HomeMy WebLinkAbout0066 CAPES TRAIL - Health 66 Cape's-Trail
West Barnstable
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.Jt --as9y CERTIFICATE OF ANALYSIS Page: 1 of 1
Barnstable County Health Laboratory (M-MA009)
h/
\yss�ctr.5w Report Prepared For: Report Dated: 3/23/2015
Nile Moore
Order No.: G1585892 Ti
Oceanside Realty Group
766 Main Street
Osterville, MA 02655
Laboratory ID#: 1585892-01 Description: Water-Drinking Water
Sample#: Sample Location: 66 Capes Trail West Barnstable, MA Collected: '03/19/201'Fl
Collected by: Received: 03/20/2015
Routine
ITEM RESULT • - UNITS RL MCL METHOD# TESTED
Nitrate as Nitrogen 1.7 mg/L ' 0.10 10 EPA 300.0 3/20/2015
Copper 0.42 mg/L 0.10 1.3 SM 3111E 3/20/2015•
Iron ND mg/L 0.10 0.3 SM 3111B 3/20/2015
pH 5.8 PH AT 25C NA 6.5-8.5 SM 4500-H-13 3/20/2015
Sodium 62 mg/L 2.5 20 SM 3111E 3/20/2015
Total Coliform 0 /100ML 0 0 SM 9222B 3/20/2015
Conductance 560 umohs/,cm 2.0 EPA 120.1 3/20/2015
Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician.
Attached please find the laboratory certified parameter list. Approved By:
(Lab Director)
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-66.05
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
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on the computer, ````�������H
use only the tab 1. Ins ectof: Jji.l D `:0,key to move your po �G
cursor-do not JAMES
use the return James D.Sears _�
key. Name of Inspector
CapewideEnterprises,LLC o Co.
Company Name �i !
153 Commercial Street
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Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
1 certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant.to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2-21-15
pector'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 1.0,000 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.
j115
Min•W13 Title 5 Offidal InVSbsurface Sewage Disposal •Page 1 OW J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
66 Cape's Trail
Property Address
Charles Constantine
Owner Owners Name
information is required for every West Barnstable MA 02668 2-20-15
page. cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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:
The system is a 1000 Gal.Tank D Box and two 500 Gal.Chambers,
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair,as approved by
the Board of Health, will pass.
Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
_ Commonwealth of Massachusetts
Title 5 Official Inspection Form
R a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):.
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
A�ff
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is West Barnstable MA 02668 2-20-15
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*"..
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in sopwing is less than 6"below invert or available volume is less
than'/2 day flow eWiA-,G
t5ms-3/13 Title 5 Official Inspection Forth: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
66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. City/Tom 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-
101000gpd.
❑ ® 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 11 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 Forth:Subsurface Sevmge Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Cape's Trail
Property Address
Charles Constantine
Owner Owners Name
information is required for every West Barnstable MA 02668 2-20-15
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN'flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal Sysiem•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•°< 66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal.Tank D Box and two 500 Gal. Chambers.
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): Well Water
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
CommerciaUlndustrial 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
" 66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. City/Town State Zip Cafe Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 2010/2012/2013
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)
El Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the i/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'( 66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. Cityrrown State Zip Cale Date of Inspection
D. System Information (cunt.)
Approximate age of all components,date installed (if known)and source of information:
2007 Permit # 2007-420.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
1"
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
" 66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
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 29"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 18"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank at working level.Tank and outlet cover at 1'below grade wriniet cover at 2". In and
outlet tees. No sign of leakage of over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r� 66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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
"< 66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. Cityrrown 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 is 16"x16"-32"below grade w/cover at 16". Box is clean and solid w/two line's out. No
sign of over loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No`
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 rMe 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ 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.):
Leaching is two 500 Gal.dry well chambers w/4'stone. Chambers at 40"below grade
w/cover at 15". 6"water in chambers,wall's are clean like new. No sign of over loading or solid carry
over.
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
"< 66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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•W13 Title 5 Offidal Inspection Forth: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
66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
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
,, Fi
.3.= 60
3D o
O
t5ins•3/13 Title 5 Official inspection Fomr.Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
66 Cape's Trail
Property Address
Charles Constantine
Owner Owners Name
information is required for every West Barnstable MA 02668 2-20-15
page. Cityfrown 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: 11'+
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: 6-18-07
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:
T.H.on Design Plan 6-18-07 no G.W.at 11'+. Bottom of chambers at 6'below grade. Bottom of
chambers at V above T.H. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
66 Cape's Trail
Property Address
Charles Constantine
Owner Owner's Name
information is required for every West Barnstable MA 02668 2-20-15
page, CityrTown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable r# ffz
g DeFartiment of Reguitato Services
rY
_ = Public Health Division Date L
..> �-
t6sA 200-Main Street,Hyannis MA 02601
hl
Date Scheduled
Ttme
Soil Suitability Assessmentfori Sewage Disposal
Perf�d By: 4�r i t� �9s-�
g peso!
