Loading...
HomeMy WebLinkAbout0025 DERBY DRIVE - Health a 25 Derby Dr_we West Barnstable 75 021 � r 1 fI : a. e, - i : k ; „ r. l i ..u,:d�,leb... ...erwt...ka._.fA_..�a.l»'nx.�..�.y..:1..,.1,.w�L..w.�.��<o!5_a.�.^::.e..is;L...:�?r_..�a,:.....e4d:,.:.3..:3„a..tt,�L�i* .�sra.4(. �_�,..,r�:..-a4'�,ikia�;a'.:i�Yutst:.:r.d.4:_�: +�<>.rtiiii.�dx'$i...s._r�:�._......J..,��_�:[s.�pi•, 1.ri._�.0 r_.�s��.�:..._41a.,..r::- .....-sue.Sb..;�...., — _ .._.. .','3 TOWN OF BARNSTABLE LOCATION ZS iJcrS&A Dr. SEWAGE# 7021 - 239 VILLAGE t.) Jacnsln S1c. ASSESSOR'S MAP&PARCEL J75- OZ 1 INSTALLER'S NAME&PHONE NO. R k,9 Excqtvo_-1i o^ y77. OGS3 SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) y5000o,I (size) 13 x 25 X Z. NO.OF BEDROOMS 3 OWNER a orrN PERMIT DATE: G- ZN- Z I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY f rr II Al- 72. 1 3t- �$ , 0 AZ� Zv),y r, 3 g2. 31rlor` O O A3- REAR t333- ZS 6 oa No. zo?, — 1)51 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftphration for MispoBal *pstrm Construction permit App ication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.1 S Nr b4 Qr tV e. W. ()oX Mkul& Owner's Name,Address,and Tel.No. $}aQ�tke Assessor's Map/Parcel %'}$ ' O-L l 2 S QR c b 064 e W. Y,�, ►c nSi a kkv Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. PA"e Spn �nt. 1A 'Q•o, %10 SandW",U%, Soil• 4 0653 PO %a. qa1 `C, `Jwndwit,l, 5,01E . 3(01• 2g2z Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(No) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 30 gpd Design flow provided gpd Plan Date 0'.1 A j %$ Number of sheets Z Revision Date Title Size of Septic Tank t 00 2Y.st eig Type of S.A.S. (-0 500 CV AM'.K1 Description of Soil '5t4, plans Nature of Repairs or Alterations(Answer when applicable) 6makic and reptaee. k-eOLdKinQ ir\ SaMQ. \oCo•A 1 or` Q S6% Q_v;%;a plans jxr Cover 6k ,on W1 60 K aafmt 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 He S1 ed Date6,111.17.1 Application Approved by �/ Date 67 ey iopm-, Application Disapproved b Op- Date for the following reasons Permit No. 7�'Z — G-��� Date Issued I `� .Y:� � 4 " � F(r��r nn r.r.._ -1.-.. .M+.+✓.-0.L.iw.^`._.k.m� y No. /,. (� ! Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -;;, .,_ » ■ Yes :� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS r � .� 'Application for bisposal *pstrm Construction i9ermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.15 �)c,v G W. \mac w 1c,4 Owner's Name,Address,and Tel.No. Asses`sor'sMap/Parcel 021 2�� �,uc �� Qt "�c Lam, 1'�At il�,An.L ;� Installer's Name,Address,and Tel.No. hj C"'I f Cale ,;;, n Designer's Name,Address,and Tel.No. NW9.e j(,, �j'iV 11,cu�c 130fK�cs,c. c6 pe> ( o. Ci2 oq I)rpe of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder a) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3`12 gpd Plan Date 1 A I `� Number of sheets Revision Date 0 Title Size of Septic Tank 000 %ca Cy,Sk r TypeofS.A.S. (Z) Sego me lc,r Description of Soil ')g e 1 Nature of Repairs or Alterations(Answer when applicable) �Q MO,,c f e fDl r(rs, `ZCc*-1 Q:,") QV_ "k, n C3� Curycj((' %�n rrN W1 e-)o nr,cr+,4 u r J Date last inspected: r s - -Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 3 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 Heal ° t S'gned \'k6rk�s _ �� Date l'o b 2. .r+t. Application Approved by1���/� -—._ Date Application Disapproved by.0- V� Date for the following reasons Permit No. ®7 I 1.3 9 Date Issued �7 t( t p 2.1 ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired()C) Upgraded( ) Abandoned( )by �3 �C.� C o va'1 r flc at c 4��� �t v "has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.*7()/r- }'�dated /zy/fn 2 p Installer �, �, 4_xtr.,,n{'.c�;• 1nc. Designer , #bedrooms 3 Approved design flow gpd The issuance of this permits al'l not be construed as a guarantee that the system wil functi as de`sig�(n d}. Date / ! Inspector t - -1 1 --•-- --- � __- - : ��7 � _. --- -------• -- - -• - - - No Feen 7 � p THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Die-posal &pstrm Construction permit Permission is hereby granted to Construct( ) Repair(X ) Upgrade( ) Abandon( ) System located atQ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions orspecial conditions. Provided:Construction must be completed within three years of the date of this permit!' '. Date //0/;7,Ll N Approved b _ f Town of Barnstable ' i. Inspectional Services i Public Health. Division Thomas McKean,Director ho °' 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Certification Form Installer& Des><ancr, l)atec 'i: Sewage Permit# Assessor's Map\Parcel I�5 Installer: Address: n4 Address: 9 On �ww�' was issued a permit to install a (date) (installer) septic system at Z 5 ,,",.4'_ based on a design drawn by ��(addds ss) U Ltd dated (designer) certify that the.septic system referenced.above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or sept' tank. Strip out (if required was inspected and the soils were foso d�satisfacto C) swoop we Q� J r P744AV c G AT n r4 �L . I certify that the septic system re of Fenced abov as installed wit major changes l.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the:septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was construct ee with the to rms of the I\A approval letters (if applicable) D AVID �=--. MASON r, (Install' 's:Signature) No.1066 n �� CV1TAQ (Design >g ature) (Affix Dcsig f s Stamp Here) PLEASE.RETURN TO BARNSTABLE.PUBLIC.HEALTH DIVISION. CERTIFICATE OF.COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. WoAdeptAHEALTMSEWER connecOSEPTIODesigner Certification Form Rev 8-1413.DOC t TOWN OF BARNSTABLE LOCATION.Q I T SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL I�1 Oa INSTALLER'S\ AME&PHONE NO. t� SEPTIC TANK CAPACITY 6 0 00 607 LEACHING FACILITY: (type) _ksize) NO.OF BEDROOM OWNER -e 0 PERMIT DATE: I©._ 9-�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /(/O 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) �a Feet FURNISHED BY 4 , 6-L1=570t 5 C 6 . - 3015 �5QJ f3_3 Q®9=31k 5 No. .v✓ _ J ( Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for ;Disposal 6pstru ConstCULtion permit Application for a Permit to Construct( ) Repair( grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /, �?r �'�) D�t Owner's Name,Address,and Tel.No. Assessor's Map/Parcel/ 2 ; t ^ + o,, N C? Installer's Name,Address,and Tel.No. aa Designer's Name,Address,and Tel.No. 1Ype of B�'ding: . Dwelling No.of Bedrooms 3 Lot Size , sq.ft. Garbage Grinder( ) Other Type of Building �C�.S' /—/aj _No.of Persons Showers( 1/) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 6eP f k5gpd Plan Date �� 2 C Number of sheets — Revision Date Title Size of Septic Tank ` A< Type of S.A.S. Description of Soil 7 Nature of Repairs for Alterations(Answer when applicable) cc Y n�, c5 ^ v + Date last inspected: sC C)h,-� `✓6,t„� Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in aczordance 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 He Signed Date Application Approved by Date Application Disapproved by Date for the.following reasons Permit No. Date Issued �� - • No. / / t ; Fee Entered in computer: THE°.COMMONWEALTH'OF M�► SACHUSETTS ',.... 0' �,.. , . ,I Yes PUBLIC HEALTH DIVISION - TOWN O BARNSTABLE, MASSACHUSETTS ftplifatlon for Misposaf ORIONConstruction 3perinit Application for a Permit to Construct( ) Repair(�pgrade(&) Abandon( ) [:]Complete System El Individual Components Location Address or Lot No. a Q Y 4' ��yy Owner's Name,Address,and Tel.No. Assessor's Map/Parcel/25 �"" '-- aZ, -.�.. jAJ Installer's Name,Address,and Tel.No. �/ rr _ Designer's Name,Address,and Tel.No. r ,���". �',c< •} � r i t(1 � SG U ��13a A 1�V q �>a .� :`�,� c�� t M� � . �,z. .. s��t:"++� !