTHE t � Town of Barnstable
Regulatory Services
* BARNSTABLE, * Thomas F. Geiler,Director
.� MASS. mot
1639. A Public Health Division
rFD MA'S
Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Stephen J. Giatrelis Date: March 1, 2005
245 Cedar Street
West Barnstable, Ma. 02668
NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V.
The septic system owned by you located at 245 Cedar Street W. Barnstable, Ma. was inspected on,
12/17/2001 by John Graci a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1995 TITLE 5 (310 CMR.15.00) due to the following:
Single'cesspool does not meet Title V town requirement. Cesspool is in hydraulic failure. ;
Our records show.that the system has been in a failed state.for more than two years:
You are ordered to hire a professional engineer or registered sanitarian to prepare a plan of
proposed replacement septic. system component(s). This plan is to be submitted to Ahe.Town of
Barnstable Public Health,Division Office (Regulatory Services, 200 Main Street,Hyannis),within
(90) days receipt of this letter. The plan will bring the septic system into compliance with 310 CMR
15.00,The State Environmental Code, Title V.
You are a lso o rdered t o u pgrade o r r eplace t he s eptic s ystem w ithin s ix months (180) days o f y our
receipt of this letter.
Any person aggrieved by any order issued by the local approval authority may appeal to any c ourt o f
competent jurisdiction as provided for by the laws of the Commonwealth. You have the option of
requesting an adjudicatory hearing pursuant to 310 CMR 15.422
Failure.to comply with this order will automatically result in a public hearing scheduled before the Board
of Health.
T BOARD OF HEALTH
Thomas A. McKean,R.S., C.H.O.
Agent of the Board of Health
CC: Board of Health
1/failed—septic—letters
.471
COMMONWEALTH OF MASSACHUSET,rs
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 4 +�
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r rZ v
MAILED INSPECTION
.a x ,
TITLE 5.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,' hx:
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM rv=t ,
PART A
CERTIFICATION
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668 vqs\—kj�)y
Owner's Name: MRS PINSON r -
Owner's Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668 �
Date of Inspection: 12/17/01
Name of Inspector: (please print) JOHN GRACI RECEIVE®
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 2 0 2001
Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN�F BARNSTABLE
HEALTH DEPT. ,
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below isx
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 F
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).o The system: �x :
` Passes `
_ Conditionally Pqsses r
Needs Furth valuation by the Local Approving Authority
X Fails
Date: 12/17/01
Inspector's Signature: ` "
The system inspector shall submit 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 1t :
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.
Notes and Comments
SYSTEM FAILS TITLE V INSPECTION. SINGLE CESSPOOL DOES NOT MEET TITLE V REQUIREMENT.
CESSPOOL IS IN HYDRAULIC FAILURE. LIQUID LEVEL IS OVER ALL PIPES. 4' s
�.
****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 irit I I�
'�ni aj'pt
c
• Y�
Title 5 lncnartinn Form (,/151)(WO I
Page 2 of 11
L
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTSL #
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Q
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668 t U
Owner: MRS PINSON
Date of Inspection: 12/17/01 1:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 :*
CMR 15.304 exist.Any failure criteria not evaluated are indicated below. ,
Comments: ,f
+�'4d
SYSTEM FAILS TITLE V INSPECTION. SINGLE CESSPOOL DOES NOT MEET TITLE V REQUIREMENT. .1 '
CESSPOOL IS IN HYDRAULIC FAILURE. LIQUID LEVEL IS OVER ALL PIPES. ',
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, 3t�*
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
IY 4"
Answer yes,no or not determined(Y;N,ND)in the for the following statements. If"not determined"please explain. £`
n/a The septic tank is metal and over 20 ears old*or the septic tank whether metal or not is structural) unsound exhibits
p Y P ( ) Y �
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: n/a {rt
n/a Observation of sewage backup or ki'ak 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 , l .{-
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced s'w
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass y
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
xr
�q
fF' ry s
ND explain: n/a �'
Page 3 of 11
rti
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM U�#
PART A
CERTIFICATION(continued)
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668 '
Owner: MRS PINSON }
Date of Inspection: 12/17/01 ;
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 '� '
i,
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 ;; ,ri
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Jr i<�;
. , Ce .
