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HomeMy WebLinkAbout0105 OLD TOLL ROAD - Health 105 Old Toll Road 109-075 West Barnstable 0 � oq .. � -- Commonwealth of Massachusetts r ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is West Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information ( ° (Sa(.0 on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S114324 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins D gltalb signed by Dan Hawkins Date:2021.03.2312:21:15-01'0o 3-22-2021 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts -- Title 5 Official Inspection Form ?� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is re uired for eve west Barnstable Ma 02668 3-22-2021 q ry page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �v - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cl� 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is West Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (Cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts �n ,lp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is West Barnstable Ma 02668 3-22-2021 required for every St page. City/Town ate Zip Cade Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal Y P rY coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Ela Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts �M1 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is required for every West Barnstable Ma 02668 3-22-2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ X! Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ E] Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owners Name information is West Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ D Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ n Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components,excluding the SAS, located on site? El ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? 0 ❑ 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. ❑ a Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is required for every west Barnstable Ma 02668 3-22-2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 2 Number of bedrooms(design): Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/GPD Description: Originally permitted for 2 bedrooms with a 330/GPD design flow (permit dated 1/28/2004) Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes [j] No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 'WELL WATER' Sump pump? ❑ Yes ❑■ No Last date of occupancy: currentDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t �a 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is west Barnstable Ma 02668 3-22-2021 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 1 year ago Was system pumped as part of the inspection? ❑ Yes M No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ----------------- . _. p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is required for every West Barnstable Ma 02668 3-22-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New SAS added to existing tank in 2004 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑other(explain): Distance from private water supply well or suction line: 102' from well to SASfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts 1� Title 5 Official Inspection Form c r� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 105 Old Toll Road L Property Address Charles Potter Owner Owner's Name information is west Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 5' Depth below grade: feet Material of construction: X 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 1 Dimensions: 000gallons 611 Sludge depth: 3011 Distance from top of sludge to bottom of outlet tee or baffle 1'Scum thickness Scum over top of outlet tee Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. Scum layer is currently over top of outlet tee. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is required for every West Barnstable Ma 02668 3-22-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments - 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is West Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan).- off Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts -------------- - . -- Title 5 (Official Inspection Form . ........ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is required for every West Barnstable Ma 02668 3-22-2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2)500 gallon chambers 0 ieaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts cp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is west Barnstable Ma 02668 3-22-2021 required for every St page. City/Town ate Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Leaching had 3" of standing water when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is West Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road •L Property Address Charles Potter Owner Owner's Name information is West Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑■ hand-sketch in the area below ❑ drawing attached separately TOWN t3P BA,RNSTABLE LOCATLON l ci lGt "C SEwAGC 0 29ZV- '9` MLAGdA AISSESSOWS &LOT ice..