witnessed By:
LOCATION&GENERAL INFORMATION
Lo
cation (o CAPt TKA!L Owner's Name
f t ,c SGC YI7Et Cfl
Addressan eLEngineer's Name 9n 0 f>r 7 D 94 tZ
CWN g pAR X ICJ G�✓, rKts.4`
Telephone#
Land Use Slopes(%)
Surface Stones
Distances from: Open Water MAY & Possible Wet Area
,—__ ft Drinking Water Well ft
Drainage Way ft._ -
PropertyLine"e----�_ft Other
ft
SKETCH:(Sheet name,dimensions of lot,exact locations of test holes,&pert tests,!ogle wetiaads in proximity to Doles)
T.0..
2
---
I
i
Parent material(geologic) i a
Depth to Bedrock r
. Depth to Groumdwater. Standing Water in Hole:
Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER�' 7. `Method Used
Depth Observed standing in obs.hole:
Depth to weeping from side of obs hole: in. Depth to Soil mottles.4Oround
1n
Index Well# Readin Dates in. Groundwater Adjustmt
g Index Well level Adj.factor A� r Level
olu PERCOLATION TEST
Observation Dole-
Hole
tion.
Hole# T me at V,
DEEP.OBSERVATION HOLE LOG Hole#
Soil Horizon Soil Texture Sal Cotor Sal
Depth trap unseltj Mottling (Structure.Stones:Boulders.
Surface On.) (USDA) .(M r tt a.-,-C ISQ4-v&—
6
OX-TT {�
L2 t Z-
u
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon . Soil Texture Soil Color Soil Odner
Surface(in) (USDA) (Mnnseln Mottling (Structure,Stones.Boulders.
d3 G , 2+
DEEP OBSERVATION HOLE LOG Hole#
Soil Horizon Soil Texture Soil Color Soil WNW
from Munselq Mottliag (Structure.Stones,Boulders
Surface(in.) (USDA). ( i Q v
- f
DEEP OBSERVATION HOLE LOG .Hole#
Soil horizon Soil Texture Soil color Soil Other
Depth from. (USDA) (Mansell) Mottling (St uctUm Stones.Boulders.
Surface On.)
r
Flood Insurance Rate Mao•
Above Sty year flood boundary No
, illitimn S(ttl vtlt 1fOUndaly No Yfi-�-"�-'-
�. DEEP OBSERVATION HOLE LOG Hole# �
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munson) Mottling (Structure,Stones.Boulders.
i 96
u
4
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil other
. (Mrmselt} Mottling (Structure,Stones,Boulders.
Surface(in.) (USDA)
t3
DEEP OBSERVATION HOLE LOG .Hole#
Depth from Soil Horizon Soil Texture Soil Color 5011 Other
Surface din.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
con
Flood Insurance Rate Map'
Above 500 year flood boundary No_
Within 500 year boundary
wthin too year flood boundary No Yes
Depth of Naturally OccurrLM Pervious Materlai - oat the .
Does at least four feet of naturally occurring pervro 'al exist in all areas observed through
area proposed for the soil absorption system? '
If not,what-is the depth of naturally occurring pervious material? --
Certification
I certify that on LOCI
� (date)I have passed the soil evaluator examination approved by the
Department of Environ ntal Protection and that the above analysis was performed by me consistent with
the required training,expertise and ex rience described in 310 CMR 15.017.
Date 7
O�
Signa
Q:1SPrnCWERCF0RM,.D0C
TOWN OF BARNSTABLE
LOC TIOONt�(/ SEWAGE#
=JILLAGE �,��� 5`��/€� ASSESSOR'S MAP&PARCEL I®� .e0�/-
INSTALLERS NAME&PHONE NO. fL�a_DS go
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) SIC° 0 �
NO.OF BEDROOMS —�
OWNER i- ., ell
PERMIT DATE: COMPLIANCE DATE: / O
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 leach�lity) Feet
FURNISHED BY
a
0/�
�� 14 A
r
No. goo q;,a '' Fee 1-D
THE COMMONWEALTH OF MASSACHUSETTS Enta�ed in computer: __V/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
pplicatiou for �Di5po5al *pgtem (Con0truction Permit
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. 66 GA p , TIZA t L Owner's Name,Address,and Tel.No.
