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0367 PLUM STREET - Health
` '367 'P1um-'Street West Barnstable '.. { . A—"a I' ,6 - 005w y 1 III No. < ` /© Fee <®e) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN'OF BiARNSTABLE, MASSACHUSETTS Yes T Rpphration for Disposal 6pstrm Construction Vcrmit Application for a Permit to Construct( ) Repair( ►Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ?Wm JA Owner's Name,Address,and Tel.No. � V3 GSA 63oJ'hS�►�"C.i C�` ��w�4J Assessor's Map/Parcel Installer's Name,Address,and Tel: o. Designer's Name,Address,and Tel.No. O `� ore t 6 S o JMN D, tau eef g: 3 Dwelling No.of Bedrooms Lot Size , ' sq.ft. Garbage Grinder 04 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided �� � gpd Plan Date (,T S` r) Number of sheets Revision Date Title Size of Septic Tank 1!®0 &c-L �C Wes- Type of S.A.S. ® QOx I'A ao Ll 149 U L Description of Soil („ w � n Nature of Repairs or Alterations(Answer when applicable). , k ck, .2.SC Z ,!0 rd bpi 3piz o,(\t� t_ C. i �r W 1 k V,,- t S"U k, (A a L rc,,� L,C 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. Signet fi ate Application Approved by Date y Application Disapproved by Date for the following reasons Permit No. 1 / C Date Issued `No..,!�10/7 —/O t Fee /©C) THE COMMONWEALTH OF-_MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWi; 'FwNE�ARNSTABLE, MASSACHUSETTS Yes ftplitation for Mis'poB pstem Construction Permit Application for a Permit to Construct( ) Repair( 114pgrade( ) Abandon( ) []Complete System ❑Individual Components Location Address or Lot No. (�7 Vlly M 11A. Owner's Name,Address,and Tel.No. to c S't C3as S�'�•lo`Q. �C,�r`cR"'�!`Z.. CC�c 1�►c1` ;� Assessor's Map/Parcel !�(74U Installer's Name,Address,and Tel.No. _= VVkV— Designer's Name,Address,and Tel.No. p of Dwelling No.of Bedrooms Lot Size ( sq.ft. Garbage Grinder(k)Q Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ?3 Q gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank t Gy%L �C'u�n�(. Type of S.A.S. Q QOX a0 !� N;1 b ,.L Description of Soil t` C,jA 6-,rc ti , ,n i Nature of Repairs or Alterations(Answer when applicable) Ck. 2 X ( >© jam,. o,r, 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. '" Sign, Application Approved by Date 6ILI f Application Disapproved by Date for the following reasons Permit No. r J�1 �p Date Issued 7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system CCoonstructed( ) Repaired( L41' Upgraded( ) Abandoned b at (-, �y�.t C 1.1-!'-� G.floS"�has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoP017/ `dated 1 1^{ 7 Installer j C,�!-� C S Designer CiC,R #bedrooms Approved design flow—.( ,3 gpd The issuance of this permit shall not be�eonstruedyas'a guarantee that the system will nc on as de�'gned., ---_ Date /� 5,�,,F Inspector No. 1 fG'C7'•. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( Vr iUpgrade( ) Abandon( ) System located at (r, - p` ,j pA. S T fR&,rnl tc-. ,6 (� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be cdmpleted within three years of the date of this peat it. lam. � ( 1 Date � � "7 -7 Approved by � I Town of Barnstable Regulatory Services s Richard V. Scali,Interim Director MAS&. z Public Health Division 039.t� Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form Date: Al Zola Sewage Permit# .ela17 -/u -Assessor's Map\Parcel �9�T C-4Ale Designer: Hv+A-,5, PC Installer: Address: ?-n.r 0Y /4. Address: 3so a� S. L�bu�ut �j .uA On was issued a permit to install a (date) (installer) septic system at 361 PLv.f Sr based on a design drawn by (address) dated ( -/z-0 t 7 (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. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS orany vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was construct _ liance with the terms of the IAA approval letters(if applicable) r& T (Ins ller's Signature) • .A, 11s , (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doe Y Commonwealth of Massachusetts �T pi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 367 PLUM STREET Property Address ESTATE OF CATHER_INE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is WEST BARNSTABLE MA 02668 _ 4/26/2021 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 on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main St. VI C Company Address W Yarmouth MA 02673 City/Town State Zip Code iarun 508-775-2825 _ SI-14423 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 16.000); 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 4/28/2021 