—.n' 1NSTALLER,s NAJN &PRONF Nt?.P: SEPTIC TANK C"Acn tt ,... LEACWNG FACUJT"Y:,(cyte) NO,,OF BEDRQQ;vfS:=__ �« B:LM-DER OR OV874ER [} GCR4PLiANCEDATE:, Separation Distance Between the., t+taximumAdjusted GtaunslwwlerTa6[t ttatlleElc Y off-caching Facility, Plnivate"Water Supply We4t and Leach og Facillty (U anY•wells exist on site or within 200 feet of le."Wag facility) in Edge of Wetland and Uaching Facility Of any Wotlands exist within 390 feet,,of leaching facility} — — Furnished by �. i 6,,Z; ll`3 c-4 an �nta�D ft�tl&Sr'' .Y 5`{ c/ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f Commonwealth of Massachusetts � _-- = Title S Official Inspection Form _t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is West Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: 0 Check Slope ❑■ Surface water 1F Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 138"feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record If checked,date of design plan reviewed: Dte2/2004 ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Road Property Address Charles Potter Owner Owner's Name information is West Barnstable Ma 02668 3-22-2021 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑� A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed& Dated and 1,2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed p■ D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i _ Town of Barnstable Regulatory Services a Thomas F. Geiler, Director ` Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: _ J`n.� ,�► 1164 �e+��'S Installer ��l fri✓� EC cc,vaco Address: N, �?� S S � Address: 11.20 IgUX l Z�� 1-2 On � l��( _ a,S - �CG JZ, y,—was issued a permit to install a (date) (installer) septic system at l�s� d Id 7c-) i?c4r1l Nased on a design drawn by (address) 6L dated ��� 21�4-- �'— (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. 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. Of PETER T. (Installer's Signature) NO.35109 (Designer's Signature) (Affix Des i p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION..- CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS- FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:HealttilSepticl)esigner Certification Form Commonwealth of Massachusetts 7eZ1-► W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Insp ector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the ILLS zx information reported below is true, accurate and complete as of the time of the inspection. The inspection a`ws """" was performed based on my training and experience in the proper function and maintenance of on site cv sewagedisposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of gym_ Title 5 (310 CMR 15.000).The system: rcc ;1 t ®r,Passes t ❑ Conditionally Passes El Fails c) >- ;. —T. ,jLdse Further Eval tion the Local Approving Authority 5-28-13 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 Inspec on rm:Subsurface Sewage D sLi•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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•3113 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 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑' Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5=28-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or 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. I Other: D) System Failure Criteria Applicable to All Systems: You must indicate-"Yes"or"No"-to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the.surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® 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 9 p Y ►Y 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 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- 1 0,000g pd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Tide 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 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 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 ® El 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 facilityoccupantsprovided with if different from owner)® ❑ owner(and 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): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins•3113 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Well Detail: Sump pump. El Yes ® No Last date of occupancy: Date 3 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/sgft, etc.): Grease trap present? . ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 ' page. City/Town 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: Owner--pumped 8-2012 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: - gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 72"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 60"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form e Disposal System Form -Not for Voluntary Subsurface Sewage sp y Assessments 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2011 Scum thickness 1 r 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 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. 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•3113 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 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in 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 IL . