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Home My WebLink About0007 WAGON TURN ROAD - Health r 7 Wagon Turn Rd r 108-023 West Barnstable : i fis-- Ei F! j 2 Bz- �li'L a 5�.� t!_1 4 Town of.Bpxnstble f Y 7�6 J®epartzzaent® Regulato�cy.Services k Pub.Ue Realth.;DIVISIon Date 200 Main Street,11yannis MA 07601 Date Scheduled Tune b_ Fee A'oA, Soil Suitability AssesAnent for Se waig D osal n , Performed-By: Witnessed By: ��1G1V t' �. - - JA Location Address '7 / _ n/�. Owner's Name Address 11 Assessor's Map/Parcel: �� Engineer's Namc Lv#-,, (kk1U ee NEW CONSTRUCTION REPAIR Telephone# �.Ja& Land Use:— 0-04666 Slopes(gb) Surface Sloacs A lit Distance's from: Open Water Body �� tt Possible Wet Area ft Drinking Water Well ft I Drainage Way ft Property Line N' t Other ft (Street name,dimensions of lot,exact locations of test holes&pore tests,locate wetlands?n proxin-dty to holes) THZ Parent material(geologic) Z Q e ` Depth tv Bedrgclt Z40. Depth-to Groundwater: StandingWatcrin Hole:. Weepingfl'nm Pitlanor Estimated Seasonal High Groundwater DETERMWAMN FOR SE.ASDN.AL EaGR WA7.TER T,A,1.tE. Method Used: Depth Observed standing in obs.hole: !q, Depth;tp s�tll xgottleat !n, Depth to weeping f.-om side of obs,hole: In, GrouudwaterAdjuslment fr. Index Well# heading Date: Index Well lAYal __ _._ p. t tcir, . _ e41t�f..Orc?uildwntePl evil EERCOLA.TION TEST milks Mine ..._._ Observation Hole# Tlme at 9" Y Depth of Pero. ie, q46, TIment6" Start Pre-soak Time @ TImo(9"-611) - - Had&-soak Rate Mln./Iuch Site Sultabillty Assessment: Slw kissed Sitp Filled: Addlbonal Tcs[lug Needcd(YN Original: Public health Dlvlsloa Observation Holt{Data To Be.Completed on Back----- ***If percolation.test its to be conducted witbin 100' of wetland,you must first notify the � (� Barnstable Coaasgvation Division at least one(1) week prior to beginning. ` :\SEPTIC\PERCFO D Q RM. OC I ' L DEEP-OBSERV9,TION110LE LOG Role-9 Depth from Soil Horizon Soil.Texture .Shcl Color Soil•. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders, o - 3 � Ic�YR3� � Iq _ 4�s q IDREP-P•OB E"J]EI•t.!V•.AT][Ol."e 110tI Y 0,G Role Depth from Soil Horizon Soil Texture Soil Color 'Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoncs,Boulders. onsis en 3"a Grave to DEEP OBSE+RVATION ROL E LOG Role g'._ Depth from SaiI.Horizon Soil Texture Soil Color Soil Othcr' Surface(in.) '(USDA) (Munscli) Mottling (Structure,Stones,Boulders. Coiislqtericy, Gravel) DEEP OIBSE'RV-&TI+DN RO LF,LOG Role'l Depth from Soil Horizon Soil Texture Soil Color Sail Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoncs,Boulders. Calls!ston cv, 6 y Flood Insurancg2ate� Above 500 year;flood boundary No— Yes Within 500 year boundary No.e'_ Yes..., Within 100 year flood boundary No.X -Yes ,;,_,,,,_, Death.of Naturally.Occurring Pervious Material Does at least four Feat of naturally occurring pervious aterlal exist in all area s observed throughout tha area proposed for the sail absorption system? �Y5 If not,what is the depth of naturally occurring pervious material's Certification �� ,t �,? �•- . I certify that on > "' .1 (date)I havapassed the soil evaluator examination approved by the Department of Environmental Protectlon and that the above analysis was performed by me consistent with the required training,expertise and experience described in�10 CMR 15.017. Signature Datb Q:MPTlaPERCF0RM.n0C TOWN OF BARNSTABLE LOCATION'n GtJ M II Ltew lz' SEWAGE# 46 K"' 431 VILLAGE O.; ,tet4Ili-A MC ASSESSOR'S MAP&PARCEL l0�'- 4-3 INSTALLER'S NAME&PHONE NO. C• 5�0�a ?"Y f- �� SEPTIC TANK CAPACITY (FX( n"4444 k004,f-f— LEACHING FACILITY:(type) --i-e-efte—'44- (size) _T> X_ J.4•V3 `,K—L e NO.OF BEDROOMS 4 ' 5��rK e-124. OWNER PERMIT DATE: COMPLIANCE DATE: 3 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) /h- Feet FURNISHED BY i G o A—3 o -�.3 a o No. � JC � Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for ]Disposal 6pstem Const union permit Application for a Permit to Construct( ) Repair 4 Upgrade( ) Abandon( ) ❑Complete System X11ndividual Components Location Address or Lot No. I Owner's Name dQd�ress,and Tel.No. �$ ?26/9-/ Assessor's Map/Parcel/�g 42 3 W. �1l-� v - � ��` V O W-G I staller's Name,Address,and Tel.No.S08 -99/-93n Designer's Name,Addre and Tel.No. 41 lath C��s�r�r#th�►, c P o- x ,eDOtJ»F4jae )n��'ir�o �'e 'er in 57 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) T tt'' qy gpd Design flow provided