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HomeMy WebLinkAbout0011 OLD TOLL ROAD - Health nld,Toll, Road. 4.W. Barnstable P A,_,109 .0.69f'-,. f I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments O 11 Old Toll Rd c M F.a Property Address �} V Hirschberger(owner of record) ►� Owner Owners Name information is West Barnstable Ma 02668 10/21/2016 required for every page. City/Town State Zip Code Date of Inspection CA IU I 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 A. General Information filling out forms S� 00115 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 L pproving Authority 21/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r/ �� rS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 11 Old Toll Rd. is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 3 3050 Infiltrators. The system was found to be in proper working condition at the time of inspection. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments < 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth; of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owners Name information is required for every West Barnstable Ma 02668 10/21/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or 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 ❑ ® 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 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. ❑ ® 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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 gpd t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 well 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown 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•3113 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 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owners Name information is required for every West Barnstable Ma 02668 10/21/2016 II 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 es volume m y o e 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 f - Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system repaired 9/4/08 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3feet 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 N, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Old Toll Rd Property Address Hirschberger( owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance frcm top of sludge to bottom of outlet tee or baffle 3" Scum thickress W 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 10" How were dimensions determined? opened covers, took measurements 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 should be cleaned soon and again every 2 yeears for proper maintenance. Tank was structurally sound. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every west Barnstable Ma 02668 10/21/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found to be in good condition, no rot, water level was even with outlet invert. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 M , 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owners Name information is required for every West Barnstable Ma 02668 10/21/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: e: ❑ leaching pits number: ® leaching chambers number: 3 3050 Infiltrators ❑ 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.): s.a.s. consists of 3 3050 Infiltrators in a 29'x12'trench. No signs of past failure observed. Old pit is still attached. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 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 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I� 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.): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Voluntary Asses sments ents Subsurface Sewage Disposal System Form Not for ry 11 Old Toll Rd Property Address Hirschber er owner of record ,ner Owner's Name trmation is West Barnstable Ma 02668 10/21/2016 uired for every State Zip Code Date of Inspection le. Cityrrown D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in th.e area below ❑ drawing attached separately 2(4 . AA= bldQ .aS 34 A 4 _ 3.3 Q� S' 0\ Lqs AS_3� Q5= (off A = Q7 r t Gar-*, �c6�� F`���cr"�.,b'�►1�d opt �� �.. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 t5ins-3113 Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Old Toll Rd Property Address Hirschberger(owner of record) Owner Owner's Name information is required for every west Barnstable Ma 02668 10/21/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Old Toll Rd Property Address Hirschberger( owner of record) Owner Owner's Name information is required for every West Barnstable Ma 02668 10/21/2016 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 r t CERTIFICATE 4F ANALYSIS Page: 1 of 1 4 Barnstable County Health Laboratory (M-MA009) � y �c�tugn Report Prepared For: Report Dated: 1 012 5/2 0 1 6 Sally Desmond Desmond Well Dr Ihg G169715n Order No.. 0 P 0 Box 2783 Orleans, MA 02553 Laboratory ID#: 1697150-01 Description: Water-Drinking Water Sample#: Sample Location: 11 Old Toll Rd.W. Barnstable, MA Collected: 10/21/2016 Collected by: DWD Received: 10/21/2016 Routine_M ITEM RESULT UNITS RL MCL METHOD# ANALYST TESTED NOTE Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 LAP 10/21/2016 € Iron 0.46 mg/L 0A0 0.3 SM 31116 LAP 10/2512016 Manganese ND mg/L 0.025 0.060 SM 3111B LAP 10125/2016 pH 6.6 PH AT 25C NA 6.5-6.5 SM 4500-1-1-13 DCB 10/21/2016 Sodium 7.2 mg/L 2.5 20 SM 3111B LAP 10/25/2016 i� Total Coliform 0 /100ML 0 0 SM 9222B RG 10/21/2016 Conductance 74 umohs/cm 2.0 SM 2510B DCB 10/21/2016 k Based on the results of the parameters tested, the water is suitable for drinking, but may present aesthetic problems (taste, odor, staining)due to Iron. - ----- - -- .... ............- --..... -- - _ I ti Attached please find the aboratory certified parameter list. Approved By: �r (Lab Director) C•� 3 / I I , a � I 3 3. f E I a a i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level 3195 Main Street, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 1 r . AsBuilt Page 1 of 1 TOWN OF BA--IRNSTABLE LOCATION , 6�U ��1 �V SEWAGE# VILLAGE U• r\IS""J , ASSESSOR'S MAP&LOT- INSTALLER'S NAME&PHONE NO. ';Fr'C,� S"n 02�1.�4 OOP_ SEPTIC TANK CAPACITY P k%Sa'r LEACHING FACIL=; (type),��.$D� �$ a��size) W )C 29'1"X NO.OF BEDROOMS ��O BUILDER OR OWNER PERMITDATE: Y 1r3 Ok COMPLIANCE f`f/0& Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility NA 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 AA ` within 300 feet of leaching facility) lam+-A Feet Furnished by ,� Al:: 39' A S'-3 Q S (off 7 A(- + yo Q7 3q V:M - http://issgl2/intranet/propdata/prebuilt.aspx?mappar=109069&seq=1 9/1/2015 Town of Barnstable P#--�� -- �y'' '� Department of Regulatory Services _ Public Health Division Date � Wetr MAE& - 200 Main Street,Hyannis MA 02601 ED AAAt h ° Date Scheduled Time J.6 Fee Pd. Soil Suitability Assessment for Sewa a v1sposgI Performed By: � ���� , l7� Witnessed By: 1' fD 1 LOCATION GENERAL INFORMATION lLocation Address 1 ��� Owner's Name Address `� Assessor's Map/Parcel: (j Engineer's Name S� ` ,(;, 1, NEW CONSTRUCTION REPAIR Telephone# -TJ Land Use s act"%� � Slopes M �i Z Surface Stones 'W U Distances from: Open Water Body ft= Possible Wet Area _ ft Drinking Water Well 1ft Drainage Way s ft Property Line �ed ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fin proximity to holes) a�a a� N ) Q: ram-- • N -71 vy CI'i � cr N r N rn Parent material(geologic) Depth to Bedrock _ Depth to Groundwater. Standing Water in Hole: X)/A- Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: _At).0 E 61-"Q"'-TZA-trti Depth Observed standing in obs.hole: in. Depth to Soil mottlft: Depth to weeping from side of obs.hole: in. Groundwater Adjustment fe. Index Well# Reading Date: Index Well level Adj.factor _ Adj.Ornundwater i cvel, p PERCOLATION TEST Date ii D Time Observation Hole# Time at 9" Depth of Perc (O�r Time at 6" 22 ; Start Pre-soak Time @ '�' _ Time(9"•6") �'AJ End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1)week prior to beginning. Q:1SEP'1'ICU'ERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other r Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Gravel) It r174-L z� A- Lo . S . rays / y 13 L . S . 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) /2 � 8 A ' y� 6 i— S A Y�- 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) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consi en Flood Insurance Rate May: Above 500 year flood boundary No— . Yes Within 500 year boundary No Yes Within too year flood boundary No— Yes MIA of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification 4 I certify that on J (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required train' a ertise and experience described in 310 CMR 15�01Z67. Signature Date6� , Q.WEV MERCFORM.DOC �FTHE Town of Barnstable 1p� yP� Regulatory Services Thomas F. Geiler,Director • B"NSfABLE, 'K + "SS.i639• Public Health Division ��� ArFD N1°�a Thomas McKean, Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Sewage Permit# W"[Assessor's MaplParcel ®`i- d 6, _ q Designer: _1�TL A I+e pe Installer: Scow FtwuJV__ Address: 2z 3 6.A Address: 113 eA b 1-4 Y AO s S , Nc A. CZ[.o f on s issued a pernut to install a (date) (installer) :_ septic system at 11 OLb TOLL— 92t> i W, 13 based on a design drawn by (address) Sj LlP H-ez-� H A-,A-S P E dated 8 f 7-S 1406 / (designer),, �i/ 1 certify that the septic system referenced above was installed substantiIally according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or 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 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. � OFr b' STEPH A. (Installers Signature) 3.. CIVIL y , No.35461 o�'�fC1S E�E� 9 (Designer's Signature) (Affix esigner'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 BAR STABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Revised.doc SEWAGE INSPECTIONS / LOCATION nIrl AA - DATE VILLAGE L� + �C fl ASSESSOR'S MAP t.LOT 6 -INSPBCTOE — I 9D4 SEPTIC TP.NK CAPACM LEACHING FACILITY: (type) �— (size) NO.OF BEDROOMS BUILDER OR OWNER OWNER MAILING (ADDRESS 'VX 59, TOWN OF BARNSTABLE t� LOCK110N` 1 6�V \l SEWAGE # V(�LAGE ``� I ASSESSOR'S MAP & LOT4�Og INSTALLER'S NAME&PHONE NO. aCl. OO �1 SEPTIC TANK CAPACITY !e .fie l Sk \ b &% 4- 0 S3 t� LEACHING FACILITY: (type) .3 6M (size) /J W X,2q I"X NO. OF BEDROOMSf BUILDER OR OWNER -y� -��r-6�� S PERMITDATE: �'LQt COMPLIANCE DATE: f YIO� 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 nn ( within 300 feet of leaching facility) dv ' Feet Furnished by y ,� 4 �'' S� � i,ng�•le Q� . I)a 39 A IA Gam` i r No. Zo08 Fee ' 3vr� /DD - / � r-_ '` V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppgtcation for Th5po5ar *pgtem Con0tructiou Permit Application for a Permit to Construct( ) Repair mrl'Upgrade( Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. \ \ (�\ (.