6AXrj5T01e . (r,t mt, 6eoR�e S6 11)7GCLA
Assessor's Map/Parcel �p p 13 010 6F?� SAm9
Installer's Name,Address,and Tel.No. R o�ZIC r Ov Designer's Name,Address and Tel.No. K CJ f;, iNQ�lc�ivs
NAr`w�cl, mA GG GrGepdv,1) D0c, bIX, FvrtPS4JAfa,/n69Qea4!
S-3p- y>2 -L)3�s� oY-477-So9Y
Type of Building:
Dwelling No.of Bedrooms Lot Size P•02 AL_ sq. ft. Garbage Grinder (r/)
Other Type of Building 140-o-SC No.of Persons ,.. Showers( I ) Cafeteria(n/)
Other Fixtures '
Design Flow(min.required) gpd Design flow provided 39
(, gpd
Plan -Date Oct -a 7 - 01 Number of sheets i Revision Date
Title Pt-04-srD S�7PPC_ cr?CJAP ; 0",ax G 6e Cq Aa TiC,A iL
Size of Septic Tank (57*1 T, 10 0,3 g A I Type of S.A.S. 2 -S_os V AIN�J C/ti,q)KteL., W V IJ Z�l
Description of Soil r - 13'0 l.®fein XI Sl�r�l
' - " o ,Ar%4 o K
I� G4 CI . S c7 C I y �
lam "' C 2 *. In PC SA,and 2, Y k f H
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. Z � C.
Signed (-,Ij �`�� Date 1� lib (j7
Application Approved by - _ Date a. -C)
Application Disapproved by: Date
for the following reasons
Permit No. ®d-a "10 Date Issued
- ------- _--------------------------------------
1-1
~.No. Fee /
4 r Tw
THE COMMONWEALTH OF MASSAC,.LIUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
' Application for MiopooaY 6p.5tem Coma uction hermit
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. 6 6 CA 0 L 3 TA W I L, ( Owner's Name,Address,and Tel.No.
QA��s���le m1c. G>°uK�e SCLV17(�,(CA
Assessor's Map/Parcel I a 1 OO th
{ Installer's Name,Address,and Tel.No. Qo ITJ av Designer's Name,Address and Tel.No. K G-T
CoG GtieP,�v,11e AX, UQQ j F-gga�4jAla,mAQ�64K1
! �►�: -�13d�s NFl�ct,��cl, mr� soC/Y
i
Type of Building:.
DwellingNo.of Bedrooms Lot Size I.OZ
IqC. sq.ft. Garbage Grinder (�✓)
f Other Type of Building 1-Iov,Se No.of Persons .� Showers( 1 ) Cafeteria(^f)
Other Fixtures
j Design Flow(min.required) gpd Design flow provided 39 gpd
Plan Date 01 - 4 7 - 01 Number of sheets Revision Date
Title PFap".)rl, 5�071 c (J?6 o\- Fob(. G(b CN Gt,S %(—
�'" Size of Septic Tank C,cI.N7. 1.oa7 oq A I Type of S.A.S. 2 - S"0a G A/1V,.) C4 A M to k/I-17U t
Description of Soil a - 1 31� �o}�M�l SLNA
C►L4 CI ! stT (44ml 1,4
G y' ' 1�1�� C Z, : M Ad, S A Nd Z,.J Y K 6)'I
Nature of Repairs or Alterations(Answer when applicable)
I
Date last inspected:
i -
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
j 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. + �, C,
Signed Cj-) t�n _y„')t Date f U
Application Approved by '(�—L—n Date / `P -
Application Disapproved by: Date
for the following reasons
Permit No. goo „ `^►�(> Date Issued � / � "� Q�
THE COMMONWEALTH OF MASSACHUSETTS
f BARNSTABLE, MASSACHUSETTS y
Certificate of Compliance
THIS IS TO CER IFY,t at the On-site Sew'a/ger isposal System Constructed ( ) Repaired X
UpgradedAbandoned( )by (� 9
at 66 CA PCs TX A 1 ( 9AX IJS 7A f-j'L.P /►'►t4 has been constructed in accordance7 with the provisions of Title 5 and the for Di posal System Construction Permit No. 9� — L-1�O dated
Installer } / Designer C E NG 1��nP(i ( N
#bedrooms ,3 Approved design flow gpd
The issuance off is pe t shall of be construed as a guarantee that the system w' u ction as dee ign d.
Date Inspector / /
v /
—— ———————————— - ——————————— — ———��.. ———---
No. g DO4 w 9)�IJ Fee too
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
X11011i.g0tar 6p.5tem Cow6truction permit
Permission is hereby granted to Construct Repair ( ) Upgrade ( ) Abandon ( )
System located at ( ta CAppS -firA l 61 ly Ai A .
i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this per.