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up.- Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3M3 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts - s Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's i ❑ 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.): Leach chambers in good condition and empty at inspection with stain line at 3"off bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M g0 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): G t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � a A 3 1 • t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28&13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar , ❑ Shallow wells i 4 Estimated depth to high ground water: 20 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: Original design plans show no groundwater at 12'. i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts b Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old Toll Rd Property Address Ken Morey Owner Owner's Name information is required for every W. Barnstable MA 02668 5-28-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness.Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ��p tHE Tti DATE: FEE: • BARNSTABLE',0 y MASS 1639- REC. BY Town of Barnstable SCHED. DATE: Board of Health 367 Main Street; Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman;M.S.P.f-I. "a u5'c f� Ralph A.Murphy,M.D. VARIANCE REQUEST FORS[ LOCATION Property Address: Assessor's Map and Parcel Number: O Size of Lot: Wetlands Within 300 Ft. Yes Business Name: No Subdivision Name: , APPLICANT'S NAME: y5rjrj C-f�(�l�(j_ •�( Phc:: Did the owner of the property authorize you to represent h.m or her? —;- -- r= No_�1/A —AciU.5 PROPERTY OWNER'S NAME CONTACT PERSON Name: � 4t►� I�tU2 7 Name: ��r%ZF-te- MC�/U Address: 1 aS A4,19 -7-dC- aD, Address: l Z �� C'20S-J-Q-LP A>,Phone: (Cco) 362--9Gt Phone: �i2CsTb�L / o;14 44 iT— VARIANCE FROM REGULATION(List Reg.) REASON FOR VARL-kNCE(May attach if more space needed) 79 UaCAQ _ Z -4=iG� ?a leF,-2 YARD �rrt �on411V g ys Checklist(to be completed by office staff-person receiving variance requesr application) Four(4)copies of engineered plan submitted(e.g. septic system pians) Four(4)copies of floor plan submitted(e.g. house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected art fee for lifeguard modifirsnoo renewas grease trap variance renewals[same owner/leasee only],outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage dispose systems';mv d'no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G. Rask, R.S., Chairman NOT APPROVED Sumner Kaufman, M.S.P.H. REASON FOR DISAPPROVAL Ralph A. Murphy, M.D. Q:/WP/VARIREQ a i / / VILLAGE-C! S Q` y` �SSES50R'S'1�#P�P ILO T - IMSTALILWS NAbl E PHONE SEPTIC TANK-CAPACITY UCH , LEACfIING FACIIM: ftypa) C � �s Oize} �� S NO.OF-BEDROOMS. bUILOER OR OVrlgER. PERII�ITI}ATE: GOMPLIAI�CE DATE: Sepai�atton I?stance Between the t�rtaactnum Adjusted Groundwater Table to the Bosom of I,eachzng Facility Fee$ Privafe�la4eY Supply Well and Leaching Fairtltty ( any wens east a�a site oc within 20U feet of feasEting faciltry) )Feet `. Edge of�(etland and Leachngaeility(If any wetlands exist within 3�fect o dcaching faci' } i~eet Furnished by 51 J� v` . U /1 JIL a, C-3 - 3,' ' �- / ` 0�19 TOWN eeOF BARNSTABLE LOCATION 10S bAC� OM SEWAGE # VILLAGEV3 AnM Sfi loll ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Pas OV( E KCaOCf )n✓1 -Tmc- 51&gLYgWb SEPTIC TANK CAPACITY 1000 GlQLhQq LEACHING FACILITY: (type)a— 6DQ Ga11CV 1 (size) NO. OF BEDROOMS o� �ltt'rl BUILDER OR OWNER ftS , ILCn PERMTIDATE: 3131U-t COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A—Z, 19 o 07-1 1 6—Z IOu.�l C 4 o D& 1d6•%Y p--b 53.10 4ci -Tyl 10020 G� 3� sq 3 A ITOWN OF 9 6e.n.A-.-, LOCATION: 142 -VILLAGE: It (�) - 07S PERMIT # : ® -®r)-- INSTALLER' S NAME: -ei)e'A-r, INSTALLER' S PHONE # : ®® / _ LEACHING FACILITY: (type)a)-foa 4 a►L Ck,*.6e..(size)/Z_� 5 NO. OF BEDROOMS: BUILDER OR OWNER: ofo'", PERMIT DATE: 3--3-© COMPLIANCE DATE: h� DRAW DIAGRAM ON BACK I 1 - I . „' 34 3. T is �� - ' No. r;�'-�'�� FEE `] COMMONWEALTH Of MASSACHUSETTS Board of Health, j3*1S "L(- , MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(. ) Repair( ) UpgradeA Abandon( ) - 0 Complete System ,Individual Components Location 10-5- 4-0 o Q.,C o Owner's Name kemvem kloacy Map/Parcel# m1w ��, q C "Z jl'- Address _ Lot# Ur -72 Telephone# 9000 3 6 2-. 96 S Installer's Name M67ZIZ45 ��cA /4�0N Designer's Name N 2t W Address i (), 136 X f 2S t S �� �� Address �2 .t44W i--:l E Telephone# �sd�j f�® _ 30 O 6 z6, - Telephone# D 477-- ,3 6 o 2-6+4 Type of Building / '�S l 0152YZ- c Sily 6-Le /1 '7' a-!;e Lot Size P3 `��2-]4—sq.ft. Dwelling-No.of Bedrooms 2- Garbage grinder ( ) Other-Type of Building / N/�- No.of persons Showers ( ),Cafeteria ( ) Other Fixtures /`)/A Design Flow(min.required) gpd Calculated design flow 2Zt0 Design flow provided ?