�'� Type of Building: Dwelling No.of Bedrooms ...">, Lot Size / A r) sq.ft. Garbage Grinder( ) Other Type of Building f7.Q No.of Persons Showers(;n Cafeteria( ) Other Fixtures Design Flow(min.required) s"I '�y��� gpd Design flow provided '240/-1 (a { � ,t �, i��,�j��,5gpd Plan Date . ? i T) Number of sheets ? vision Date ` Title X Size of Septic Tank�/ S , / -�_ kf r Ty e of S.A.S. (/- �CJC) Y V �� a Description of Soil _ e^ I , -A ) (! t'rA /1 �f �" -✓'r i EA L10- f Nature of Repairs or Alterations(Answer when applicable) ,• r^ 1 <1 } Date last inspected:. , P ,fit, � r Agreement:" y 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 Realf. t ` c — ( Signed Date t o" / Application Approved by r ( R Date / V-Gj -! Application Disapproved by V Date for the following reasonsen 1.` �,. Permit No. ..- Date Issued !O / "r v --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS 4� Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded(V)-' Abandoned( )by at ! " i, k t Lk as been constructed.in accordance ci v - v with the provisions of Title and the for Disposal System Construction Permit No. dated Installer ry�� lo,f V%/() Designer a �/ { ' � - 5�t7�h/ r #bedrooms / J�� Approved design flow �, Q gpd The issuance of this permits all not be construed as a guarantee that the system will functio( design d. Date f' -�- _ a l) Jc� Inspector C - - - --- --- - --------- ---- + ------ - - No - - _ 26�87� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Misposal *psteut Construction Vermit Permission is hereby granted to Construct( ) Repair( 1)` Upgrade( J) Abandon( ) System located at r,) _a and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be compjeted within three years of the date of this permit. ---- t Date Q Approved by ,c rom: 10/24/2018 16:14 #879 P.001/001 Town of Barnstable Regulatory Services Richard V. Scali, Interim Director NAM. Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer &Designer Certification Form Date: D ILt dq Sewage Permit# Assessor's Map\Parcel ! 7 ��� Designer: Installer: r4yma p n4 l-I/ -�Q Address: Po ' Address: U/3-1 'R=b MA On (date) (installer) was issued a permit to install a septic system at 2 D ea f-* ix . based on a design drawn by (ad ress) ��1�r`i2-✓\ M&\A'f­1 dated (designer) iffithatMeseptic C f4 �'I system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approval letters (if applicable) DARR,EN n e ns e s Signature) 1 4 �Igo. 1140 F (Designer's Signature) (Affix ere) PLEASE RETURN TO B STABLE PUBLIC HEALTH DNWON. ERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc Commonwealth of Massachusetts 9-3 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p 25 Derby Drive "fi�� f Property Address Patricia Stapleton ; Owner Owner's Name information is West Barnstable Ma 02668 6-12-15 ; required for every r. page. City/Town State Zip Code Date of Inspection , Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to.move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation Q Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -A'6 /1 6-12-15 Insp Si ature 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. �/ ZVy9a Vs t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owrer Owner's Name information is West Barnstable Ma 02668 6-12-15 required for every _ page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a.Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 I / Commonwealth of Massachusetts Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: El Cesspool is within 50 feet of a surface water Pool or privy Y ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts IlaTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is West Barnstable Ma 02668 6-12-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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 r more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. 0 ® 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 Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection El 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•3,13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 r t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® 'No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2013- 188,000gallons 2014- 157,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow.Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 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•3/13 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 25 Derby Drive Property Address Patricia Stapleton Owne- Owner's Name information is West Barnstable Ma 02668 6-12-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date linstalled (if known) and source of information: 2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1'6" 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.): At time of inspection building sewer appeared to be in good working order with no sign of leakage. Septic Tank (locate on site plan): 2'4" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is imetal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 4" t5ins•N13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M ,•''p 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 3 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 14" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order, tees present with no sign of back- up.Liquid level equal with outlet invert. Tank is not in need of pumping at this time but should be pumped every 2 years for maintenance. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank(tank i f Tight or Holding a k(ta must be pumped at time o Inspection) (locate on site plan): Depth below grade: P 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 l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): r 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.): At time of inspection d-box appears to be in working order with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 16 infiltrators(23.48'x11.52') ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Infiltrators were dry at time of inspection with no high staining. 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 3/13 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 ' M 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1 t5ins-3/13 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 �. 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: Z. hand-sketch in the area below ❑ drawing attached separately �33- �alait icy— 51' 5- 14 65- 39f q'' 5 4 3 A BAR t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 r Commonwealth of Massachusetts ARM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. Cityrrown I 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: No Gw 144" 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: 5-15-12 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: Plan on file at BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Derby Drive Property Address Patricia Stapleton Owner Owner's Name information is required for every West Barnstable Ma 02668 6-12-15 page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION '�$ 0cr3L4 _DriuC SEWAGE# 201 VILLAGE ►�$ - O a 1 (,,]• -�ar��-Ict�lc ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 3 ;, C3 EXCaVa-I O/� y77-QLs SEPTIC TANK CAPACITY /000 9ct LEACHING FACILITY:(type) ADSA31, e/G) (size) NO.OF BEDROOMS OWNER �<xi n c i a- S-iaOlt-Aon PERMIT DATE: O-i a. COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist.on site or within 200,feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Ai- 274 Az- 30 ' BZ- A3' 3 z '53- z I O O A+ 13y- y9' A a RcaLc- f No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: • Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Disposal *pstrm Construttion Permit Application for a Permit to Construct( ) Repair(wj/Upgf'ade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 25 �(�y d <<u Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ' A 02 ?h+rl u-a- 5v n ple fOn Installer's Name,Address,and Tel.No. Des gner's Name,Address,and Tel.No. 3-t'f3 �Xr�r .