Date — (�"v� Approved by �- _
Town of Barnstable
°FtME Tom, Regulatory Services
ti
Thomas F. Geiler, Director
' B" MASS.Mp Public Health Division
9Q 1 0
prFDMA'�p Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: I i ,^10 0"1 Sewage Permit# 0-1-4,�!D Assessor's Map/Parcel IC9 fa,rce.l 60
&. oo7
Installer & Designer Certification Form
robe_v f-- A -D v-a_ve
Designer: K C f Installer: Eo c_y-/-� f�) °Q lA.•r (,b f�C
Address: e,0V 1 JDC Address: WC5k"r-n
r (�` I-LrwICh1 1`Y1c�
09-G 44- 0"4 5
On N6V 20, -,)C)U-( 2 'J- a u-.r-L Xc was issued a permit to install a
(date) (installer)
septic system at (pG GJ3_pe_5 Trcu based on a,design drawn by
(address) W= f nsfa(, I
KCJ E-ea t nee e tM dated 9 11 (0-7
(desi er)
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. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if required) was inspected and the soils
were found satisfactory.
F_ P:,-> 0 .4-nc
.. G m P��N OF Mass
(Installer's Signature) ��Lt - o�y'� ROBERT A. 9cyG
DRAKE
/ .� f o CIVIL C 8
l�✓l►^^' � ,Q No.41642 Q 3
(Designer's Signature) (Affix � ere)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DSION. 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.
gAoffice forms\designercerfification form.doc
i
TOWN OF BARNSTABLE
LOCATION _L o?b �"� ?E-z;, SEWAGE # �--,
A
VILLAGE VV• f 7�e- ASSESSOR'S MAP & LOT j&2_Dl -607
INSTALLER'S NAME & PHONE NO. - O4 h 1-4v /; -y
SEPTIC TANK CAPACITY 1000
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNERS c v�c,S /t�`r,e 5
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No .'�/
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TOWN OF BARNSTABLE
LOCATION Cel/r�,s SEWAGE # ��®
r
VILLAGE W. ASSESSOR'S MAP & LOT 67-613-Da
INSTALLER'S NAME&-PHONE NO. Ain
SEPTIC TANK CAPACITY ' ova
LEACHING FACILITY:(type) /�j (size)
NO. OF BEDROOMS -3 RIVATE WELI OR PUBLIC WATF.Or-/1.4-1''
BUILDER OR OWNER _ /Y� k �� S /�Od►-� <s
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 7 -
VARIANCE GRANTED: Yes No j/
1
6ol'
i
�� . . oop
P
No....
THE COMMONWEALTH OF MASSACHUSETTS�
BOARD OF HEALTH i
...........Tawa.............OF.,......ehW.....S1.4tv�..._"....._......-----------------.-----...----
Appiiratiun for Uhipuiitti World Tonotrur#iun Vlerntit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: 4 �(
•--.../---..)__»»._»»».._.hT.._..-�.._..._.4. MA-ZI..- r�--»�...._ .C• c` c.-
���//��1 /�® Location- dress or No.'_.--..-•................................
a304. ff 6m ...........................................
M Installer Address
~a]i Type of Building Size Lot.... y.7.- ... .. Sq. feet
V Dwelling—No. of Bedrooms............ ..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures --------------------•••-•-••-........_
Q a-rt::::•-•-------------------------- ----j-:�--.--.-----.---------•---------
W Design Flow.............. .�?___..__.._.________....gallons per n p�r t�ay. Total >lyr flow_.____.__.__..._ ?.........__._gallons.
WSeptic Tank—Liquid capacity ..._gallons Length__ .kt...... Width..V.I_O_... Diameter________________ Depth.S:__f�...
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.....................sq. ft.
3 Seepage Pit No.........J........... Diameter......40....... Depth below inlet..._�........... Total leaching area._4?_�......sq. ft.
Z Other Distribution box j�) Dosing to ( ) '/ /
'~ Percolation Test Results/2 Performed by..._._.... fl4estPil
._.._ ....................... Date.___.Z..4.G. ............
Test Pit No. L...............minutes per inch Depth of ......__.... Depth to ground ater...ftl0..�...._ .
Test Pit No. 2... Z...minutes per inch Depth of Test Pit----. -•-f.. Depth to ground water....1�(J /.
........ ... ............••--••---••--•--....•-•----------•-............-•---•--......._.......----•-......•-•--...---•--.............................
ODescription of Soil... �..I .` ----------------••---•-••--------•--------...-----.....-----------------•----•---------•--•---•-
V ------------------------------------
•--•-------------------------------------------------------------
•--------------
•--------------------
•------
•----------------
•-------
�W, •••••----••.............................................•-----•-----------•........_.....-••--.................--•- -----....................•--•--•......-••-•-......•••••••-•••-........•---•.........