✓3S: gpd Plan: Date '2-1 12 t0*+ Number of sheets Revision Date Title 5�ajJC 9YSM!i Ff�iJ2��1(�a /A1 —OLQ TOLL P4>.. W, &AXJV9—J-AaL% t MA Description of Soils) 6-36"P�. -36 -4Z,"� y Z`—&6"" % s�-,�p�t> 3� C: 1M-C� - cevtcl Soil Evaluator Form No. f�0}tIN�S�3LE- Name of Soil Evaluator R—rViZ MCF11 /Bate of Evaluation o DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a ees of t in operation until a Certificate of Compliance has been issued by the Board of Health. Signe Date 3_-a_" _ 23 �p Inspections \I; FEE # o ✓ COMMONWEALT14 ®F MASSAC14USEIIS Board of Health, A1,Z4V.5_r"LE MA. _IZZ APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT .- pplication for a Permit to Construct( )"Repair( UpgradeX Abandon( - ❑Complete System ,Alndividual Components k Location 105 QLD O /ZO Owner's Name eim E7�j ma�' Map/Parcel# Mae 101 /D/Rod ,- W7 Address fm Lot# CP Telephone# (S-00) 3&Z W -� 90 s- Installer's Name ?,+,s IMIZ C',,C CAVA n ON Designer's Name -j N 21N W4,14 4, Address Jvi Q /�Q K �2� �Q�y rD4� V4 Address rZ A G Us�,,Sr:1 6:�L 120 E tP4 Telephone# (5-09 ) 4Z9 _ 3o p t)Z64 4" Telephone# U 477_ 3l3 MA-. -026+4 Type of Building!12�N71,4C -- 23!/V 64_6 /T'/"lI L%e Lot Size '3.Y; j 2-7 t sq.�ft. Dwelling-No.of Bedrooms Z. Garbage grinder ( ) Other-Type of Building ,V/,4 No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.require�d) gpd Calculated de ign flow Z.ZL) Design flow provided, 33 r gpd Plan: Date 2I l s t ot- Number of sheets ~ Revision Date ' Title �77 C 5 yst�'M �dpaile/�!� 12 I[1S'G IB�TZIti C �-0 �l/� 1�A TV9773 3�L M/l Description of Soil(s) "JFi J//`�� '3�i I� +aZ`�/4 i , �JL`.u- (oG JJ SLr�pQ tJ ��✓�� yy_C S414G! r -/Z AICJ rA J 04 Soil Evaluator Form No. l�l�t(y.JT�/3LF Name of Soil Evaluator ate of Evaluation .DESCRIPTION OF REPAIRS OR ALTERATIONS V The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a. ees-W of t ..plac the in operation until a Certificate of Compliance has been issued by the Board of Health. Signe Date 4— U 3 �p a Inspections k No. COO V'V' LALT14 OF MASSAl_.ltlti SETTS FEE ��lll`rll Board of Health, '8-K JeNS7A13LL , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned O , by: r JJ G yIL) r !" at � UI ��jf G i �S% v/�lTb has been installed in accordance with the r)bvi ions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. '� �d dated /. L Ap • ved Design Flow (gpd) 1 d r Installer Designer: Inspector: • - ) Date: Ally The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. r FEE ✓ C) COMMONWEALTH OF MASSAC14USETTS Board of Health, ,(3i4/ZA-1 577+13 LC AM DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby gr/a ted t�o;'Construct ) Repair( . U grade( ) Abandon( ) an individual sewage disposal system at IU J A). Y o// t`P- � 'J % as described in the application for Disposal System Construction Permit No. 6C-C1/ dated 3/3 Provided: Construction shall be completed within three years of the dat of this e it. 1 local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date ✓ 1b `t Board of Health TOWN OF BARNSTABLE LOCATION I� 61Ck SEWAGE # VILLAGEV3 .�nCn SCOW ASSESSOR'S MAP & LOT 7E; INSTALLER'S NAME&PHONE NO. � �< �i �� '� �►'�- 4Zt�9 SEPTIC TANK CAPACITY C� LEACHING FACILITY:(type) Ilfr/) (size) �_Q Q I�✓S NO. OF BEDROOMS BUILDER OR OWNER Yftyeu 1L111 PERMIT DATE:113L0A COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bott m 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 Feet within 300 feet of leaching facility) Furnished by 04-I 13 a2 A-2. 19 _ / 6 ID A n 11, C-3 32 S3.1P Field Y+n goo.zA 40-0 �-� Sq 3 Towel of BarnstableDepartment of Regulatory Services - • Public Health Division Date 's'@' 200 Main Stree4 Hyannis MA 02601 Scheduled N vA-�� .��"-- Ti tre. 6—A Fee Pd. C)®� Date bili Assessment for Sewage Disposal Soil Suitability Witnessed By: Performed By: - r. -- ------ LOCATION & GENERAL INFORMATION owner's Name KV,Nlvo-TH l�o2R�y Location Address 165 OL.p T t.t.. 1'-oRt7 VJ,'DA-RAW TPaLC- Mgt Address sk"s €;ngimecr's Name,!� 6 Pv Assessor'sht90arcel: Mel )(3q 'P/-(LC"f-511- '1 5- t!�eN�Jd✓R- IMPAIR � Telephont# 65-09 °4-7? '"3 13 _ NlEVY t`OhtsTRUCTIOK _-_ .r. Land Use ���'���� Slopes(°i•)..�..+....�-- Surface Stones /1S oF./G Lhstances frotn. Open Water Body fl Possible Wet Area —!? Drird:in`W'actr We11 �s R Drainage'Way -_ -ft Pruperty Lint . --- it UUttt � SKETCH:(Street name,dimensions of IDt,exact locations of test holes&pert tests.locate wetlgnds in proximity to kolas) 607 I 4 V,r y.J A-M Depth to Bedrock_ Paient mater.ai(geoiogic) -- L�- Weepirmg from Pit Face_ --- Depot to Gtoutidwater. Standing Water in);olt: Batimated 5casonal High GMURdwawDETERMINATION FOR SEASONAL HIGH.WATER TABLE PXethed Used. in. Depth to a0il twottics: in. Mpth Obsmcd standing irs obs.hOW in. (3roturdwater Ad}uatrmwtt Depth to weeping ttont side of obs.hole: - Ad' (actor Adj.� �" �--_ Index Well y _ Rending Date.:---- index Weii ievet_--�_. J --- -- VV PERCOLATION TEST NO Time_, } Observation ' T'ino at 9" Hole 0 -- Depth of Per,; r?"Ll .- -�- Tune at 6" — Start Pre-sostk ruve End Pre-roak Rate Min./inch o�---2- M'j 1 m Site Suitrebilir�ARsessmerK: Site Passed W r_ site Failed:- Additional Teating Needed(YIN) origtinr0: Public Nenith Division Observation Hole Data To Be Completed on Back ----- -- ***I.f percolation test is to be conducted within 1011' of wetland,you Must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q•?