�e Owner's Name,Address,and Tel.No. Z��t� ���sc� cr- Assessor's Map/Parcel (MCA Installer's Name,Addres ,and Tel.No. Designer's Name,Address and Tel.No. S cons\ `�- J►/ �J- ram, s�cv-c_ �� 3 c�a `3 Type of Building: cc tt Dwelling No.of Bedrooms Lot Size (A 0 01 sq. ft. Garbage Grinder �j Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 3 x gpd Plan Date Number of sheets Revision Date Title Size of.Septic Tank Type of S.A.S. -�.`�a.lhr , Description of Soil J J X @ 9 ,1 )c 7 Ci Nature of Repairs or Alterations(Answer when applicable) aLQkc,C e—K k uk "�„j (A!& Sub � 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. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2(�ot�. � Date Issued ZA7.oA No. 206E' J'� "yI Wild°"" -vk �. .k F n 1 _ ee /�v computer:Entered in THE COMMONWEALTH OF MASSACHUSETTS PUBLIC(HEALTH DIVISION--TOWN OF BARNSTABLE, MASSACHU�SETTS Yes application for �Bi5po5al *p5tem Con.5truction VeMit , Application for a'Permit to Construct( )' Repair(y/Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. Q 2� (� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel v�l Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building:, Dwelling-..', No.of Bedrooms ? Lot Size L� �i (� U sq. ft. Garbage Pirider S jo Other Type of Building. No.of Persons Showers( )'r Cafeteria( ) a Other Fixtures fc x Design Flow(min.required) y gpd Design flow provided R2Y gpd t Plan Date Number of sheets Revision Date Title Size of.Septic Tank p v. �>c��� Type of S.A.S. Description of Soil / 1cl") A 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. Signed -- _ Date Application Approved by r / Date Application Disapproved , Date for the following reasons - r s_ Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (' ) Upgraded ( ) Abandoned( )by at C�\o !6s`` a J has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _ dated A Installer �� Designer �,�,,.{'s�.. ViG.,c - C��e.�2 p #bedrooms ? Approved design flow 2,'z_ A gpd v o The issuance of this permit shall not bem nitrued s a(auu'arantee that the system tw ll function as designe/d. fp Date _. �,. '/ /3 Inspect / tJ I V rfjr(VV-Yr'V, 4f' —=_ 31YI Y it Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS I� OgaY 4&p!gteM Cott!gtrUCtioft 30ermit Permission is hereby granted to Construct ( ) Repair ( �� Upgrade ( ) Abandon ( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:: Co strucfon must be completed within three years of the date of this pe-4rmit. Date Approved by _ r a FEB 0 8 2005 DATE (U4tity OF BARNSTABLE 1 � HEAL iH UEPT 0 5� . — — 11 Oid 7oU Rd. �V PROPERTY ADDRESSTEI . IJ.,Ba2n,3t a P..ee Ma.i 13 02668 On the above date;thea4eptic system at the address above was Inspected. This system consists of the following: 1, 1000 gaiion zept.ic tank:, 2.4-d.izt2.igut.ion fox., 3., 1-1000 ga. eon 4each.ing 12.it.1 Based on inspection, I certify the following conditions: 4.,7h:i-6 .i.3 a tithe dive �e/�t ico e2�wo2k in y. o2de2 at the p?e,,ent time., 5.i7he 3ePt.ic hybtem '6 in Psa /z 6.,7he wazte wate2 .in ieach.ing pit was 38" &ejow the cnve2t pi/?e. SIGNATURE Name: Robert A. Paollnl Company: Josh P. Macomhpr eR & Son Inc . Address: P. O. Box 66' Centerville. Mass 02632 Phone: 508 775.3338 or 50&775-64L2 «6. - joSSPM P. MACOMBER & SON;, INC Tanks-Cesspools-L,eachfields pumpoo &'.Installed TOwn Sewer.Conneolons P.O. Box 65 . Centerville, MA 026.3Z-0066 77.5+3p$ 775.6412 COMMONWEALTH OF MASSACHL3SETTS E+XECU'i M'OFPIGE•OF F+IvfR4NM NTAL AFFAIRS DuARTMENT'OF . NVI 4I TAI PROTECTION r 'TITLE 5 OFFICIAL INSPECTION FORM_.NA•T FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A _ CERTIFICATION Property Address: .11 O ed TQ i e _Rd o Gl a2nha� �er(7a.i Owner's Name: %UU12 H z�3chge Ge.2 Owner's Address: S a m e 11ZL� 5 of Inspection:Date p . 1'. . Name of Inspector: (please print) a.a F A,2 t. ?j a Company Name: P ma,.a ngeat & . on I c. ; Mailing.Address: en z zv c. e, ifl.a s e. 06 32' Telephone Number: 5 0 8-7 7 -�3 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal.systetri at this address and thatthe.infonnationreported below is true.,accurate and complete as of the time of the inspection.-T-he inspection-was performed based on my training and experience in-the proper fiinetion and maintenance of oni to sewage disposal systems.I am a DEP approved system inspector pursuant to-afctionJ5:340.of•T,itle 5(31.0 CM)E ISA00). The system: xxz Passes \ -Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority Fa-i Inspector's ROOM'.. Date: /17 105 The system inspector shall submit a copy of this inspection reporC to the.ApproAng Authority(Bosrd of Health or has a design flow of 10,000 DEP)within 30 days of completing this inspection.If the systw is 4 Phaced�syAtem or gpd or greater, the inspector and the system'owner.shall'submit the report to the appropriate;regional•offiee of the DEP.The original should be sent to tha.system ORMIM a�dcopias sontw tl buyer;if�pp(icable,and the approving authority. Notes and Comments ****This'report only describes conditions at the time of inspeetibt'and under the conditions of use st time.This inspection does not address how the system will perform in the future under the same or.differfferent conditions of use. Page 2 of I I OFFICIAL INSPECTIONYORM—••NOT FORVOLUNTARY ASSESSMENTS � SUBSURFACE SEWAtGE IIISPOSAL SYSTEM INSPECTION.FORM. PART'A CERTIFICATION(continued) Property Address: O irL 7° Rd., Owner:Ph.i_e-i12 7ia. ceh&e2Gee Date of.Inspection: 1/1-7/0 5 Inspection S.tj,%many: Check A;R,C,D or.V A:WAY'S'.00mplete all of Section D A. System Passes: n.o 1 have not found any information which-indicates•that and+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: no' One or more system components-as described in.the"Conditional:Pass"Lsection need to be replaced.or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements. If"not determined"please explain. no . The septic tank is metal and.over'20 years old*or the septic-tank(whether metal.or not)is,structurally unsound,exhibits substantial.!infiltraOQn or exfiltration.ar.tank failure.is.,imminent:System will pass inspection ifthe existing tank is replaced with'a complying septic•tank:as-Approved by theZoard of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: a°. Observation of tewage 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 inspectinn•.if(with approval of Board of Health): broken pipe(s).are replaced. . obstruction is removed disti`ib-d ion box is leveled or replaced ND explain, v v n° The system required pumping:more than 4 times a year due to broken or obstructed pipe(s):The system will with approval of the Board of Health): pass inspection if( pp , broken pipe(s)are replaced obstruction is removed ND explain: . IL Page 3 of 11 OFFICIAL MP-ECT.ION FORM•NOT VOR VOLUNTARYI RM ASSESSMENTS SUBi tRFACE SEWAGE O'ISROS�►L SYSTEM IN . PART°A.. . 'CER•TIFICAMON'(6oritinued)' : Property Address: 1 Oici 7o.U. Rd'6 Owner:.1 Date of Inspection: C. Further Evaluation-is.Required by the Board of Health: no Conditions.exist whichrequire further••evaluatipn•by•the Bcrard:of Heaith:in order,to;detertriine if-the system is failing to protect public•health,safety or the environment. ,a OO 1. System will pass unless Board-of,Healtb determinesiin as eordance with 310.CMR 15:303 l .b that the system is not functioning in.a•marinertwhich . 11l.protect public health,safety.ano ttle..eaviroument: no Cesspool or privy is.within,50 feet of asurface water n oo Cesspool or privy is within 50.feet of•a bordering vegetated wetland or a salt marsh.; 2. System will fail unless the Board-of Health{and Public Water Supplier;-if any),determines:thatthe system is functioning in a mariner,that proteets theptiblic Health,safety and environment: no The system has aseptic tank and soil absotption'system.(SA•S).:and the SAS is within 100 fe.et.ofa surface.rvater supply ot.iributary to asurface water supply. no The system-has•a.sepbe tank and SAS and the,,SAS is V•itllin a Zone 1 of a--public water.-supply, no The system has a septic tank and•$AS'and-the SAS is withinM feet of a private water.supply wen. n o The system has a septic tank and SAS and the•SAS is less than 100 feet.but 50 feet oF:niore fionl a private.water supply well" Method used to determine distance• **This system passes if the well water analysis,performed at a DEP certified laboratory,,for coliform bacteria and volatile organic compounds indicates that the w.ellss free from•pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5,ppm,.provided that no-other failure'.critefia are triggered.'A copy of the analysis must be attached to this form. • Y. 3, Other: Page 4 of 11 OFFIC AL•INSPECT ON FORM NOT>FOR;YOLUNTARY ASSESSMENTS SUR, URFACE.SEW'AiGR DISPOSAL SYSTEM.INSPECTION FORM PART A CERTMCATIGN, (continued) Property Address: 1 U ed 7o to No a2nz;t eQ, Ma.� Owner: 1)' i z,, c/r ea ea . Date of Inspection: D. System Failure Criteria applicable to all systems:. You must indicate."yes"-or"no"to vach.ofthe:followirig for all inspections: Yes No x Backup.ofsewage,:into•fattjt.y.:orsyrstern:component.due•_to.overloaded:orclogged•SAS,Qr.cesspool _ x ' Discharge:or-ponding of effluent to the.surface.of the:,ground or..surface maters due to.anoverloaded or clogged SAS or cesspool ' _ x Static liquid level in the distribution box above.outlet invert due.to an overloaded or clogged SAS or cesspool x 'Liquid depth in-cesspool is less than.6"below invert or,availablesvolume is less than'�S day flow x Required pumping more-than-4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ' x Any portion of.the SAS;cesspool or privy ig below High ground water elevation. _ z A�dy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface T water supply. x Any portion..ofa•cesspocal,or.privy isvithin•a:Zone!1 of•a-public.well.. _ x Any portion of a cesspool-or privy is within.50 feet of a private water supply well. _ z Any portion ofa 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—IT-his.system.passes if the well water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic.compounds indicates:that the well is:free from pollutiow.from:-Ib*t.factlity and:thg presence, ammonia nitrogen and nitrate nitrogen is equal to or less than.5-ppm,provided that no other failure criteria •are•triggere&A copy of the analysis•niust be attached.to this for•.m.] no •(Yes/No).The system fa,oA•have determined that one or..more-ofthe:Aove.