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HomeMy WebLinkAbout0074 COACHMAN LANE - Health 74`Coachman Lane. W. Barnstable F/R q A = 152 043 r P I i I' i �I i No. 4210 1/3 BLU p � 90SK % 10% (s o e 0 0 TOWN OF BARNSTABLE J. OCAT10N I� ( ���� `�'°�"'—' SEWAGE # 7 VILLAGE L \AbL4 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0 LEACHING FACILITY: (type ��� (size) /000 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility- (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by IA- BA �� Q 6M3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE MA 2/21/13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information Whenfilling out forms forms on the computer,use 1. Inspector. only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name VQ P.O BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and th�a�the information reported below is true, accurate and complete as of the time of the ihs ection. T% insp ction was performed based on my training and experience in the proper function ano m intenan(�of ola-ite sewage disposal systems. I am a DEP approved system inspector pursuantst�b,Section`1,15.34 'f Title 5(310 CMR 15.000). The system: I t -n C, Val 2 Passes ❑ Conditionally Passes ❑ Fails -, ❑ Needs Further Evaluation by the Local Approving Authority 5 s••,) ate+ 2/21/13 Insper Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP:The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official In pection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNST:ABLE M A 2/21/13 every page. City/Town State Zip Code Date of Inspection B. Cer'tification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System(Passes: ® ,I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM MET PASSING REQUIREMENTS AT TIME OF INSPtCTION 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 ornot) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 IL � Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of 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•11/10. Title 5 Official Inspection 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 �„ y< 74 COACHMAN LN Property Address LUBLIN Owner Owners Name required is W BARNSTABLE MA 2/21/13 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal >to or lessthan 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or plugged SAS or cesspool ❑ liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is W BARNSTABLE MA 2/21/13 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous.two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health ❑ ® Determined in the field (if any of the failure criteria related to Part is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official 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 , 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every page. CityrTown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND A 10X40X2 FT S.A.S CONSISTING OR CULTEC RE CHARGERS Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: WELL WATER ACCORDING TO TOWN Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holdingtank resent? Yes No P ❑ ❑ Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•,11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE MA 2/21/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: S.A.S INSTALLED IN JAN OF 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 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: 1000 AS PER AS-BUILT Sludge depth: LIGHT t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name requir required is W BARNSTABLE MA 2/21/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness TRACES CLUMPING Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 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 °M 74 COACHMAN LN Property Address LUBLIN Owrer Owner's Name information is required for W BARNSTABLE MA 2/21/13 everY page. CitylTown State Zip Code Date of Inspection D. System Information (coot.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 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 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every 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 0" 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.): BOX LEVEL NO LEAKAGE 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 't 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: CULTEC RE-CHARGER Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): OBSERVATION PORT WAS OPENED AND CHAMBERS WERE FOUND TO BE EMPTY WITH NO SIGNS OF FAILURE AT TIME OF INSPECTION 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•11/10 Title 5 Official 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 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name required is W BARNSTABLE