Inspector's S nature 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts is - -� , Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST BARNSTABLE _ MA_ 02668 4/26/2021 _ 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: ® 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: SYSTEM IS IN WORKING CONDITION 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): l5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts 1 i Title 5 Official Inspection Form �; to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is . WEST BARNSTABLE MA 02668 4/26/2021 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: l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 1s Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER- PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is WEST BARNSTABLE _required for every MA 02668 4/26/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ` ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent'and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts -- lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER- PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST EST BARNSTABLE _MA 02668 4/26/2021 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 ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 pp m, 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 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. r Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER- PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is WEST BARNSTABLE MA 02668 4/26/2021 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 an inspections: 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) 1 ® ❑ 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)J 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 la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER- PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST BARNSTABLE _ MA 02668 4/26/2021 _ page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: UNKNOWN Does residence have a garbage grinder? ❑ Yes ® 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 El 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: UNKNOWN Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER- PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is WEST BARNSTABLE MA 02668 4/26/2021 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form �I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET V Property Address ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 _ 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 2017 PER PLAN ON FILE AT BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts -,wp Title 5 Official Inspection Form Subsurface a Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Property Address ` ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST BARN_STABLE MA 02668 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON Sludge depth: 311 Distance from top of sludge to bottom of outlet tee or baffle 211 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 How were dimensions determined? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 6" BELOW GRADE , 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 i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Lr' P:•operty Address ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 4/26/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. 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 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): 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 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t� I'r✓ 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is WEST BARNSTABLE MA 02668 4/26/2021 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): Depth of liquid level above outlet invert EVEN 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 LEVEL AND WATERTIGHT l5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts ` ----, Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments «a � 367 PLUM STREET V Property Address ESTATE OF CATHER_INE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 4/26/2021 _ 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.): * 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): J If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-LC6 ❑ 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 Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET u Property Address ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name equine fo d fo information is r every require WEST BARNSTABLE _MA 02668 4/26/2021 _ ______ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 4-LC6 CHAMBERS FOUND DRY DURING INSPECTION WITH NO EVIDENT STAINING. COVER IS 6" BELOW GRADE 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow, ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .. 