U Nature of Repairs or Alterations—Answer when applicable.. ........................................................................................
..-•-•-•--••--••--••-•••••---------------•--••••--•---••-•-•••••••-•••-•.........-•-•--•••••.....-•---.....---••--------------•--••••••••-•----•-••-•-•••-•--•-•--••••----•--•-•........._..........•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'LITA11, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee i sue y the board of health.
Signed......... ........ ......�' �� »�'�.
. --�.....•.........._ ._....Date
ApplicationApproved By..--. .-- ...................................d..._ . - - ........................................
Date
Application Disapproved for the following reasons: .. ••...----•------••••--•••---•-••-••----•-••-•--••••------•---•-•-•---•••--.:...---•--......--•--••••_..»
..................................................... :_.. ....____._........__.___._..____._.__.____.._._.._...._....__..___ _______ ..............»
PermitNo....... - -------- ------------------•-•---._.. Issued........ -- ---D/---•--- - ................Dau »
�'' •�• i�� :l -r�_'�'r' 1' t� -. - �'` f -_i. r .. �.'�Z - 'st�_'"�%fir,"_4.__a'.yr,a` _
r �v,-�' pdr ` ^k 5•�> � „�^" ti �'.� �� .,-� - J � •rim r �`� x -
>vo fV:
';ii. g t
t hES
'f( .............
THE COMMONWEALTH�OF MASSACHUSETTS
'8O �RD OF HEALTH
n
/ Afli✓� . ✓�,�t
........................
OF t ...............y:
-., �ltratiliYt for
Application is hereby made for-a Permit to Construct ( ) or Repair ( ) an''Individual Sewage Disposal
System•at1
LOT - G?L!A i� v ..�!� / � c �, i�iY[.:� �._.
.pA LocadCss o
or Lot�N 3
Owner ...............................................��-t - - -
Address
v�
...................
ppqq Installer t f i t f'' Address
d; Type of Building ; ' , Size Lot_.............................Sq: feet
U Dwellin Noi of Bedrooms _Ex ansion Attic
a g P ( ). Garbage Grinder
Other—Type 'of. :_.' No. of ersons__________________ Showers'
Gr YP g p (. ) —'Cafeteria
p, Other fixtures ............... ..............................................
W.
Design Flow _. 0 gallons per,:person per day. Total daily flow:___.:. 3v gallons
•, f: - Septic Tank Liquid capacttyt :_:_ga]lons Length._ :____. Width.1" �.2_... Diameter :____ :.___. Depth.: !f .--.
.Gz3
x Disposal Trench_ No ____________ ______ Width __._ Total Length Total leaching•area....................sq. ft.
3 Seepage Pit.No, (._. Diameter 0........,Depth below inlet __ Total leaching area_ZhD:___.sq. ft.
Z. Other Distribution box,(�) ,, Dosing tank ( )
''Percolation Test Results Performed?b ::.��h_(A. .' ........................
a y-- _-. _�.._...- Date: '
Test Pit N 1 C 2 .:_minutes per inch Depth of Test Pit Z y Depth to ground-water.I.Z�(6 4t/.
`Test .Pit No 2 ._minutes per inch Depth of, Test Pit v� ___ Depth to ground'water AA)��
w0 . f
Descnption of'Soil . 71
: � :__.
x ... •---•- --•••- • .............................................................................
y
U' -- . ...
W ------ ------ -- --•••--- ----- ..................................' --• '
•
U Nature of Repairs or.Alterations Elnswer when applicable.._.:..... :.. . :... . ........
Agreement
The, undersigned agrees.to install the aforedescribed Individual Sewage Disposal System in accordance with,
the*'provisions of.: 'Li ; 5 of the State S.nitary Code— The undersigned further agrees not to place the system in
operation.ui til a-Certificate of.Compliance has beeriitssuedCby the board of health.
Signed .. t�f�f L'-;y •--•-• ^ ................................�
Application A roved B ...............
v�h..............
Date
o
.r pl? . y - ,> -----------------------
Date
A lication Disa roved or*the` ollowin reasons:._...__ .:__
PP pp roved Jt, _3` 9. ......
r
PermitNo -•- ................................................. Issued.............................I u..
- - Date
,
THE`.COMMONWEALTH-OF MASSACHUSETTS
1
BOAR b` OF HEALTH
/ : .
THIS IS TO CERTIFY, That the Inu,`vidual Sewage Disposah System constructed ( )''or 'Repaired ( )`
by .---- .--• ----. ._... ---•-• ---•- _
has been:installed in accordance with the provisions of TITIL. 5 of The.-State Sanitary Code as described in the
application for Di q>osal'\Vor3a Con`structi�>n Permit �o.____. �__.__
= •••--- ated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED'AS A GUARANTEE THAT THE,.