+can 5os��I��-b�53 6y.e ,46o n S� 5og -3�z—�922 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures TT Design Flow(min.re uired) 33 V gpd Design flow provided gpd Plan Date .5 �. Number of sheets 2, Revision Date Title 5 I Ct.r^ Size of Septic Tank 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 o ealth. d Date � � I�•ql Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. Fee _40 THE COMMONWEALTH OF MASSACHUSETTS Entered inccmpater: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ; Zipplication for BisposA.L'Opsteilt Construction i3ermit Application for a Permit to Construct( ) Repair Up Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 2 5 `� �. y 1�� � 'O"'(w�ner's Name,Address,and Tel.No. � j� Gj 1 Assessor's Map/Parcel Ci 1 IS PCB r e f- j (� r '� C 1 C E Q i I(' on / Installer's Name,Address,and Tel.No. irDesigner's Name,,Address,and Tel.No. ��5; y j�` � n 92�. Type of Building: _v Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) rOther Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �_ gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title -- «. -r 7 ``t Size of Septic Tank Type of S.A.S. Description of Soil r 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. r---Signed __( - .a C� ��, Date Application Approved by _ Date Application Disapproved by Date for the following reasons Permit No. �/�, _ A Date Issued-z a/ ��- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Vj Upgraded( ) Abandoned( )by► k +-� i �,� �`} 1 / ,t 1 at h,` has been constructed in accordance with the provisions of Title 5 and�the for�Disposal System Construction Permit N�/ Q dated�/ Installer D/1 J p�� } / , Designer ,) l� #bedrooms a J ✓ Approved design flow gpd The issuance of this permit shaZot be co strued as a guarantee that the system will c' =desid. Date ,� Inspector --------------------------------------------------------------------------------------------------------------------------------------- No. � Fee,. U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair( �� Upgrade( ) Abandon( ) System located at C)�I � �, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date 1 ///! /', Approved by I f - Town of Barnstable ,ME Regulatory Services Thomas F. Geiler, Director 3AMSTAB s LE. Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 08-362-464-: Fax: 503 90-630d Installer_& Designer Certification Form t Date: 14 )v Sewage Permits 20 19. ssessor's ivlap\Parcel tis 02� Designer: YV A. '"`L' Installer: Address: Or �'Q O :address: IL4Mc e SIN d IN(CL, �Z) �—r<S*U0A lc McL On - O-/o-IQ 04 13 EKOaue 4i OrU was issued a permit to install a (date) *-� (installer) . septic system at Z'5 VC ID12-vf based on a design drawn b,, S 14 dated (designer) XI certify that the septic system referenced above was installed substantially according to the design. which may include minor approved changes such as lateral relocation of t,!= distribution box andror septic tank. I certify that the septic system referenced above was installed with major changes (i.e. Greater than 10' lateral relocation of the SAS or an,. vertical relocation or anv component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. of Mgssq� o� D REN M. cGYlr � Y R) -a (Installer's Siv r ) p p ') STENO ` SOI TAR�I'� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BAR, STABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COti1PLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-26-04:'doc 0 f- I . I Town of Bastable P# 1� of� Department of Regulatory Services • Public Health Division Bate �nxxareBL& = I PEAM s6�9. tee$ 200 Main Street,Hyannis MA 02601 i �lfD MAT' i - 1 ate Scheduled Time Fee Pd D . 1 . `oil Suitahility Assess l lent.for rye - e Disposal Performed By: Witnessed By: i LOCATION & GENERAL INFORMATION Location Address'11�—:) b��`�y i Owner's Name 1)67;P-I0 I- & -�7 VQ � �zj[ l JVy C I Address Assessor's Map/P4rcel: 7S ?� I Engineer's Name ale�lt NEW CONSIRUtON REPAIR ~ Telephone# fe/2) 360 33 Land Used Slopes(TO) Surface Stones ° Distances from: Open Water Body > zoo ft Possible Wee Area U ft Drinking Water Well �ft i prainage Way hoa ft Property Line ft Other ft SKETCH:(Street name,dimensiods of lot,exact locations of test holes&pere tests,locate wetlands in proxitnity to holes) • I . I I _ 90 . ERS.I,OGOG FYlS. ING 100 h __ _—__ �---102 �.�-- 04. 1J ------ 1OG r ------ 108 _ TBM-eL 105.E TOP Of 5TOOP / / +105.3 1 - I +104.1 DERBY DRIVE +105.2 i . - i Parent material(gedlogic) CtS� Depth to Bedrock Depth to Groundwatdr. Standing Water in Hole:' i Weeping from Plt FACe 1 Estimated Seasonal i iigh Groundwater DETERMINATION FOR SEASONAL HICIII UVATR TALE Method Used: I In. Depth Cfbperved standing in obs.hole: In. Depth to sell mottles: tt Ateto Depth tofweeping from side of obs.hole: ! in. -pletor Adj.�rpundwnterLevel..,,,e, wnrer Adf uetment Index Well# _ Reading Date Index Well level -- _ ......_.4- I • PERCOLATION TEST . Date 'xlnse Observation I Time at 9" ------- Hole# 11 S Time at G" Depth of Pere Time(9"-0) Start Pre-soak Time-@ End Pre-soak Rate MinJlnch Additional Testing Needed(Y/N) Sire Suitability Assessment: Site Passed Site Failed: Original:.Public k;e'�Ith Division Observation Hole Data To Be Completed on Back— test is to be conducted within 100' of wetland,you must first notify the *** If percola�lon t . Barnstable Conservation Division at least one (1) week prior to beginning. DEEP OBSERVATION HOLE LOG Hole#_L- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel all-(tl A C m SGA M0 I (�t1}'► Cam- ►�.Jc:h �. ���' DEEP OBSERVATIONHOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel) -q 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 D OBSERVATION HOLE LOG Hole# r Depth from Soil Hon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consisten ravel) Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No 1 Yes Within]00 year flood boundary No Yes Depth of Naturally.Occurring Pervious Material Does at least four feet of naturally occurring per i �s p�laterial exist,in all areas observed throughout the area proposed for the soil absorption system? L 1 If not, what is the depth of naturally occurring pervious material? Certification I certify that on �C (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with the required 'ping,expertise and experience described in 3.10 CMR 15.017. Signature / Date IQ:\SEPTICIPERCFORM.DOC down cape engineering, inc. SIEVE SOILS ANALYSIS 25 DERBY DRIVE WEST BARNSTABLE, MA DATE OF REPORT: 1/4/12 .JOB : GRAIN SIZE ANALYSIS-SIEVE TEST SITE: 25 DERBY DRIVE WEST BARNSTABLE, MA LOCATION: DARREN MEYER TESTHOLE SIEVE ANALYSIS Weight Sample(Grams): 291.7 SIZE :WEIGHT RETAINED % RETAINED % PASSED ------------- ......(Sum )... --- ------------------° ._.... o- 1 0.0: ___------0 0/o�------___1 00.0/o ...................................... ----- - 0.0: 0.0%: 100.0% -------------- ..........................A---------------------L------------------ 1/2" 0.0: -------------0.0%; --------100.0% -------------•-------------.-------------•---------------------�------------------ #4 : 0.0: --_0.0%: 100:0% -------------•--••--•---••......•-- ---------- #10 18.3A 6.3%: 93.7% -------------•-.- --------------------• - #20 : 89.0: 30.5%: 69:5% #40 - 193.566.3% ------.................3 #50 254.3;-------------872%------------12:8% #80 ; 276.1a-------------94.7%: 5=3% #100 •-------------•- 282.-A------------- -- 7%`_------------ 3.3% PAN------ �-----•----•......... 286.8T--=--_------100.0%:=---_-------0.0% SAMPLE ----------:-- --------------------------- -- -- ---------------- --- ------------- NOTE:TEST ON PASSING#4 ONLY, 6.8% RETAINED ON #4 <45% O.K. RESULTS: SOIL CLASSIFIED AS AASHTO A-3 (GRANULAR, COARSE SAND) (UNCOMPACTED) PERCENTAGE OF MATERIAL PASSING#4 SIEVE : #4 100% (TEST ONLY MATERIAL PASSING#4) O #5010%-100% OK #100 0%-20% OK #200 0%-5% OK SAMPLE MEETS TITLE 5 FILL SPECIFICATION >98% SAND 0" F pfgS RESULTS: PERMEABLE MATERIAL-CLASS 1 <2 MINJIN. MATERIAL ��'``� s�o NONCOMPACTED �° DANIELA. 