�EAL�"}#/iW Pi P C.t1C'FU ttM DEED' OBSERVATION HOLE LOG Hole#�_ I pte'+t om Sail>fiori�n Soil Texture Soil Color soil $ttr (In.) (USDA) (MUI o®11) madifin$ ($t00%3t a BMW. � r DEED OBSERVATION H®LE LOG :a,.� H6le Depth from Soil Horizon Soil Texture Sail Color � Scaii. Other Surfixe(in) (USDA) (Munsell) Mottling (Strtteturg,Stor+e8,could � DEEP OBSERVATION HOLE LOG Hole#_ Other Depth vom Soil Horizon Soil Texture Color soil ( Soil(USDA) (Murw;!) Mottling (Structure,Stongs,SOWdM SWAM(in.) ....—.--- I�EEI' ®B Li R`4lAT ION HOLE LOG 1. Soil ®tlaer k Depth from Soil{�o�i�r, Soil Texture Sail Color Mottling (Struotarre„Stone&,Boulders. Surface(m) -^ (USDR) �(Munssll) !3 L �+�'90 d 1, Ins ce&te are. Above 500 year flood boundary Na__.__ yes Within 4100 Yew boundary No t'as Within it]di year flood boundary.Na Yes— - e of ttt a{{ ®ccorrin )Pcrviods list i 1 four feet of rnatumlly occurring pervious materiel exist in all areas ob Does at least served throughout the sires proposed for the soil absorption systen+? m�s.�—• If not,what is the depth of naturally occurring pervious matt:riaVt �^z 1 certify that on 0l a 5(date)I have passed the soil evaluator examination a�apro��by the Dt.psttmernt of Environrntntal protection a at thelsabove analysis as POD rfarmed by me consistenn t With ed in the rewire at g,expertise and experience Signattarve - q.11EALTlr11WP/PERCF014,.M. LOCATION ~, SEWAGE PERMIT NO. VILLAGE � f7 25. I'MS-TA LLER'S NAME & ADDRESS co B U I*L D E R OR OWNER DATE PERMIT ISSUED s _ :7 Iz DATE COMPLIANCE ISSUED - W" ,�. �. • ,;- -ti r �� � - `�,� ,��:' _ e � ,T t i� / J � � �. i. t i .��k. r ......................... Eas........................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... '........_..-- .OF............ ........ .....................-•-- . , ...................... I ppliratinn -fur Biipuiitti Works TD[nutrurtion Prrntit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: Q Old Toll Road,"TRAILVIEW" West Barnstable I �� B 7� 79 . ` -------------------------••-•---------•--............---•-- .....-----•-•......---•--•--•-•--•-- •-----•----•----••--•---•------••-----........••--••--•-------•------•--------•---.............-- Location.Address or Lot No. Kenneth E. Morel 70 Bishop's Terracef Hyannis,_MA 02601 a Pam. owner t 17 Burbank St ,Sandwich, MA 02563 Insta er Address Q Type of Building Size Lot-------_-------------------Sq. feet rooms.... neDwelling- No. of Bed ......................_-.-----Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ----Frame No. of persons..TWA----------------- Showers ( ) — Cafeteria ( ) QOther fixtures ---------------------------------------------------------------------------------------------------------------------- ------------------------------ W Design Flow--------------------------------------------gallons per person per day. Total daily flow----------------------------------------.---gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth---------------- x Disposal Trench—No. .................... Width.................... Total Length--------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inl t..._.. .... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) V �G L /0 -A G` 7 7 ra Percolation Test Results Performed by----------------------Alan-_Jones----_-.-----_-•--.•-•-- Date----10--26--77-_---------- Test Pit No. 1................minutes per inch Depth of "Pest Pit.......... ......... Depth to ground water......._- ----....__-Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......-.-------------.. ••-•--------------------------------------------•-------•-•-•------•--••--........--•-------•-•----.......................................................... O Description of Soil.--See at ached percolation test report -- (J — 3 — 3 _ k` I x :'- 2 - w -------------- - %' - � � ------------------------------------------------------------------------ ve VNature of Repairs or Alterations—Answer when applicable............................................................................................. .. ---------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------. Agreement: =r� 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 undersigiiel, ,ether agrees+not to place the system in operation until a Certificate of Compliance has be n issued by the board x th Signed......-. _ j0�-^—� --------------------• .--- .....-•--••--•••--•••-•...... ..... ......................... Pate Application Approved By---- - .... .7-7------ 7 Date Application Disapproved for the following reasons-----------------------------------------------------------------------••---•••.................................. -----•-------------------------------------------------------------••....---•--•---•-----•-•--•--•----------------------------------------------------------------------------...-••-•••••--------••--- Date PermitNo......................................................... Issued..... ------••---•--------•. Date Sw THE COMMONWEALTH OF MASSACHUSETTS BOD OF HEALTH ApV iratiou -fur IR uvuuttl Mirko Tomitrurtion PPrui t `^ Application is hereby made for}a Permit to Construct (X). .or Repair ( ) an Individual Sewage Disposal System.at• , r' Old Toll Road,"'1'RAIINffiP7",West Barnstable 79 •-•------------•---••--...