WILL FUNCTION SATISFACTORY /
SYS4EPtA
DATE ..........................................
�- -�
`�.. . -�i --... w.. ._..._ . •Inspector _ _y
�.-- \
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H-EALTH
,
�1 F �-� - .......
'N o / r O FEE.
..Permission is'hereby granted -----=. --•- ......__--••--- . ... •--._.._. ...
to Construct ( ) or URepair.( )man Individual Sewage Disposal System
1, n(u xl�G /!c'1Cl// 9 �iX1 N
ri5Zk_, I
atNo. r;;,�.... - ;�------- -____ _-•---- -----••-- _•------
tl
• - •t .p:. `: ,:::' ...•': -: - ,., .-, ,..Street. i �/� �.'.
as shown on the application for Disposal Works.Construction.Permit No------------ Dated /
IJ
._ ................
t�
r
i,
•(� Bo of Health �
. F
..., ,.....'._.ff. ._..•n. ..:. .,.1 .:_;. .iit. .§,.,Mx
t
t�
, r
No.------L------------- Fee-------- -----
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appricationl,forVell Cow5tructlonpermit
Application is reb de for permit to Construct ( ), Alter ( ), or Repair ( )an individual ell at:
PP Y
---z ---- -----„ / � .E-� /2�--------�'-- ------- ��---------------------
--— Location — Address — ! Assessors Map and Parcel
-f------------- - - - -------------------------------------------- ----------------------------------------
Owner Address �
-----------
Installer --Driller � � ddr/ >
Type of Building
Dwelling------
Other - Type of Building No. of Persons----------------e7------------------______________
Typeof Well—------------- - -- - - - Capacity---------------------------------------------------------------------------------
Purpose of Well------------------------- - -
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 f Co m 'ahce s been issued by the Board of Health.
Signed------- -- --------
------- -------- ---------------
da
Application Approved By ----------------_-
date/
Application Disapproved for the following reasons:-_---------------------------------------------------------------_______________________-------------------
------------------------------------------- ---_—-— --
date
Permit No. ----------------------------------------
------------------------------ Issued----------------------------------------------------------------------------'----------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate ®f Compliance
THIS IS TO RTIFY, That t
Y- — - In 'vidua� Well Constructed ( Altered ( ), or Repaired ( )
- -------------------------- - --------------------- -------------------------------------------------
Installer
at---------------- ----- t }1_ __ U 6J-- - ----------------------- -
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. --------------------------Dated----------------------------
THE ISSUANCE OF THIS CERTIFICATE;SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------------------- ---------------------------------- Inspector-----------------------------------------------------------------------------
BOARD OF HEALTH
TOWN ; OF BARNSTABLE
Yell CongtructionVermit
--------
No. � 3��-------��-- � Fee =- �Z
Permission is hereby granted--`- 2� C --
to Construct (_), Alter ( ), or Repair ( ) an Individual Well at: '
No. ------�^®-� -��- _ s 1 1S r I��-`- ----------- -------------------------------------------------------------------------------------------------------
Street
as shown on the application for a Well Construction Permit
---- Dated--------------- ------------------------------------------------------------------
---------------------- --------------------------------------------------
Board of Health
DATE----------------------------------------------------------------- ---------------------
� .r.
No.-----�------------ Fee---------`=--_------ -
-BOARD OF HEALTH
TOWN OF BARNSTABLE
Appricat ion-*rVell Con5truct ion Permit
Application is hereby iade for a permit to Construct ( ), Alter ( ), or Repair ( )an individual,.Well at:
•1 C= 117__•__ _ c-� ------- -----------------------
Location — Address Assessors Map and Parcel
__r��_�. �'__l---------- ----
-----------------------------------------------------------------------------—----------
Owner � Address
Installer.—'Driller `Address
Type of Building
Dwelling
------- -
Other - Type of Buildingf--------------------
No. of Persons---
-----------------------------------------------------
-------
Typeof Well- - - _ _-- ------------ ------- Capacity -----------------------------------------------------------
Purposeof Well------------------------------------------------------------------
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 Certificat df Compliance has been issued by the Board of Health.