6- OJA.LA SOIL DESCRIPTION: Fine-Medium Sand �' CIVIL N No.46502 /S T 1//Ea Gr/c-�� "lam wind w 4 aYy�' -5061 office C-1 i i 0 =pp 0 I— r/2/R game room Loun.dry mech. Walk—in closet t 26 ' -1 ;� Commonwealth of Massachusetts � 7 ID Title 5 official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'M Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information Important: When:filling out 1. Property Information: forms on the 1 7 5 �j� computer,use 25 Derby Drive West Barnstable, MA only the tab key Property Address to move your Mary Butler-Adamo curso.--do not use the return Owner's Name key. 65 Morris Island Road Owner's Address Chatham MA 02633 �r-1\A?, City/Town State Zip Code Date of Inspection: December 10, 2006 II Date 2. Inspector: David D. Flaherty Jr., R.S. Name of Inspector Flaherty Environmental Services Company Name P.O. Box 81 Company Address Yarmouth Port MA 02675 CitylTown State Zip Code 508-362-1657 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Nee Fu er lu n the L al Approving Authority f December 14, 2006 Inspe or's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 Cityrrown State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection 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 working adequately but evidence of past overuse.Water readings from Water Co. show the Y 9 q Y P 9 design flow was exceeded in usage from 2003-2005(rental property?) System was designed well and installed well. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditi al Pass"section need to be replaced or repaired. The system, upon completion of the r lacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the r the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years d"or the septic tank(whether metal or not) is structurally unsound, exhibits substanti nfiltration or exfiltration or tank failure is imminent. System will pass inspection if the exi ng tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pas ' spection if it is structurally sound, not leaking and if a Certificate of Compliance indicating th the tank is less than 20 years old is available. ND Explain: t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 City/Town State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection 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 distri ion 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 tha 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with ap oval of the Board of Health): ❑ broken pipe(s)are replace ❑ obstruction is remove ND Explain: /eEal tion is Required by the Board of Health: xist which require further evaluation by the Board of Health in order to determine if is failing to protect public health, safety or the environment. will pass unless Board of Health determines in accordance with 310 CMR b)that the system is not functioning in a manner which will protect public health, the environment: sspool 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 t5insp:doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification Cont. 25 Derby Drive Property Address W. Barnstable MA 02668 City/Town State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Sup ter, if any) determines that the system is functioning in a manner that protec the public health, safety and environment: ❑ The system has a septic tank and soil absorption syste SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wa r supply. ❑ The system has a septic tank and SAS and th AS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply ell**. Method used to deter ne distance: "*This system passes if the ell water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provide that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 City/Town State ZipCode Butler-Adamo 12/10/06 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® 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. Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 Cityfrown State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve acility 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 followin , in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drin ' g water supply ❑ ❑ the system is within 200 feet of a tributary a surface drinking water supply ❑ ❑ the system is located in a nitrogen sen tive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II a public water supply well If you have answered"yes"to any question in Section the system is considered a significant threat, or answered"yes" in Section D above the large syst has failed. The owner or operator of any large system considered a significant threat under Sect E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. Th system owner should contact the appropriate regional office of the Department. t5insp.:doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M yv C. Checklist 25 Derby Drive Property Address W. Barnstable MA 02668 Cityrrown State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes" or"no"as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 25 Derby Drive Property Address W. Barnstable MA 02668 Cityrrown State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): '06: 294 gpd; '05: 773 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 2006 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): allons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to a Title 5 system? ❑ Yes ❑ No Water meter readings, if av 'able: Last date of occupan /use: Date Other(describe . t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form D. System Information (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 City/Town State Zip Code Butler-Adamo 12/10/06 Owners Name Date of Inspection 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 5/15/1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments o Subsurface Sewage Disposal System Form M D. System Information (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 City/Town State Zip Code Butler-Adamo 12/10/06 Owners Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >50feet Comments(on condition of joints, venting, evidence of leakage, etc.): joints tight, venting appears adequate, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gallons Sludge depth: . 3" Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 1" 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 13" How were dimensions determined? sludge judge, tape measure t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System f Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 City/Town State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend maintenance pumping at this time. Inlet and outlet tees ok, tank seems structurally sound, liquid levels appropriate, no evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ pol thylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to /inlet r affle Distance from bottom of scumlet tee or baffle Date of last pumping: Date Comments(on pumping recolet and outlet tee or baffle condition, structural integrity, liquid levels as related to outle of leakage, etc.): Tight or Holding T k(tank must be pumped at time of inspection) (locate on site plan): Depth below gr de: Material of onstruction: ❑co rete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments r` Subsurface Sewage Disposal System Form M D. System Information (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 Cdyrrown State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection Tight or Holding Tank(cunt.) Dimensions: Capacity.: r1lon Design Flow: r day Alarm present: ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(conditio alarm Zand float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): 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.): dbox level, evidence of some solids carryover, no evidence of leakage. Pump Chamber(locate o e plan): Pumps in working er: ❑ Yes ❑ No Alarms in rking order: ❑ Yes ❑ No t5insp.