MA 2/21/13 required for every page. Cityrrown 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•11110 Title 5 Official Inspection Form: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 M 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately l5ins•11/10 Title 5 Official Inspection 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 M 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: GREATER THAN 4 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: 2/21/13 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: DESIGN PLAN BY R J OHEARN DATED 1/5/04 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 74 COACHMAN LN Property Address LUBLIN Owner Owner's Name information is required for W BARNSTABLE M A 2/21/13 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L e 1 f TOWN Of BAXNSTA13LE n _ - pry "a LOCATION y \ �ICl�� �v. SEWAGE �C�q ' o VILLAGE - ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. U �� I SEPTIC.TANK'CAPACITY I 0a0. LEACHING FACILITY. (type) � (size) 10�Y 4C). NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 12I-:�6 6 , COMPLIANCE DATE: OLI 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 r 0 I I ' � i 66' gys a� t Hv� ---------------- , a 10 coo W ,� ADO 1 OCt. l TOWN Ot�BAKNSTABLt LOCATION y C1ICl41 � If, SEWAGE # 00q • 0-*`0 VILLAGE I/J • ASSESSOR'S MAP & LOT15-2-d'13 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1000 LEACHING FACILITY: (type) 3ALto r,. % , (size) Oozy 4o a NO.OF BEDROOMS BUILDER OR OWNER II PERMIT DATE: i�l�6 COMPLIANCE DATE: I Q-8109 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,faci1i n { Feet Furnished by J a� 3 �y C �— • Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS VYe �� Zipprication for Miopoof bpotem Conotruction 3permit Application for a Permit to Construct( )Repair( )Upgrade(t/)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. .Assessor's Map/Parcel IP/,1J'1 e v `M�� Installer's Name,Address,and Tel.No. Desi er's Name,Address and Tel.No. ,?J�LC� 1 -66 s lclOw Imo , a watn,. ✓ Type of Building: Dwelling No.of Bedrooms _ Lot Size STsq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 11,0 gallons per day. Calculated daily flow qqo gallons. Plan Date la W 43 Number of sheets 01 Revision Date Title Size of Septic Tank t000nType of S.A.S. -i ti 0"Y Description of Soil, acts da4j4 . Nature of Repairs or Alterations(Answer when applicable) td And NyAk)- C_�o /� >z Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed v Date l a Application Approved by 'b 5 ® Date Application Disapproved for the following reas Permit No. Date Issued Fee j' �rr THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / PPUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Ye ✓ Rpplication for Zi.5pont &pztem Conaruction Permit Application for a Permit to Construct( )Repair( )Upgrade(V)Abandon( ) O Complete System El Individual Components Location Address or Lot No. 7,��{J S3-v. Owner's Name,Addresq and Tel.No. Assessor's Map/Parcel " " �Z Installer'sAddress,and Tel.No,- C,�� Des er's Name,Address and Tel.No. !3 Cl_ 1)-6 9i 5c$ - y 32- 5700 35 ft134 PO 1 ,937 . mjnko> Type of Building: Dwelling No.of Bedrooms _ Lot Size 3 5�D91 sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) r Other Fixtures Design Flow I D gallons per day. Calculated daily flow � gallons. Plan Date la IJI 103 Number of sheets 2- Revision Date Title Size of Septic Tank WOO Type of S.A.S. 3�n,�nnc,, %0 Y 40"� a Description of Soil: Y!QN, r i Nature of Repairs or Alterations(Answer when applicable) d ,nna ,cxlt(1 ms/111-' s a S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Board of Health. 10 Signed/. ;r ® /� .� Date .;L 6 'd 3 Application Approved by � C ; Application Disapproved -® _..,�;�• �- d-._-- - -Date -- for the following reas,ons� r v Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(A Xoandoned )by n' at L + has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. D 001 -0.�6 dated ,�Id v ✓r I Akr� 'Installer �. D � P The issuance of this ernut shall not be corsu cu as a guarantee that the �'�zn wi,h�fitretio as des.i ned. Date �- Inspector Gti J n ..v No._ �C/ l10 —_—_--------� —————————Fee i- v f2 THE COMMONWEALTH OF MASSACHUSETTS ��•� J J PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS migoal &p.5tem Con!5tr,iiction Permit Permission is hereby granted to Construct( )Re U�P,grade - ))}Abandon'( ) System located at '1 �t7Z� C'V r�'1 k t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5��tand the following local provisions or special conditions. Provided:Constructton� st a 6mpleted within three years of the date of '''s pertrii� / �Date: Approved by,.