-- --- - Location Address or No. i` Kenneth E• Morey - x_____ 70 _Bishop's Terrace, I s MA 02601 w ie d j caner1. �� 17 Burbank St. ,ea"]Ydwich, MA 02563 n lt aa r Address uild ng U TypeDwell ng l�No. of Bedrooms.............................................One Expa,lion Attic'( ) Size Lot-Garbage Grinder(feet ' Frame .'N g ..._. e6we'rs Cafeteria ( )O er—Te of Building r a d Other fixtures 'If... ................ r s gn Flow...........................................Jgnllons. per person per day Total daily flow .._.._.........--_-- -__--_.___gallons. :9.. -- .. W eptic Tank—Ltqutd capacity------------gallons Length ___ Width: Dtam�ter_... Dehtlt----------____ _ x Disposal Trench—No- ____________________ Width-_ __,___-______-- Total Length __ s......... Total leaching.area--__ _-____-_..___-sq. ft. l Seepage Pit No---------__ Diameter __________________ Depth below inlet Total leaching area-__-_.____ _ ;sq. ft. Z Other Percolation Test box ( ).;� Dosing tank ( ) �. /� /d �, � 7 y s G Test Results Performed b --_..Alall r� OnE?s.... ..... ........ Date_ 10 _26-77�-_-_--- a Y Test Pit No. 1.....r f __'_minutes per inch Depth of "Pest Plt >.--------- Depth to ground water------------------------- Test Pit No. 2..... :._.:minutes per. inch Depth of Test. Pit f__________. Depth;to ground water______________________ _ ......................................................... p S.ee attacMd percolation test report Description of Sotl -- x i . j/� �((\ff� f ._ 404 .---- --- a- / �' ' fa`" rr "�o�ar..► - - - ----- .--- ----- -------- --- ......--- V Nature o Repairs or Alterations t Answer when applicable ..................................:..... .. ------- •- - -----•--•....................•-•-••••••---••-•-----........_.......---.---------- ------- Agreement: F µ The undersigned agrees to insta aforedescribed Individual Sewage'Disposal System .in accordance with the provisions of Article XrI of the State Sanitary,'Code—Tlie undersigned f 'ther agrees not to place the system in operation until a CertificatiApf Compliance has bee 'issued by the board of e th. M. Signed ....., - ._.:. Date ---------.. Application Approved By __ aae � DY Applicajon Disapproved for the following reasoais. ----------_/--_ ---- =----------------•-- .._.........7-"_" ------- ------- -------•- . ...... ._----••................. ----------------•--•--••-----•-•---------- --: -------•----- L Date Permit No -•---------•----_-- ......................... Issued.••--V--- -a- Date THE COMMONWEALTH OF MASSACHUSETTS, BOARD OF HEALTH , N � I OF......... . ........................... ' p tt$ikab u f uut 1' iafirr f _ T S T 'C IFY That e vidua . ewage Disposal S;stem consfr'ucted ( or,•: Repaired 6 "`( ) by n' .................................................. z st1111 at_"_�'' j / --- --- has been installed in a ordance with the provisions of : ele I of The State Sanitary Code as described in'the a lication for Dis o tWorks Construction Permit No:��7;_s'"s dated �.2 r•1 ...... . PP P ----------_-- THE'ISSUAN'CE OF THIS='CERT.IF:CATE SHALL NOT BCE CONSTRUE© AS A GUARANTEE THAT THE SYSTEMI WK FUNCTION-SATISFACTORY., DATE-- '......... .... .....� L ---7�---- ----------- Inspector---_...._ ...� L ... ------------------------- THE COMMONWEALTH OF MASSACHUSETTS^'- ' as BOARD F HE LT f.. x. -,. .....E._ ..... FEE_ %rivulitt IUu k Cnuuii u tutF it Permission is hereby granted----- ------ ............ ------------------------------•- to Construct ( o epair ( ) an I dividu Sewage/ 'sposal stun, at No.. -•---- ,,� "y. � --��'fl� Kl ,�s rs. t 6E"'r�r�M� Y �� Street a . � a� as shown on the applicatioZ., Disposal Works Construction Perm No._ ____.,.______ _ Dated___-f 2_____________7.�`......... r �-- - ar of Health iG � -- ' DATE..... FORM 1255- HOBBS & WARREN. INC.. PUBLISHERS ®4t w,)-,, r 2.4 -— -. a i 7Z I Ibz;. % 4 Z7- - 11 C, :_ ` IOne d aspp- �{ -- --- - -- - Tom- - s 1!o a G-- Ail 14Et' - �f�_� firms � �ct�+� • ' i Igo, . Aery� Pc�,�. ,,i1��oP 1l`1 ` IYV E • G I � 1 •1 ii e ,71y/p���py. f a.� i � -� �!� I � :�. •� .-a- :.-.I:.-�-,(ems{ t �_ { ! ., { . � I ! � f I �I'� yr• 1 I I I 1 � tl , - a _ CY t I 1 , I _ LEGEND G98 99 PROPOSED CONTOUR T 99 PROPOSED SPOT GRADE o F 61 ---110_---� EXISTING CONTOUR FJ(ISTING LEACH. PIT. 110 EXISTING SPOT GRADE TO BE PUMPED, FILLED WITH SAND,AND ABANDONED. TEST PIT y A 52700512G°E —G— EXISTING GAS SERVICE LLOCUS 1 552 40' --- UU ——EXISTING UNDERGROUND UTILITIES r � 6 � -- A55E55OR5 MAP 109 EXISTING TREE S`Pe �' �%� ° I f J % °� ~' PARCEL 75 / ROU �`�• \ °j i f AREA 4 35, 127± SF FISTING SEPTIC TANK.TO REMAIN-5U TE 6 5' � \ \ �\ OWN APPROVBJECT TOAL RI5ER ELEV. = 109.9G INV.(OUT)= 104.4± DECK f �� LOCUS MAP N.T.S. zam � 007 GENERAL NOTES: 1 . ALL CHANGES TO THIS PAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE e' pS LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: Zt� v VARIANCE REQUEST TO LOCAL 150 FT., WELL TO S.A.S.. SETBACK. 