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. t
_ 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. i
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water ��
supply well**. Method used to determine distance n/a r
` performed at a DEP certified laboratory, aLL
**This system passes if the well water�analysis,p rY�for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia r, .
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: i
n/a � `x.
1- �Y
iPage4 of 11
f }
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ��:
,
PART A
CERTIFICATION(continued) ��
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668
Owner: MRS PINSON
Date of Inspection: 12/17/01
D. System Failure Criteria applicable to all systems: ,
You must indicate"yes"or"no"to each of the following for all-inspections:
Y�
Yes No # k
X _ Backup of sewage into facility or system component due to 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 A ry
SAS or cesspool;ems
. ��
_ 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 ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s .Number of times
q P P" g Y gg P P ( ) �
pumped nLa,
X Any portion of the SAS,cesspool or privy is below high ground water elevation. f
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 .'i
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,: a �
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.) .
X _ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 3 10
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. , ;
t�
E. Large Systems: +11
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following: ;
(The following criteria apply to large systems in addition to the criteria above) tx� .
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mappedZfl
' ;
Zone II of a public water supply well k
* a
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. ;
k
Page 5'of 11 ;.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS s'`'e.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST '{
�-
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668
Owner: MRS PINSON
Date of Inspection: 12/17/01 '. i "
ti. V
ty6jt� F',,
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 provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks? ;C��sgg
X _ Has the system received normal flows in the previous two week period?
114
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 back up? �` �
X _ Was the site inspected for signs of break out'? "rt
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manhole's 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? >a '
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 System(SAS)on the site has been determined based on: Y
Yes no "
X _ Existing information. For example,a plan at the Board of Health.
r
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)]
f
t
� r ,
.'Page 6 of 11
F^R S
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ¢ '_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION =;r
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668
Owner: MRS PINSON #i
Date of Inspection: 12/17/01
ri F
FLOW CONDITIONS ,
RESIDENTIAL
Number of bedrooms(design): 1 Number of bedrooms(actual): 1
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110
Number of current residents: 1 '' z
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`):'NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a =�sa
Sump pump(yes or no): NO '
a�
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no):NO ,$
Non-sanitary waste discharged to the Title 5 system(yes or no): NO ;
Water meter readings, if available: n/a
Last date of occupancy/use: n/a "
OTHER(describe): n/a t
GENERAL INFORMATION ' '
Pumping Records "
Source of information: n/aay�
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--_How was quantity pumped determined?n/a
Reason for pumping: n/a ,fF 'X
TYPE OF SYSTEM F §x
_Septic tank,distribution box,soil absorption system `
X Single cesspool
Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from;
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1940 , R
n.
�4
Were sewage odors detected when arriving at the site(yes or no): NO
4 _
K
Page Tof I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .=; fhf
PART C
SYSTEM INFORMATION(continued)
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668r
Owner: MRS PINSON }`
Date of Inspection: 12/17/01
BUILDING SEWER(locate on site plan)
Depth below grade: 12" *�
Materials of construction:_cast iron _40 PVC Xother(explain): ORANGEBURG £`
Distance from private water supply well or suction line: n/a � I .
Comments(on condition of joints,venting,evidence of leakage,etc.): ��"
TOWN WATER
SEPTIC TANK: (locate on site plan) ':
Depth below grade: n/a d
Material of construction:_concrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Wage confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) }
Dimensions: n/a £ ,
Sludge depth: n/a ,
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a .,:
Distance from top of scum to top of outlet tee or baffle: n/a i A
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: n/a �.. �#
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related r RS :
to outlet invert,evidence of leakage,etc.):
V'y
n/a
GREASE TRAP:_(locate on site plan) Yam•
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene other(explain): n/a
Dimensions: n/a �
Scum thickness: n/a
r J,4
Distance from top of scum to top of outlet tee or baffle: n/a �.