� / 6 4 . z•uwN Of BARNS'I'At3Lh LOCATION �� �,�'��°'�f^�n� � SEWAGE # ao 7 ASSESSOR'S MAP &`LOT -dti VILLAGE /I.A^� j INSTALLER'S NAME&PHONE NO. SEPTIC.TANK'CAPACITY loop. . LEACHING FACILITY: (type) ti�nDMC� (size) 10 1 40 NO:OF BEDROOMS BUILDER OR OWNER PERMTTDATE: I I�.b COMPLIANCE DATE: Separation Distance Between the. Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility , Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leachin facility)1 Furnished by �� d 1 ' � A A- t 35' 3 gy I FAILED INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i DEPARTMENT OF ENVIRONMENTAL PROTECTION NOV 14 2003 9V ++ OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: q COai Asolos a�j Owner's Name: Owner's Address: Date of Inspection: 0 /S o NEAP -* %y�rPr PARCEL Name of Inspector: (please print) 0 o ,sue . - Company Name: E/Y �vi — T is N LOT a Mailing Address: O O x /A_ a-r .-? O1` 2 Telephone Number�� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Further Evaluation the Local Approving Authority Fail Inspector's Signature: WT O 9 g Date: / 03 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments dr C4 CA L �Gt 1 1(4/C, t� ****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. Y Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART-A . /j CERTIFICATION (continued) Property Address: Owner: Gt et✓i 1 Date of Inspection: e O 3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A./�Sy�stem 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: B. System Conditionally Passes: Z�e or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old' or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM CERTIFICATION(continued) Property Address: COGt G A✓vto pi O1r19 f Owner: /41 OL r� Date of Inspection: (O p C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ___. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - -- _ PART A CERTIFICATION(continued) Property Address: ( ,©G C a�'► L- Owner: Date of Inspection: / p D. System Failure.Criteria applicable to all systems: - You must indicate"yes"or"no"to each of the following for all inspections: Ye o _ _ 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'/z day flow T,,-'ftequired pumping more than 4 times in the last year N T due to clogged or obstructed pipe(s).Number of times pumped _� y 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. portion of a cesspool or privy is within a Zone 1 of a public well. "y portion of a cesspool or privy is within 50 feet of a private water supply well. T _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.} i�es/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve afacility 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) 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 _ _ th stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 CUR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _PART B_ / CHECKLIST Property Address: �Y" (,f-i G�1 V-1a 0 Z—, Owner:_ /7 e., Date of Inspection: l0 1$ O Cheek if the followinghave been done.:You must indicate ,> u ,> des 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 ✓�Havearge volumes of water been introduced to the system recently or as part of this inspection Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site. Were the septic tank manholes uncovered opened;and the interior of the tank inspected for the condition of thelia$Ies.or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum 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: Yes xisting 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 I5.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART-C - - _ �f SYSTEM INFORMA'T/ION Property Address: ( (� a G v`?a`1 ��/ Owner. Date of Inspection: ® 0 OW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 Cl�(R 15.203(for example: 110 gpd x#of bedrooms): q qv Number of current residents: (J Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system es or no),A�[if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no): 14 400 Water meter readings,if available(last 2 years usage(gpd)): (A,-e Sump pump(yes or no): /-4 n Last date of occupancy: L� l0 G C.,t /{PS i C'o h Sat C�j C�i ox ✓�o�'�' COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/scAetc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspecti (yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: OF SYSTEM h 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/Alterative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all compoIG I 3te i talled(if known)and source of id u Were sewage odors detected when arriving at the site(yes or no):�(/� Page 7 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM __----- - ------ - PARTC__. __. SYSTEM/ INFORMATION(continued) Property Address: 9ZI 160ac4v"4c"n I— �J� �h 1e � Owner: //�'lC11, ✓i i Date of Inspection: S BUILDING SEWER(locate