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form D. System Information (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 City/Town State Zip Code Butler-Adamo 12/10/06 Owners Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: (1)6'X 6'w/2' stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): soil dry, signs of previous hydraulic overloading (NOT failure), 26"of standing water at bottom with 2" of sludge, inlet pipe in riser, minimum 4'of effective leachpit remaining, +/- 13'from inlet pipe to bottom of pit, no ponding, vegetation typical (lawn) t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 Cityrrown State Zip Code Butler-Adamo 12/10/06 Owner's Name Date 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 Comments(note condition of soil, signs of hydrauliXfail , l of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System • Commonwealth ofMas"chuseft ici l t ®r ug Not for Voluntary Assmaments Subsurface Sewage Disposal System Form D. ys lrn information (coat.) 25 D�rb�s®rive — Property Address MA 02668 W. _-_-- CdyfPown state Zip Code Sutier-Adam® - CAroner s Na3r+e Date of inspection Sketch of Sewage Disposal System: Provide a s,ketch 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. i 3343 63 t5insp.doc•0812006 'Pule 5 CNriciaf Inspection Form:Subsurface Sewage Disposal System Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y` Subsurface Sewage Disposal System Form D. System Information (cont.) 25 Derby Drive Property Address W. Barnstable MA 02668 Cityrrown State Zip Code Butler-Adamo 12/10/06 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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. 10/9/85 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: no water encountered during perc test on 3/18/85, elevation of bottom of pit is 9.5' above bottom of test hole. t5insp.doc-03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Health Complaints 13-Sep-05 Time: 9/6/2005 Date: 3:42:00 AM Complaint Number: 18437 Referred To: DAVID STANTON Taken By: JOAN AGOSTINELLI Complaint Type: CHAPTER II HOUSING Article X Detail: UNSANITARY CONDITIONS Business Name: Number: 25 Street: Derby Village: WEST BARNSTABLE Assessors Map_Parcel: Complaint Description: The interior of the house is extremely unsanitary. Police were called there with a woman in physical distress. They are notifying us of the filth in the house. Actions Taken/Results: DS WENT TO SAID LOCATION. NO ONE HOME. THE YARD WAS CLEAN. GARAGE DOOR WAS LEFT OPEN, AND IT WAS CLEAN. NO ODORS WERE PRESENT ON THE OUTSIDE OF THE DWELLING. DS DID NOT GAIN ACCESS INTO THE HOUSE. THE PEOPLE DO NOT HAVE TO ALLOW US ACCESS INTO THE HOUSE. Investigation Date: 9/12/2005 Investigation Time: 1:40:00 PM 1 � Mir— -RFCFJVFo MAY231986 3624541 926 main street yarmouth mass. 02675 down cape engineering civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys site planning May 21, 1986 sewage system designs Barnstable Town Hall inspections Board of Health South Srreet Hyannis, MA 02601 permits Gentlemen: Please be advised that Down Cape Engineering inspected the septic system installation for Lebel- Sollows Realty property located on Saddler Lane, Hunter Hill, Centerville. We hereby certify that the installation complies with the intent of our site plan #85-215-63 dated October 9, 1985. Sincerely, Arne Y. Ojala, P.E. AHO/amp Inspec-ed by: Michael Mc Donough May 14, 1986 d i LOCATION 2S S I W . AGE. PERMIT N.Q. YtltAGt SO IIS top NO: tNST :A LLER'S XAME ABQRES vi e t1 l L D R OR OWN ER DATE. PERMIT SUED DATE C0MFtIARCE I-SSUED '1 � e 0 r LO CAT ION '2S SEWAGE PERMIT NO. Y I L L A C E ,�KESSORS NIAP NO: %cxor�PKEL K. I N S T A LLER'S NAME IL ADDRESS c_` - t d U 1 L D E R OR OWN ER DATE PERMIT ISSUED PAT E C0M ► LIANCE ISSUED � -� J � � Y1 ,.,r t; .t,, ��s t>. _ , �� � i �' �� �� � � Q I ^� n ,�, ,� t��,�„ � �� �. i S �I FEE THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , ...... ....OF...... ............. Application for Uis' pooal Work.5 Tomitrudion Itermit Application.is hereby.made for a Permit to Construct or Repair an Individual Sewage.Disposal System at: ................... ...................... Location-Address or�k Lot No . ..............:._... : .CI i ---------------------------------------------- ------------ nerAd VC_ ........ ...... .......... ........................ .... .............. .... ... .................... 44 .......... Installer Address Type of Building Size Sq. feet Dwelling—No. of Bedrooms................:._?S....................Expansion Attic Garbage Grinder 04 Other—Type of Building.-.......................... No. of persons......._.......-.---.------- Showers Cafeteria 91.4 Other fixtures .............................. .......i................................. ..................................................................... < -=L -_';�' Design Flow........LUZ;?.......................gallons per pepsmi-per day. Total,daily flow.............. ......................0-AlloN. Septic Tank—Liquid'capacitylOOD..gallons Length._O.tlb..... Width;!:Z�,.-4-... Diameter................ Depth.4�td.. Disposal Trench—No..................... Width....... ............ Total Length.................. ............. .... Total leaching area............. s q. ft. Seepage Pit No. .......... Diameter.......1 ..10.... Depth below inlet........(........Total leaching areaZ.&..LJO.sq. ft. Other Distribution box Dosing tank Percolation Test.Results CA-Performed by.:.Z? .. ............ Date....5. -_I g .................. Test Pit No I................minutes per inch Depth of Test Depth to ground eater.14.ok Test Pit No.. 2................minutes per inch. Depth of-Test Pit.................:..'Depth to ground water........................ .................. ------------------------------all..."I',"",..............e............................................................................. 0 Description of Soil.... 1.44.......f J7 . .... .. ................. 1�u-.0. ............ ........................................................................................................................................................................................................ UNature of Repairs or Alterations-Answer when applicable............................................................I.......................4............. ...................................... ............. Agreement: • The. undersigned-agree�s�o install the aforedescribed IndividtiAe ge Disposal System in accordance with the provisions of SITU TAU 5 of.the State Sanitary d The pild ther agrees not to place the system in operation until a Certificate of Compli cc has b u b i�e ar f ealth. igne ........ ..................................... ...... ....... ........... Application Approved By...................... . . ..... . ....... .............. ....................... ........ Date Application Disapproved for the foll i g reasons:............................................................................................................. ....................................................................................................................................................................................................... Date PermitNo.................................................... Issued..--------... ................................... Daft No, lb THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........6F..... (---e................ Np#ftrativn,Jrlhipviial N.orkg Tuniarurtion thrmit Application is hereby.made fora',Peir.7� to, Qo­nft �Q)Construct or Repair an Individual Sewage Disposal System at: LZ>r Q e7 t—A ,) trrc,Pe_- L L,L_ .... ...................... Location-Address orLo N .!E�!2L — f. ....................................... 4P., jeo of* V .... ..ne.r..... ..4 r................ ........ ............�: _. .. ............. .................................................. ............. InstallerAddress Type of Building Size Lot-_.._.. -7 5........ . feet Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder 04 Other—Type. of Building............................. No. of persons............................ Showers Cafeteria Other fixtures ..........................................t............................................................................. ................Design Flow........1 A..r_2.......................gallons per person.per day. Total daily flow............ ---gallonp .E r Septic Tank—Liquid capacity.WDO..gallons Length. .Ko".. A- Width;!_=-\' .... Diameter........ ...... Depth 4- 1 D Disposal Trench_:No. .................... Width........i............ Total Length I.................."' Total leaching area....................sq. ft. I- Seepage Pit No..........I.......... iameter....... .0.... Depth below inlet........Cs?....... Total leaching areal-..A.2-.Q.sq. ft. Z Other Distribution box Dosing tank 0­1 1 >Q1 Percolation Test Results Performed by..-r,........)0W .... t_-A..C2. A, ....... Date..... ._ (F ... Test Pit No. 1........ ._.minutes per inch Depth of Test Pit.. Depth to ground water..Q L74 Test Pit No. 2.................minutes per inch Depth of Test Pit.........._..__..._. Depth to ground water................._...... .............. .......................... ------------------------------ ........"..............­*...... 0 Description of Soill..... �4x . ............ ....... ..............ME �.d >.......... ......... t....... .......... ............................................................ ....................................................................................................................................... . U Nature of Repairs or Alterations-Answer when applicable.............................................................................................. .............................. ...... ------------ ----------- . ................. ------ Agreement: Z The undersign' ed a rew 0 install the aforedescribed I i ewAge Disposal System in accordance with .g ndividt 014t Z ..., �� 7 `the provisions of TI T LZ 5 of the State Sanitary Cod unclersi ea further agrees not to place the system in /I— The -'/sue V operation until a Certificate of Compli ce has bein issued b t e boar , V61th.has s D 7 igneed.. ..... ........................... ........................................... .................. ......... Dar," ApplicationApproved By................... .. ... ...... ....................... ....................... ......... ..............? Date i g re Application Disapproved for the Poll * g reasons:................................................................................................................ ....................................................................................................................... ........................................................ .......... Date PermitNo-------------------------------------------------------- Issued...................................................... Date ........................ ....... ...........w........ ...................... ....... THE COMMONWEALTH OF MASSACHUSETTS ` h/ �'' BOARD/-QF HEALTH 2 2 r,,y AjA1 .............................. 0 X,.......... ............. (lutifiratr Lit ToutpliltnU THIS 11S�'TO CEYTOY That the Individual SewageDisposal System constructed (&,)��Repaired ,by........................ X l" lf.., ......... ....................................... . .............................................. .......*............."*--­---------7--- Install- .............. at........................ ... ..........).......................... f I--- 11 has been installed in accordance with the provisioiyX; o' T '17 -described in the 5 of The State Sanitary Code as,, application for Dis'posal Works Construction Permit No........ ....... dated-----._..� ............. TH E ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. X2:5j L DATE................?.......... ............................................. Inspector... 7.......................................................................... .................I....a ...... -rH E_ D.FS)6 A/ 1146 CNGJW"*,. . THE COMMONWEALTH OF MASSACHUSETTS M4,5*r ccal. rl. ro w 6 171 ovy!5 ro it 0 N--St*t C_S rV1*tt_ BOARD OF HEALTH )OAS -T jo tl�v t"4 vic 7-NSTAII-Al Aj/ iLr W he ij.6j.............OF)4 t ....... As t:e - ....... . '...) ................. ................. No FFx.......... ...... 1 t T la-iosal WarAg atisnutiatt 9if 0.7 : . ', Firmit " V Permission is hereby granted I 1.... 7 ............................................ ........ ..... -7­ to Construct (�,)wor,,.Re In ndi 1,�d Sewage Disposal System pDal vic at No......... ....... ....... ....... .......... ............. ............................ Street as shown on the applicationfor Disposal Works Construction Ier'mi`;9%S_-111R,/DatA ....rz. Z ......... 7 ............. ............................ and of�eal I -,.,DATE.................. i q,.,.5�....................................... rw i LEGEND W. BARNSTABLE 80 — — / 90 PROPOSED CONTOUR ROUTE 6 � -•_ ® PROPOSED SPOT GRADE / EXISTING CONTOUR SERVICE ROAD + 96.52 EXISTING SPOT GRADE N�♦ W— EXISTING WATER SERVICE O� o TEST PIT SCALE: 1" = 30' 1p0,90 r LOCUS EXI5T. I,000G EX15T. LEACHING SEPTIC TANK NOTE I O 25 DERBY DR. 00 - -" 102 LOCUS MAP ..9 ?5. 1 vent` --- 104 104 LOCUS INFORMATION O h ____ _- _---- I OG TITLE REF: BK 21713/PG 347 ti ` PARCEL ID: MAP 175 PAR. 021 r FLOOD ZONE: PROPERTY NOT IN A FLOOD ZONE. 0610 �� -- ---___ 108 EXISTING LEACHING SEPTIC SYSTEM (NOTE 10) REPAIR PLAN / LOCATED AT: +109.3 GENERAL NOTES: 25 , DERBY DRIVE \ �6. 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL W. BARN STABLE, MA BOARD OF HEALTH AND THE DESIGN ENGINEER. PREPARED FOR / TBM = EL. 105.E 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS TOP OF STOOP OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE 104. I LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: S T A P L E TO N I + / (BARNS G15 DATUM) - 310 CMR 15.405 (1) (B): / 1 1) A 0.30 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING DERBY TO BE 3.30 FT (MAX) BELOW GRADE VS REQ'D 3 FT. AUGUST 9, 2018 / (H20/VENT PROVIDED) DRIVE TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE OF 105.2 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLFD PRIOR + DESIGN ENGINEER. 4. ANY CONDITIONS_ ENCOUNTERED DURING CONSTRUCTION DIFFERING DARKEN y� FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN l ENGINEER BEFORE CONSTRUCTION CONTINUES. R 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. ME 1\ 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF . V '0 �\ THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF I� HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. EEO 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. NITAR�a� 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. • �� 9. IT $HAIL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND REMOVED PER TITLE V. 9, REPLACE WITH CLEAN MEDIUM SAND PER TITLE 5. MEYER & SONS, INC. 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY P.O. B 0 X 9 81 AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING 14. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPEC. OTHERWISE) EAST SANDWICH M A. 02537 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A GARBAGE GRINDER 4 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING (5 0 8)3 6 2—2 9 2 2 1 SHEET 1 OF 2 J 1387 ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (105.0) = 106.0�n�F.G.EL: 105.0 F.G.EL• 104.90 F.G. EL: 105.0 MAINTAIN 2% MIN SLOPE OVER LEACHING AREA VENT :6 is 2" OF 3/8" DOUBLE WASHED STONE OR FILTER FABRIC 3/4" - 1-1/2" " DOUBLE WASHED STONE ^ ` 4" SCH 40 PVC 10"I a as®� O ®aaa 14 ® S= 1 (MIN.) aaaaaaaaaa13 TEE'S ARE TO BE INV. F a®aaaaaaaaa :Y 4" SCH 40 PVC 2 E F. DEPTH aaaaaaaaaaa INV.101 .37 INV.100.95 4' 2 X 8.5 4' EXISTING OUTLET BAFFLE PROPOSED DB-3 , •. . .•.• DISTRIBUTION BOX EFFECTIVE LENGTH = 25 INV. 101 .62 AM (1-120) INV. ELEV.= 100.70 EXISTING 1,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON ���`� �F '�,sf9 BREAKOUT OUTLET TEE AS MANUFACTURED BY �``� cy� ELEV.= 101 .70 TUF-TITE, ZABEL, OR EQUAL DA EYE M' �, TOP CONC. ELEV.