Distance from bottom of scum to bottom of outlet tee or baffle: n/a `g
Date of last pumping: n/a 4 a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related f _ ;
to outlet invert,evidence of leakage,etc.): ,A
n/aJt
!,
-Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` s
PART C.
SYSTEM INFORMATION(continued)
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668
Owner: MRS PINSON ;
Date of Inspection: 12/17/01 k
sk
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction: concrete metal fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons ' .
Design Flow: n/a gallons/day . *`
Alarm present(yes or no): N/A % F},
Alarm level: N/A Alarm in working order(yes or no): NO7;
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a �#x
DISTRIBUTION BOX: _(if present must be,opened)(locate on site plan) � t
Depth of liquid level above outlet invert: n/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.): ' A
n/a t ,.
PUMP CHAMBER:_(locate on site plan) l
Pumps in working order(yes or no): NOAd
*,
Alarms in working order(yes or no):NO $
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
F
+ �sI
d " N3._
Y
N,
R - f
Page 9 of 11
� a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C p
SYSTEM INFORMATION(continued) *
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668
Owner: MRS PINSON "
Date of Inspection: 12/17/01 .- 4
SOIL ABSORPTION SYSTEM(SAS): _ locate on site plan,excavation not required)
If SAS not located explain why: �-
n/a ,5 .
Type
n/a leaching pits, number: n/a 'g=
n/a leaching chambers, number: n/a
A wA.
n/a leaching galleries, number: n/a r¢t ,1 �
n/a leaching trenches, number;,length: n/a
n/a leaching fields, number. n/a `
overflow cesspool, number:- r=.
n/a P n/a
n/a t : innovative/alternative system
T e/name of technology:9Y: n/a
4,111:,.
,U?..
F S
x a g
f r
Comments(note condition of soil;signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
n/a r;
CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan) :
Number and configuration: 1 t
Depth—top of liquid to inlet invert: n/a �3 3 w:
Depth of solids layer: n/a :
k
Depth of scum layer: n/a
Dimensions of cesspool: 5' X 5"' F
Materials of construction: n/a �,,�
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): p ''
a�
CESSPOOL FAILS.SINGLE CESSPOOL DOES NOT MEET TITLE.V REQUIREMENT.CESSPOOL IS IN
HYDRAULIC FAILURE.LIQUID LEVEL IS OVER ALL PIPES.
PRIVY: (locate on site plan) Y I v$
Materials of construction: n/a d .
Dimensions: n/a .
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): �p ^
n/a
r
-Page 1-0 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS *``4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `
PART C y
SYSTEM INFORMATION(continued) v o
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668
Owner: MRS PINSON
Date of Inspection: 12/17/01 `
SKETCH OF SEWAGE DISPOSAL SYSTEM t'
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building. t:x:
7 41_•
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Wage 1-1 of 11
F VOLUNTARY ASSESSMENTS = r+
OFFICIAL INSPECTION FORM—NOT OR A, a y.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 245 CEDAR ST WEST BARNSTABLE,MA 02668
Owner: MRS PINSON 4?'
Date of Inspection: 12/17/01
SITE EXAM :
_Slope
_Surface water
_Check cellar
Shallow wells - `
Estimated depth to ground water 12 feet
Please indicate(check)all methods used to determine the high ground water elevation: - y7
NO Obtained from P system design plans on record-If checked date of design plan reviewed: n/aas
Y g
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a � }
NO Checked with local excavators,installers-(attach documentation) %i?_...•
YES Accessed USGS database-explain: n/a
n
You must describe how you established the high ground water elevation: '`
USGS MAPS AND CHARTS- 12 FT. `
djyY
7.
1 �;j4(Ir.f Y
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'k;444"
W
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LEGENDTOP FNDN. AT EL. 101 .1' SYSTEM PROFILE NOTES
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) 1. DATUM IS APPROXIMATE NGVD
-<
100.0 PROPOSED SPOT ELEVATION ACCESS COVER (WATERTIGHT) TO ACCESS COVER TO WITHIN 3" OF FIN. GRADE
2. MUNICIPAL WATER fS NOT AVAILABLE
29e SLOPE REQUIRED OVER SYSTEM
100.9' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE �ovf
STEM
100x0 EXISTING SPOT ELEVATION 82.8' 3. MINIMUM PIPE_ PITCH_ TO BE 1/8" PER FOOT.