on site plan) _ Depth below grade: Materials of construction:_cast iron —A9'PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: / � Material of construction:�concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) S� Dimensions: Sludge depth: 101, Distance from top of slue to bottom of outlet tee or baffle: Les o? Scum thickness: / '" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom outlet tee or bale How were dimensions determined: o ``e 11Cg S 4ol c� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid:levels as ated to outlet invert,evince of leakage, tc.);� , /-Cn "If- ✓le r ee air i h &4 <o . A'o L--e,, 6oc GREASE TRAP:&(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or bale: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - _PART_C SYSTEM/INFORMATION(continued) Property Address: ©� N ✓�'��h L-/v �jJ �v n Owner./"� I A h I' Date of Inspection: TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(loc ate on-site plan) - Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level,: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: A/af present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_j40*),go Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage es a out of box, e Gv^� i o PUMP CHAMBERGlocate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - - - - - PART C- - - SYSTEM INFORMATION(continued) Property Address: �T 609R c 4/"ia-n Z--41 Date of Inspection: <o /S,o�? T SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type / �^' �7 e leaching pits,number. 'j' / leaching chambers,number: leaching galleries,number: C - leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): D ) 'C /N I✓r v� — ��q n G� To p'T T, rGiK l L r (4 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 constriction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PR IVY: v�pocate on site plan) Materials of constriction: Dimensions- Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - - PART C.-- - SYSTEM INFORMATION(continued) Property Address- Coei040,zC;&,1 L y Owner: ✓1 e Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the buildin A .r ul- -33 3 � i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYSTEM INFORMATION(continued) Property Address: �� l.�/DG•c V'1 eA X. 4-41 Owner: .� , ,/f .S /c� �J Date of Inspection: SITE EXAM - Slope- Surface water Check cellar Shallow wells �L Estimated depth to ground water 0 feet Please indicate(check)all methods used to determine the lugh ground water elevation: Obtained from system design plans on record-If checked,date of design plan.reviewed Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You m scribe how you established the high ground water elevati n: / 0o lei�.�io b /0 to wee. a� 7 H / O i- �, O ' lfio K t.c cam, C. . c+ s -5 1,5 A bove Sal 10 D r r.• ?:4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI i DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 74 COACHMAN LANE W. BARNSTABLE C 5D' L Name of Owner SALTER d Address of Owner: C/O CENTURY 21 COBB NOWAK 1660 CENTER PLACE CENTERVILLE MA Date of Inspection: 12/7/99 i Name of Inspector:(Please Print)JOHN GRACI p I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) ~ C Vl0 Company Name: n/a i"040" 1999 Mailing Address: n/a to Telephone Number: n/a �OEpI C? CERTIFICATION STATF:MFNT" 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection Is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evalu ion By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date: 12/8/99 The System Inspector sha submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION,RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:12/7/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass Inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:12/7/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a se ptic eptic tank and soil ( absorption system S p y (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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla_ (approximation not valid). 3) OTHER nta revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:1217/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped n1a. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a 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 I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic om ounds, ammonia nitrogen and nitrate nitrogen. 