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:systiein must.serve.ad'aeility with-a•design flow of 1,01000 gpd to 15i000. gpd. You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to-the criteria•above)• yes no x the-system is within 400 feet of a surface dr'inkingmater supply x the system.is within 206 feet of a tributary to a surface drinking water supply x the:system is located in a nitrogen sensitive-area Qnterim Wellhead Protection Area IWPA)or a mapped Zone II of a public water supply well If you have-answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The ownevor operator of any large system considered a significant threat under Section E or failed tinder Section D'shall upgrade the 'system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office.of the Department. 4 Page 5 of 11 OFFI'CI•AL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS gLiRSURFACE-SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART CHECKLIST Property tyAddress: 1�l/1fL I.+ OiZ Pan n 7Ao-�9/2!7�/2 O c . Owner: I ' � �h�l/in ���riz�eILg Date of Inspection: Check if the followin have been done.You must indicate` s'or"no"as.-to each.of the following: Yes No x — Pumping information was provided-by the owner,occupant, or Board of Health _ x Were any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? — — _ x_ Have large volumes of water been introduced to the system recently or as-part of th�Inspection?g x _ Were as built plans of,the system'obtained and examined?(If they were not available hote is N/A) g x Was the facility or-dwelling inspected for signs of sewa ge back up? x — Was the site inspected for signs of break out? X. — Were all system components,excluding the SAS.,located on site.? e the se tic tank manholes uncovered, paned,and the interior of the tank inspected for the condition x Were p d de th of scum? .— depth of slud e an p of the baffles or tees,material of construction,dimensions,depth of liquid,d p g y _x _ Was.the facility o wrier'(and occupants if diff6reitt from ownet)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of tbe•Soil Absorption System(SAS).on the site.bas been determhzred based on: Yes z _ Existing information.For example,.a plan at the Board of.Health. x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance - is unacceptable) [310 CMR 15.302(3)(b)] • 5 Page 6 of 11 OFFI-•IALINSPEC'TION::1`�?1t1VI'-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SE-WAGE DISPOSAL SYSTEM,INSPECTION:FORM PART.0 SYSTEM.INFORMATION Property Address: Rd.i ld:,/3a2nz�-aUe, Na.i Owner: / i UQ Hen �rh eaae2 Date of Inspection:, 1//7/ll5 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): ;:3 �tumber ofbedrooms.(actual):.3 DESIGN`:flow-based on'3ID CNIR 15.2.03':(for exa4le:'110 gpd z#-ofbedrooms):l'�0x 3=3 3 0 g/zd Number of current residents: .: 2 IDoes�.,residence have a garbage grindera(yes or no): n o Is laundry on a separate sewage.system(yss or.no):.n oo Elf yes&eparate inspection required] Laundry system inspected(yes or no)ye-3 Seasonal use:(yes or no): a o Water meter readings,if available(last 2 years usage(gpd)): \. Sump pumT (yes or no): n o � W a�'ivn Last date of occupancy: R2 e z e n l- fi w?)�F q �9 (-�es AS6 ft. COMMERCIi�Im bUSTRIAL Type of estabnt: �. Des. 310 C 15.2U3):• na gpd- Basis.ofd$sigiiy tow(seats/persons/sgft,etc.):, na Grease trap#esent(yes or no):._a Industrial waste holding tank present.(yes or no): na Non-sanitary waste discharged to the Title 5 system•(yes or no): n u Water..meter readings,if available: na Last date of occupancy/use: .n a OTHER(descri> e):. . GENERAL INFQR ATION Pumping Records Source of information: J.,P.,ft c o m g e2 and b o n Was system pumped as part of the inspection(yes or no):n o If yes,volume pumped:�0 0_0,_gallons--How was quantity pumped determined? m e a 6 u 2 e d Reason for.p..umping: main z a i n c e TYPE OF SYSTEM , xx Septic tank,distribution box,soil absorption system _Single cesspool _Qverflow cesspool —Privy w _Shared system(yes or no)(if yes,attach previous inspection recbrds,if any) _Innovative/Alter<native-technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) n.. —Tight tank. _Attach a.copy-of the DEP:approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no)-!n 6 _ _ BARNSTABLE COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT P.O. BOX 427 O` ""'4'y SUPERIOR COURT HOUSE BARNSTA.BLE, MASSACHUSETTS 02630 Q PHONE: 362-2511 A'A5' EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sampl; wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bonles sterilized at home are not acceptable. 2. It is recommended to use a stAight faucet, preferably NOT swingtype. 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not fill bottle to the top. Be careful not to touch -the inside of the bottle or cap with the faucet, your hands, or anything else. S. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, sodium and copper) is S25.00. Checks should be made payable to Bnrnstable Counrv. Exact change is required if paying in cash. Additional tests require additional fees. Consult lab or a price list for exact information.. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 AM to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated, 8. Completion of tests and results takes 7-10 business days. Results will be, sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory fpr availability. NOTICE: 'h%A ER FROM THE SAME SOURCE CANPRODUCE rONTRARY RESULTS FF US-CE�D AT D>FFE�} NT Trl„rES bhp/OR DM&ENT L0CATMJ1 THE COUNTY OF BARNSTABLE SHALL NOT BE LIABLE FOR, DANtAOES ���Q FROM THE RELIANCE �� pEgCn TS OF WATER TESTS ACCURATELY PERFORMi� PLEASE COMPLETE: REVERSE UDE QF FORM =P'RIVATE WELL WATER SAMPLE DTT?% COLLECTION SHEET VIAL 1.104."sERS FIELD DLANK ,E ID: tIU=1:IDER DATE REC ' D COLLECTION DATE ?At4T,1f'NG ADDRESS COLLECTION TIME WELL DEPTH 5TP,E1-T ADDRESS " YEAR WELL INSTALLED MAP/PARCEL T:CLC'PH0NE COLLECTED BY : E APP0I147I4ENT NE-L*DED' a F N FOR TESTING : ( ) SUSPECT A PROBLEM (EXPLAIN) ( ) REQUIRED ( ) FOR INFORMATION ONLY ( ) NEW WELL ( ) REAL ESTATE TRANSACTION ( ) OTHER ( EXPLAIN) C 4CE OF WELL FROM POSSIBLE CONTAMINATION SOURCES ( IN FEET) : SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY ,AS STATION OTHER TAP—PrTIENT USED; ( ) NONE ( ) WATER SOFTENER ( ) FILTER; SAMPLE TAKENa BEFORE/AFTER .TREATMENT (CIRCLE) RESULTS VOC ROUTINE CJ)LDAOFORM TOTAL COLIFORM\1.00 ML 1 . TRICHLOROETHANE ( PPB) Pli _ CONDUCTIVITY IRON (PPM) NITRATE-NITROGEN ( PPM) SODIUM (PPM) COPPER (PP14) Ai T_S DATE ; ANALYSIS DATE: Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I I O ed T o-te Rd., Owner:%hi-ei N c2,s c ea ge.¢ Date of Inspection: A � N BUILDING SEWER(locate on site plan) „ Depth below grade: 18 Materials of construction:_cast iron`x 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints;venting,evidence of leakage etc. �onz�z c�R�ea2 tight. No evidence, o� �eaage. System vented. thzough .the hou.3e ventzo SEPTIC TANK:—(locate on site plan) Depth below grade: Z Material.of construction: x x concrete_metal fiberglass_-polyethylene _other(explain) If tank is-metal list age:n Is age confirmed by a certificate) Certificate of Compliance(yes or no):_(attach a copy of Dimensions: 8' 6'.gong/5 ' 8'h.i.gh/4' 10'wade . Sludge depth: 2A. Distance from top of sludge to bottom of outlet tee or baffle: Z' 4" Scum thickness: t a a c e Distance from top of scum to top of outlet tee or baffle: 5 Distance from bottom of scum to bottom of outlet tee or baffle: IT" How were dimensions determined; m o n a e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural irate as related to outlet invert,evidence of leakage,etc.): grity,liquid levels Pump tank .eveay 2-3 yea2.6.,7ank a1212ealtz zt zuctulta eey zoundo aka e.�In.Pet and ouzzez zeez—z, GREASE TRAP: n o(locate on site plan) Depth below.grade: , Material of construction: concrete_metal fiberglass__polyethylene other (explain): n a Dimensions: n a Scum thickness: n a Distance from top of scum to top of outlet tee or baffle: n a Distance from bottom of scum to bottom of outlet tee or•baffle: na Date of last pumping: n a �- u Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,as related to outlet invert,evidence of leakage,etc.): h'�liquid levels as not iee sen;L ,rm,A S TnanPnfinn Rnrm gig siInnn 7 Page 8 of I I OFFICIAL INS•PECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS 9,", URF'A►CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I I O ed 7o e Rd., GJ 13a2n� a e. a.i Owner,.• e2 Date of lus.pectlon: TIGHT or BOLDING TANK: no (tank must be pumped at time of inspe`ction)(locate on site plan) Depth below.grade: na Material of construction: concrete. metal fiberglass__,__polyethylene other(explain). Dimensions: na Capacity: na gallons Design Flow: na gallons/day Alarm present(yes or no): HE Alarm level: na Alarm'in working.order(yes or no): Date of last pumping: na Comments(condition of ai.arm and float.switches,etc.): 7i ht o2 hoidin tank,3 not /22ebent.i DISTRIBUTION BOX y2,s (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: no 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.): 13oz hc�, one .9a e2a.e 1N0 evidence- o� .Reakage into 02 ou-t o� PQx iiln v»irlvnro, 4o.&db Ca221/01)e2. -- PUMP CHAMBER: n-o (locate on sife.plan) Pumps in working order(yes or.no): na Alarms in working order(yes or no):na Comments(note condition of pump chamber*condition of pumps and appurtenances, etc.); �u hamIe2 not 2ehen _ 8 Page 9 of 11 OFFICIAL INSPECTION PO.RM—NOTYOR VOLUNTARY ASSESSMENTS SE$SURFACE-SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART-C SYSTEM INFO TION(continued) Property Address: 11 Oid 7oLe Rd., 0 !3a2n,3ta .fie. (7a. Owner:./) ' Oi n Ni n trh0.o29e2 Date of Inspection: ,97 l 5 locate on site plan,excavation not required) SOIL ABSORPTION SYSTEM(SAS): If SAS not located explain why: Located see qGqi 10 Type its,number:l-10 0 0 ga U o n L l) with 2' .3 t o n e y e leaching p _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.): nce o h daau.eic acQuae. Ve etation 1" t o invent i e.1 3' stone aaound ieach.ing /2it,, CESSPOOLS:n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: nu Depth-top of liquid to inlet invert: n a Depth of solids layer: na Depth of scum layer: na Dimensions of cesspool: .na Materials of construction: na Indication of groundwater.inflow(yes or no): condition of vegetation,etc.): Comments(note condition of soil,signs of hydraulic failure,level of,pondtng, ooL6 not 1. 2ehenL PRIVY. no (locate on site plan) I Materials of construction: na Dimensions: na f Depth of solids: nu Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): l2.