i5 5 gpd Plan Date c�C..Qy 7•'4.G V, Number of sheets Revision Date / Title iii4w_s- Size of Septic Tank L 1V�S 'r►e � ' ql� Type of S.A.S. Description of Soil Q 1D4 Nature of Repairs or Alterations(Answer when applicable) Au Lr Di4n t r Cj pG 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 Enviro al C e and not to place the system in operation until a Certificate of Compliance has been issued by this Board of th. S' Date Application Approved by c Date 1V 5 1J Application Disapproved by Date for the following reasons Permit No. Date Issued �� s No. �`" 5 oZ 3 Fee Q Q THE COMMONWEJAKMO� MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS {- Zipplitation for Disposal 6pstrin Construction Permit Application for a Permit to Construct( ) Repair 4 Upgrade( ) Abandon( ) ❑Complete System ArIndividual Components Location Address or Lot No. !(e✓i/1, Owner's Name,Address,and Tel.No. -9)8 Assessor's Map/Parcel/a$ /�3 W QaftNo". �- r' '� l¢1LM Y��A✓l! -:,ti. o t3ox P v W. o a�&F , staller's Name,-A and Tel.No.5h$ -77/-93n Designer's Name,Address,and Tel.No. 50 r 'IvG�" anS+ W71 rs l5 x VArrn Por 4- Type of Building: Dwelling No.of Bedrooms / Lot Size J57315 -' sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) T yU gpd Design flow provided S gpd Plan Date 71cJ,j "),-a_g 1�S 1/ Number of sheets / Revision Date ,� r Title 1,�Ie_ 5 ' :5; T"fCE ra u- 1 u 2 ri � l� ��/ Size of Septic Tank: UC-1 Type of S.A.S. j;&JJ& (--S _SCY r ��1� C of AA Description of Soil Nature of Repairs or Alterations(Answer when applicable) y ;D1,51r-1eLn� LK 3if1C� ]UGS (� /, MA.Q) t t�v, ct 3� > >( N�k D 1&_Idvle �5�� Sx! �(. P�,• 9� 3 � ,�/u.c�� , l'cnrn2�¢�.r"/a ®��5��cr� Date last inspected: Agreement: l 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 Envirmn nta� 1 Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He la th. Date 14145— Application Approved by Date !E� 51-5 r Application Disapproved by Date for the following reasons Permit No. 5 ` �\ Date Issued 5 --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS ,. BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS T-O CERTIFY,thdi the Op-siJA Sewage Dispos system Constructed( ) Repaired Upgraded( ) Abandoned( )byat G[J (f, I 1 has been constructed in accordance with the pro 'sions f Title 5 and th f r Di sal Systerp Construction Permit No. C3a 15-a3/dated � 1 Installer D f1� Designer;1k ___--1 nC r #bedrooms Approved design flow y S 3 gpd The issuance of this ermit sha?l of b construed as a guarantee that the syst will- ch signed. Date 3P /1 5 Inspecto ----------q-------------------------------------------------------------------------------------------------------------- -------------- No.aU15 ` —R3 i Fee /0 C) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *psttp Construction permit Permission is hereby granted to Construct( ) Repair( ill Upgrade( ) Abandon( ) System located at' '� (.C�1 e 9,.> > t 444E T 6 e 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:Construction05� t bompleted within three years of the date of this pe it. Date 5 Approved by AUG-05-2015 02:43 From: To:150e7906304 Page:1/1 FROM :down nape engineering ine FAX NO. :15083629WO Aug. 04 2015 02:01PM P1 -Tower of i3eflistable Rectory vices, b Thom. 5 iV.QaP�'tie�, Dx�C�at�r hab9c Houlth Divide. a � sot-b6z �t �+ say-iga63aa �Da ang�oae 0 UJ,+�, me►� I�sa�e�: _ la ` t G- 1SI� �Dri�►TY� 4i :,laedapaaz 'Ca lnsttilX a Mai it f7 MO IA) OU � . septic system Fit_ u D✓1 wY'�- _ based oat a desip d wW11 by - Tw ddexi Ll�—(a l Y cry tJa.t the Sc iac T pzt:M 1 r jref ur�'d abuvo tiva� a �} as Tech iL rel r. ian ' -Whirl m tLe design,-Whiay utclu& mi-D.ar 4Pwv'Q ck,k►n� dintribidioal7rJ'M?--/pT,2e.V c'trek. T ce=&j Iqt*,J:r, sepkic system.Tufafaced abaw',-vvu instoll?d vrith L01 rbaxiges (i..e. of ihr S,l�.�;c� t�►ve�iic .�elor�lfinn of may'cM ne►� oftb septicysn rea'rdanex tivifh Si�l�:& .teal t..errti�us. P.l rE:v]�tuu ox rzjtffic )' 'b9 dos, 'to (1¶.vw- DANELA , OJALA {�6tEil�C]E'9,]x�l,'t1I18� C1 465O2 " Qk D i e T - f j �- nsT's N (A't-�ntl��, � c€ . f / 1 } �5ME Town of Barnstable Barnstable .