367 PLUM STREET Property Address ESTATE OF CATH_ERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is WEST BARNSTABLE _ MA 02668 4/26/2021 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: -- Dimensions — Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I i t5in sp.doc-rev.7126/201 B Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 18 i Commonwealth of Massachusetts -- ,`P Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Property Address —"- ESTATE OF CATHERINE CROCKER - PO_ BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is WEST BARNSTABLE _required for every � .._.._..,____. MA 02668 4/26/2021 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 f AI,.qu3' I ina�•� t r t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET Property Address ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST BARNSTABLE _ MA 02668 4/26/2021 page. City/Town State Zip Code Date of.Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +9 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: 4/5/2017 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: TEST HOLE DATA PER PLAN ON FILE AT BOH SHOWS NO GROUNDWATER ENCOUNTERED AT 1108". BOTTOM OF SAS AT 36" Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i10 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 367 PLUM STREET t , Property Address ESTATE OF CATHERINE CROCKER - PO BOX 59 W. BARNSTABLE MA 02668 Owner Owner's Name information is required for every WEST BARNSTABLE MA 02668 4/26/2021 __ 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 ® 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 l5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 M TW2842 TW2836 TW2836 FACTORY MULLED S x TW2032-2 , r - �� f --------i-E3W i W I E BEDROOM E BATH E NEW BLK DINETTE E KITCH Y � r R 00� r fig,�3 . 0 P IOUIN d ` I E BEDROOM 4 E. LIV ROOM V m E" POY kll ' 2868 R5 TW2842 TW2 42 BRICK TW2842 TW2842 O STOOP A f" (NEW) 9; Z NOTE: ALL NEW WINDOWS TO BE LOCATED IN SAME AREA AS WINDOWS REMOVE HN1 EP.fY \ GRADE TRANSITION I I FIELD DETERMINE DECK/STEP HT. NEW STEPS TO PER GRADING GRADE TW2432 O 9-LITE I FACTORY MULLED -- TW2032-2 POSTFUtG-"%B- i HAL ----------r E3ltl i W p WAL Q V EW AREA E GARAGE, 0 I f ATH) E a o; _.__ a E KITCH �o> &7G�I:RIDGE L AD 09W ---- ------------ -- POST JGw i� JD i•I] O O R O O W j Z I i IIll j C. l ,i EXISTING I I INFILL I I P O 1 N \\ 28 POST TW24RICK 8-6T"W24 STOOP (NEW) 2 I _ I TW28424' • O F- az zWNEW BRICK O WALK E LIV ROOM A Q CUcocc��2 12'-O" - _ FIELD LOCATED of 5 10" SONOTUBE W/ 24" FOOTING TREATED BAND I I 2'-10" NEW DECK FRAME 0 CUT NEW O ARAGE PEOPLE EXSIT GARAGE DOOR N N ® I I I I I NEW CMU BLO K =- ------ -------- HAttfND---- ----------- ._-_-- -__ ______________ ____________J I I I I I I I EXSIT LL ACCESS rr a , I O fr Uw I Op J �LL EXISTING NEW HDR FOR GARGE JOIST HERS rr I LLL N- fr Z IL(v LL INFILL OPN NEW CMU BLO K ' WHERE REQ. _____-_--_-_J . I �- --- ---- (SITE DETERMINE) I TOO I I SL 1 - I SLAB FOOTING I I O I I I ��FIELD LOCATE WALL FOOTING O � y REINSTALL CUPOLA ASPHALT ROOF SHINGLES TO MATCH EXI T ............-. -- RAKE TRIM AND SOFFIT - - .-.-.-.-.-. TO.MATCH_ EXSI T 28 2 T 2 4 28 T 2 4 T 28 2 NEW W.C. FLR FLR SHING . _.- - - - - -.-.-.-.-. BOXES_ MATCH - - - - ..................-- - EXIST �Elm' ' TW2842 ! LASHING ! AGAINST BUILDING NEW RETAINING WALLS AND WALKWAYS ----CONTRACTOR-TO DETERMINE O FINAL SIZE AND LOC. Q PER SITE CONDITIONS (-3 SLABr FOOTING i I II I it i i . RIDGE VENT ROLL VENT RIDGE BOARD - ��J (STRUCTURAL SIZES - MAY VARY)- - SIDING (SEE ELVS.) 15# FELT PAPER "TYVEK' HOUSEWRAP 5/8' CDX PLYWOOD - 1/2' CDX PLYWOOD RAFTER VENT STUD WALL WIDTH TO .MATCH EXIST RESIDENCE R-13 BATT INSUL HI-BHI-P ATT L MIL. POLY VAPOR BARRIER INSUL 51, r _g. 2x10 RAFTERS - - TYPICAL STUD WALL 2 RIDGE VENT DETAIL SCALE H/Y-Y-O' O SCAM H/2. p-O. -- -- -- - -- _ - - - - !f ' r2 A.0 RIDGE VENT RIDGE BEAM ROOF PITCH TO MATCH NEW ASPHALT SHINGLE �.