9 P X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:12/7/99 Check if the following have been done:You must indicate either"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 None of the system components have been pumped for at least two weeks and-the system has been receiving normal Flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorptiorftystem,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been een determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. I� revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:1217/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-M g.p.d./bedroom Number of bedrooms(design): 4-- Number of bedrooms(actual):4 Total DESIGN flow: 44Q Number of current residents:Q Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): N-0 If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): N-0 Last date of occupancy: n& COMMERCIALIINDUSTRIA Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NO If yes,volume pumped nLa. gallons Reason for pumping: n& TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 19ti7 Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:12/7/99 BUILDING SEWER: (Locate on site plan) Depth below grade: aLC Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n& Comments: (condition of joints,venting,evidence of leakage,etc.) n/a. SEPTIC TANK: X (locate on site plan) Depth below grade: I Material of construction:X concrete— metal_ Fiberglass _ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ n[a. Dimensions: L B'S"H 5'7"W 4'10" i Sludge depth: 1"" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:-Q Distance from top of scum to top of outlet tee or baffle:6" Distance from bottom of scum to bottom of outlet tee or baffle: 0 How dimensions were determined: MEASUREn Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE TRUCT 1RALLY SOUND, RECOMMEND PUMPING YSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n/a Dimensions: nla Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:-n& Distance from bottom of scum to bottom of outlet tee or baffle WA Date of last pumping: E& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nLa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:12/7/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n& Dimensions: n& Capacity: n[a gallons Design flow: nta gallons/day Alarm present: NO Alarm level:jV& Alarm in working order:Yes_No_: NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n& DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n& PUMP CHAMBER: NO (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: i (note condition of pump chamber,-condition of pumps and appurtenances.etc.) n& revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:1217/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: ji& leaching galleries,number: ,a& leaching trenches,number,length: nLa leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n& Name of Technology: -n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND F NTIONIN EMPERLY-THE PIT WAS MPTY AT IHE TIME OF THE IN PFcjION Ton nFFp TO SEE HOW F -- CESSPOOLS: _ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: nLa Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indic3tion of groundwater: n& inflow(cesspool must be pumped as part of inspection)nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n[a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 Page 9 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date of Inspection:12/7/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a Aq jjq o AB 318 O PA 191. C,k- 33 revised 9/2/98 Page 10 of 11 f A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 COACHMAN LANE W.BARNSTABLE Owner: SALTER Date:of Inspection:1217/99 NRCS Report name: n(a Soil Type: n(a Typical depth to groundwater: n& USGS Date website visited: n& Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Desc-ibe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 , , 1. J LOCATION SEWAGE PERMIT NO. .. LT � VILLAGE ii5E. 7 W - 'i AR- jS Ab9v j INSTA LLER'S t NAME ADDRESS %D N B U I L D E R OR OWNER ' I DATE PERMIT ISSUED 3 ��� DATE COMPLIANCE ISSUED 1 f�0 T J 19 I 3Z s r FE: No......................... B THE COMMONWEALTH OF MASSACHUSETTS- BOARP-,,OF HEALTH ................0 F. -------_---------------- Appliration for DhipvS" '8"rkii Tomitr 1h urtion rutit Application is hereby made for a Permit to Cons ruct or Repair an Individual Sewage Disposal System at: .....0,QQLh.Tr)L0_n ...�._qLbL...................k . ................................................................. Loc' tire -Adde 1 0, .fr .... ........ ............... ...... ....... Address T. . ....... ------------------------*--------- ------- . ......... .................. Installer AddX_en Type of Building Size Lot...Yd.0.V,.0,._.2t:Sq. feet Dwelling—No. of Bedrooms...........S--­-----­---­-----­---Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Other fixtures ............................................................................................ , ----------------------------- Design Flow��. a......11C).........gallons per person per day. Total daily flow.._......: .... ............gallons. 