� Regulatory Services Department "3 Public Health Di I 3�. � vision J.F200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL # 7014 1200 0001 0358 4008 June 15, 2015 Mr. John J. MA r 7 Wagon Turn Road West Barnstable, MA 02672 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 7 Wagon Turn Road,West Barnstable, MA was inspected on June, 01,2015 by Paul Martin, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level,<12" below pit (per Town Code 316-9.1) You are ordered to repair or replace the septic system within two (2)years from the date of this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. ORDER OF THE BOARD OF HEALTH 7 Thomas McKean, R.S., CHO iAgent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\7 Wagon Turn W.Bam Jun 15 2015.doc 6/10/2015 Parcel Detail 1; BARNSTh iLE "�j� Logged In As: Parcel Detail Wednesday, June 10 2015 Parcel LeokuD Parcel Info Parcel ID 108-023 Developer Lot LOT61 Location 7 WAGON TURN ROAD Pri Frontage 266 Sec Road Sec Frontage i Village WEST BARNSTABLE Fire District W BARNSTABLE Town sewer exists at this address No ( Road Index 1772 i = ; Asbuilt Septic Scan: � � x Interactive Map 31 ; 108023_1 --M il, _ ^c Owner Info owner MARK, JOHN J & KATHLI Co- owner streeti 7 WAGON TURN RD i street2 city WEST BARNSTABLE i state MA Zip 02668 Country Land Info Acres 0.81 use Single Fam MDL-01 Zoning RF Nghbd 0106 Topography Level Road Paved Utilities Gas,Well,Septic Location Construction Info Building 1 of 1 Year 1979 Roof Gable/Hip��J Ext `Wood Shingle Built Struct .e Wall � .. Living 2026 Roof Asph/F GIs/Cmp AC None Area Cover Type style Colonial J uvali Drywall Rooms 4 Bedrooms Model Residential Int Carpet Bath 2 Full-0 Half Floor.o® Rooms Grade Average Plus Type Hot Air Rooms ,8 Rooms stories 2 Stories Heat Oil Found Poured Conc. Fuel ation Gross 3 Area418 • Permit History Issue Date Purpose Permit# Amount Insp Date Comments 1/1/1979 'Dwelling B20969 $0 1/15/1980 12:00:00 AM WB 2 STOR I Visit History http:/fssq 12fi ntranet/propdata/Parcel Detai l.asp)<?ID=6131 1/3 I of ZHe tgy. Town of Barnstable sAruvSTABM 9�Ar 059. �,� Regulatory Services Department Fa � Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/28/15 . DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water "supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) (§360-9.1) Leaching pit or cesspool with high liquid level, <1.2"below pit(per Town Code .+l a OTHER Repair deadline: 7 a. 3�+ Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc I - 2 Commonwealth of Massachusetts M/P log" VJ3 The 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Wagonturn Rd. - --- --- -- — Property Address John Mark --- -- ------- -- ----- — Owner Owner's Name / information is West Barnstable MA 02668 6/1/2015 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 A. Genera! Information filling out forms on the computer, use only the tab 1. I nsoector: key to move your cursor-do not Pau! Martin use the return Name of Inspector key. Cape Cod Septic Services_ r� Company Name 350 Main St Company Address W.Yarmouth _ MA 02673 City/Town State Zip Code 508-775-2825 _ S15016 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/3/2015 I spector'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. �0��tdVS t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 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 IL Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Wagonturn Rd. Property Address John Mark Owner Owner's Nance information is required for every West Barnstable MA 02668 6/1/2015 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•3/13 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 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x4= 440gpd l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts NNW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. Cityrrown 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 information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A Well 9 ( Y g (gP ))� Detail Sump pump? Yes No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 7 Wa9 onturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. Citylrown 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: BOH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'M 7 Wa9 onturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1989 for added pit and 70's for original system Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"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 properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 16 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: 1500Gal H-10 Sludge depth: 6-8 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 7 Wagonturn Rd. Property Address John Mark Owner Owners Name information