� _ �,/ EXIST TO MATCH EXIST -� NEW 2XI0®16" O.C. R-30 INSUL H W i - S 2 (MATCH EXIST) w U ` SIDING (SEE ELEVS.) Q F TYVEK HOUSEWRAP ` VAPOR BARRIER A.0 1/2" GWB 1/2 COX. SHEATHING 2X4916" O.C. 3/4" TtG PLYWOOD R-13 FBGLS. INSUL FLOOR GLBUDED AND NAILED FIRST FLOOR FLUSH W/ EXIST _ — (TYP) CMU BLOCK WALL R-19 INSUL CRAWL SPACE DUST CAP d 2" DUST CAP 6" COMPACTED FILL 1 EX: ----------- AGi i r NEW 1 � ' ' JOI: - - EXSITING FOUNDATION I BULKHEAD FND ' SLAB FOOTI G 190 -------------- ROOF PITCH TO MATCH ",-- EXIST `i= IT ' TW2892 -.-.-.-.-.-.-.-._ -.-.-.- - - - - - - - - - - ------------------------------------ ,NEW W B LK H D DECAADT LL LEST ELV TfO�I �(o� �L✓avo 5r uj DOG5 ® REINSTALL CUPOLA TW2842 - - - ROOF PITCH TO MATCH EXSIT SHINGLES TO MATCH EXIST. - /.-.-............. - WIN O_ O R AI WINDOWS TO REMAIN An 0 K dk I 3�. -.-.-.-.-.-.- ht � s REINSTALL CUPOLA NEW ROOF AND SHING ES TO. ROOF PITCH TO MATCH EXSIT E—MATCH EXIST RAKE TRIM TO — — — MATCH EXSIT ® F G6 6 T 23 28 a TW2032-2 FAC. MULL TW2836 W.C. SHINGLES TO MATCH EXIST; i GRADE TRANSITION FIELD LOCATED REAR ELEVATION NIEW WINDOWS TO BE G��C KC ice_ �TETED IN SAME AREA INDOWS REMOVE UNLESS .RWISE SPECIFIED a . e TOWN OF BARNSTABLE LOCATION �p l ��L9 P� S�1'22T SEWAGE# VILLAGE WQS lt���Ab��2 ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. (2We- Cod_� �� SEPTIC TANK CAPACITY /� W 5A l LEACHING FACILITY:,(type) L C 1p C,A u beC5 (size) (I w� 3 L -At td NO.OF BEDROOMS "J BUILDER OR OWNER -' Cc'U Ck2r PERMIT DATE: 4; �)' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ��m r Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) ��� Feet c Furnished by . 4 �i Al.. , Rti- h3` sc� r Frv�tbF Nape ��-39 �R�LC-ujpf rl f Town of Barnstable r �a(off Departitnent of Regulatory Services $ Public Health Division Date 200 Main Street,Hyannis MA 02601 S7O tEt►tax+" Date Scheduled Time 'Fee Pd._ ' t—a Soil Suitability Assessment for Sew ge zspT)Z�1, WPerformed•By:. �� r'�"�"►"S ��� Witnessed B :y eS LOCATION&.GENERAL INFORMATION Location Address 3 1 Owner's Name • y Io (1 . Vjef i rj�!=1�'h�13 Address Assessor's Map/Parcel: ` l� �� Engineer's Name j NEW CONSTRUCTION l REPAIR �,,� Telephone# tend Usa- Slopes(96) 7z Surface Stones Distancea ftom: Open Water Body l� ''` ft Possible Wet•Area Z��" ft Drinking Water Well ft Dral'nage Way i ft Property Line !�' r ft Other ft: SKETCH:(street name,dimensions of t,exact locations of test holes&pare tests,locate wetlands-in pmxlmity to holes) Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water In Hole:. Waeping front Pit Face �Z Ir . Estimated Seasonal High Groundwater 7 2 DETERMINATION FOR SEASONALMIGH WATER TABLE Method Used: yi Dcpth Observed standing in obs.hole: In, Depth to soll mottles: °^lE Dc(th to weeping from_side of obs.hole: 7:Z,P1 In, Umundwater Adjustment tt. ►rider.Weller iteading 17ate:._ index Weil level:___�,- jr. atbr, ,_ Adj.Ordundwater Leval PERCOLATION TEST ngt®�... Time Observation Hole# Tinto at 9" Depth of Pere Time at 6" Start Pro-soak Time @ Time(9"-6" End Pro-soak Rate Mifi./inch e,- -2 Site Suitability Assessment Site Passel! SitF Palled: Additional Testfng Neaded(YIN) Original: Public Health Division Observation Hole Data To Be,Completed on Back---------- ' ***If percolation test is to be conducted within 1001. of wetland,you must first notify the. Barnstable Conseirvation Division at least one(1)week prior to beginning. Q:\SEPTIC ERCFORM.DOC' DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Shcl Color Soil. Other Surface(in.) (USDA). (Munsell) Mottling (Structure,Stoned;Boulders. o lsistency.96'Oravell ' 7 it � �L' � v�33 • DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Sol]Color Sail Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Oravell • f I J {,� iUL�sL /�l �Zl /} . ��• (fjYa s/B ?`t fit.(-e 5A,,,a YA- '/c. c - DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Solt Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,SRopes;Boulders. Flood Insurance Rate Map: Above 500 year Mood boundary No Yes Viltltli 500 yea boundary tqo --f Yes Within 100 year flood boundary No. Yes Death of Naturally Occurring:Pervious Material Does at least four feet of naturally occurring pervious material axist in all areas observed thrpughout the area proposed for the soil absorption system? `C 5 If not,what is the depth of naturally occurring pervious matorlal? w.._..._,r... Certification I certify that on l i, !y��`� (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 trainin x arose and experience described in�10 CNM 15.017. Signature Datb Q:%S•BPTI0PBRCPORM.DOC 1 TOWN OF BARN_STABLE LOCATION 2 SEWAGE# TILLAGE VA&!A "A-4� b tf ASSESSOR'S MAP&PARCEL I q 6-- INSTALLER'S NAME&PHONE NO. L/ SEPTIC TANK CAPACITY r LEACHING FACILITY:(type) a (size) NO.OF BEDROOMS N OWNER PERMIT DATE: f f x �j 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 f xr FURNISHED BY �. C%,em o ID ('.j-A all! •f I �•. a D LI > Y1 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered incom uter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpYitation for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. Owner's Name,Address,and Tel-No. Assessor's Map/Parcel q to .