�vy not �aehent. • 9 Page 10 of 1'1 --\ OFFS 4,L INSPE y.'IQN F`CARM;�+NOT FOR'.VOL 1T1�`--AR'.Y ASSESSMENTS SiAE'SE.l�AGEDISci�05 "S' EA .IINSE'EG�'1C30N:FQRNIF PARS'Ct SYSTEM W ORMA'TLON(continved)` Property. Address: 91 O-ed 7o.e.e Rd,, y B Cl.' Own er:_%h.i�Lj.azch e2yet Date of Inspection:1 E SKETCH OF SEWAG)EM18POSA,L SYSTEM. Provide a sketch of the sewage disposal system including ties to at least two perinanerft referenee landmarks or benchmarks.Locate all wells w}thin 100 feet.Locate where public'water supply enters.the building. . *' Q%f s. -- 10 Page 11 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(continued) Property Address: 1 1 Led To—Pi Rcl-, /3rinnAIaP• PP IN,-, Owner: ? l O_T.s 0 h 0 2 gee Date of Inspection: SITE EXAM Slope Surface water Check cellar, .. Shallow wells Estimated depth to ground water feet _ Please indicate(check)all methods used to determine the high ground water elevation: 110 Obtained from system design plans on record-If checked,date of design plan Mviewed: \ . y,Observed site(abutting property/observation hole within 150 feet of.SAS) ,checked with local-Board of Health-explain:is g u i i L c a a d yeXhecked*with local excavators,installers-(attach documentation) yes Accessed USGS database=explain:h;t t,? •t own 9a2n,6.t.a ,ee.1 ma.i u,6 You must describe how you established•the high ground water elevation: used,Gaherty & Miller model 12/16/94 around water P _yatfnnG used,USGS observation well a a 7u e used• Technical bul — — wa er a eva ions. 10. Leaching Pit : "eet Groundwater: Feet Below Bottom-of Pit 14i&h Groundwater Adjustment 1.8 ft per Ygimpte Method :2 Therefore,the.vertical•separation distance betwten the bottom of the leaching pit and the adjusted groundwater table is feet: 3S I%J 4 . 11 e • •T.Tlrtt>—Rt'i��'T'C-tlJ��i1T'ItT�JSrTttT•iTTt'.TtT:T'OfTJ!R.Ttr![R9TT••tTJ1TLTT.T.fS TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART Dr- CERTIFICATION _.. r.••::*--.tt-^.--nr.. .r..rrt—rms*ra-r'.rr+'rsn rstmraarrttm—+T+'t •tea Ci A rsm n•ms�np•+rrrnrre+n5-rtr•rr•r.••�.•—..� —TYPE OA PRINT CIrEARLY— PROPERTY INSPECTED STREET ADDRESS ASSESSORS MAP, DLO;CK AND PARCEL # (� OWNER' S NAME r' - PART D - CERTIFICATION NAME OF INSPECTOR Qllr� , COMPANY NAME 7• 'C t 1 y !► 1LY11`i 0 � COMPANY ADDRESS : • + CQ 11� a e LIP Street Town or City S t COMPANY TELEPHONE G�oq, 1 �75 - 3�� FAX ( 1 . R CERTIFICATION STATEMENT I certify that I have personally .inspected the sewage disposal system at this address and that the information reported is true ,. accurate, and omplete as of the time ofom .inspection . The inspection was performed and any rne ndatiorls regarding upgrade , maintenance , and repair are consistent rec with my training and experience in the proper function and maintenance of on site sewage disposal systems . Check one : System PASSED The inspection which I have conducted has .not found" any information, which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR. 16 . 303 , Any failure cri t eria not evaluated are as stated in the FAILURE CRITERIA section of , this. form. , System FAILED* The inspection which I have con treted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspecti n fo . tr '" Date Inspector Signature I /( Oe copy of this certification must be provided to the .OW'NER, the, BUYER n where applicable ) and the 130ARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade ' the ayetem. within o•ne year of the date of the inspection, unless allowed or regui;red otherwise as provided in 3.10 chJR 16 . 306 , partd.doc f ��,�i Jr dip PARCE1. JAN 1 8 2005 LOwr TOWN OF BAD,'NSTABLE HEALTH DEPT. DATE 1/7/05 — PROPERTY ADPRESS 1 ' O ed 7o U Rd. AP �0 Gl U, Baan.6tag2e Ma.i 'ARCEL. (0 02668 On the above date,the,.�eptic system at the address above was Inspected. This system consists of the following: J., 1000 gaiion ZeRt.ic taak:- 2, 9-dizt/zigut.ion Sox. 3.4-9000 gaeion ..eeach.ing Based on lnspectlon, I certify the following conditions: 4. 7h:iz .is a t.itie �jve zept-ic e2hwo2k.ing code) ortde2 at the /s2e�ent time. 5.i7he he/Zt.ic �,yhtem .iz in /z2o/z 6.,7he waste watea .in ieach.ing /z-it way 38' ge-2ow the invent /2t/2e SIGNATURE.. ' Name: Robert A. Paolini Company: JamPh P Macomber &Son Inc . Address: P. 0. Box 6fi' Centerville, Mass 2632 Phone: 508 775.3338 or 508-775-0 2 •oupH p. MACOMBER & SONO. INC'. Tanks-Cesspoolsd.eachfieWS • Pump�d &••.Ins#alled Town Sewer•ConnsOtlons P.O. Box 66 Centerville, MA.026•3Z-0066 77 88$S . 7.75.6412 COMMONWEALTH OF MASSACHLtSETTB EXECUTIV'E OFpiGyOF'EjmperNM NTAL AFFAIRS kip I�EPA tTMENTOFj jMlif)kk TALPRt�T CTION TITLE 5 OFFICIAL INSPX-CTION kORM_.NO3'FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE*DISPOSAL SYS't'E,M FORM PART•A _ CERTIFICATION Property Address; 1 Oed To Le "i?d. No a znhta&,ee. Na.i Owner's Name: %hLiiI2 /U/t4ch`9vaae2 Owner's Address: S a me - Date of Inspection: I/7/0 5 Na»ie of Inspector: (please print) r,A_a a L Company Name: ? p.,Alaaom&,eh & 49n 1 40- i Mailing•Addt'ess• Pax -66 en e2y.c. e, ab e..Oz632 Telephone Number-, 5 0.8-7 7 j 3 3 3 8 CERTIFICAT10N STATEMENT . I ceitify that I have personally inspected the sewage disposal systoitt 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•�ite sewage disposal systems.I am a DEP approved system inspector pursuant to�Sectiowl&3400TWS 5(31.0 CMR•45:,100). The system: xx�c Passes \ -Conditionally Passes Nee Further Evaluation by the Local Approving4Authority Fa Inspector's SignatVtre: Date: The system inspector shall submit a copy of this inspection reporC o the.Approving Authority.(Board of Health or DEP)within 30 days of completigtg this inspection.If the systetti is.d.ph*d'sy#�or has a design flow of 10,000 gpd or greater, the inspector and the system'ownensliall`submit the•report to the appropriate regional office of the DEP.The orig'mal should be sent to�the.systcm ovmat andcopias sontto c> boyeY if�pp(icab(e,and the approving authority. Notes and Comments ****This'report only describes conditions at the time of inspectibr'and under the conditions of use at-that v^ thhe.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION:F01IM—NOT FOR=VOLUNTARY ASSESSMENTS � SUBSURFACE SEWAGE DISPOSAL.SYSTEM.INSPECTION.FOR_ PART`A CERTIFICATION(continued) Property Address: U ec� T o /2d. GI.,L3a zrz t aP tee Na., Owner:%hi iip 8i z.3ch9eae/ea Date of Inspection: 1/7/0 5 Inspection Summary: Checi A;B C;D or.E•/ALWAiYS6comp1etvaH of Section D A. System Passes: ho I have not found any information whicli 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 Condltionally Passes: n o One or more system components.as described in the"Conditional:Pass"section need to be replaced.or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not-determined(Y,N,ND)in the for the following statements.If"not determined'please explain. n o . The septic tank is metal and.aver 20 years old*or the septie-tank(whether metal.or not).isstructurally unsound,exhibits substantial infiltration or exfiltration.or•tank failure.is-.mrliinent.System will pass inspection if3he existing tank is replaced with'a complying septic�taok as approved by the:Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20'years old is available. ND explain: n o. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broker;settled-or uneven distribution box:.System will pass inspectipn.if(with approval of Board of Health)' broken.pipe(s).are replaced. . obstrridt 0fi is removed distfiBritiohbox is1evel0d or.r6plaeed ND explain: v Y' n o 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 pipes)are replaced obstruction is removed ND explain: r Page 3 of 11 00.1CIAL MFECTION-FORM-NOT VOR VOLUNTARY ASSESWENTS SUBStJRFAArCE SEWA.'CE�SR'OSWL SYSTEM INSP-tCTIdN,;FORM PART A.. . 'CER.TIFICAMON'(6ontinued)' Property Address: 1 l Oi'd 7oi e Rd., Owner:. Date of Inspection: C. Further Evaivation•is Required by the Board of Health: whichre uire further..eYaluation by•the Board:ofrHealth:in•order.to;ddtertriine if-the system. no Conditions.exist q is failing to protect public•health,.safety or thb environment. a: .s ( )( )that the 1. System will bass unless Board-of Health•detertnines�i�h accordance with 310.CMlt 15:3031 .b system is-not functioning in,a•mariner which:wlll•protect public health,safety:at[Q•ttte:.enstiroament; n o Cesspool or privy is.within,50 feet of asurface water n oo Cesspool or privy is within 50 feet of-a bordering vegetated wetland or a salt marsh. . . . � Z. System will fail unless the Board-of Health(and Public Water Supplier;-if any),determines:that the system is functioning in a mariner,that protects thepnblic health,safety and environment: no The system has aseptic tank and soil absorption system•(SA•S)..and the$AS is within 100 fe.etofa surface.water supply or-tributary to a surface water.supply. no The system-has•a.septic tank and SAS and the,,SAS is:within a Zone 1 of a••public wateresupply, no- The system has a septic tank and.SAS:and-the SAS is within:.50 fErx of a private water,supply welt'. n o The system has aseptic tank and SAS and the'SAS is less than 100 feet.but 50 feet oxatiore froit a private-water supply well". Method used to determine distance- **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic cozripounds indicates that the w.ell_is.free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or.less than 5.ppm,.provided that no-other failure'�criteria are triggered.'A copy of the anaiy5is must be attached to this form. Y 3, Other: Page 4 of 11 4FFIC AL•INSPECTIO'N FORM-NOT TOR VOLUNTARY ASSESSMENTS' .SUBSURFACE.SEWAGE SSYS'TEM.INSPECTION.FORM PART A CERTIFICATION(continued) Property Address: 11 U.e cl 7 o i i i2�• I., P-nnAt 9—ft, 77., Owner: ')` c h e 2 'e 2 Date of Inspection: " D. System Failure Criteria applicable to all systems:. �. You must indicate-"yes"•or"no"to.eacb.of:the:following,for all:inspections: Yes No x Backup.of sewiigo:into-facnity.:or system-cQmponent'dut'_to overloaded.oi clogged SAS..:4r.cesspool _ x ' Discharge:or-ponding of effluent to the.surface.of tber.ground ctr,surface maters due to.an'overloaded or clogged SAS or cesspool ' x Static liquid level in the distribution box above'outlet invert due to an overlbaded or clogged SAS or cesspool x Liquid depth inlcesspool is less than.6"below invett or.availablevolume is less than'/day flow x Required pumping more-than-4 times in the last year NOT due to ologged or obstructed pipe(s).Number of times pumped It x Any portion of-the SAS;cesspool or privy is below High ground water elevation. _ x Ariy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water-supply. x Any portion.:ofa-cesspool,or•privy s'within,a,Zone:l.,of.apublic.Ater x Any portion of a cesspool-or privy is within 50-feet of a private water supply well. x Any portion of a,cesspool-or-privy is less•than 100 feet but greater-than SQ.feet from a.grivae water if the well water�,analysis, .— m. a sses i ' .[This s ste supply well with no acceptable water quality.analysis.[ y . P . performed at a DEP certified laboratory,for coliform bacteria and volatile organic.compounds indicates:that the well is:free from pollutioq:from:tliaT,fac nlity thrat noesencoth�er f inure criteria on a nitrogen and nitrate nitrogen is equal to or less than.5.pp ,provided are-triggered.A copy of the analysis'niust be attached.to this form.