is required for every West Barnstable MA 02668 6/1/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1-2 11 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.): 1500Gal H-10 tank. PVC tee in place on inlet. Concrete baffle on outlet has rotted and fallen off. Tank is showing signs of wear with aggregate showing through. Tank at normal operating level. Inlet cover 6" below grade with outlet 16" below grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'l 7 Wa9 onturn Rd. GM Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 7 Wa9 onturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. Cityfrown 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.): D-box viewed with sewer camera and was found in fair condition. Walls are intact. Signs of solids carryover. Box shows signs of being overloaded. Cover 3'6" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-6x6 leach pits were found completely full at time of inspection. Pits are in hydraulic failure 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 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. Cityrrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +14'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: Grade change of lot next door drops dramatically with no water. Bottom of pits at 9'. Minimum of 5' separation. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Wagonturn Rd. Property Address John Mark Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2015 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 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION��/ -7•, .' $EPdASiE VILLAGEG__1 1e _'L SSOR'S MAP & LOT /0 8 613 INS'i 1.i.LER'S NAME& PHONE NO.:EJ,f� PTiC TANK CAPACITY LEACHING PACILITY:(tppe),,,'4%f'6/ _ (size) NO.OF BEDROOMS c_�l PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER i _. DATE PERMIT ISSUED: DATE COMPLLANCE ISSUED: cp VARIANCE GRANTED: Yes Nc C http://www.town.barnstable.ma.us/assessin�z/IlMdisplay.av?rnao par=108023&sea=1 5/27/2015 . V l,� TOWN OF BARNST ABLE LOCATION -7 /% "z SEWAGE # �% -�✓ VILLAGE , SSOR'S MAP LOT /4 8+� INSTCALLER'S NAME PHONE NO. ? Y�:_ TIL TANK CAPACITY LEACHING FACILITY:(type)lJt_ ems' Q N1� 1(size3 NO. OF BEDROOMS .- PRIVATE WELL OR�PUBLIC WATER BUILDER OR OWNER E. DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:-- VARIANCE GRANTED: Yes Ne �� /,,: ,% /�� o 'I / i .i � ,. � �,h` /� �=- -' �J '�.�0 � , � ,'' ,�- ^ ^-• `, a No.....� $ 20.00 ---- Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS /V o a3 BOAR® OF HEALTH l Town.....................OF......Barnstable. . . . . . . ............ . ......................... Apphration for Di-spatial Workg Tonotrurtiun ramit Application is hereby made for a Permit to Construct ( ) or RepairXR an Individual Sewage Disposal System at: Mr. John Mark ................__.•....................................•--.....--•--....._.........----------- ----..._.................--------...------......••-------••••--•-•--------........................ 7 Wagon Turn 1�69dn-A ftb t Barnstable or Lot No. ......................--.......................................................................... ..........--..................................................................................... W J.P.Ma e omb e r Jr. Owner Address Installer Address UType of Building Size Lot............................Sq. feet DwellingX-No. of Bedrooms............3-----______________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons-_----_-__-______-________ Showers ( ) — Cafeteria ( ) 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. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date............................. Test Pit No. 1________________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------ :..____.__.._... •---•---------------------•---------•--------•----------....-----------...--•-------•-....--............-•-•------•------------........----•-...-••--••....•. Descriptionof Soil Sand.............•-•--•-----•--••-•--••••-----•••-•-•-----••---••-•••-•--••••---•--•--•-••--•-•------...........--••- x W -------------------- -------•-•••......---•-- -••----•-•-----------•--.....__....----•••--•-•-••-------•••---•----••--•-•••---•-•-••--•-•-•--••-•---•-•-•-•------••••-----•-•-•-•-------•-••---••..... V Nature of Repairs or Al rations—Answer when p i bl .._-.___. eachiri it g p- • �. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issue Pb he the oard of lth. Signed 06�.f '•--•------•-----•--- •.1111a9.......... Date ApplicationApproved By............................................................ ........................................ Date Application Disapproved for the following reasons----------------------------••--•----------------- .............................................................. .........---••••-•••----•----•-•-----•-••-•--•-••------•-•--•--•--••--•--•-•--••-----...--•-••----•---------•-•--•••-••-•-•-••-•-•----•------•--•••--------•-••-•-•-•--- •---••--•------•-••--•---••-••- Date PermitNo......................................................... Issued-....... ��..................... Daze NbS c1.......J. 3 FE$:............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH To,n. :.�a.rinctable ..............................;............0 F.........................................------.------•----......--------........_........ Appliratillu for Diopooal Works Tottotrurtiott "truth xx Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal !system,a�ln ;4arr: • Y.._.. ..................... ...••••....._..•,•--•••..a ---- .-. --.---- ---------------------------------- ---- ----•---------------•------------- ------KCI6caion-Arises I�,arntc Mlle- or Lot No. ......j.....n................... .......................................................... ............•_-__._....___.........................._.........---........_........ O t ,r j'r'. Owner Address W Installer Address UType of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms.......... ...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.1 _�__•--_-__. 4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....,---................ 9 ........................... •--•.............•-•-•••••.....-•-••••...........----...........---•-----..........•-•-•-----•-••••........................... p Description of Soil----------------------•--•-•----•.----•-b.a.nu..........----.......---------...--•-••--•------•----•-•---•------•-•---•-•-••-•----•---•--••••......•••.........---•••- x W U Nature of Repairs or Alterations—Answer when applipbl_Vdje3_________________________•_•-________.._-__-__�_.......;......._......____...________..... f� ---- Agreement,,�� v - The.7tndersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLi: 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 board of health. . Date Application Approved B L�! - Date Application Disapproved for the following reasons----------------------•----------------------------------------------....----------------------------------...... .............................................._.......T...................................................................................................................................._............. �. d ........ •• ......----.......�-�._.............. Issued.----- // d� Date Permit No..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH lo.._n .................OF...B`Erns ta'�le ........................... Trrtifiratr of Toutpliattrr THIS IS.T�OFC.ER JIFF, Y, That the Individual Sewage Disposal System constructed ( ) or Repaired.( ) by. '....... ....-•-•-•---------•--•---....---•--•....................•-------••--•-•• ---••......._.........-------•----..._....-••---•--------•-•--............-••--•---....._---•-- rl or. Lur-) Road T- s t 3arnf ;aIns l_ler at..............................................................7..------•-------------------•--------- has been installed in accordance with the provisions of 11"IT L' 5 of The State Sanitary Co�lq ssde7cc in the application for Disposal Works Construction Permit No.-tS ..... _.�— dated............. .................................. THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ T ....................... Inspec or.... 2...•. THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH Torre .Barnstable ...........................................0 F............................................---._...............................--_.. No��1..._�, ,.�j FEE__ :? �rl Disposal sal Works %Toatoirurtion Vamit .P.Ivlaco!n ber Jr. Permissionis hereby``-grante ........._...••••-•••..........................I•-•-•-••-•------•-••-••-•----••---•--•••-•-------•-•-•••••...---•...•--•••.............---_.... LSl..A to Construe-1 0) or�I�epal (ae) anelndividual,r$,ewaagJep sposal System atNo.............•-............................... ,..............._.._...... -....