9 Septic Tank—Liquid*capacity............gallons Length.B.L.G.-.. Width-_'%.'1Q.-. Diameter.A.2....... Depth...-5:....... Disposal Trench—No..................... Width............._._.... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet..............._._.. Total leaching area..................sq. f t. Z Other Distribution box N) Dosing tank ( ) Percolation Test Results Performed by.................................. --------------15-;;----------­­- Date........................................ Test Pit No. ....minutes perinch Depth of Test - ... . ...... Depth to ground water...................... p14 Test Pit No. 2................minutes per inch Depth of Test ........ Depth to ground water...................._... .......... P4 ................................i............5;�.... ..............bzF� t--- --------------­­ ............... 0 Description of Soil ___c� ........ T,_4 4 _Y1... ... ...... ...... ................................................... ----I------------------- I. ..... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ......................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT Li, 5 of the State Sanitary Code—The undersigns urther agrees not to place/thh/es/stem in operation until a Certificate of Compliance has pbessu 1by t oraf health. 0, �i gg ine d. G/ -&t .. ......................... ...... . ... ............. ;r lat Iva FIX'1 4 Application Approved By, .... .......................................................... ....... ............ Date Application Disapproved for the following reasons:.............................................................................................................. ...................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date • 1� kk • i �— q THE COMMONWEALTH OF MASSACHUSETTS I BOARD.OF HEALTH c ��...._? OF...:... .....6 �.1: _ -.. o. ........................ Appliration for Uiipnstt arks Tnnitrurtiun rami# Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: ... � Locat.i•on-Add or ess j ................ .•-.•---.- -•--.--•---.-_-•.-••_------ .Lot No. • C Y ! �_1 �.. �l t C�ic�/� . .-------------............--......... ......... W per Address ............................. ...._.....�...... •-•-•- ....._......................._ ....--•---------......•.................--- Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......... •---------------_--------•Expansion Attic ( -) Garbage Grinder (—) 'PL44 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures -------------------------------- . . W Design Flow.. � ...... .........gallons per person per day. Total daily flow........:.:.0..................gallons. WSeptic Tank—Liquid*capacity............gallons Length.R..G. .. Width4_'10.".. Diameter_1Z. ..... Depth_.-L{ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No.......... .......... Diameter.................... Depth below inlet.................... Total leaching area...........0......sq. ft. Z Other Distribution box ) Dosing tank ( ) Percolation Test Results Performed by..........................................� ��_._ a --------------- Date........................................ Pit No. 1'C."` .___minutes per inch Depth of Test Pi .Z_. .." Depth to ground water________________________ Test Pit No. 2................minutes per inch Depth of Test fit.__.........._.._... Depth to ground water........................ O Description of .... c f.h��r,o l ��: mac=1 ---A- i k. =----- V41---------- --------•---•--•........._. .... 1 W --------------- ----------------------•-----•-••-----------------•---------------------•---•••••--•---------------------•-----•-----------•--••-•-••••-----•••---•-•------•-----•-------•---•--•------ UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with tze provisions of TITLij 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the board of health. igned------.•........................•--•------•-•-••-•---••................._•---......_ • ...... ---------- Application Approved By... ......_.__ Date Application Disapproved for the following reasons---- -----------------------••---------------------------------•----------------------------------••--••-.------ ......-•---•--•-•-•••------•--•••----------•------•-------•-•---•------------•-•---•-•----•------•--•---•--••-••--•--•--------•--•-------•-•-•--•••-•----------•--•--•--•-----•----•--------•--•-------- .�,�---. •.-•""� �.q Date Permit No........`+ .....----- Ccr•�.(_ ."�._.. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS �•__,,._ BOARD OF HEALTH �. _...q............OF.......... . ... ...► ............... Trrtifiratr of Trrntpliatta T I I T CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY -•--•-•..................