= 101 .70 NOTES: � -+ !E3E3E3E313E3A1E3 1) CONTRACTOR SHALL VERIFY ALL EXISTING 1 No. 4 INV. ELEV.= 100.70 aaaaPIPE INVERTS PRIOR TO CONSTRUCTIONaaaaaa2) D-BOX SHALL BE SET LEVEL AND TRUE TO6/$TtR�" GRADE ON A MECHANICALLY COMPACTED SIX �NITAR�a� BOTTOM EL.= 98.70 INCH CRUSHED STONE BASE, AS SPECIFIED IN 3.75' 5 FT. 3.75' 310 CMR 15.221(2) (� 11 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK 1 SEPARATION 4.00 FT.** EFFECTIVE WIDTH = 12.5' WITH 1500 GALLON SEPTIC TANK IF FAILED, DAMAGED OR UNDERSIZED. SEPTIC SYSTEM PROFILE BOTTOM OF TESTHOLE EL. 94.70 SOIL ABSORPTION SYSTEM (SECTION) 4) INSTALL INLET & OUTLET TEES W/ GAS BAFFLE AS REQUIRED (**BARNS GIS GW EL. 37.0>5FT. REQ'D) (500 GALLON H2O LEACH CHAMBER) GENERAL NOTES: DESIGN CRITERIA 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL LOG P#: 13500 NUMBER OF BEDROOMS: 3 BEDROOOM BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: DECEMBER 29, 2011 SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. #1614 DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS. EXCEPT AS LISTED BELOW: WITNESS: DONALD DESMARAIS, BARNSTABLE BOH - 310 CMR 15.405 (1) (B): DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. 1) A 0.30 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING Elev. GARBAGE GRINDER: NO (not designed for garbage grinder) TO BE 3.30 FT (MAX) BELOW GRADE VS REWD 3 Fr. TP-1 Depth Elev. TP-2 Death SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK (H20/VENT PROVIDED) 106.70 A LOAMY 0" 106.75 0" 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 1OYR 3/2D LOAMY SAND = 445.94 S.F. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 106.20 6" 106.25 tOYR 3/2 (330)6" LEACHING AREA REQUIRED: DESIGN ENGINEER. B DY LOAM B SANDY LOAM •74 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING IOYR 4/6 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 105.03 20" 105.08 1oYR 4/e 20" ENGINEER BEFORE CONSTRUCTION CONTINUES. C C USE TWO 2 500 GALLON H2O PRECAST LEACH CHAMBERS W 4' 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. FINE SANDY LOAM FINE SANDY LOAM STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D S. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 1OYR 6/3 THE CONTRA R OR OWNER TO NOTIFY THE LOCAL BOARD OF 103.70 36" 10.3.7.5 10YR 6/3 " BOTTOM AREA 25 x 12.5= 312.5 SF HEALTH FOR TOPER INSPECTIONS DURING CONSTRUCTION. CFINE SANDY LOAM C2 36 SIDE AREA (25 + 12.5) X 2 X 2 = 150 SF 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 1OYR 6/4 FINE SANDY LOAM 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 101.37 64" 1OYR 6/4 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 101.42 64" FINE TO MED DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE SIEVE 70 10YSA SAND 144" FINER/EDTHE LOCATION " CONSTRUCTION.OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 94.70 94.75 144 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5, 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION PERC RATE <2 MIN/IN. WATER HORIZON) PER SIEVE SAMPLE 25 DERBY DRIVE, WEST BARNSTABLE, MA 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY NO GROUNDWATER OBSERVED Prepared for: Sta leton AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY Design and Site Plan by: SCALE DRAWN DATE 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. MEYER 8 SONS,INC. 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. • 1. Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 N.T.S. DMM O$�09�18 15. ALL PIPING TO BE 4" SCH 40 • 1/8%FT (UNLESS SPECIFIED) to conduct soil evaluations and that the above anoyeis has been performed by me consistent with the PO BOX 981 requirements of 310 CMR 15.017. 1 further certify that 1 have passed the Soil Eval. Exam In October, 1999. EAST SANDW/CH,MA 02537 CHECKED SHEET N0. 508-3622922 DMM 2 of 2 / _.. LEGEND W. BARNSTABLE 80 / / 90 PROPOSED CONTOUR ROUTE 6 / PROPOSED SPOT GRADE EXISTING CONTOUR SERVICE ROAD 06 73 S / + 96.52 EXISTING SPOT GRADE W— EXISTING WATER SERVICE 0 o TEST PIT S'T� � r LOCUS EXIST. I,000G EXIST. LEACHING 10 25 DERBY DR. SEPTIC TANK NOTE 10 100 — LOCUS MAP 104 104. nsp ports LOCUS INFORMATION I OG TITLE REF: BK 21713/PG 347 PARCEL ID: MAP 175 PAR. 021 108 T13M = EL. 105.E SEPTIC SYSTEM TOPo� srooP � REPAIR PLAN LOCATED AT: +109.3 GENERAL NOTES: 25 DERBY DRIVE I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL W. B A R N S TA B LE, MA �•� �� BOARD OF HEALTH AND THE DESIGN ENGINEER./ PREPARED FOR 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE I +1 04. 1 / LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: S TA P L E TO N - 310 CMR 15.405 (1) (8): DERBY / 1) A 2.79 FT. VARIANCE FROM 310CMR 15.221(7) TO ALLOW LEACHING / TO BE 5.79 FT (MAX) BELOW GRADE VS REQ'D 3 FT. MAY 15, 2012 / (H20/VENT PROVIDED) DRIVE105.2 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR + TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. OF MAss9 _ 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING ENGINEER NEEROM OSE BEFORE WN EREON CONSTRUCTIOSHALL ONT NUES.BE EEO TO THE DESIGN ' DA;R E� M —— 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. V (e -� i 1 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF No. '11 �\ THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF ' HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. '�fG/STEM \� 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. j t 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED \ TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE V.11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION MEYER & SONS, INC. 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 15 NOT TO BE C:UNSIDEKEU A PROPERTY LINE SURVEY P. O. B 0 X 9 81 13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING t 14. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC. OTHERWISE) 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW EAST SANDWICH, M A. 02537 FOR THE USE OF A GARBAGE GRINDER 1.6. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING (5 0 8)3 6 2— 2 9 2 2 } „` SCALE: 1" = 30' SHEET 1 OF 2 J#1387 NOTE: TO PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:101.21 FOR A DISTANCE OF 15' AROUND THE 1f PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETt=R INSPECTION PORT OVER f4" T.O.F. EL.=106.00 INSTALLED OUTLET AND SET TO 6" OF. FINISH GRADE SET TO 6' OF GRADE ONE CHAMBER (MIN.) AND SET TO 3 OF F.G. LENG114 F.G. EL.=tO5.00t F.G. EL.=104.90t F.G. EL:106.0t F.G. EL: 107.00(MAX.) �F Mgss9 f VENT 9 45" <� '�� IARR N M. �✓ ME L 12't 9` MIN COVER/ i L = 35' L = 15'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) " 0. 114 "1i9 ® S=1X (MIN.) 36" MAX COVER � � S=19b (MIN.) ® S=1� (MIN.) 12.37" 4"SCH40 PVC 4"SCH40 PVC 4"SCH4C PVC C/ E 10• 14• 6 10.38" TONITAR�a� \IN 101.62 48"LIQUID INVERT COUPLER DETAIL LEVEL INV.=101.37 INV.= 100.75 GAS BAFFLE PROPOSED s )aj I� D-BOX 4 ROWS OF 4 UNITS ® 5'/UNIT + 3 COUPLERS ® 1.16'/UNIT = 23.48'/ROW INV.=101.02 pB-5 -20) INV.=100.85 AM SOIL ABSORPTON SYSTEM (PROFILE) EXISTING 1,000 GALLON SEPTIC TANK EXISTING OUTLET RESTORE VEGETATIVE COVER BACKFILL NTH CLEAN PERC SAND 60" NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING TO TOP OF CHAMBERS PIPE INVERTS PRIOR TO CONSTRUCTION . 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=101.21 GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.=100.75 INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 99.88 310 CMR 15.221(2) EXISTING SUITABLE 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK 2.88' MATERIAL WITH 1500 GALLON SEPTIC TANK IF FAILED, 5' MIN. ABOVE BOTTOM OF T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.88' = 11.52 DAMAGED, NOT H2O LOADING, OR UNDERSIZED. (5.18' PROVIDED) USE 4 ROWS OF 4-ADS ARC 36HC 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL.=94.70 - (H20) UNITS - NO STONE W/ 3 COUPLERS GAS BAFFLE AS REQUIRED _ IN EACH ROW SEPTIC SYSTEM PROFILE TYPICAL SECTION N.T.S. a rs 16` SOIL LOG P#: 13500 DESIGN CRITERIA DATE: DECEMBER 29. 