'r � �!` �-
Signed------- ---- -- �-- ,�.='�.,."'."'.�►-------------- --------------------
- -------------
da T
Application Approved By--------------�`'//"-------------------------------------- ----��j��l�-
/ date/
Application Disapproved for the following reasons:-----------------------------------------------------------------------------------------------------
-------------------------------------------------------------------
------------------------------------
date
PermitNo.-------------------------------------------------------------------------- Issued-----------------------------------------------------------------------------'---------
date
` BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
r-
THIS•IS TO CERTIFY, That the,Individua`l Well Constructed (Altered ( ), or Repaired ( )
IL 'l��ta L�I� - -r` -- - -- °L-} ?----------------------------------------------------------------------------
Installer y
r--d ` �f�t�. IKV�
at------- - _ -
------------------------------------------------------------------------------------------------------------------------
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. -------------------------Dated---------------------------
i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------------------------------------------------ -=---------- Inspector----------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
VeYI Con5tructionPermit
No.--------------------- Fee-------------------
Permission is hereby granted-------- - -- ---- - ------------------------------------------------------------------------
to Construct (_), Alter ( ), or Repair ( ) an Individual Well at:
No. -----C'.- ----- -------- Jf\i 4-- �2 can) ------------------------------
---------------------------------------------------------------------------
, Street
as shown on the application for a Well Construction Permit `
No.----�-�-�-�-------E��'�---- ----------------------------------------- ,
------------- Dated--------------- --------;---------=----------------------------------------------
Board of Health
DATE-----------------------------------------------------------------------------------
i
LEACHING FIELD
INLET + OUTLET ACCESS SS COVER TO BE
"
BROUGHT WITHIN. OF FINISHED GRADE 1.) THE PROPOSED LEACHING FIELD SHALL CONSIST
OF 2 500 GENERAL NOTES
F -
GALLON LEACHING TANKS .WITH 4 FT. 0 3/4 1,/2 DOUBLE: WASHED.
„ N OTHERWISE NOTED ALL SYSTEM COMPONENTS AND
_ 1.) UNLESS 0 E ,
» _>_,__ .. « _.- 10 s STONE AS SHOWN ON THE. DETAIL SECTIQNS ON THIS PLAN. :.
4 9 MIN. 36 MAX. FINISHED GRADE OVER
,.�_. � '� I t i ,�,; �- R, h - CONSTRUCTION METHODS SHALL BE IN ACCORDANCE
r _ � DISTRIBUTION BOX 98.00 I r •
, ENVIRONMENTAL CODE AND ANY
_ WITH TITLE 5 OF THE STATE ENVIRO E L
2. THE GROUND ELEVTION AT THE If+ACIING FIELD IS AT EL. 98.00 f ,, �,
_._
« « .. , •a.: APPLICABLE0 A RULES.
» V 5 DIA. OUTLETS ti LOCAL L
9 24 DIA. MANHOLE
REMOVABLE COVER O
=
,� , , 3s MAx. THE ELEV. AT. THE .TOP OF THE LEACHING FIELD IS AT EL. 95.59
-7_Fj COVERS :Abe9i . t NI,
1
, 13 � PVC
4RVI PIP ARE AT EL. 94.76 f
THE ELEV. OF THE SE CE Eli E .,.
_ , , _._ __ , ... � Y CHANGES T THIS PLAN MUST BE •APPROVED BY THE BOARD
_ 14 � I .._--. �, � � __ ,.,.: _ .:•. ,. 2. AN C GES 0
I PROVIDE WATERTIGHT THE M F THE EAC LNG FIELD IS AT EL. 92.76 f
, THE ELEV. AT E BOTTOM 0 E L H ` -.,- R
N� ,,. �'�„, ,. OF HEALTH ;AND THE DESIGN ENGINEER.
JOINTS TYP. - „
PVC IN FROM
BOTTOM OF TEST. PIT AT EL. 86.83 f, NO GW FOUND • ,. ,;,.: o
-rp I r TAN , , • y -_. . , - .4 LIQUID LEVEL SEPTIC -.-_K 4 PVC OUT FROM LEA-CHDIG
` THEREFORE 92.76 86.83 5.93 CLEARENCE
-/ 3. 4 SCHEDULE 4d PVC PIPE WITH WATER TIGHT JOINTS SHALL
- OUTLET TEE FACILITY. MINIMUM SLOPE 1 X � .:.;<.�,; 2,. ,.,••� )
i , « \ C _
I _A.. _ n BE USED IN DISPOSAL_ SYSTEM -UNLESS OTHERWISE NOTED.
f y ,2 25 -0 .r L ,
, 95.13 t rrrrt. - •
I » -.. , .� -_. __._.> -
I 6 CRUSt-_D STONE
{ _
Q '
h r "b
.,. ,,, _.__ _ ... OVER MECHANICALLY `�. . � 1 ,;
�_ �_ V PERFORATED PVC PIPE SHALL E USED
< ~' ,. 4. 4 SCHEDULE 40 PVC
COMPACTED BASE '" [
•. - -- • . - p �. , ,: INSIDE LEACHING TRENCHES OR LEACHING FIELDS.