-] n° (Yes/No)•3'he system ails.I'have determined that or..more:ofthe:Above.failurc criteria exist as m owner.shou'1d contact the Board of described in 310 CMR 15.303,therefore the.systenj.-fails.The-syste Health-to determine what will be-necessary to correct the failure. E. Large Systems: To be considered a large system 4he:system mustserve.aAcjlity with.a'design flow of 1.0;000 gpd-to 15�Q00. gpd. You must indicate either"yes"or"no"to,each of the following: (The following criteria apply to large systems in addition to-the criteria.above) yes no _ x the-system is within 400 feet of a surface drinking-water supply _ x the system.is within 200 feet of a tributary to a surface drinking Water supply �` T x the:system is located In a nitrogen sensitive are.4(interim Wellhead Protection Area IWPA)or a mapped Zone 11 of a public water supply well f you have answered"yes"to any question in Section E the system is considered a swner-or operator of any large system ignificant threat,or answered Ii yes"in Section D above the large system has failed.The o considered a significant threat under Section E or.failed under Section D'shall upgrade the 'system in accordance with 310 CIvilt 15.104.The system owner should contact the appropriate regional.office'of the Department. 4 I Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS $ttSURFACE SEWAGE DISPOSAL•:SYSTEM INSPECTION FORM PART P CHECKLIST Property Address: II 0-9d 7o U Rd., Owner:1h.ip.in d1A_ c_L e2gen Date of Inspection: 9/-71105 Check if the following have been done You must indicate"yes"or"no"as-.-to each.of the following: Yes No x — Pumping information was provided-bytFie owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x _ Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this-inspection? x _ Were as built plans of the system'obtained and examined?(If they were not available:tote i s N/A) x Was the facility or-dwelling inspected for signs of sewage back up? x Was the site inspected for signs of break out? X. Were all system components,excluding the SAS,located on site.? X. _ 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? _x _ Was.the facility owner(and occupants if diff6rent from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(AS),on the site.bas been determtived based on: Yes z — — Existing information:For example,a plan at the Board of Health. _ x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance . is unacceptable) [310 CMR 15.302(3)(b)J Y Page 6 of 11 OFFICIAL 1-NSPECTIOA1::11,QR,M'-NOT FOR VO:I UNTARY ASSESSMENT'S SUBS 'ACE-STWACE DISPOSAL SYSTEM>:INSPECTION:FORM � PART.0 SYSTEM jNFOItPvIATION Property Address: 11 O ed •7 o Le Rd., GI:,Baanzta&ie, Mao Owner: Ph% _112 HL'"chleapea Date of Inspection: 1/7/(15 FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design):�;<3 - Number of.bedrooms.-(actual):3 DESIGN':flow-based on*31fl CN IR 15.2.03*:(for eitample:'110 gpd z#-ofbedrooriis)' "' Ox 3=3 3 0 gad Number of current residents: .: 2 Does-,residence have a garbage grinder(yes br no): n o Is laundry on a separate sewage.system.(yes or.no):.n Eif yes Separate inspection required] Laundry system inspected(yes or no)y a hh Seasonal use:(yes or no): a o Water meter readings,if available(last 2 years usage(gpd)): Q \. Sump pump(Yes or no): n o + Last date of occupancy: /?2 e b e n t p eta is6 y COMMERCI LO STRI L Type of estali 'fat: n . s Design flow. on310 CMR 15.203):• I na apd Basis.of dsigi' low(seats/persons/sgft,etc.): na Grease traps resent(yes or no):.`n a Industrial waste holding tank present.(yes or no): na Non-sanitary waste discharged to the Title 5 system•(yes or no):n u Water..meter readings,if available: na Last'date of occupancy/use: .na OTHER(describe):. . GGENERAL INF QRIVICATION Pumping Recprds Source of information: j.,1.iNacom&en and son Was system pumped as part of the inspection(yes or no):n o If yes,volume pumped: �000 000gallons--How was quantity pumped determined? m e a u 2 e d a Reason for-pumping: a i n x ace e m TYPE OF SYSTEM - xx 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 tec}inology.Attach a copy of the current ope ration 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: � Were sewage odors detected when arriving at the site(yes or no):n o 6 NSTABLEC COUNTY DEPARTMENT OF HEALTH & THE ENVIRONMENT BAR , P.O. BOX 427 �� °"4ti SUPERIOR COURT HOUSE i BA.RNSTA.BLE, MASSACHUSETTS 02630 0 � PHONE: 362-2511 �r.�sy � EXT. 337 SAMPLING INSTRUCTIONS FOR PRIVATE WELLS An improperly taken sampi,e wastes your money and has neither scientific accuracy nor legal acceptance. 1. Obtain sterile sampling bottle from the County Lab or Town Health Department. Bortles sterilized at home are not acceptable. 3. It is recommended to use a st.Aight faucet, preferably NOT swingtype- 3. Turn on the cold water and let it run for five (5) minutes. 4. Fill the bottle leaving one inch air space. Do not till bottle to the top. Be careful not to touch the inside of the bottle or cap with the faucet, your hands, or anything else. 5. Fill out the reverse side of this form. The laboratory requires accurate and complete information. The person filling the bottle must sign the form 6. The charge for a routine well analysis (coliform bacteria, pH, conductivity, iron, nitrate, ould be made payable to Barnstable County. sodium and copper) is S25.00. Checks sh Exact change is required if paying in cash. Additional tests require additional fees. Consult Lab or a price list for exact information. 7. Samples are accepted Monday - Thursday from 8:00 AM to 4:00 PM and Friday 8:00 Alva to 1:00 PM. They must be delivered to the lab within 6 hours of collection or 24 hours if refrigerated. 8. Completion of tests and results takes 7-10 business days. Results,will be. sent in the mail. 9. Special requests such as results in 2 -3 days and sample acceptance on Friday from 1:00 PM to 4:00 PM are available for an additional charge. Contact the laboratory for availability. j�TiCE; `WATER FRO' ` THE S"* E catruC CAN PRODUCE CO F g=R 1 RFSt_1LT1�{E M( THE r �ry v 1.1.E .�v v .�n„�ti r,rt:�>~R1 NT LOCAT ONS )F jjj D AT D'► QOiJNTY OF BARNSTABLE SHALT, NOT BE I TABLE ? uAmA T S ��Si T[ TiNG FROM THE WATE ACC R_ATELY PERFOR D PL)ASE COMPLETE: REVERSE ODE QF FORM PRIVATE WELL WATER SAMPLE DATA COLLECTION SHEET VIAL t 1:U(.t 48:ERS FIELD DLANK , <tIU1J0ER DATE REC ' D COLLECTION DATE )-AA- 2G ADDRESS COLLECTION TIME WELL DEPTH SrRE T ADDRESS YEAR WELL INSTALLED MAP/PARCEL TfLE'PHONE COLLECTED BY : E APPOIN`i`MENT NE-L*DED• a F N FOR TESTING : ( ) SUSPECT A PROBLEM (EXPLAIN) ( ) REQUIRED ( ) FOR INFORMATIOtt ONLY ( ) )IE14 WELL ( ) REAL ESTATE TRANSACTION ( ) OTHER ( EXPLAIN) CJ-67RNCE OF WELL FROM POSSIBLE CONTAMINATION SOURCES ( IN FEET) SEPTIC TANK\CESSPOOL FARM SALTED ROAD UST LANDFILL INDUSTRY SAS STATI01l OTHER TAF-PrTIENT USED: ( ) NONE ( ) WATER SOFTENER ( ) FILTER; SA14PLE TAKEN BEFORE/AFTER TREATMENT (CIRCLE) . *** * ****** ********* ** ** ***** **** x * * * * * RESULTS . VOC ROUTINE CIFLOAOFORM TOTAL COLIFORM\100 ML 1 . TRICHLOROETHANE ( PPB) pli _ CONDUCTIVITY IRON ( PPM) _ 11ITRATE-11ITROGEN ( PPM) SODIUM (PPM) COPPER ( PP14) Ai ?S DATE : ANALYSIS DATE: Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Oid T o ii Rd., Owner:%h.i,e i K.t2h c eagea Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron-"-"' 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage etc. � nt� a�znea2 tight.,No evidence, o7P- Katage.,Syztem- vented, thitough .the hou-6e ventz., \. SEPTIC TANK:_(locate on site plan) Depth below grade: 2 Material of construction: -"-"concrete metal,_fiberglass_polyethylene _other(explain) _ If tank ate) al list age:n o Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8' 6",eongl5 ' 8'h.igh/4' 10"wide Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffle: 2' 4" Scum thickness: t 2 a c e Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: l 3" How were dimensions determined; Comments(on pumping recommendations,inlet and outl et tee or baffle condition structural irate `as related to outlet invert,evidence of leakage,etc.): ' gnty,liquid levels l um tank e 2 vey 2-3 yea/z,3., Tank a/2/2eaa,3 6tauctuzaiiy zoundo ka e.,In.eet cLnd out e ee , GREASE TRAP: n o(locate on site plan) Depth below.grade: , Material of construction: concrete_metal—fiberglass e g ___polyethylene_other (explain):lain): n a _ Dimensions: n a Scum thickness: n a Distance from top of scum to top of outlet tee or baffle: n a Distance from bottom of scum to bottom of outlet tee or-baffle: na Date of last pumping: n a Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,as related to outlet invert,evidence of leakage,etc.): liquid levels 2a not rcezent.,. Tit A C TnenPntinn Rnrm Aii gftnn 7 Page 8 of I I OV ICIAE INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS .9>�&V�':ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 O.-c1 T o ei Rd.. .. (� , 3 L u.i Owner: i e2 Date of I•uspection: n � w TIGHT or PIOLDING TANK: no (tank must be pumped at time of inspection)(locate on site plan) Depth below.grade: na Material of construction: concrete_ metal fiberglass____polyethylene other(explain): Dimensions: na Capacity: na gallons Design Flotiv: nn gallons/day Alarm present(yes or no): na Alarm level: i na Alarm"in working-order(yes or no): Date of last pumping: na Comments(condition of ai.arm and float-switches,etc.): ae�ent. Ti ht o2 ho edin tank,3 no /2 DISTRIBUTION BOX yeh (if present must be opened)(locate on site plan) Depth of liquid level above outleC invert: no 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,): ,1 ham, env i te2ae 4o evidence' oe .leakage .into oa out o� .irks caaa ove2.l PUMP CHAMBER: (locate on sife.plan) Pumps in working order(yes or.no): na Alarms in working order(yes or no):na Comments(note condition of pump chamber,condition of pumps and appurtenances,etb.); A not 2e�ent. 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE.DISPOSAL SYST':EM INSPECTION YORM PART—C SYSTEM INFORMATION(continued) Property Address: 11 0id T o Le Rd., lJ l3aa 7'ee. (�a. 0 w n e r:.aoLi0» Nin trhD 'zgeIL Date of Inspection: �r SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation-not required) If SAS not located explain why: Located -3ee Pe 10 Type y e�leaching pits,number:�- 10 0 0 g a g e o n L l with 2' s t o n e • _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.): nce o h d1tauLic aiQuae. Vegetation 7 ' n .t o .in Ue 7-t 12 t e. 3' a.tone aaound ieach.ing Rat. CESSPOOLS:n o (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: -na Depth-top of liquid to inlet invert: n a Depth of solids layer: rz Depth of scum layer: na Dimensions of cesspool: . na Materials of construction: na Indication of groundwater.inflow(yes or no): c failure,level of ponding,condition of vegetation,etc.): Comments(note condition of soil,signs of hydrauli 00 I PRIVY: no (locate on site plan) v Materials of construction: na Dimensions: na Depth of solids: nu signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Comments(note condition of soil, la.cvy not PaeZent. Page 10of11 OMCIAL-INSPECTION.FORM_'NOT FOR,V.OLUNT-A3tV-:ASSESS-M ENTS SUBSURFACE SE WAGED ?.OSAL SYSTEM,INSPEG'TION•:FORM PARS'C" SYSTEM INFORMATI.ON(p©ntinued)' Property. Address: 11 Ud 7 o to Rd., �l nn12bta.kQO . Ma.i Owner: PULL K�I"phP,e/tge/z Date of Inspection: 1 /7/Q 5 SKETCH OF SEWAGE.DI$POSA,L SYSTEM including ties t4 at least two permanent reference landmarks or Provide a sketch of the sewage disposal system benchmarks.Locate all wells within 100 feet.Locate where public water supply enters. the building. 