® Installer's N ne,Address,and Tel.No. Designer's Name,Address,and Tel.No. SCo kcvWjj nnr- obbCA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons" Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) \LQp�Le _ ra�,�� L�� Rrop , 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 s Board of Health. e ign Date / oZ Application Approved by Date Application Disapproved by Date 3 for the following reasons Permit No. Date Issued No. (J/V'J/J Fee E THE COMMONWEALTH OF MASSACHUSETTS Entered in coin user: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21ppflcation for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ndiv,,idual Components Location Address or Lot No.3 ra-? w" Owner's Name,Address,and Tel N„o. `� Assessor's Map/Parcel ` Cj to f OGA4X_t Installer's Name,Address,and Tel.No yc. a J Designer's Name,Address,and Tel.No. M� C,%A bC1 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when applicable) Q $ ��sscau6 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 r Compliance has been issued ,T'this Board of Health. /� ,ig. n y M Date ( ia Application Approved by /%, i � ,L / Date Application Disapproved by V Date for the following reasons ,.� Permit No. f Date Issued , ® � � '� THE COMMONWEALTH OF MASSACHUSETTS �/ i BARNSTABLE, MASSACHUSETTS Certificate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired )__..Upgraded( ) Abandoned( )by r`�r , n 1 Rr J` at �M 5 ��t S f�esn ,\T-W . has been cons d in ccor• %c with the provisions of Title 5 and the for Disposal System Construction Permit No. ted /1,�� 1 t i f Installer '�('�,�� r11 t �W _ Designer #bedrooms v ►`z i)a Approved design flow ) !t gpd P The issuance of this permit'hall not be construed as a guarantee that the system will-function as desiP- Date � � f Inspector (-f G- - r= - - - - - - - - - r=---------------f - - --- --- rIX - No.- -- _I ` Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS . - Disposal 6pst to Construction 3pPrmit Permission is hereby granted to Construct(- .) Repair'( Upgrade( ) Abandon( ) System located at (r, 7 `� ,,� -� (, }e J �J Cf/'oa+Z, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons ction mt{st be�completed within three years of the date of this permit. Date ( Approved by / j LOCATION SEWAGE PERMIT NO. a 6 7 VILLAGE I { t� 005 I N S T A LLER'S IRE i ADDRESS /c�k 2'it&,tde,-nL,4 INAMMIWel OR OWNER 0 A T E PERMIIT ISSUED 1,2 DATE C0MPLIANCE ISSUED, r2. - � � 0 -� CIV\ 5 a 3& Fee— BOARD OF HEALTH TOWN OF BARNSTABLE < �� Applicat ion,forwell ConOtrurtion�ermtt�`'� lr / Application is hereby made for permit to Construct ( ), Alter ( ), or Re air (man individual Well`t: Location — Address Assessors Map andParcel �� -- ----------------------------------- Installer — Driller Address Type of Building Dwelling a� —_E�------ — Other - Type of Building--- ----=---- No. of Persons----_____________—__—_--______ -'r Type of Well 6 ~MIlklt Capacity---— -- ----——---- —--— Purpose of Well------ p-T!g6T--�-- — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. S � --- -- --- date Application Approved n — -- ---—— --��- — date Application Disapproved for the following reasons: ------- ------ -------- -- — —Permit No.� -- Issued-- � � CS - ---date ------ date BOARD OF HEALTH TOWN OF BARNSTABLE (tertificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well .onstructed ( ), Altered ( ), or Repaired �� S AhJ� l __ / --- ----- - by----- --- ----- ' - `� — /"� c ---- ------ -------------- ----- ",taller at- � vim s% Goe s� f}'`C/1/-f Z� ------------ - - has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.IT -5 �Dated I AP9-( ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- ---------- -- Inspector-------- - - - - —- --- 0 No.---- � �J 3 - Fee---------------- --------- .