- ....,...._.._......._... q Street c as shown on the application for Disposal Works Construction Permit Ia---� �Dated_._... ............ ................. --......-•---.---- .--••� .- •-------Board of Health•---•------t----•-•-----•----...-•---•-- DATEt Z• ...............•--•----...... 125 FORM 5 HO B§ & WARREN. INC., PUBLISHERS go.......7....... FEz....6;................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA TH ........ OF....... .............................................. --- - ---------------- Appliration for Disposal Works Tonstrurtion Permit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: 6/ ................... j��..... .......N. ........................................................ ti�h-Address ........................... ........... .....6......oa. .ez,.....7.4- Or �ddress...... ................ ....41. .......................................... ......... Installer Address Type of Building Size Lot...:t ....Sq. feet Dwelling-7 No. of Bedrooms............/.............................Expansion Attic Garbage Grinder Other—Type of Building ............................ No.. of persons............................ Showers Cafeteria PL4Other fixtures .......................................................................................................... .................................... Design Flow ........... ..................gallons per person per day. Total daily flow.._.._..... ................................gallons. 9 Septic TankTLiquid capacity/z7)-gallons Length................ Width..._._.......... Diameter.............._. Depth....._.......... Disposal Trench—No. .................... Width-7.............. Total Length..... Total leaching area....................sq. ft. Seepage Pit No-------/----------. Diameter........1.Z T.... Depth below inlet....... .......... Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing�tan% Percolation Test Result Performed by ................................ -------- Date.... Test Pit No. I .....minutes per inch Depth of Test Pit.................... Depth to ground water..__.................... rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.............._.._.. Depth to ground water...................._... Ix .................. ....................................I........ - --- 0 ......... ......... . -----------r / — -- Description of Soilf.. . ....0. .2.../ - ----------;k Zg. ............................. ------------------------- -------------------- ............................................................................Z......................................................... .................... . U Nature of Repairs or Alterations—Answer when applicable.............. -e.................... ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'L I'�ITZ' 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 board of health. igneo...........A....................................................................... ................................ Date Application Approved By......... ------- ......... Date Application Disapproved for the following reasons:....................... ......................................................................................... ......................................................................................................................................................................................................... . Date PermitNo......................................................... Issued_............. ate ...................... No........... ......... THE COMMONWEALTH OF MASSACHUSETTS BOA!RD F' �-I EA T .. f1 &...........OF.....-- - ApplirFa#ion for Disposal Works Tonstratrtiun lirrmit Application is hereby made.for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ........ e� drab Address •-- ....--°.e. - __.._._....•------------------------- ....��.._ �.� �?�._ ��?� � ... ��`rr a/W caner E • ddress �! Cent _...e n _ �'? f.. r __ W .....•---------------------••••-••••.- � Installer Address Type of Building �p Size Lot.. --R�._..Sq. feet ellin —No. of Bedrooms .............................Ex ansion Attic a � p ( ) Garbage Grinder ( ) aOther-Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures.•----•------------------------------•-••--------•--•--•-•-----•••--•-•••----•--••-•--•-••---•--- W Design Flow_ ____________ _.✓`.. _--__..gallons per person per day. Total daily flow...... 7 .......................gallons. WSeptic Tank Liquid capacity _gallons Length....w_a....... 