10 Page 11 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: .11 62d 'T o y-.P Rd., /3rmnA rz Oo.. /rIn_ Owner: th; OI n N:n A^h 9 2gplt Date of inspection.:1/7/65 • /AfR SITE EXAM Slope Surface water Check cellar, Shallow wells Estimated depth to ground water feet Please indicate•(check)all methods used to determine the high ground water elevation: n o Obtained from system design plans on record-If checked,date of design plan Mviewed: _cLe_�Observed site(abutting property/observation hole within 150 feet of.SAS) checked with local Board of Health-explain:a,3- .iiL crud yer_hecked:with local excavators,installers-(attach doctunentation) yes AccessedUSGSdatabase=explain:/itt�:�owrz u2ri�stu fie. ma. u� �-. You must describe how you established the high ground water elevation: used;Gaherty & Miller model 12/16/9a around water P1Pvat'�nnc used;USGS observation well data June 199� used- Technical bul - - wa er a eva ions. Leaching Pit : ;eet Groundwater: Feet Below Bottom of Pit Hi&h Groundwater Adjustment 1.8 ft per&Limpte�Method 7berefore,the.vertical•separation distance between the bottom of the leact ing pit and the adjusted groundwater table is feet: ' 9 • 11 � . k:,•,� n,.-,•,•: .,r-.m- ..,,.,_-,.= r%m= .,n.,•�„J-�,.�. �,��.�'TOWN OF IIUARU OF 11EALT11 SUIISUIiFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION RRIR�ispTTSRTTRfIRR.•.TRT•T•^t••••••� ...�...-T„,..,.T-_. -^.--r..r.�n•n.•rrt-svrasc'.t:rr'r.'r+'ran rs:rer.-vrn+vrT�'�+� '� . —TYPE OR PRINT CI.EARLy— PROPERTY INSPECTED 99 STREET ADDRESS ASSESSORS MAP , BLWK AND PARCEL OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR COMPANY NAME COMPANY ADDRESS q:� + � CQ �-'�� Toxn or City Stag LIP Street COMPANY TELEPHONE (�� , 1 ��5 - � � j FAX R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this addr ess and. that the information reported is true , accurate, and omplete as of the time of •inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: System PASSED The inspection which I have conducted has not found- any information which indicates that the system fails to adequately protect public health or, the environment as defined in 310 CMR. 16 . 303 . Any failure criteria..not evaluated are as stated in the FAILURE CRITERIA secrtion of this form . System FAILED* The inspection which I have con Vcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - IAI.LURE CRITERIA of this inspecti n fo ,. r Inspector Signature Date Oe copy of this certification must be provided to the OWNER, the, BUYER n where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade ' the system. within o'ne year of the date of the inspection., unless allowed or required otherwise as provided in 3,10 chj.R 15 . 305 . partd.doc AsBuilt Page 1 of 1 SEWAGE INSPECTIONS LOCATION 1I I T. DATE VILLAGE I ±�I� a�(o ASSESSOR'S MAP L LOT JtN •INs BcToa olia roltbor ayiA Vim. SEMC TMK CAPAC= LEACHING FACILrIY: (type} (sizc) NO.OF BEDROOMS BUILDER OR OWNER E�t l rc' h 1 0�2 OWNER MAILING ADDRESS 30 90, / / I y ,\ http://issgl2/intranet/propdata/prebuilt.aspx?mappar=109069&seq=2 9/1/2015 L O C A T`' S PERMIT NO. TVf 4_ VILLAGE ap--�j �g�i INS LE S NA i ADD SS r--� 7� SUIL ER 0 OWNER S7 C DATE PERMIT ISSUED DAT E C 0 M P L I A N C E ISSUED (� 2-6 �5 l o �� p� L'Oe T10N' I � SEWAGE PERMIT NO. LoT 0/-0 -TOLL RI) VILLAGE i .ij , t3r9�/�s T�4�[E 1®� () `q INSTALLER'S NAME i ADDRESS SKr P M i o c4j B ER. Q U I L D E R OR OWNER P Hfrs H 13E ROC k DATE PERMIT ISSUED :5 1 —$S DATE COMPLIANCE ISSUED 6 Lo� 61g5 (7U 7701_ Quo O eu A IL THE COMMONWEALTH OF MASSACHUSETTS , _ BOAR® F )HEAL.TH I�1 ........... OF.....,. Y!X .���►! s- Appliratiou for Diipntial Worse Towitrurt.inn Frrutit OApplication is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: / ...GQ�...�..3........... t�......,1... : 6...... A&IJ ....--- .........._ ... --- ocat' n-Add e �e� Lot = � . . ......... .........•••°=�........ --- ��- ------_1................................. ,A Owner YAidress Installer Address Type of Building Size Lot.....4 Z 160 1Sq. feet Dwelling�. of Bedrooms______ ____ _--------__-------------------Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons___--_______-__--__.._--____ Showers ( ) — Cafeteria x� Pa Other fixtures -------------------------------- . -- w Design Flow.....................5.5............gallons per person ep day. Total daddy flow............... ..----------- ons.� WSeptic Tank—Liquid capacity..fOgallons Length. . ._ Width -._=�Q Diameter---------------- Depth. _. x Disposal Trench—No..................... Width._. 8__..___._._ Total Length..... Total leaching area-_____-------------sq. ft. Seepage Pit No._______-_1________ Diameter...........-__. Depth below inlet...4 .---- Total leaching area ......sq. ft. Z Other Distribution box ( ) Dosingnk ) 0-4 Percolation Test Resu s Performed by.__..... . j .`` _____ b ..�'._......... Date........................................ 14,-a Test Pit No. 1..�-.Z--minutes per inch Depth of Test Pit----- .. Depth to ground water..... :�:r/(a fXq Test Pit No. 2................minutes per inch Depth of Test Pit......,/ -_-- Depth to ground water------.__a.._.........` O Description of Soil-----....... ......... / ' �! .._ V x w . t. .4 . ') - U Nature of Repairs or Alterations—Answer when applicable______________________________r. Y i::`__-. _s......__._....___...__......._......._..... ---------------------------•---------------------------------------.....---------------•--------..._........•-•------••----••-------......-•••-••--------•--•-•----•-•---•-•----------------•--•--••-• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TT?,4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue oar health. Signed-- ..... .. ....... ...... .... ......................... .------. . �'l� ate ApplicationApproved By..... --• •----- ----••�•..----•...........................•-•-•..............•---_..: = � Date Application Disapproved for the following reasons---------------------------------------------------------------•--------- ....................................... •----•--------•------•------•------•------------------•-•••--•-------------•-----•------...... Date Permit No 4�.._.6. - 0 Issued................................ Date NO.,!C� iI Fps.. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD/OF HEALTH // 5. Appliration for Uigprrii al Workg Tonotrurtion Vamit Application is hereby made for a Permit to Construct X ) or Repair ( ) an Individual Sewage Disposal System at: _ /� , .......... - - ..................... Location-Add e /��lr /_ i« / 1�c:�L� ----------------- ..........��__GX---�.... tA.r��i. ------------..........------ • Owner ddress co .............................. -- J ...- ••-•-•---------------•............ InstalIer Address d Type of Building Size Lot....4_7_ .e-Sq. feet U g �,,,._ __.••Expansion Attic age Grinder( ) Garb ( )Dwelling�—''•�To. of Bedrooms___..:.__. _______________________a —Other—Type of Building ____-_---_.•________________ No. of persons............_--------------- Showers ( ) Cafeteria Other fixtures W Design Flow..................... ... •----.-:-----.gallons per,person ,er day. Total dajly flow.......__.__................._ -_n......_..... lons., WSeptic Tank—Liquid capacity.!� gallons Length_ .: ... Width.4._-:/6. Diameter_-._--__-____-- Depth :4t._. x Disposal Trench—No. .................... Width_.__,,........... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........../-------- Diameter---------y..... Depth below inlet.............. Total leaching areaZ�......sq. ft. Z Other Distribution box ( ) Dosing tank ( ? _ W Percolation Test Rest�is Performed by..___-- - -------•------ ----- -----�-...._._-_.__-_-- Date.....-......---------------........... --- ,.a Test Pit No. 1_G-_ minutes per inch Depth of Test Pit___-_1_...._ .... Depth to ground water_-_ (i Test Pit No. 2................minutes per inch Depth of Test Pit......ll�._-_-_-- Depth to ground water......................... a - j: -_------------- - rl .. O ; !escrpton o o ---------- ----..... � . ...... I ._. ��V x / *-- J � W UNature of Repairs or Alterations—Answer when applicable._.............................................................................................. ---------••-• ------•---•---•--•---------------••••-•••--•-••-•••••••------•--------•---........-----•---------•---------------••---------•---•-••-----------•-•----•--•----•-----•-----...........••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T'iE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in Si ned___....__�'' � e boar o health. operation untila Certificate o Compliance has been iss>�� t - � �r ,�.� ,, j � `� at Application Approved By-........--:._-�...._... __ . ......4 ...-----•---- Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•-------------------------•-•--- ........•----•--------------••----•--...----•------....--------••••••••---•------•---...•-----------•---------••----•---••--•---------•---•-•----••--------••••---•----- ............................... ` Date Permit No.�...0_ . `v <. Issued................................................. Date �, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........:...............................OF..................................................................................... Trrtif iratr of ToutpliFanrr THIS IS TOCBRTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) 4 er----------------------------------•---.....-----------•---•--...............------------....._._.. = by......................... - Installer J at has been installed in accordance with the provisions of f T!Z 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.... ----- t_!: ?... dated-..... ._�. _._�. __ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CT R E® AS A GU RANTEE THAT THE SYSTEM WILL FUN TION SATISFACTORY. DATE...---.k7. . .[�.. ........................................... Inspector.... -- ...... •••--- .............................. THE COMMONWEALTH OF`MASSACHUSETTS BOARD OF HEALTH ..............OF .....: No....... .......