INSTALL INLET 2" DOUBLE WASHED PEASTONE
100 PROPOSED CONTOUR *98.9' TEE 1" ABOVE LFUR FIRST 2'RUN PIPE EL OR GEOTEXTILE FABRIC
PROPOSED 1500 OUTLLT INVERT / 3' MAX.
4. DESIGN LOADING FOR SEPTfC TANK TO BE AASHO
100 EXISTING CONTOUR GALLON SEPTIC H- 10; D'BOX AND LEACHING FACILITY TO BE H-20
16.75' 96.50' 6" SUMP79 8' 5. PIPE JOINTS TO BE MADE WATERTIGHT.
TANK (H- ) GAS o0 �
BAFFLE 79•27' �� o p p p p O p p p p DETAILS T IN ACCORDANCE H `sr Qu
79.0' 0 p 0 p p a p = p 6. CONSTRUCTIONLS 0 BE WITH
( 2.69G SLOPE) =6CRUSHED STONE OR MECHANICAL p 0 p 0 0 0 p 1-:1O MASS. ENVIRONMENTAL CODE TITLE V.
COMPACTION. (15.221 [2]) $ 2' 0 p 0 0 (] 0 0 � 0 77.0' 6 LOCUS �
DEPTH of FLOW = 4' ( ) 1 0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO o�e5 Willow
1 1 X SLOPE ( % SLOPE)
T-E SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. Street
INLET DEPTH = 10„
OUTLET DEPTH = 14" 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
' ' ' LEACHING 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
FOUNDATION 81 SEPTIC TANK 150 D BOX 12' FACILITY 9'5, WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION
OBTAINED FROM BOARD OF HEALTH.
LOCUS MAP
*THE INSTALLER SHALL VERIFY THE 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
LOCATIONS OF ALL UTILITIES AND ALL DIGSAFE (1-888-34•4-7233) AND VERIFYING THE LOCATION SCALE 1"=2000't
BUILDING SEWER OUTLETS AND ELEVATIONS BOTTOM TH-2A EL. 67.5' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO ASSESSORS MAP 131 PARCEL 2
PRIOR TO INSTALLING ANY PORTION OF COMMENCEMENT OF WORK.
SEPTIC SYSTEM
LOCUS IS WITHIN AP OVERLAY DISTRICT
11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND
REMOVED OR PUMPED AND FILLED WITH CLEAN SAND.
12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
LPIT REMOVED 5' BENEATH AND AROUND THE PROPOSED
( 1 �2 LEACHING FACILITY.
c�a TEST HOLE LOGS 13. NO LEACHING NFFACILI Y OWN POTABLE WELLS WITHIN 150' OF PROPOSED TEST HOLE LOGS
ENGINEER. DAVID FLAHERTY, R.S. DANIEL A. OJALA PE
/ DRIVHELLEWAY EWAY// \ ��F WITNESS: DON DESMARAIS, R.S. ENGINEER:DAVID STANTON, R.S.; DON DESMARAIS, R.S.
DATE: FEBRUARY 7, 2007 WITNESS.