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 ( ) Dosingota*Percolation Test Result Performed b -_... ? %4 a Y 'Z - �- Date . Test Pit No. 1. .-,___-minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ... ----- d 914 �-- 0 .^Description of Soil ...... ''. "`...... -." ,...[__. '"._ _-�1_ f W ------------------- UNature of Repairs or Alterations—Answer when applicable...................................................................................._........_.. ------------------------------------------------•--•--•----•------------•-•-------------•-•---....................................................... = Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TAITLE 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 board of health. Sign( r::. ..............................•-•--......_----•-•-----••-------_...-- ................................ / Date Application Approved By........:_-;:_:.. . ;.....-•............. V,, -------•-••-•-•------ t�w �!� � ... Application DisapprovedDate PP for the following reasons:_....----•--------------------••----•--------------••-•-------•----------------...---------••--•-=....----------- - ..-•-•...............•--•--•---------.....--•---•-••-----........................---.....-----••-•-----•-------....-----------•-•-----•-------•-•••----•--•--•-----•-•---------•••••-•-•-......-•----••- Date PermitNo...................................................-.... Issued.................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL ........ OF................. .. .... , '°- ...................................... Tr -firatr of TuntpliFanrr TZli, IS TO CERTIE hat t i6 ndividual Sewage Disposal System constructed ( or Repaired ( ) by !2 [tt ----• --- ------ -- Lt.`""w.- Insta er at._m....��--'i ,;. G .. .--• -- - ..Eli has been installed in accordari�e with the provisions of r of The State Sanitary Code as describ d in the application for Disposal Works Construction Permit 'oU__.__...�....................... dated...... ......____.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ a. .�5.._7. .. .......................... InsP -Inspector .. �' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �........f- r .....'I..........OF...........;KtT..4.41. .No............ .,...... FEE........................ vR'r. i n 1 nrks To tr rrant Permission > eb ranted._ JlIY......_ .•................................................................... to Construct or RepaiTi (/1.�I) i Indivi4, al Sew e6 Fsposfdti 1lSys r *I eA Streetf. ` as shown on the application for.Disposal Works Construction Permit Ngo� _______vDated.... ................. ............. yyyyyy ,.....--•-- .., f :-------_--------------- // Board o HalxK DATE......-•-~ ...... ...:......................•---------• .. � FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - ,1 10 Ok 603 E WALTElik E. U SM1512 ASv°yr t"zc)s )tii t� , SCALE- fps o 611 O IO'PVC Sd. p�si,8ck S�.O J`8•S � �� G n r ` �FT Utrtt-1 S P t G TIN 58 c.64�A r �. 4, c o 0 t, t r 3i=•T r 1' I;LEl. Oro G-,ROVNp �� b�c A P_COt.A,'ri Pt,) P—A-rE Z M r ►.� � t �C.t4 P.0 P 57,0 24'' `i:Cr PE QF'DeMCD 11--twe 4- 12 R t►0CgPD = 44 0 !eAr,+At .l IE = cz-1 i4..Pa to$E P oso, 25 o- r� t C_ �#j e, 'SPs�jD t: PAC ,5+4 55't FS�TWit, 1QY, Io x 1 , v ; i 010 C-7PO ? IDES - 4 )e-GK 10 x Z' S i,O0 7PD CA Pk 11-4 Via -7 0 0 �-►PO rF 'f"'�C..C_....►+�..L 1�F^+�� t,�l.j (T�. �`"�.�V j �I�t"-��., Q 4-7-0 14 4" No 6pouti o UJA LU 4— 6, 1 Ira i lv i c:AJ SYSTEM PROFILE MALL SYSTEM ARKED WITH CMAGNETIC TTAPE OR BE NOTES (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS ASSUMED ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2^pEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE 2. MUNICIPAL WATER IS NOT AVAILABLE \ TOP FOUND. EL. 112.4' FILTER FABRIC OVER STONE 1� 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. a 0 MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 105.0' o Leo a PRECAST H-10 NOTE: MIN. WALL THICKNESS 2" sLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST • PRECAST RISERS er e2Q z�g RS m'R.) a^>7�scHao Pvc UNITS TO BE AASHO H-110 �o� Locus �r 110.15 MORTAR ALL INVERT IN 101.17 �n PIPES LEVEL 1ST 2' COMPONENTS 4' S. PIPE JOINTS TO BE MADE WATERTIGHT. �ENDS (TYP) SIDES 102.0' Jtc o„� Orid 10" EXISTING 14" ; ono° ® ® OBER ®® o`oo°°°°°° 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE p ��% Willow _ ® ® ®® t e t TEE SEPTIC TANK TEE f*108.7 °°°°°°°° ®®p®®®®® ® ®®� ® '°°°°°°°° WITH 310 CMR 15.000 (TITLE 5.) boo° Scree Str e 0 0 0 0 0 6"MIN.SUMP 'o°°°°°° °°°° ° MQPIe > ®®®®®®®®®®® �1®®®®®®®®® °° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND GAS BAFFLE..,' �0��4 0�0 12"MIN.INT.DIM. ci i°o o°o°o ®®®®®®®®®®® ®®®®®®®®®®® ,00°o°000 101.44' 101.27' ° °°°o°°° 99,17' NOT TO BE USED FOR LOT LINE STAKING OR ANY WATERTEST D'BOX °° ° ° ° °°° ° ° OTHER PURPOSE. FOR 3//44"--1E-1 2EDOUBLE WASHED STONE 4'MIN. H-10 500 GAL.LEACHING CHAMBERS BY ACME PRECAST OR EQUAL 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. 