•----.....-- •-............-•------------•......_....--•---...••---•-•------••---••-•-•-•--•--•...•-•-----.........---•------...-•---- ( Installer , at................I�:c`-------------"- -�+...... 014a�, .................fin s= ............. Eas been installed in accordance with the provisions of TITLE 5 of The State Sanitary C de s dqs ibed in the application for Disposal Works Construction Permit No7 `a ®_._._ �. dated__.. tl/G/_ ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE SYSTEM WILL F NCT ON SATISFACTORY. J� � DATE.....-_.. ............. ..................................... Inspector....._ ..........-----...-----•----------•--------------•-------•- r _ 41? THE COMMONWEALTH OF MASSACHUSETTS �(�( BOARD OF HEALTH �•�- Y �`1..........O F......:..... ���1 �'�r No......--••--.... . FEZ DispR 1 nrk %nnira ifrn "permit Permission is hereby granted.................�..... ................---.........-•---------....-•----------------•---••---.....................................--- to Constru ( or $epair_( an Individual ewage isposal System at No.- .��`_..............---=?... �._.... .... ------------------------•----------------•...................... ........... Street as shown on the application for Disposal Works Construction Permit .- Dated........ -0 �.. 4..... t -• ................... Boar o Health DATE. . 3 �-•---------•---•--•---•-------•-------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 20 FT. MIN. ---- TOP OF FOUND. _ EL. 10 FT MIN. CONCRETE COVERS 4" SCH. 40 PVC j CLEAN SAND PIPE- MIN. PITCH tJf 4= 1-- 1/8" PER FT. COVERETE .: 2" LAYER OF 4" CAST IRON PIPE - MIN. P17C1' 12 MAX. 1/8 1/2 WASHED 1/4"" PER FT STONE FLOW LINE ` :, F=`LFj_: j 10 EL = I , LMIN. EL.= I `. EL. r' I • EL.= EL s DI ST Lu } LOCATION MAP BOX �� ' 7 I 3/4"- 11/2 P � o WASHED STONE �, p`fl 2 " W G ° v0. _ GAL. PRECAST LEACHING �� ° - El j BASIN OF. EQUIV. \�— _ SEPT I C 1 6,0' TANK BOTTOM OE IF- EL. ` 'f .B PROFILE OF GROUND WATER TABLE( / / ) EL. = 4��,� �-�- SEWAGE - DISPOSAL SYSTEM NOT TO SCALE 77 I �`� t � DESIGN CALCULATIONS SOIL TEST NUMBER OF BEDROOMS .. , .. DATE OF SOIL TEST GARBAGE DISPOSAL UNIT., WITNESSED BY 4. 1 TOTAL ESTIMATED FLOW III GAL x � �' PERCOLATION RATE__, MIN./INCH {J BR. ). . GAL/DAY t REQUIRED SEPTIC TANK CAPACITY.. . . .. r OBSERVATION HOLE I OBSERVATION HOLE 2 ACTUAL SIZE OF SEPTIC TANK..... . .... . . ... . IJC�U GAL r ELEVATION = I24 ,-ELEVATION = LEACHING AREA REQUIREMENTS t24 f I - ,r/ SIDEWALL AREA. _ �' GAL./S.F. "3ct3r. / TO cl< min BOTTOM AREA _/ �? GAL./S.F. F( = I2t.8 .i LEACHING CAPACITY ( BOTTOM + SIDEWALL) . 44 Z' GAL. I u} t r' rXit�Fssdl �� al T RESERVE' LEACHING CAPACITY ............... ... ... GAL. . NOTES \t 1, ALL WORKMANSHIP AND MATERIALS SHALL 4 CONFORM .. TO D.E.Q..E. TITLE 5 AND THE TOWN OF � r - RULES AND REGULATIONS FOR SUBSURFACE DISPOSAL / F C'C`+ m Y OF SANITARY SE WAGE W 2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO . WITHIN 12 OF FINISHED GRADE. 3. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY 12 t: MIN. FRONT SETBACK G 1 t THE SAME. MIN. REAR SETBACK 4. NO DETERMINATION HAS BEEN MADE BY THIS OFFICE AS TO MIN. SIDE SETBACK _' ,• COMPLIANCE WITH TOWN ZONING REGULATIONS. OWNER/APPLICANT APPROVED : BOARD OF HEALTH I IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. , �y, _ DATE AGENT PROJECT LOCATION I-- r . A �Z4 APPLICANT i J + SCALE: DR. BY - DATE ' J , LEGEND EXISTING SPOT ELEVATIONS 00 0 �ZN ra ' � 's x � ," f tt JOB NO' APPD. BY REV EXISTING CONTOUR - -- - - - 00 - - - - - p \ R C,:� E��. 1=F\ El r taw I _ RIC ARp ! JA ,ES FINAL SPOT, ELEVATIONS 00.0 "{ i EARN J. D�HE�4R/V INC DRAWING 1 FINAL CONTOUR 00 `� C)'{� r^`, 9 r� o. a9at �i SOIL TEST LOCATION ® " ' � zl6 � `� `` } vP �,c t REG. LAND SURVEYORS- REG. SANITAR/ANS N O SITE PLAN � ��=s�r�� SR^1I A??��, 35 ROUTE I34 — UNIT 2 -- SOUTH OENNI S , MA SS. 0 F e ��OTF ALL COVERS TO SANITARY N 6 FIRST FL EL UNITS SHALL BE BROUGHT 4' SCH 4D PVC S�� = 129.72 1O FT. MIN. TO WITHIN 6 INCHES OF 118 1 8 - MIN PITCH 1/8" PER FOOT EXIST. FINISH GRADE ;J N �- TOP OF FOUND CULTEC EL= 128.72 CONCRETE 4" SCH 40 PVC APPROX. COVER PIPE - MIN PITCH RECHARGER 330 W FIRST 2' TO J/8" PER FOOT CLEAN SAND 2 LOGUS�, P. SLAB EL = BE LEVEL Ad/N. 2X 7 MAX EL = 118.6 121.68 - EXIST GRADE MIN EL = 116.6 �8 1/2 DOUBLE v �2" LAYER Of ��t� WASHED STONE N cow o O FLOW LINE M N EL= 11 EXIST. v 10" MIN. — EL = 115.6 7 a — _ W EL-1 15-1 o-Q, EL 1 15.1 a z m RACE LANE 9 4" CAST IRON OR �., it It - 1 a ; v o EL = 1 13.1- EL = 1 13. OUTLET TEE EQUAL ) PIPE - MIN. W LIQUID DEPTH TEE DEPTH PITCH 1/4" PER FT. 3/4" TO 1 1/2" 0 j /) r �j/) T BELOW FLOW LINE DIST DOUBLE WASHED 4 FT MIN (_/ A, -�1 O/ ff,4 4 FT 14 INCHES STONE ( <4 