0 ° a> A 48 foot variance is requested to well on subject site for a � N g D S �� �F MAJ, 102 foot setback. to Q % �� 87 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR � � / � •. �' � � TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE O � N PETER T• DESIGN ENGINEER. rn �/ �.' rh O 0 N .p MCENTEE - 6— f O �� / O �� o CIVIL 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 7 O / �U _ ' FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN J O a! 0 No. 351�9 ENGINEER BEFORE CONSTRUCTION CONTINUES. MAINTAIN 15'O \ � I UFF�FGISZE 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 99 --� ` SS I Id 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF BREAKOUT --- ��3 1 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF EL: 101.00 101" 1 A� HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY PRIVATE WELL. UNDER UNDERGROUND LOCATE STRI OUT i�2 S. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 100' OF THE S.A.S. UTILITIES �� 5EE DOTE I 1 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED Q �� OF MqS TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 1y0 RPpt� LL - �Q2 =��Q� RICHARD sq��� 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE T�ijtTING / �o THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING NFAi� J.I00 CONSTRUCTION. HOOD ' o No. 35031 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS SWELL G o� 9ES/S1 �J� AND REPLACE WITHIN THE AREA ATH CLEANDFILLLRAS SPECIFIED IN INS 10 OF CMRTHE S.A.S. 255(3). SEPTIC SYSTEM REPAIR/UPGRADE / 165.49' 105 OLD TOLL ROAD, WEST BARNSTABLE, MA 527049'09"E Prepared for: Kenneth Morey 105 Old Toll Rd, West Bornstbles, MA EDGE OF PAVEMENT Engineering by: Surveying by: SCALE DRAWN JOB. NO. OLD TOLL ROAD Engineering Works HOOD SURVEY GROUP 1 "=30' P.T.M. 04-04 12 West Crossfield Road 18 Route 6A DATE Forestdole, MA 02644 Sandwich, MA 02563 CHECKED SHEET NO. (40' WIDE) I � (508) 477-5313 (508) 888-1090 2/12/04 P.T.M. 1 of 2 1 eA r NOTE: TO PREVENT BREAKOUT, THE PROPOSED TOP OF FOUNDATION F.G. EL: 104.5(MAX.) FINIFORSA DISTE SHALL ANCE OF NOT BE < ETH01.0 EXISTING F.G. EL. EXISTING F.G. EL: 1 1 1.16t(EXISTING) F.G. EL: 103.8t PERIMETER OF THE S.A.S. MAINTAIN 2% MIN SLOPE OVER S.A.S. 36" MAX. COVER a-500 GALLON LEACHING CHAMBERS IN SERIEG INSTALL RISER OVER CHAMBER/S INSTALL RISERS OVER INLET & OUTLET SHOWN ON PLAN AND SET COVER/S CELLAR FLOOR m; TO WITHIN 6" OF FINISH GRADE SURROUNDED WITH STONE ALL SIDES WITHIN 6" OF FINISH GRADE L =62' L =13'(MAX) 4" SCH 40 PVC 4" SCH 40 PVC 2" LAYER OF 1/8" TO 1/2" EXISTING i0" 75' ®® $ ®® DOUBLE WASHED STONE a,. is ® S= 1% (MIN.) @ S= 1% (MIN.) ®®�®®MM 2' EFF. DEPTHT ®®®�®®® EXISTING EXISTING 1000 GAL. 3/4"-1 1/2". SEPTIC TANK INV, ELEV.=100.80 INV. ELEV.=100.63 3.5'_ 5.2' 3.5' DOUBLE WASHED INV.EL: 104.4t EFFECTIVE WIDTH = 12.2' STONE INSTALL INLET & OUTLET TEES INV. ELEV.=100.50 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY TUF-TITS, ZABEL, OR EQUAL TOP CONC, ELEV.=101.5 ---BREAKOUT ELEV.=101.0 INV. ELEV.=100.50 a mom BOTTOM ELEV.=98.50 4' 2 x 8.5' = 17,V 4' SEPTIC SYSTEM PROFILE 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH -- 25'' - -_ T.P. EXCAVATION OR G.W. N.T.S. 9 3.2 LEACHING SYSTEM SECTION_ - (3) 5" DIA.OUTLETS DESIGN CRITERIA ��� 15.5" o PETER T, McENTEE 6 e" NUMBER OF BEDROOMS: 2 BEDROOMS CIVIL T SOIL LOG No, 35109 T ,..� '°'� SOIL TYPE: CLASS I DESIGN PERCOLATION RATE: 2 MIN./IN. lSSF�``��`� D—BOX �-'�'' fSS G� i�6`t K " DATE: JANUARY 28, 2004 DAILY FLOW: 220 G.P.D, "" 1 DESIGN FLOW: 330 G.P.D. C- �:�" SOIL EVALUATOR: PETER MCENTEE ,moo INSPECTOR: DAVID STANTON GARBAGE GRINDER: NO77 000, � �03) BARNSTABLE B.O.H. LEACHING AREA REQUIRED: (330) = 445.9 S.F. INVERT ®®®® ® ®®�� �� 5w�° Gi Elev.- TP Depth .74 ®®®®IaE3IE3®®EE 3e" �pgA�'e ®,,,rs°"" 104,7 0 EXISTING SEPTIC TANK: 1000 GALLON (SUBJECT TO APPROVAL) ®�®®�®®�®®� �Np� " "' FILL 24,E ®Q�E2E3®®®E3E@® �,,� 101.7 A 36" USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 102" 1 SANDY LOAM SECTION d DAB�oR 10YR 3/2 SIDEWALL AREA: 2(12.2' + 25.0') X 2 = 148.8 S.F. 101.2 42' 12.2' x 25' = 305.0 S.F. _ BOTTOM AREA: a" KNOCKOUT \�� !/ �, SANDY 5�8M TOTAL AREA: 453.8 S.F. 20" OIA. COVER h / ° / �� BOULDERS = 99.7 - 60" DESIGN FLOW PROVIDED: 0.74(453.8) 335.8 G.P.D. 4° KNOCKOUT 4° KNOCKOUT 62' / Q // C 4•, KNOCKOUT M-C SAND SEPTIC SYSTEM REPAIR/UPGRADE PL/nnnyfN S.A.S. LAYOUT 2.5Y 6/4 105 OLD TOLL ROAD, WEST BARNSTABLE, MA N.T.S. Prepared for: Kenneth Morey_, � 105 Old Toll Rd, West Barnstbles, MA 500 GALLON CAPACITY, H-20 LOADING 93.2 138" Engineering by: Surveying by: SCALE DRAWN JOB. N0. CHAMBERS i NO G.W. ENCOUNTERED EngineeringWor°As HOOD SURVEY GROUP N.T.S. P.T.M. 04-04 12 West Crossfield Rood 18 Route 6A MT.S PERC!RATE: 2 MIN/IN. ('C" HORIZON) Forestdole, MA 02644 Sandwich, MA 02563 - DATE CHECKED SHEET NO. (508) 477-5313 (508) 888-1090 2/12/04 P.T.M. 2 Of 2 a eM ' LEGEND 99 99 PROPOSED CONTOUR x iQO� 99 PROPOSED SPOT GRADE _ lF 61 110_ EXISTING CONTOUR EXISTING LEACH. PIT. 110 EXISTING SPOT GRADE TO BE PUMPED, FILLED WITH SAND, AND ABANDONED. TEST PIT 52700512G°E --G— EXISTING GAS SERVICE — a��h LOCUS rh 152.401 UU —EXISTING UNDERGROUND UTILITIES A55E550R5 MAP 109 EXISTING TREE S Ne a mm°j PARCEL 75 �r / R AREA = 35, 127± SF � e s cn.cn s� EXISTING SEPTIC TANK. TO REMAIN 5UBJECT TO TOWN APPROVAL RISER ELEV. = 109.96 s� INV.(OUT)= 104.4 - LOCUS MAP N.T.S. �0. 