- BOARD OF HEALTH TOWN OF BARNSTABLE t A.pplicat ion for Well Congtru'ctio Vermin`'`- Ap lication is/hereby made for a permit to Construct ( ), Alter ( ), or,Re air (,41)an individual Well at: l//"1 5T llJc�J 1/ Si�6�F if ��_�p ,� - — - - — Location - Address Assessors Map and Parcel ----------------- ---- ------------ Owner Installer — Driller Address Type of Building Dwelling �`����J�'" l-- Other - Type of Building ' ------ No. of Persons---------------- Type of Well ------ fE _ ---� ----- -- - Capacity--------------------------- i Purpose of Well---- /'q 6/ip ---�— - I Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to - place the well in operation until a Certificate of Compliance has been issued by the Board of Health. 7o> late ' r Application Approved B, --—------—— � - date Application Disapproved for the following reasons: -------- —------ - date Permit No. Issued-- -- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (4-1' -,nstal-------- --- — — -- — — --- ----- r at � ler iliv '/ ---------- alias been installed in accordance,with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.l (J� Dated g —` ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------- -- ---- — Inspector-- ——-- - - ----------- E BOARD OF HEALTH TOWN OF BARNSTABLE Well Congtruct ion Permit No. W� C) Fee— Permission is hereby grantedto Construct ), Alter ( ), or fair (PTan Indivi ual Well at: street j as shown on the application for a Well Construction Permit i No. _ aC� C:)-3 — -- --- -- - Board of Health DATE Fizz../ ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. .... ....................OF....................................................................................... Allpfiratiou for Bispoiial lark Cann ern iun �ernti Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 7 7-0............z a .. ..................... I.. t_f .. .... ... ................................................................................................... 0. . � cation-.A ess or Lot No. ........................ ............ ... .... .............................. ................................................................................................. �ddresr C 5W ......... ......................................... ..... . .......... ................................. ........ .. ........ Installer ,,Address Type of Building .�'',Size Lot.-2.0....C.-9....0...0........Sq. feet U Dwelling If`No. of Bedrooms...........................................Expansion Attic Garbage Grinder �4 A4 Other—Type of Building ............................ No. of persons._.___-._...______-_.-__---. Showers Cafeteria Otherfixtures ....................................................................................................................I.................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacity............gallons Length---------------- Width_._...._.__._.._ Diameter--.-----_---___. Depth_____--______... Disposal Trench—No_ .................... Width_____...__._.._-__._ Total Length---___.____..__.____ Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter_-------_----------- Depth below inlet._-.._..____________ Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) , Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit---_--_-..--..__.___ Depth to ground water_.---..----______._...-. Test Pit No. 2................minutes per inch Depth of Test Pit-_.__...____________ Depth to ground water----_-_....__---___----. ---------------------------------.......................................................................................................................... 0 Description of Soil........................................................................................................................................................................ ---------------"-------*------------------------*---------------------------------------------------*----------------------------------------------------------------- -------------------------- .......................................................................................................... ........... Nature of jZepairs or Alter ions Answer wh�pp=' ble._-'�?'-_. .......................................... ....... ............ U, ... - ------------/a--�- ... .... .. .........-------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance wi 1 41,the provisions of L I'!Z- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in ' i operation until a Certificate of Compliance has been i ued the boa of health. Signed 4A............. .... Date ApplicationApproved By.................................................................................................. ....... z....... DtApplication Disapproved for the following reasons:............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo........................................................ Issued_. ............................................... Date s Nol ..._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................................I.....OF........................................................................................... ApplirFafiun for Uiipus al Workii Tomitrurtion Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: =..'t� _...--------•••.....................••----- ..........---._...._......_..--•-----••-- f Location AAddfess or Lot No. e............................ --•-••-•----•....... ......... .....• ddress- ----•-. t ---.._..... Irl »» a ....� i .� C. ...`� r s �l1..................................... t' •`•."�J. -2 ��t�C�lfi'...---•--...................-- f Installer Address Type of Building Size Lot.. Q�.� .....Sq. feet U , Dwelling-PNo. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _-----------------_.......... No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other 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 inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ,4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•----•--------------------------------------------------•------------........._-___-_-__-__----••......................................................... 0 Description of Soil........................................................................................................................................................................ W U -•-•------•••••-••••-•----------------------•-•-----•-------------.................------------•••-•••-••---•-------------------------------•----•-••---••--•••----••••--------•--------••--------..-••- U Nature of Pgpairs or Alter ions Answer wh pplicable.___4i ----------------------- ....- .'�..... °�........ -----•-----------------••......•-•-------------•-•••-------•---•--•---•-------•-------•-------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI - 5 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 boar oj health. Signed--J�f ............. - .................................. ..................... Da e . ApplicationApproved By...........................................................................................•••---- ------ �� �` ...-- ' Application Disapproved for the following reasons:............................................:................ ...........................................................••----•----•---•-•--...._....------......--•-....._...._..•-•-••---•-•-----•-----------••----•------------------------......-•----......---- Date PermitNo......................................................... Issued- -'a---............................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..................................................................................... Trrfifiratr of TompliFaurr THIS IS TO CERTIF That the Individual Sewage Disposal System constructed ( ) or Repaired by.. s .... c,!.f I .� /� L +�•�• Installer ...... has been installed in accordance with the provisions of T�;LE _5 of The State Sanitary Code as''�des ribed in the application for Disposal Works Construction Permit No..___ ..`..1� ram................. da.ted_...� - � ---- •------•••-•---••-••. THE ISSUANC O THIS CERTIFICATE SHALL NOT BE CONST AS A GUARA�TEE THAT THE SYSTEM WILL F C ON SATISFACTORY. DATE......../Z:.----7 -- .............................................. /-----------•-•-----•--•--•---_. Inspector.......... --••••.._..-•••-•---••..................•-...•--...._-_.......-_-_--•. THE COMMONWEALTH OF, MASSACHUSETTS BOARD OF HEALTH r r .�..O F.................................. T No...... ............... FEi........................ Dtupog,�-at hii (Laagnu#rnrtion amit Permission is hereby granted...l.z... ...................................................... ......................................................... to Constru °� p pair ( Indivirluaf. gage D osal Systea J at No. .: �+Y. . .. ............... _'� -- --- / `--....- Str'e t as shown on a application for Disposal Works Construction Per n�iitf�(0N-o._{.r..............,fDated:....... �A ............... DATE.............................................................--•------......- Board of Health--• fJ` FORM 1255 HOBBS & WARREN. INC., PUBLISHERS I ACCESS COVERS MUST BE WITHIN 9" MINIMUM. 'INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NO TES : 6' OF FINISH GRADE 3' MAXIMUM COVER FIRST 2' TO INVERT AT EXIST PIPE: 103.2 DESIGN FLOW: M1N 2" OF PEASTONE INVERT IN SEPTIC TANK: 102.6 3 BEDROOMS AT I l0 G.P.D. PER 1. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION BE LEVEL 103.9 103.6 MIN OR F I L TER FABRIC INVERT OUT SEPTIC TANK. 102.35 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4' PVC INLET 46' N el0 lOZ.2 AT CESSPOOL 15 3/4" - I l/2' D I A. INVERT IN D I S T. BOX: `[ =lAE DOUBLE WASHED STONE NO GARBAGE GRINDER2. VERTtCAL DATUM lS ASSUMED. FOR BENCH MARKS INVERT OUT DI ST. BOX: 102.03/02.35 IO2.03 � /2` %0 SET. SEE SITE PLAN. us � v o 102 O $ 10/'0 INVERT IN LEACH CHAMBER: 102.0 l02.6 BAFFLE 102.2 t0l 0 SEPTIC TANK REQUIRED: ' 3 OUTLET 4 LC-6 LEACHING CHAMBERS BOTTOM OF LEACH CHAMBER: 330 G.P.D. X 200% - 660 GAL. 3. ALL CONSTRUCTION METHODS AND MATERIALS AND D-BOX W/4 ' STONE SIDES. 2' ENDS OBSERVED GROUND WATER: 96.0 SEPTIC TANK PROVIDED: 1500 GAL. MIN. MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1500 GAL H-20 CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL I l 'w x 34'! x l2"d BOTTOM OF TEST HOLE �2: 9I.0 SEPTIC TANK 6" CRUSHED STONE OR SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DESIGN PERC RATE l 5 M l N/l NCH NPROF I L E : NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER OBSERVED 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF Wl TH- OR OUNDWA TER. EL-96.0 STANDING H-20 WHEEL LOADS. et-4e ��� � PROVIDED: 4 LC-6 LEACHING CHAMBERS W/4' STONE SIDES, 2' ENDS. A-448 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 448 S.F. x 0.74 - 331 G.P.D. APPROVED EQUAL. 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED SOIL TEST PIT DA TA s PRECAST CONCRETE OR APPROVED POL YETHYLENE. INDICATES V INDICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER PERCOLATION = OBSERVED TEST _ GROUNDWATER TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE / TP •1 P+15268 TP s2 OUTLET. 0. HOR SANDY IOYR I ZON TEXTURE COLOR 104.5 0 HORIZON TEXTURE COLOR 102.0 SANDY IOYR 7. BEFORE CONSTRUCT 1 ON CALL "DIG-SAFE". A LOAM 3/3 A LOAM 3/3 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. CB/DH FND ��`\ ��\ / I/ \ 7 - - - - - - - - - - - - - - - 103.9 /0- - - - - - - - - - - - - - - - 101.2 FOR LOCATION OF UNDERGROUND UTILITIES. \ SANDY IOYR SANDY IOYR B LOAM 5/8 B LOAM 5/8 - - - - - - - - - - - - - - - 102.3 32' - - - - - - - - - - - - - - - 99.3 8• SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE - ' /00• FROM EDGE \ \ Cr SILT IOYR SILT IOYR OF pErLAND \ \ C l DESIGN ENGINEER TWO DAYS PR l OR TO CONSTRUCTION \ \ LOAM S/4 LOAM 5/4 \ j� FIRM IN WEEP ING*72' FIRM /N 96.0 OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE \ \ PLACE PLACE CONS TRUCT J ON l NSPECT IONS. /off �t 74' - - - - - - - - - - - - - - - 95.8 1 I C2 MED-COARSE IOYR 9. EXISTING CESSPOOL AND 0 VERFL OW P I TARE TO BE \ -----� SAND� /• LOOSE 7/6 PUMPED DRY AND BACKFILLED. _ \ / _� \ \ � �--\ �� \� / l/ loB• No WA TER 9s.s 132' 91.0 /D. ALL UNSUITABLE MATERIAL (A 4 B HORIZONS. Cl) TP#I \ \\ `\ \ ___-_ - // / ENCOUNTERED BELOW THE INVERT OF THE LEACHING ® DATE: FEBRUARY 14. 201T 3s�Maat` l � FACILITY TO BE REMOVED FOR A DISTANCE OF 5' \ TEST BY: STEPHEN HAAS \\ 4 MA LE CB/DH F // WELL WITNESSED BY: DAVID STANTON AROUND AND REPLACED W 1 TH SAND IN ACCORDANCE _._:..PERG.RATE:.._.L...2.M/N//NCH IN C2 _,...._.._:.�...._..,.- .:_.. ,,.:_.._........ __._W1 TH: TI TLE.-:5•_1 .......�. tV \ 1 NVERT-193-:2_- _ / %00' \ 29� / CB/DH TI PPE \\ \ \\ 1500 GALLON TP - v \\ \_EPTIC TANK .. ' 1 VARIANCES REQUIRED : \\\ \\ OVERFL `\� �6'TkEE 1\ TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS M1 A k PIT UP 152- / fi PART X11:SECTION 3.00. PART l l I:12: WELL LOCATION 150' IS REQUIRED BETWEEN THE SOIL ABSORPTION SYSTEM AND A PRIVATE WELL. 100* AND 107' ARE PROPOSED. 50' AND 43' VARIANCES ARE REQUESTED. O 9M. CORNER APfON EL}-106.14 WELL \ ` o / _ AREA \=� \ , �, S ER TIC S YS TAM DE� S / G !V 47. 758+ S.F. \\ \\ ' `\ \\ 367 PL UM S TREET , MAP / 96 . PARCEL S RA DAD 34 3 W E S T BARNS T A B L E . MA . PREPARED FOR 9 g ROPO LEGEND SB/DH FND I CA T H E7 R l / Y E7 C R O C K E R PpR h ■ CB CONCRETE BOUND -w WATER LINE SCALE : l - 30 APR / L 5 2017 L OCUS GARR TS 4 HYDRANT POND c GAS LINE STEPHEN A . HAAS C� OHW- OVER HEAD WIRES A LIGHT POST ENG I NEER I NG INC P . O . Box 1 6 `--E- UNDERGROUND ELECTRIC LINE / _�N+ o Suth De n n i s MA 02660 -T- UNDERGROUND TELEPHONE LINE / i�\~ ( 5 O 8 ) 3 6 2-8 1 3 2 -CTV- UNDERGROUND CABLEVISION LINE +40.4 SPOT ELEVATION WELL � / IVIA ...••40....... EXISTING CONTOUR D 15 30 60 JOB N0: 17-003 LOCUS V S A P q0 PROPOSED CONTOUR