6 pJ�� ALL AROUND PRECAST STRUCTURES (3)UNITS REQUIRED 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE:33.5'X 12.83, 9. COMPONENTS NOT TO BE BACKFILLED OR COMPACTION. (15.221 [2]) CONCEALED WITHOUT INSPECTION BY BOARD OF U) HEALTH AND PERMISSION OBTAINED FROM BOARD (3.9% SLOPE) ( 1 % SLOPE) OF HEALTH. FOUNDATION- EXIST. SEPTIC TANK - 187' D' BOX 12' LEACHING 93.5'BOTTOMTH-1 10. CONTRACTOR SHALL BE RESPONSIBLE FOR FACILITY NO GROUNDWATER FOUND CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES ** VERIFYING THE LOCATION OF ALL UNDERGROUND & INSTALLER SHALL CONFIRM MINIMUM SEPTIC OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO TANK SIZE AT 1500 GALLONS AND ITS 5' REMOVAL OF UNSUITABLE SOIL REQUIRED WORK. NOT TO SCALE INSTALLING ANY PORTION OF SEPTIC SYSTEM SUITABILITY FOR RE-USE. REPLACE WITH 1500 AROUND PERIMETER OF LEACHING FACILITY, GALLON SEPTIC TANK APPROPRIATE TO SITE DOWN TO SUITABLE SOIL LAYER. REPLACE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 108 PARCEL 23 CONDITIONS IF NOT SUITABLE WITH CLEAN MED. SAND, TO MEET SHALL BE REMOVED 5' BENEATH AND AROUND THE SPECIFICATIONS OF 310 CMR 15.255(3) PROPOSED LEACHING FACILITY. VARIANCES REQUESTED UNDER BARNSTABLE 125' \I 12. EXISTING LEACHING FACILITY SHALL BE PUMPED HEATH REG. AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGENDSAND. 3. SAS TO BE LESS THAN 150' TO A WAGON TURN ROAD I \ PRIVATE WELL BUT GREATER THAN 100'. (GREATER THAN 125' PROPOSED) 99- EXISTING CONTOUR EXIST.WELL \ v�'ryh0 N_ \ \ / X 99•1 EXIST.SPOT ELEV. PROPOSED CONTOUR ALT.BENCHMARK:SURVEY NAIL AT ELEV.103.0' 198.41 PROPOSED SPOT EL. / SYSTEM DESIGN: TH 1 36"OAI\ /TH TEST HOLE 5112 1 02.�99 GARBAGE DISPOSER IS NOT ALLOWED / 0 2>_ SLOPE OF GROUND / \ 4 �102 EXISTING 4 BEDROOM DWELLING � \ UTILITY POLE \ACCESS EASEMENT LP,LP DESIGN FLOW: 4 BEDROOMS @ 110 GPD = 440 GPD e\ � FIRE HYDRANT 1 \ USE A 440 GPD DESIGN FLOW NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING / / 03 SEPTIC TANK: 440 GPD (2) = 880 \ o ( **RE-USE EXISTING 1500 GAL. SEPTIC TANK TEST HOLE LOGS / LR=165.00 \ \\ QvP� 12"BEECH o� \ ^o� ` J� LEACHING: y / 2 ' AK \ SIDES: 2 (33.5 + 12.83) 2 (.74) = 137 GPD DANIEL E. GONSALVES, SE #13587 z ENGINEER: m \ r ^�1 ° 20"PINE BOTTOM 33.5 x 12.83 (.74) = 318 GPD WITNESS: DAVID STANTON, RS 12 �° '°s �� ( DATE: 7/7/15 G 1 ) TOTAL: 615 S.F. 455 GPD 7 �° °e � o m � o o a m USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) PERC. RATE _ < 2 MIN/INCH EXIST.WELL 709 � � WITH 4' _STONE ALL AROUND CLASS I SOILS P# 14748 � ELEV. ELEV. 1 •• p" 1 105.5' 0" 2 105.5' / � A A 11 0 � � �� \ (� MA APPROVED SL SL d S DATE BOARD OF HEALTH ' 391 10YR 3/2 4" 10YR 3/2 GRAVEL D VE \ �- �) \ TITLE 5 SITE PLAN B B WELL. EXIS FNON.EL. 112.4 SL SL T°IoELEv.1oa.6' INVERT OUT EL. ,; 7 WAGON TURN ROAD 10YR 5/6 10YR 5/6 109.4' o�� * 4-8" 101.5' 48" 101.5' WAS S.�EPs / ��^� M - WEST BARNSTABLE, MA L HR J I DECK I � �... G C, _ , PREPARED FOR LFS LFS 000 2.5Y 7 3 2.5Y 7 3 �� •1NOFMAs DANIEL RTOLOTTI CONSTRUCTION/ / / INVERT OUT OF ST EL.108.7't S A. 96 97 5 78 99.0 BENCHMARK:USE � qc o a �� 9. RR TIE / GAR.SLAB AT EL. �° DANIEL A. yGs " OJALA N MARK 104.6' o OJA No,40980 CIVIL " �°a �o C2 C2 �'� / No.46502 7qESS o� DATE: JULY 7, 2015 SIEVE S'o �c �``. . 0 U RV E 1 MS MS LOT 61 / STEEP UPWARD SLOPES T� ��HOF'Mj off 508-362-4541 W/ POCKETS W/ POCKETS 35,325± SF / (NO ACCESS) �o I LA icy ` DANIELsgcy°N fax 508-362-9880 OF SiL OF SiL o OJALA A. 1� I downcape.com CIVIL OJALA • 10YR 5/4 " 10YR 5/4 � .46502 � down cope engineering, iac. 144 93.5 144 93,5 No. Scale: 1"= 20' / / � s oNT N �NF SS ° civil engineers NO GROUNDWATER ENCOUNTERED �-�-�� 939 Main Street Rter6AyOrS 1 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 D CE # !9 5- 1 4 9 15-149 BORTOLOTTI-MARK.DWG