015) GENERAL NOTES ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE j� I 0, LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: Z Imo' �I VARIANCE REQUEST TO LOCAL 150 FT., WELL TO S.A.S.. SETBACK. 05 A 48 foot variance is requested to well on subject site for a 102 foot setback. 1 Q ' �` '` , 87' N P�� f9� 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR sue � TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE PETER T. DESIGN ENGINEER. RI �;, j / q N �• g Mc IVIL 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING CVIL "' 99 49 O `yh/ z� FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN - I I ! O No. 35109 ENGINEER BEFORE CONSTRUCTION CONTINUES. 98 - U Rec/S1E��� ��� 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. MAINTAIN 15' 99 1 �� F G� BARE KOUTO _ �p3 ` ~' c� OFS3I �. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF EL: 101.00 101----- THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF t0�^y_ - _ HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. ZIL 7. WATER SUPPLY PROVIDED BY PRIVATE WELL. UNDERGROUND LOCATE STRI OUT ��2 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 100' OF THE S.A.S. UTILITIES �J 5EE NtOTE 11 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED OF �qS TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 150 RP�1115 LL /mac' _�`� RIC� 9�yG 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE NI T�tj�S1NG / J. . THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING 100 CD HOOD CONSTRUCTION. o No. 35031 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS EX15TING o yo IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. WELL F' �'FG/S1E ��` AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). I�F�a SEPTIC SYSTEM REPAIR/UPGRADE 165.49' 105 OLD TOLL ROAD, WEST BARNSTABLE, MA 527049'09T Prepared for: Kenneth Mor, 105 Old Toll Rd, West Bornstbles, MA EDGE OF PAVEMENT �— Engineering by: Surveying by: SCALE DRAWN JOB. NO. OLD TOLL ROAD Engineering Works HOOD SURVEY GROUP 1 "=30' P.T.M. 04-04 }} 12 West Crossfield Road 18 Route 6A 4 Forestdale, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET NO. (40' WISE) (508) 477-5313 (508) 888-1090 2/12/04 P.T.M. 1 of 2 NOTE: TO PREVENT BREAKOUT, THE PROPOSED k� TOP OF FOUNDATION F.G. EL: 104.5(MAX.) FINISH GRADE SHALL NOT BE < EL:101.0 EXISTING FOR A DISTANCE OF 15' AROUND THE F.G. EL: EXISTING F.G. EL: 111.16t(EXISTING) F.G, EL: 103.8± PERIMETER OF THE S.A.S. MAINTAIN 2% MIN SLOPE OVER S.A.S. 36" MAX. COVER INSTALL RISERS OVER INLET & OUTLET -500 GALLON LEACHING CHAMBERS IN SERIES INSTALL RISER OVER CHAMBER/S CELLAR FLOOR TO WITHIN 6" OF FINISH GRADE SURROLINDED.WITH STONE. ALL_.SIDES SHOWN ON PLAN AND SET COVER/S WITHIN 6" OF FINISH GRADE L =62' L =13'(MAX) 4" SCH 40 PVC 4" SCH 40 PVC 2" LAYER OF 1 8" TO 1/2" EXISTING 10° 14 ® S= 1% (MIN.) ® S= 1% (MIN.) ®® r� ®� DOUBLE WASHED STONE A; " 6' ®®e� r��� A ®®®�®®® a' EXISTING EXISTING 1000 GAL. 2' EFF. DEPTH ®®®®®®® 3/4"-1 1/2" INV. ELEV.=100.80 SEPTIC TANK INV. ELEV.=100:63 3,5 5.2 3.5 DOUBLE WASHED INV.EL: 104.4± EFFECTIVE WIDTH =.12.2' STONE INSTALL INLET & OUTLET TEES INV. ELEV.=100.50 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY TUF-TITS, ZABEL, OR EQUAL TOP CONC. ELEV.=101.5 - - -v -BREAKOUT ELEV.=101.0 INV, ELEV.=100.50 _ _._ - a 00 00MSH7 ®®®®®®®ammo BOTTOM ELEV.=98.50 4' 2 x 8.5' = 17.0' 4' SEPTIC SYSTEM PROFILE 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 25' - - - -- T.P. EXCAVATION OR G.W. N.T.S. 93.2 LEACHING SYSTEM SECTION_ - (3) 5" DIA.OUTLETS DESIGN CRITERIA ,��' �� 1 " PETER T. 5.5 0 6` e" NUMBER OF BEDROOMS: 2 BEDROOMS McENTEE CIVIL ' SOIL LOG No, 35109 ''� SOIL TYPE: CLASS I 2„ DESIGN PERCOLATION RATE: 2 MIN./IN. oECIS����`c `� D-BOXDECK DATE: JANUARY 28, 2004 DAILY FLOW: 220 G.P.D. FSS ONAI.E��� SOIL EVALUATOR: PETER MCENTEE DESIGN FLOW: 330 G.P.D. N` INSPECTOR: DAVID STANTON GARBAGE GRINDER: NO �9ovG e \o5� BARNSTABLE B.O.H. LEACHING AREA REQUIRED: (330) = 445.9 S.F. l ND 0 Elev, TP Depth 74 INVERT ®�®� 0 ® dam ®®®000®®®gym 39" e 104,7- 0„ ®®� �®®®� vp�'� ��• EXISTING SEPTIC TANK: 1000 GALLON (SUBJECT TO APPROVAL) 24„ ®Q=®E3E3®®®��0� FILL — 101.7 36" USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 102" ""', A SANDY LOAM SECTION `9d 0,0- p 1 CYR 3/2 �,• SIDEWALL AREA: 2(12.2' + 25.0') X 2 = 148.8 S.F. 101.2 - 42" BOTTOM AREA: 12.2' x 25' = 305.0 S.F. 4" KNOCKOUT a, `/ ti S.F.— SANDY S�BM TOTAL AREA: 453.8 S.F. z0" bla. COVER y et yyy,,, (p` o" KNocxour '�4" KNOCKOUT fie" /� y � 99 7 BOULDERS 60" DESIGN FLOW PROVIDED: 0.74(453.8) = 335.8 G.P.D. O �! i4 �/ C i '" KNOCKOUT �, M-C SAND SEPTIC SYSTEM REPAIR/UPGRADE 6/4 S.A.S. LAYour 2.5Y 105 OLD TOLL ROAD, WEST BARNSTABLE, MA PLAN N.T.S. Prepared for: Kenneth Mor' 4 `2105 Old Toll Rd, West Barnstbles, MA 500 GALLON CAPACITY, H-20 LOADING 93.2 138" ° Engineering by: Surveying by: SCALE DRAWN JOB. N0. CHAMBERS No G.W. ENCOUNTERED Engineering Works HOOD SURVEY GROUP N.T.S. P.T.M. 04-04 — S PERC RATE: 2 MIN IN. C" HORIZON 12 West Crossfie0 Rood 18 Route 6A KT. / ( ) Forestdale, MA 2644 Sandwich, MA 02563 DATE CHECKED SHEET N0. } (508) 477-5313 (508) 888-1090 2/12 04 P.T.M. 2 Of 2 •i