�.... ... FEE. J. ....................... Djisvos al Works %'WnmArmlion irrntit Permission is hereby granted............... Q n 6fx....................... to Construct ( ) or Repair ( ) an Individua Sewage Disposal System r '^�� a`�� ... .C-I., _4_.----•----�� at No.... � f `��� Street . lUr� as shown on the application for Disposal Works Construction Permit No_____________________ Dated.......................................... ...q_l P Board of Health ................ ... l---------------------------------------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS - - BAXTER & NYE, INC. Registered Land Surveyors and Civil Engineers 7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131 WII.LIAM C.NYE,R.L.S.-President RICHARD A.BAXTER,ILLS.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering ` June 21, 1985 Board of Health Town of Barnstable 367 Main Street Hyannis, MA 02601 RE: Lot 73 Old Toll Road, West Barnstable Disposal Works Installer: J.P. Macomber & Sons, Inc. Applicant: P. Hirshberger Dear Board: Pursuant to your written request of June 5, 2 have conducted design evaluation of the installed leach pit at Lot 73 Old Toll Road. It can be concluded from the evaluation that the system, as installed, meets the minimum. requirements of Title V and Town of Barnstable (excluding the present variance. request) , ' The design evaluation was based .upon the following: 1. Test holes verifying the depth and consistency of the leaching .strata. 2. A test hole verifying the depth of dry material below the existing system. 3. A percolation test to evaluate the suitability of the leaching strata. The percolation test was conducted in strict accordance to Title V pro- cedures and resulted in a 1 inch drop in 6 minutes. 4. A conservative assumption was made on the amount of stone physically in place. This was based upon measurements taken at the top and bottom of the leach pit. MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORSIAMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACRUSKTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS Page -2- Board of Health Town of Barnstable June.21, 1985 Analysis shows that the installed system has a- moderate factor of safety above the estimated daily flow (330 G.P.D. ) . , Please note that .although the installed system is adequate, the proposed system as originally designed, would have been a far better system for this site resulting in a longer working life. I trust this meets your present needs. If I may answer any questions, please do not hesitate to call. Very truly yours, Peter Sullivan, P.E. Baxter & Nye, Inc. PS/bc CC: P. Hirshberger J.P. Macomber & Sons', Inc. �,,✓'�� OF �9S"9 o� r PETER SULLIVAN No. 29733 ` p .0P, STE�.�\�.tr��r Jj n� s M 38 (O 39, aN iv .y P Q � 1 N Np �} O 17z,4 CE,� /E4 SLOT EA �2EG/STE.eE� L�{�c./O .SU.e{iEyb,C�S �STE.21i/.G��a �l.4SS. R. A. •Bousfield Backhoe Service 17 Burbank Street Sandwich, Massachusetts R'' f 02563 C1 tlame ��� � _��rzasT,�2 �� ��`�� Sewer Permit No. -E 51 7 4-" Location. Builder's Name and Address 42a.2,S7lPl cziac. .21-Y Date Permit Issued: 17_ 6 - 7/ ELL --fir U9T1oM Date Compliance Issued: G N.. `� ,� � .� �09 _ 061;7 / �-e No.................... '...... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... .....-- .OF.............601.t. . . . .............................. Appliration -fear 13itipwiaf Works Tonstrnrtinn Vamit /�► Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -----�°..-----j7��/......P-v--------------------•---------------------------. ..........................7��------------------....------------------------------------ Loca'on-Address Lot VSK Address A W !1----�-•------ O V �/—. ....... f�(it Z......�' f!'� �. Installer I Address ��CC� Type of Building Size Lot.�?t__Jr76,3----Sq. feet Dwelling A?N_`o. of Bedrooms-------------S-------------------------Expansion Attic (No) Garbage Grinder (14� aOther—Type of Building ---------------------------- No. of persons._-_--------____---____-_- Showers (A) — Cafeteria ( ) Q, Other fixtures ...................................................... W Design Flow._ _._-___.._____ ............_�a`llons per person per day. Total daily flow.......��r�---_-.............gallons. W Septic Tank T Liquid capacity/"--vgallons Length................ Width................ Diameter......... ...... Depth----...... ...... x Disposal Trench—No. .................... Widt19 �To�Length.................... Total leaching area..............------sq. ft. Seepage Pit No......../-_-------- Diameter. ept?1i'b``elow let-. Total leaching tre:l.._...__ 1. ------. _sc ft. I z Other Distribution box ( ) Dosing tanlj ) G 01iol` - 7 ~' Percolation Test Results Performed by...- .. •... ..... ... .... Date... a Test Pit No. 1----------------minutes per inch Depth of "1'es Pit..______.___.______. Depth to grown water__._____.__.___.__.__._. fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water- .---___._-.-_-_-._. . G Description of 1 "� 2_.r'a..... :......--• -- �A x --•----- _dam - -- W _ UNature of Repairs or Alterations—An wer when applicable....................................................... -------------------------•------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersi ed further agrees not to place the system in operation until a Certificate of Compliance has be issued b leg boar f health. / Signe . .. .. .../... ................. ........................... •------ Dat� Application Approved By----- ---------- -- �------- Date Application Disapproved for the following reasons----------------•------------------------------------------------------------------------------------------------ --••--••----•---••--•--•--------••---------------•••••----•-•---•-•-------•------•-••-------••••-------......--•-••-•••---••-....-••••---------•--•------------------------------------......-----•---•-- Date Permit No. � 1 Issued.... �l..!......-- Date �J 0 No............ _t /A................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... -....OF............. !..... .._.......... ................................ Appliration -for Utspoiial Works Tonmrurtion Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ --.......... ./------...='-// ---•/'`f-----•-----------------------------------•------ j� -------•--•---.....------------------...__......----- r / Location.Address /,,• or Lot No. 1.. ice: ii L A •.... ................; ........ Owner ....................... ..........r•..........................Address-----• •- ------...----- /try ✓7y tl 1 W ..�_..�.../----- --- �---•�t=r. �.�--------------------------••--•--•--• ........................'----- ... ...... ' =._.---------------------------- Installer Address UType of Building Size Lot_.=:,....: ....Sq. feet Dwelling L-No. of Bedrooms.............. .2-------------------------Expansion Attic (0j) Garbage Grinder (11)' � Other—Type of Building ---------------------------- No. of persons....__._......_............. Showers Cafeteria ( ) Otherfixtures ------------------------------------------------------ ------------------------------------------ Design Flow......-'-----------------------_---_-___.-_ tllons per person per day. Total daily flow........-_--__......_-.._.._.._-------------gallons. W . --��-rJ WSeptic Tank—1 Liquid capacity/e_V_'. allons Length................ Width...........-.... Diameter--------------- Depth----..----_--- x Disposal Trench—No. .................... Width............... _.--_-------..------ Total leaching area..-..---_----..-----sq. ft. f �o�LengthSee a e Pit No........._ Diameter_. ..d` � �UDe Total leaching area._._..___._._____sq. it. p g /___ ptlow inlet z Other Distribution box ( ) Dosing tanl , ) © 1 ' �•G �'�'I 7 Percolation Test Results Performed by 1'�"''.. IOUI�...�.... ----- Date---- �1,. F - /---�- Test Pit No. 1----------------minutes per inch Depth of Pest Pit.................... Depth to ground water...--------..-..--.-.._. f� Test Pit No. 2................minutes per inch Depth of Test Pit--------------------- Depth to ground water-..------------------- ------------------ .. - S ---------------- 0 Description of S•il_-.-_.-- �:.c- ` X_ 7 7 L l,� - ' --�t x -- ---- ------_--- --- U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------- -------------------------. ----------------------------------------------------------------------------- ...................... ------------------------------------------------------------------------------------------------ Agreement: -- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by.the board of health. Signe ..X... ....... ��� 74 .?s✓r ✓/ /j/ ' Date Application Approved By------ - f .. ------�_-G------ ------- 7 7� Date Application Disapproved for the following reasons---------------------------------•------•-----------.....-•---------------•-•--•-------------•---•---....._--•-•- ••• •_..._ .....--••-----------------------•----•-•--------•-•----•----•--_...._ ...-----...-•----- Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... .. ..........OF.......... . .. �j� O.rrtifirate of f".1ompliatta THIS TO E F That e.In i f'al Sewage Disposal System constructed ( <or Repaired ( ) by L' >�IY► '�-�' ` �� .i. . ---------- ��/[�/' 7/ / J�/ (////[ / / at. ___ _.v.!.._____!-_f.-__ __ ____.� !__�6 (!` ---- ---- Lr / has been installed in accordance with the provisions of A XI of The State Sanitary Code a described in the application for Disposal Works Construction Permit No............... .. .. ............ dated.._.__7'. -__ 7Z_................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................��...- ---- -- ---- -----V7.7......... Inspector...................... --------------------- ------------------------ ----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No................ FEE.��J............. iottl or ii ClIonitr ti .$ Vrrmit Permission is hereby granted.----- � - to Constr ct ( �or eepatr ( ) an Individu_a Swage DispoS 1 S. / at No.- 1�.c MSG;/� L� �'L`'= — ! T//{. X t✓�'-/%[_G------------- u'ti'G( '.-------- / ---•--•----- '-Street---• _ as shown on the application for Disp sal Works Construction P r,.m' No.___'__._...,._� Dated..... 7 6 ._.. - ------ , -. .--------------------------- DATE / j J' / 7 7 Board of Health •.............................................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • ((( j Ir! , _ I 1. f : 'r t r �✓ I t i I j ) I 1 : i t I I . i I Ir Jz ; I • i41 i 1 /, � I I I i r- I -41 ! I I o ri. ! i Ir AL'AN W. JONES: &' ASSOCIATES' { CONSULTING-ENGINEERS, ' � r a� •; y tJ r � : .A. ��{+ t of �� f {. , CARLETON DRIVE f .c EAST SANDWICH, MASS.02537 TELEPHONE 888-3154 R f TEST,FIT �NPD,•PE 2 0LA!10 J TEST T"�8ri3,, 197 � «•� f . .r. .�. � :.hs f TO, 5avery �o. � Inc; . ` P���arinel Presents �'aul tAurray' ! a r�x 899 ' Charles' Ne'rr�.`s�rn u t Sandw ch Mass.