2011 SECTION 1D38" NUMBER OF BEDROOMS: 3 BR DESIGN SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. #1614IN PER T SOIL TEXTURAL CLASS: CLASS I WITNESS: DONALD DESMARAIS, BARNSTABLE BOH HEIGHT END CAP DESIGN PERCOLATION RATE: <2 MIN/IN Elev. TP-1 Depth Elev. TP-2 Depth ADS - ARC 36HC CHAMBER (H20 LOAD), DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 330 G.P.D. 106.70 A LOAMY SAND 0" 106.75 0" 1oYR 3/2 A LOAMY SAND MODEL ARC 3 11 6HC GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) 106.20 6" IOYR 3/2 LENGTH 63" B SANDY LOAM 106.25 6" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SEPTIC TANK: 330 gpd x 200% = 660 gpd USE EXIST. 1,000 GALLON SEPTIC TANK 10YR 4/6 B SANDY LOAM EFFECTIVE LENGTH 60" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. 105.03 C 20" � 105.08 C 10YR 4/6 20" SIDE WALL HEIGHT 10.38" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. FINE SANDY LOAM A " DISTRIBUTION BOX: 5 FINE SANDY LOAM OVERALL HEIGHT 16 . OUTLETS (MINIMUM)(H20 LOADING) 1OYR 6/3 10 6/3 4640 TRL/EMAN BLIND 103.70 36" 103.75 OVERALL WIDTH 34.5" PRIMARY S.A.S. C2 C2 36" 10.7 CF MrAw. HILLIARD, OHIO 4JO26 USE 4 ROWS OF 4 - ADS ARCHC FINE SANDY LOAM 3616 H2O UNITS-NO STONE � FINE SANDY LOAM CAPACITY 10YR 6/4 A 10YR 6/4 (80.0 GAL) ADVANCED DRAINAGE SYSTEMS, INC. AND EXTENDED 1.16 W/ COUPLERS IN BETWEEN EACH UNIT 101.37 64" 101.42 i BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF LF OF CHAMBER) SIEVE ® FlNESA D ED FINE TTOOp ED 64" PROPOSED SEPTIC SYSTEM/SITE PLAN CHAMBERS: 4 ROW 16 UNITS x 5.0 LF x 4.80 SF LF /384.00 SF EL. 9994. 1oYR s/a 144" 1DYR 6/4 - ( / ) � 94.70 94.75 144" (COUPLER: 3/ROW) 12 UNITS x .1.16 LF x 4.80 SF/LF = 66.82 SF -_ 25 DERBY LANE, W. BARNSTABLE, MA TOTAL AREA = 450.82 SF PERC RATE <2 MIN/IN. ("C31" HORIZON)--PER SIEVE SAMPLE Prepared for: Stapleton DESIGN FLOW PROVIDED: 0.74GPD/SF(450.82SF) = 333.60 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN MEYER&SONS,INC. Ilel/er & Assoc. NTS D.M.M. • I, Darren M. Meyer, R.S., CSE, hereby certify that 1 am currently approved by MADEP pursuant to 310 CMR 15.017 Po BOX981 (508) 375-0735 DATE to conduct soil evaluations and that the above analysis has been performed by me consistent with the EASTSANDW/CH,MA02537 CHECKED SHEET N0. requirements of 310 CMR 15.017. 1 further certify that I hairs passed the Soil Eval. Exam in October, 1999. 12 15 508-362-2922 05/ / D.M.M. 2 OF 2 t< WIN, s y. - . t av C.. I r ..,. • :..-., .. .. .. .. ':: ... .-, yr -«,=..' ., by:^ v=< i :. sEwAG� . .. . �, . , ECTION - 5„ y.. SEPTI T - —"D#'BOX LEACH TOPI OF fON f (MSL "2"OF /8T0 4i WASHED STONE t o dp MIN; ' ��'l Gova IZ L IN. 1 77\ OUT N. OUT, �': _J�•� ✓_ p IN to o G 3 _ SEPTIC 153 ELEV ;,- TANK + t_E L , • - .ELEV. _:,'. ,• ,.. 1: r„ �. 1.25 ELEV. ELEVof WASHED STONE TEST HOLE LOG P�-42 52 ' TEST BY K�7jalk G�.p�E�IC� � Gp{.I,t,O{.l �6dD�('•(I) E.LEYd 7r.J" S , "' � � 1 � _ �° <:{" WITNESS TEST DATE 3 161 e5 DESIGN. 3 BEDROOM HOUSE / T.N: w 1 1 T.H. � 2 ELEV. C/ Ii� ELEV. NO �, ' M IN:' DISPOSER DISPOSER/ �j7,S PERC RATE IN/ FLOW RATE S30(GALJDAY') 5 l.D SEPTIC TANK /- REQ'D SEPTIC TANK SIZE �!L. LEACH FACILITY _ 3 - '50 FAT SIDE WALL,Lo•rr�^ ( � (I,�j Z G/D. r, ,. BOTTOM (I We)zTT-=79,, 5 ,.'7'1 p = 2 G/D. -- IC�4�11 75,51 TOTAL 2G7 ,0 �F a ,2 ��� /a2 /`ESL 9F- USE: dtiE. _ LEACHING I \ I�1F b i1✓( x �15 I WATER ENCOUNTERED NOTE (UNLESS OTHERWISE NOTED) 1.DATUM tMSU*TAKEN FROM— '�'} .. - ����KO�T � �� ryC QUADRANGLE MAP 2:MUNICIPALWATER AVAILABLE 3.PIPE PITCH:W"PER FOOT Qf ^t( 4-DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- I� •44 4g`�N 'Q 5-MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. 6.PIPE JOINTS SHALL BE MADE WATERTIGHT ARNE H. ;' . __ 7-CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS`. �$ OJALASITE STATE ENVIRONMENTAL CODE TITLES - / ��M Q �• PL $. r%_I�t pt.A�J Fob. 7'�O'7�e3�cv w1C>+ ►� c .`� 6►�ty �+iaeJL6 _.. __ _ - ,.,��. �c LOCUS• ARNE yG� 1il5lSlTbt� MNTE�I1>LE'1-ylEE1J �I.E1l� �<o,�. " I. �.}w ---- 11 H. 15 —— %1 OJALA "' R L ENGINEER 41tJ D EI.E�/. elo,ov `T4 e'E_ to .0 Ai•1U.IzEI�Lb.r-EU #76 8 � REF ►.�L IT4 e-I.E,b-N• COA PZ� T-0 M F�I it M e .z�i.D .. . �r , l01 s-ROLW0 l,.Et�L4- lf4c-A '&KE down cape en�►ineerin� PREPARED FOR: i �. 1:IC��vE TU CE12r-r>✓Y �rL C_(X N-T7C )kjS 'rC�,L� �C�S) J _ CIVIL ENGINEERS L. _ -- LAND SURVEYORS BOARD OF HEALTH REG.LAND SURVEYOR (EXISTING)............. { i `�I ip �� ��/!�. CONTOURS (PROPOSED)-0-0-0 O- APPROVED DATE `MA I r �Al ATE l- f .. �..w.Yr.r •t•.Tt'I•-�...�,rfAY+7•,,,: - e...._:e. !r ai•..-. - -. _._.. _.._.- - ,.Y'�<....a. .'"'aAae.-sb•rt'-4t.1�1'-.v...a•..s�.d. -. ! '«,.. _'" •-.^. ...w.a. .. � .s.• _..t.VI�s.110lrfC 7' Y..��' - �... .� ..C.P. ...r•s _�.r - -swrAll- ._�_- -� _•.-�It�--_ .y ..- yea.`.w.37►+iai-+"-f.'�--r -_wwr ...._..._..-.�.�i../.�1i4+r,�M.. •. �• � �. -TF -- -- _ testa:-?.io.i S.wtl t: vironmerttal _ _ D TOM � �� y� IN r ''�� U art?Alt•H, :, �d AT. � ��; cJl� '"\ � Sept"C }IS s. �, .r t .._ SP(�i �1;"`S-a� r f � ` �{'� t.�a`"��e � L��� ,f� ��✓�,:�>,.-1 •L 5 Ietl3 i. ,-•� ,�.�ansh�,l; n��beins`����.. .�t. pw v�� approval ;n _ :_ _': .,. _PR7it frnf±:t ? ;}pi, tlti:; �✓ # :. IL I' installation, t ... r W ins a lla ion,Ii. t�.+_. ��r1�t 11fV'tt1Q�t?Cd'�lC.'^4. - ,_ .+?r�:, t1'ee a_. se,iv� �, 1A�( 1YZ-- k L✓ ~� �i \ , ! �_/ �y Z_. "- — Y ' existirsg septic tomu�.:t,•:r, . - +, instat!ati6r.. ! gravity r P p" g;ti bo. c.-: 5. edule�40 PVC at 1;it' , . <::-. - 't SPitiLf i it+' EC.' cr t, t •.+: � I.�- fit5i� feet :!'.1` distribution box shaii!,'� Ik vt All�t ir. . P +s connections to \ i /! v ,P tiC Ctc?Si rl i ! (� i2 t: is= i �U Fj �I t2 c!for rc per y tine :t r fLs'any/:zth�t �J Jtr� ID ���(�yJ/�J���/// r "r �O pose oth�i tr:_.l ti:Q c�rc��ase:i jai ,, . ,Ysterr i,z5tallatin+ cellj// c�3rnpo:rents ar ^a+:, , I Tit > saeclftCaifon5. % , k:-It;shall be p!ohibitef ;�iee r:Yit C�'l{k)rla?rStS IJr►#Qi.. ;1 ^.t. it+ NZ(3,oatien o N kj 4-t�,a 2xistillk ieathing C:Ytir �i.e.)r!` •»::i'+ be pt:ilTilf.'f� and ffiir L IC' t,a�tl ;1erTii!e 4' s WCA� !D +/ it t �-•lo dk�3(;�U±`t 'c'tli�rt�Cetii:,c� !�3:fltt, -A cesspcollS)and c._ ++•_ + i+.,, is - -Mthin the I Lie' IbM i%;..p;nsF . SAS sfi-tt -.'aced withar. sa=, i ► t2s� �01, ,: o ng e e- line- FZ" pc ettatn; - via!er Servicr t 31 t►I�rtDy1( .� ='_ _teevtd :vitt ar ap,�r � �'stP,Ciute'-10 PvC vltxk �i: Ft-P water s@rv;Cm ►-i the s;eevt'. bi.!n9JJ -,sing Vie fit?E 40 g c ottE Q X3StS i t 7±i':+_r;:t:'� re,!l i`i TO t7f. rF:T4Dt. l' '�t=i Sterl is not arf3 rr�tdPr e tr,air / �_?(yyg �y �, ��y�'�w'Ly`.�- { :instatk�i,is tF 4r...,bi `u, . : eavati•x:�ar�ur .: a. roperi y ate, 711"1.1jectiltu tt'e 5tr ,M: • 'F i ;i =.tnJCt,Jrt!s I,l�r ^E ri 1':i; { C�sS ^.'';lr: 1e{!1 . �"1 _. - ;� :f•iy fE'"': h' ? t ct o t i fit' t, r y \ ^ : ?•_ .e� i; ?5ti3rrt_arl b i ZS �' :y�.*eti T!Ltf' t: n1�e Iy c�ti�rrah ;:vi.,v iterie N t •r. r r�'h:'i aiC'.•; rt *.0 3f, rove iRA flow. ;Irsteltatic' :J! ;i, ;,?rrri_ • , tem a5 propc.sed and re,e:;3c+;ti il!?nt t Jt !#'}e Cie iI1i` / `0 / ��— "�' -- --. ;+i1;t be deemptt apprc.i!!;ff,� ru .1s'ri itef-ica bvthe prope0y n ,wt '_(?t US. I' Ydt•1.fit at _21i5 plat, _4 u :' (e the t, 5 t t: � 11 J." f f. F!.. i !.1 v i t l e: , I1, - !t ,t � �} !: { '� 4 I'dtlUrl 1t 1:' !.iJ`:'.• .f, ..1 J perms � St1P.i, i 1 q a�n Or the 1v !I�c#d;t rat.i• a osrt ,:)n tile�ex ira4 f .. _ ofi C c� tp,1P rc f, 7P? . 5 pf..!,, Cie �IZINO � :t + � .�8?�" DN V1A \ a ✓ Nvy, �.. r a u' -PL4) TE. 1050 700, , 6y4oc) -- „s 'flev,FY, V io �� ,t'Ia�J L �i►a�� ++'gyp, .� g fir) w Z ► L i 5�-uD ���,��-n Za Z- ZS fA Iry 77Y/'�p PLAJ Xt/0 9-1606aY75 A. ZW I A Ale= > ''cam- i T f-T rAv - F ..-aas:e.'t:•..►�wss..-r•ssaeernwsr>,.s.�.:at:��.amr •r�.-.. ... ._._...:.�_..�..-..:.�a.a.:.,: -•v-r:. ..+.t.. ..- ....- - - -- - - - �. rye. �� ry a r�,.- �S�tt�7!' .. +`�►8i,a7@••raQJ. � -r-*,�;��a"c�.Qaot,. .re:.ia�x_� ........... ....,..,.<...•ivwro+....n:r _ _t.�•wrtr+••.c+•.. :iar+.:e.rc•r..'.'x .i•s.:�w+•. -