M/N/IN) 5 FT 19 INCHES >000 CAL- EXIST BOX 10 FT x 40 FT A 2 FT DEEP 6 FT. 24 INCHES S'E'P7'IC 7 FT. 29 INCHES TAN11' 8 FT. 34 INCHES BOTTOM OF TEST HOLE OR OBSERVE) WATER TABLE EL = 109.1 PROFILE OF AD.JUSTEO GROUND WATER TABLE ( / / ) EL = 1 DEEP OBSERVA TION HOLE LOG DATE OF TEST 11412010,3 SEXACE DISPOSAL SI'lyrl�l w NOTE: ALL UNSUITABLE MATERIAL TO BE REM 0VED WITNESSED BY NIA NOT TO SC.4LL UNDER AND FOR 5 ' AROUND TOO THE "C PERFORMED BY R. W. WILCOX LAYER. h 50' DEPTH FROM SOIL SOIL SOIL SOIL j _ yV!DE ti 12 ELEV. E�S� SURFACE HORIZON TEXTURE COLOR MOTTLING OTHER EASEMENT I UTILITY �2 120.12 p 2 0" - 34" f7LL NONE EL�ATIONS NEE 1 117.3 i , 34'' - 41' A LOAM SAND 10YR411 ROOTS VENTED IF 116.7 SS TEM TO E LO13EEp 41" - 57' B LQAM SAND lOYR6/4 ROOTS I NOTE: B 115.4 .5 7" - 132" C MED/FINE 2.5Y812 i 74 109.1 SAND PERCOLATION TEST DATE: 11120103 DEPTH OF PERC. 58"�__,____ TIME: -__ 1:00 RATE MIN PER INCH< 4 11ME FOR DROP FROM 9" TO 6" = 10 MIN 43 ECONDS DESIGN CALMLAT10,1VS ` ; OLD T. W. J� NUMBER OF BEDROOMS .................................... 1� GARBAGE DISPOSAL UNIT NO fl, � TOTAL ESTIMATED FLOW �y � 2� ( I 10 GAL/RR./DAY x 4 BR. ) ...... 440 GAL.%DAY REQUIRED SEPTIC TANK CAPACITY. L. ................... 880 GA �' ACTUAL SIZE OF SEPTIC TANK......................... 1000 GAL. S.T. & / EFFLUENT LOADING RATE 0.74 GAL/SF - PERK /y // LEACHING AREA PROVIDED r _ -- - - ----- .- _ �- _ o\ SIDEWALL + BOTTOM --- ` a _ o\'/ 10 FT x 40 FT + 10' + 4O' x Z'x 2 FRO / - ' - o E...............I ...................... soo S.F. M y LEACHING CAPACITY (SIDEWALL + BOTTOM) .. 444 GAL 50 F WEE � 1`r� � o�P�\� � ( 400 + 200 ) x 0.74 � RESERVE LEACHING CAPACITY...................... N/A GAL EXIST �,�`L ,�,2`� PR0� � NOTES: 1, ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 EXIST. 1000 GAL AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS FOR THE .SUBSURFACE m DISPOSAL OF SEWAGE. � 4 SEPTIC TANK 2, ALL COVERS TO .SANITARY UNITS SHALL 8E BROUGHT TO WITHIN 6 INCHES �,� \ 2�6D j OF FINISH GRADE (J) 3. EXISTING AND FINAL GRADES SHALL REMAINS ESSENTIALLY THE SAME, EXCEPT AS INDICATED 4. NO DETERMINATION HAS BEEN MADE BY THIS OFFICE AS TO COMPLIANCE WITH TOWN ZONING REGULATIONS. OWNER f APPLICANT SHALL. OBTAIN SUCH a DETERMINATION FROM THE APPROPRIATE AUTHORITY, O �; - 5. THIS PLAN IS VALID IF IT IS STAMPED .AND SIGNED IN RED. THIS OFFICE ASSUMES NO RESPONSIBILITY FOR INFORMATION CONTAINED ON COPIES ^' sv� �' Ll � _ WHICH DO NOT HAVE ORIGINAL STAMPS AND SIGNATURES. 00 6. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF vf- WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 / DRIVE FEET OF DRIVES OR PARKING'. H-20 LOADING SHALL BE USED UNDER OR / PAVED WITHIN 10 FEET OF DRIVES OR PARKING AREAS. 7. CONTRACTOR IS RESPONSIBLE FOR, VERIFICATION OF ALL LOCATIONS AND f ELEVATIONS, INCLUDING EXISTING UTILITIES, PRIOR TO CONSTRUCTION IF ANY DISCREPANCIES ARE FOUND, THIS OFFICE SHALL BE NOTIFIED 60 t IMMEDIATEL K 8. ALL UNSUITABLE MATERIAL SHALL BE REMOVED UNDER AND FOR 5 FT AROUND LEACHING FACILITY AND BE REPLACED WITH CLEAN GRANULAR SAND PER SECTION 1.5-255(3) OF THE STATE ENVIRONMENTAL CODE, T7 L' P,I T T 7 iI TITLE 5. IJ.L: T, 11, LAi 9. EXISTING SANITARY FACILITY SHALL BE PUMPED AND ABANDONED TO THE SATISFACTION OF THE LOCAL BOARD OF HEALTH. o a� H . �o ► a� LOCATION- 74 CoACH fAAT ZA V J REGISTERED SANITARIAN �/L�' �� y 7AME9 - -PROFESSIONAL _ ti. �1 . 1 1 f j�I �� �HAI� ,1 aHE; i V�5'TA 81,E, ^ fA, LAND SURVEYOR ,,I �u A Irvr O'HEARN Via. �?87" I t T � 1 1 --------- z35 ROUTE 134, F 0. BOX 237 �� ®� � `` '" _ � -.�.��x��t-T°7- � �B `'� �` t ��'�� ASSESSORS MAP 15ti� PARCEL 43 SWAN RIVER PLAZA, UNIT 2 1 . L. S. I�� : _ _--- - So UTH DENNIS, ILEA. 02660 a ___—..__ �_ FLOOD ZONE___G"_ELEVA710N� MAP DAT'�'_ ?f02,��9,� _ { Y .... L_. ,4 1` 7 c � r%4 3 Wf a_L c� r ?-.4 '�� EXIST. \ WELL LOT 4 r. ? Q o d. S,T. z 'w 1150 i LTr , \ \ �, 4 1' 4 25 \ -z �i 19fl < 126.E H 124.8 -- I i . ov � / 123.422 123.5 xo 124.9 \ w_ 118.2 121.3 w a � E i 30.9 1. f j C1,10A IV I 1 ' Lai f t I + LOT 21 LOT 19 LOT 20 LOT 18 o 1 0 , I . Q) 1 ; EXIST. I WELL WELL WELL I i 1 I I 1 i 1 ' 1 ' NOTE: WELLS TAKEN FROM TOWN RECORDS AND — - - -- REV- JAN. 13, 2004 - MISC. CHANGES FIELD LOCATIONS. � NO 102803>? 1JATF )Cl-- - �, ! r TOWN OF BA RNS TABL E CLIENT MARINI ; r ;, 4c FT OR BY: R. 0'H. SHEET 1 OF REGISTERED SANITARIAN A,p D �z ARD EA N ,�� oa��� EJ.A RN y F, LOCATION. �. J: 0 ��e a r PROFESSIONAL RiCHf��R 74 CDfI CHAN LAND' LAND SURVEYOR DAT A CPA rT rvw 35 ROUTE 134, P. O. BOX 237 ROAM �a 27871 aQ SWAN RIVER PLAZA, UNIT 2 R. T, C C co��r�nrTs , Is , q 1sTJ`` 3 ASSESSORS MAP 152 PARCEL 43 . >J. �J . s '< E. 7 OZ 9z SOUTH DENNIS, MA. 02660 `" v__ FLOOD ZONE.�_ELEVATION LEAP DAT