« .,-Alan V ',Jpnes- f gip:°r Lat11 '8 E LI�Gt3ent� Ort�'i®3S CC9rT1£X' ofk, ,.1`4r1 • R' ,' r'F.. - .;„ a +•,, 101t, .. ♦fx ,a'` � ,r F li.. Ba lf7•dQ.MJl Gi S'.' - , �,�7^+,'+�.'r"► '�l•. �jf y�s�+ ,l��.y '•. r i.. 7 ,i�t T...� r �, '0 i© •. A. L7.1.ound "®ua.i agg topsoil & sub soil JY }J 2! k h - r . Y j '` 2. .. / 1 s ' -'� � YAK r lM j . .Vrti',P<` "�'' "t"•' �J••.'� t } �T x 'J• a r. P+ .r '� +'. r t, ! Pr ° .y„' '. � �'" F+~4,.a' i,r,+ a .' y ♦ _' ,: F` + '� -. f` �+i a�+ a ° ; I•• t is r'. a Y` '� 1 }�IgjjT.pactl},,,ye ' 3. .• �y `r ! . S oo r .P ` �, q a + s Ave�rago erica atidn F.�tto t . .IN. 'dro in ess 'th n ins. �0" y r '� of l"i,rm." fine, white x O ,A , • ,. � ., tiro a rJ v(r ! •. ` �c,. Nta .}Yater erze©U3"1't�'ret�:: ' Nc 51b � ��• � F - A }Waterilevels indicated, f a as a those observed when: test F a x" y ! p, ' excavated and`'dog .nod necessarily represent ;permepent "ground water le 4 - • tt ' L�.'�•,Ga.0 Z �j� � sf` 8oTTOKA= 0 ,FXt SF =S?3GP0 / / j .- �'' j ' sk V EC SF X Z� 5�=3�5 •h a� u '� G i 156 YT / icx�. ASSv 70 � f Stu TIA 0 G� 3` .42 _- T ccvc�z T� L � � h.Qt� D.�.,�x -" \ vvv ct�• ►� � fr.�1 �U ZU ' 1 �► tMI V � h1C. �G1+ _ 5 S tb t ,p tUl•Z 161,4 Ib1,te $ GX(. r a n!Ta v�I St I TZ)P Z, y� sa.7 t Tn WIT12 (A--L to D Nti wT S i DE Sy ell Taq vCp-c Qh:F-; rt J r Z t / t50 t 'G Tt P--f TOT .. Tic A13&4E stAe- vo J T F 1c) sc-- CCA—)1=41 JF!rat 1-6> 1141ca S\ r Luc (Ze u l F jr-� ' .6 r TN .� E-ST � ��Qs F{V� LE 1 �4 A. CF c� MLLIAM ,� �,£ Les! ll-�re�) to Z' -8 wl u-C _-­ ___`­­-__­-1 I '­­ ­11 ­1­1­11 ­ - 1 , � "�-I I-—-I" - ­ �­,­ ­,­,"..­ I'll " .-�­-- --.-t-- , , - -_ , , ,, ­_ , , " , - -__ --, --I- --------I'---- _­­-__7----:--­77�-----I.--- ___­-------.---,- ­ --�-,-­­­_____.._.___.­..l.l.........I'A­.­.­­.�� . . � . . . � � I I -� I I I I I I "I , �I � , I - �11 I - I I � I -I I I I I .., �- � � I I . , ,, I � .. I � . I I -1 I 11 milm R.11 �, � -_-,-1p--- __ __ - --- - - I I � I � I . . I I .. . .11 � � I� � � I I .. I � . 1 I I I I I I I I . I , I I I ,.11 � I I - � . .. . � I . I I I . "I � - � � I . I - . I � I . I I I . - I I I I . I - I .I I I I � - I I . . � . I I . . �, I I I - I I � I I I I 4 � I I - I I I I I I I � I � I I I I . I I I � . � I I . � - � - � . 11 I I � . . - I I � - I I � I I I I . 1� � I . I I . I 11 � I � �� I � . - . � I -_ . . I . I I . ll� . I I - I I ., 4 1 . I I 1�11, � � I � - I I I ­', I I ., I I �l I I I I �I I 1, lw� � I I . � . I I � I I . � I I I -., ,; -� I* I I � - . I I I I , . "" � I �_I.,­I� -I I I I I I . - .� I � - . . I 1�oft 4 1 1 . : I .. I I ( , I � - � I I . � I I I . - . � I � . I . I I . I� � I il I ,I- I . , , I � � I 1. . I . � I I I .� I I I - � I I , I I I - I . I I I I � I �l . 11 I I,- I I � , * I I � � I - . I I _/ - ..1 I� '. ACCESS COVERS MUS r BE WITHIN - I I I MIN 2' OF PEASTONE � I I � . _� I , I I . , I INVERT EL EVA T I ONS : DESIGN CRI TERIA : " I -, I I 1 6' OF FINISH GRADE I OR FILTER FABRIC �I . i �7­1 __.) I - - 1 9' MINIMUM. . INVERT OUT SEPTIC TANK: 10!5,.w DESIGN FLOW: 1 4 ___,_:��l,� I I I . I . - � . - I , � , .� � A � . I - I FIRST 2' TO , . I- I I ' �� , J14' - 1 112" DIA. INVERT IN DIST. BOX: 104.27 3 BEDROOMS AT I/O G.P.D. PER /.', THIS PLAN IS FOR THE DESIGN AND, NSTRUCTION - I I I � . - BE LEVEL . I . I � ,� I . .. . I . � DOUBLE WASHED STONE �INVERT OUT DIST. BOX: ;,� AL SYSTEM OA(L-Y, � I . ff�7 r-T _\ 14),I. 1 .P.D. - - � - .� I � � I 1 3* MAXIMUM COVER I I . ; � 1 4' DlAk PlPf , . I � 110q. C. � o ,��_ , . . . I I - __ - .1. 104.5 . 'INVERT IN LEACH CHAMBER: . �d , - __ : __ ; I � 2. 4 VERTICAL DATUM IS ASSUMED. FOR � ' '� I I f � . 1. � I I �BOTTOM OF LEACH CHAPBER: /0 t.e� NO GARBAGE GRINDER . � I - ,O�H MARKS I - III %; 40 MILL POLY f 3, SET. SEE S I TE "PL-A N. .. _�� I,, Jr-;�_,o f T2- I � Z-<- --- . I � . I ;r eA S I /Oz.O.d I � ,U/A '�­ .,�_. ,"-I-"- I RAFFLE) I 0 � - SEPTIC TANK REOUIRED: , I �..1,, %�_ � I I, - , I I I 1 3 OUTLET 3-3050 INFILTRATOR CHAA48ERS �l BS P,IA 330 G.P.D. X 200V - 660 GAL. 3. 'It ALL CONSTRUCTION� METHODS AND MATERIALS AND - 11 . " i I i ` '' I I . I EXISTING 102.5 ��BOTTOM OF TEST HOLE *I: 9's.c�i SEPTIC TANKPRO VIDED: 1000 GAL. EXISTING 4MAINTENANCE OF THE SEPTIC SYS S d I I 11 I D-BOX W14* STONE AROUND. , 12'r x 2_9*/ x 2*d ) ­'. TE4 HA . .1, /000 6AL� . _� I I I" I It . � 11 I . � - �CONFORM TO MASS. D.E.P. TITLE ;5�ANb LOCAL 11 ' I I I � , - ,__`r_ � - � SEPTIC TANK 6' CRUSHED STONE OR . ) I . I I I . ; SOIL ABSORPTION SYSTEUREOUIRED: WARD OF HEALTH REGULATIONS. ­­ - I . - . I I .,-"-:�:," I COMPACTED BASE i . t - I "I I .; . I ! - t 'l__.' � I . � � I I I I I SOIL TEXTURAL CLASS - I 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER - . . . ' � � . . PROFILE : NOT TO SCALE I � . . EFFLUENT LOADING RATE - 0.66 GPDISF �REAS SUBJECT TO VEHICULAR TRAFF��"-OR GREATER I . � I ,� 11 1. I I � . . . � -, � 1 �HAN 4- IN DEPT14 SHALL BE_CAPAiL F W I TH-, I ,__�,,�/ .. : I I � I -1 I � I ­1� i I I STANDING H-20 WHEEL LOADS. . ,� I . . I / .� ; I I I i . . I I . . - I ­1,1 " __ I I PROVIDED: 3-3050 INFILTRATOR CHAMBERS I - ,,, I ; ­ N I ) � / 1, /I I/__11' '__�1-1 FEL L. . I � W14' STONE AROUND. A-512 S.F. . . 5. AL SCHEDULE 40 PVC OR - .- . I � I / 1�, i. ,,,�� I f I ---,---, " _�'11,I � 1 512 S.F. x 0.74 - 338 G.P.D. APPROVED EOUAL. � I I I� �.�, 1-11 4 � , � �, I I I A I . . . / 1\ Z.11-1\ . � . 6. SIPTIC TANKAND D-BOX SHAL 1 � � I . C�,/ I 1� SOIL TES T PIT DATA & Pk OVED POL�k'THYLENE. - � � I Q_ .0 0, I- . , c .r � ECAST CONCRETE OR APPR �­ ,,,�XA�\ , � 171, � k" .,� , � / I I 1. '. I �l !�; �s �T-p - � 11 BOTH SHALL BE WATERTIGHT. D-BOX.,SHALL BE WATER " . . I 1�, I \N I 4 \. I ," � Q e�, ­�--__ I INDICATES V INDICATES 11 "- \ 0, 4 � , / � . ! . TiSTED FOR LEVEL WHEN THERE IS M�R�EHAN ONE �� ­ .1 N _ �,,, ' � PERCOLATION -= OBSERVED � I I � .11 I � = . I I 1-1 t� \-L Ocus'*4�' // / � ;, I TEST . GROUNDWATER I N_ . I.. I 'N I "/' � z 11 -1 � I O U7L E T. - __�� � : $I-- " / ! � �. 4'�_ " I I I � � ---, I 1_�1041 \ I ,I I . 1�1��l " � . ,,, � - I , "�, & ,Ajkp��_ '11, � TP *1 I TP #2 -DIG-SAFE-. - 11 . , 1 7. 8EkORE CONSTRUCTION CALL I - . - '��"l.,:,,N,", I I , / I . ; . � I I I I��- q �", - RIZON TEXTURE t� 1 . I . I I IN, 1, _�� I . i HORIZON TEXTURE ' COLOR COLOR � . ND THE LOCAL WATER,DEPT. I I I I - I "_ "",�'. . v I � ; u - /08.0 O' - 108.0 FOR LOCATION OF UNDERGROUND UTILItIES. , . ----' � , I ! . � ­__ . - I _� 11 �"" I /k, .I i I �. I , � , � ____ I , � . 1-1 / \1 � - FILL � - - - FILL - � I I � 1, ___- ", ,% I :, _. - HALL NO 7)f y THE L � I.L I I �� \ I I 1. d. SEPTIC SYSTEM INSTALLER 5 I - I I __�-, ---__ ll�l , / . 1.IWL 16-- ------a.................................X., - 106.7 12.. ...............................:.......... - 107.0 � I 11 -_ " � lk � LOAMY IOYR .­,,I , LOAMY IOYR S RIOR TO !�ONSTRUCTION- - I I '. ; I Nl-.,, �_� , \ I : 'f - - . I. , .1 I I . - . - \ �_ - A A OF iik'E S YS TEM TO AL L 0 W FOR SCHEDUL I NG OF THE I � I � I 1\ %. t SAND 411 . SAND 411 . I I I , ., I . 1� \ � I . I CONSTRUCTION INSPECTIONS. k - � I . , , I I �l \ \ C) . � 1 20.. .......................................... - 106.3 /6'- .--,............................I.....I— - 106.5 . - I I I I 11 - I 1, , � I \ I � I LOCUS MAP - \ I . �,f I � I : 11 I '. � ", . \ \� ,;:"Ik � LOAMY IIOYR LOAMY � IOYR I . I I �� . ,� I- � . I I . I � \ 00 \ � I . I � - B i � - ,. . - g I STING LEACH PIT TO BE PUMPED DRY AND I I .� . 1, I-, I \ , I I � SAND 416 � I SAND - 1 9. EXI I I ­ I . I I 1 . \ I . lz.� I � I � � I I � �, L' 7 .1 . . . � . - 1\ I \ \ ; 44-- --------------------I........................ - 104.3 40.. .......................................... - 104.7 BACKFILLED. , I I � 1� . . � � .� � - I I , I I I I I I � I . � . I � I � \ - \ I I - I i I � �, 1\ � I .� \ 0 RM. CATCH PAS I IN � C I LOAMY , , - IOYR � _ Cl LOAMY IOYR I 11 � I - . . 11 .1 I .. I . . L � . . I 11 I I I 1 . � 11 \ \ RIM-910.38 � - - I . - ; I I I . - I I L � I .1 I I � . - I',, . .. 11 \ \\ I , - I SAND AND , �614 . . , 11 SAND AND 614 � I I 10. ALL UNSUITABLE MA TER IAL (A A 8 HORIZONS) ,, `�, - I I I L � I I I . � .__ I � 1� 11 \ . \_-� � I . . I �� I ' - � - . . "I I I I , � 601 1 6RA VEL AND , � - - � ORA VEL AND I - �. � i� � I .11 - . I ENCOUNTERED BEL.OW THF INVERT OF THE'LEACHING-' , � . I . . � I I I I I I N.- \ - \ I I . 1 � "I , I I 1. - 1 � , . I � I ,_1 _al I 1� �-, L I I I I . � I � �I',- . . /+ � I I \ \1 � \ , C) I _ 5 COBBLES I I � 1 ..'�.Z��_ 1 �l I I � I FACILITY T6.9,F-REMOVED FOR A DISTANCE,OF ,5. �- .".�I . � -.� . . I I '_�, �. - I \ . \ \ I , � - , I - �1 1(4 - 1. I I " I I � . I" . "I ­ I .� I - � I � � I .��, . - - I- I, - \ ., \ .1 ____ - -, � ­ -11,A- .� , I �. I . I� - -, � I . � I , I I . \ \ 6 1711 I - I.- I I—.I . - I � -­ -­�,�r-�, _­:i--_ �_ � I I ­ ------- �. . - I � WITH SAND I N ACCORDANCE _,� ­1-_�.�­ I I I . I I - I . . I I � . . ,1� , � � \, � . I � 11 ; I - I - - � - . -- - ­ � I '------ _____I - I .--- .-- I � - . 1 . I ­ - I I � . . . I I I I-.�I I ,I 1 \ , . I - � - . . � I . . 11 I I WITH T/TLE 5. IL I I I � � 1�, -I I 11 I i''I .. . . I I . I I - . I _____> ,� . I I ­ , .----- N, > , '7k I . - , ., -" - . I .1 - I � . I . - I I I 1, I 1 -1 I I , " 11 . I—I I...� � I . I , � I I 11 � lk 4zo 1 1 7 , I , I I . � . - - ­ I 11 � _� �1� �­ . 11 5\ � --- . � L I . I ­ . I . � I � I I - � . I . , . I I I \ . � . I I � . 1� 11 I . I '. . - � I __.�__ , �f- , ­ ­ \ . , 0 � I I I I I NO WATER I I NO WA TER 1, I I I I" � I j I - - � I I 1� I " 11 I . I ­ . . I I � I � I I � LL 0 \0 - � � .-- I � \ I I 10 , - 98.0 - I I I - - - ­� ­­ 11 � I I 11 . () 6 . I /I------- � I , ,0'�, -lop-, \ I k .\ * . I I *?� I � 120-1- 1 1 L I--� 98.0 1 ,�,1. 120* . .. . --I __1 I I . I I .. I I I I - � I . -1. . I - I 1 ,Z'�5- -­I lo�-I-/- I I � - . � v � I 1�� ,� \ . I � I ': . I� � - I I 1. - I I . � I I I . 1� .. I .- I , , "I 11�� � I . � . I ,, / I I t - � . � I I I � - A:, �'_�"I �'­ . I I , � I I '� to I � I 6 Ev vm5 I r. . C) . i I . - . - I I I I � . I . �, I I . 1 '. I I � I � , I 1.� I � DATE: AUGUST. I 1. 2008 � I I I ,, .11 I . � I � I ­ "'��I' . I � � I I I � -- I I I I I I.- , . , � .I � � 1� I I ,,, � � '. I L � I I . I . � ,I I .1 � I � ! ."� ­- ,"Ill"', 1. � � . . . � . . I I I I I I � I � I I � -------- - .\ .... � N . � . I I I I I - ,�- ,�,:, '.i�_ /le I, .1 I . . r. � I � �I .N I � I r '� � ­*� " . I � . TEST BY: STEPHEN HAAS � . � I I I I I I I .. � - - _-, �'. ol I � \ .1, I '- � I . � I- 1_. -" ..- . 1. I . I I � . . � I ,I - I . I � I.. I � , �. . . . � 11 I . �11 I I 1. / , 11.,I . 11 �� I­­ � - - ,I - I I :I I I -�N I I 0 1 .. ."., -...'\ ., \_ . . � "> I : I I I , � I I- 1. . I "I . � . � � I . I ''I _­I - ,- " ,":`J . I I V " � , ­ ,� � I � \ . . . .. \ I - I ; I � �. I ' 'WITNESSED BY: D014NA MIORANDI , .: I I I . . I I ­�, , � . :: ! . I � - I . 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