DATE: APRIL 7, 2004; FEBRUARY 7, 2007
PERC. RATE = 10 MIN/INCH FAILED
- PERC. RATE _
96,703 SO. FT.t CLASS SOILS P#11615, 111616 CLASS SOILS P# 10707, 11616
2 ACRES± \
4 ELEV. ELEV. ELEV. ELEV. ELEV. ELEV.
\ 0" B 81.5' 0" 81.5' p" 82.0' 0" 84.5' 0" 93.5' 0" 82.0'
O/A O/A 0/iA/E O/A O/A O/A
I �0' °�� i \ LS LS L'.S LS SL SL
EXISIIN , 10YR 3/1 10YR 3/1 10YR,1 3/1 10YR 3/1 1 OYR 3 2 10YR 3 2
96 DWELLIN g" 80.7' 6" 81.0' 6" 81.5' 8" 83.8' 4" / 93.2' 4" / 81 .7'
rEl=101.1
MARK � �
ULKHEAD °� ' B B B B B B
' 0
98 /' PROVIDE LS LS L S LS LS LS
o C.O. � 1OYR 6/8
Sao (C� 24„ 10YR 5/4 79.5' 1801 10YR 5/4 80.0' 22" 1OYRZ 5/4 X' 29" 10YR 5/4 82.1' 30" 10YR 6/8 91 0, 30" 79.5'
0 97 R Y'S �o� C1 C1 C1 C1 cl1
O I _ i
LS C I 2.5Y 7/4
CO 53" 2.5Y 7/3 77.1 '. 54" 2.5Y 7 3 77.0' 51 ., 2.5Y 7/3 80.2 53" 2.5Y 7/3 80.1' /
� 9S � PIT `�/ /
PERC 120" 72.0'
r 9 4 0)/fn C 2 S L
O C2 C2 C:2 FMLS
O 93 H-1A g o0 0 �� �� PERC PERC
92 / v X 144" 10YR 7/4 72.5' 2.5Y 7/4 C2
���, /
FM LS FMLS FM1 LS
91 C3 MCS
90 40 2 M C S
^\� 144" 10YR 7/4 69.5' 144" 10YR 7/4 69 5� 132" 10YR; 7/4 71 0' 162" 10YR 7/4 71 0' 156" 80.5' 174" 10YR 7/3 67.5'
89 8�
NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED
87 H-4
5'REMOVAL OF UNSUITABLE SOIL
REQUIRED AROUND PERIMETER OF 7S
LEACHING FACILITY, DOWN TO a�j O PROP. H-10 1500 GAL. SEPTIC TANK
SUITABLE SOIL LAYER(TO C2
LAYER, APPROX.ELEV. 77'). N O
REPLACE MITN CLEAN MED. SAND.
TO INSPECT MD
TH 2
lb 3
BENCHMARK CP
SPIKE SET141:41TE PLAN
EL= 86.9' ...............
IT I T L E 5 %03
TH-1 SYSTEM DESIGN:
OF
GARBAGE DISPOSER IS NOT ALLOWED
0[)
NTH 2B
DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD 245 CEDAR ST.
USE A 330 GPD DESIGN FLOW
� SEPTIC TANK: 330 GPD (2) = 660 (WEST) BARNSTABLE, MA
USE A 1500 GAL. SEPTIC TANK PREPARED FOR
Cs
2 LEACHING:
82 _._�� 8' SIDES: 2 (30.5 + 12.83) 2 (.60) = 104 GPD KAREN & JOHN COOPER
0
BOTTOM 30.5 x 12.83 (.60) = 234 GPD
83
84 TOTAL: 563 S.F. 338 GPD DATE: FEBRUARY 13, 2007
8`3 82 85 USE (3) 500 GAL. H-20 LEACHING CHAMBERS (A1CME OR EQUAL) REVISED DATE: MARCH 7, 2007 (SAS)
WITH 2.5' STONE AT ENDS AND 4 AT SIDES REV MAY 9, 2007 (MOVE ST, H-20 UNITS)
d'6 d'S 86 Scale: 1"= 30'
�� 87
�9 88 MA 0 15 30 45 60 75 FEET
89_ APPROVED DATE BOARD OF HEALTH
9� 4541 90- off/ _ _
fax 508 362-9 80
9�
IN OF p4ASs9 ZH OF id,S, ,
ARNE H oyG� �o�� AR R Fg�`�,\
OJALA �, H. , down cope erg gln eerin g, inc.
\\ CIVIL N 0.)AiA Nf
a No. 30792 o No.26348 ! 1 Cl VIL ENGINEERS
L AND SUR VE YORS
y R1111
D E ARNE H. OJALA, P.E., P.L.S. 9.39 Maim Street - YA RMOU THPOR T, MASS.
DICE ##04- > 06
04-106 COOPER_TOPO_SITEPLAN.DWG