V A , !.
LEVEL BASE 3 OUTLET DISTRIBUTION BOX (H 10)
.. PLAN VIEW
6 CRUSHED STONE TO BE RESET ON A LEVEL STABLE ,
CROSS SECTION VIEW ... �; r,,
. . OVER MECHANICALLY BASE. FIRST TWO FEET OF OUTLET PIPES
5. SLOPE ALL SOLID PIPE AT 1.O% MINIMUM.
COMPACTED BASE TO BE LAID LEVEL
.. M I NOT DESIGNED FOR A GARBAGE DISPOSAL.
I ,. �. ,;::,. ,..� 6. THIS SYSTEM S 0 DES I
CROSS SECTION VIEW )
TANK H 10
EXISTING 1,000 GALLON CONCRETE SEPTIC
I
T 5.33
I
5 WIDTH 5 67 DEPTH ,
LE
NGTH 10. 0 ._:.
DESIGN ENGINEER TO BE NOTIFIED
-� 7. A BOARD OF HEALTH AND DES G
DISTRIBUTION BOX DETAIL ��.. . .:,. )
. . ,
I NEARLY COMPLETE AND
W .:..-�- PRIOR TO BACKFILLING WHEN SYSTEMS L
N.T
.S. , d f
EL.= 94.76 --� - - �-- EL.- s4.7s �,:;��_ ;� R A Y FOR INSPECTION. SYSTEM IS NOT TO BE BACKFILLED
SEPTIC TANK PROFILE 1 a �.( E D
! �..
i
st3amataW!�cu fvoronAto
N.T.S.
' � � w, , 'f-; WITHOUT..FIRST OBTAINING .APPROVAL FROM THE BOARD OF HEALTH
> >
o_ + ! _ AND DESIGN ENGINEER.
= INFORMATION FROM PLAN DRAWN BY 'YANKEE
, � .. . 8.) SITE PLAN IS FROM FO
FINISHED GRADE OVER n PLAN VI
TOP OF FOUNDATION m ., .
20 MIN. AccEss COVER _ ;:;- ,;.•. SURVEY CONSULTANTS, DATED 10 24 94,PROVIDED BY T01NIV OF
(ASSUMED EL=,00.00) DISTRIBUTION BOX -98.0 t / /
(TYPICAL OF 3) `;•<'`w
FINISHED GRADE OVER "1 1�+t +�raeoaEmo7,D. 7 BARNSTABLE. ELEVATIONS BASED ON AN ASSUMED TOP OF
FINISHED GRADE 36 MAX. '
4 PIPE � DISTRIBUTION BOX =98.00 t i
EXISTING OVER TANK EL. 98.02 t " ' " „ FOUNDATION ELEVATION OF 100.00 AS SHOWN ON PLAN.
SCHEDULE 40 PVC 1 5 DIA. OUTLETS _-- , _ - --r.-- - 9 MIN. - 36 MAX.
MIN. SLOPE O 2% " " 2 REMOVABLE COVER 36"MAX. ( � ` - =✓"- P TRENCH 1
- IN MAX s � e .�'. . ,__�_.�.. �_.,.>��_. ,..-,u_�_zt�--�, TO OF
3 :
i,
\ 95.59 f
r�:. .---.�---._ i� ____L_ _ , , _-_ r=., .-_, �_� _� r___ r� .� ,. � �--, ITY OCATIONS PRIOR TO
_., " � , o o ,-� , , ;,( ,�� � I (( `` , ,,, ,, 9.) CONTRAGTOR SHALL VERIFY. ALL UTiL L
4 PVC IN FROM - _ 4 PVC OUT FROM r ,.'_� �--- � ( ``{{ / � � V � �� ,\�, �.� �_ !LOCUS MAP
I / � . ,
� SEPTIC TANK LEac►+wG FACILITY. __ � �, �, . � � _ � THROUGH DIG SAFE AT LEAST 72 HOURS PRIOR
: I , _, �� !_� � �� � r- � _ , ;\.� �, ,,� , �,� >,.� ,��C. CONSTRUCTION ROUG
` i ��� ,_l
_�- 9 �'1,,,.-�.-...,.-•, � r::. MINIMUM SLOPE O ,X i���.<. W � ,_/,
t �^, r R C TO COMMENCING WORK ON SITE AT 1 888-DIG-SAFE D N
, r .ems ,, r � ":-1. '"-• , i-� --, � �._J � _�
�__� I,
. ssas � � }- 3 ,4 I -- ; _ ?-,�> { � /, r � � OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES TO
I , 97.00 t � S 94.96 t �; _. r � f»
�( 95.,3 t ,� x _: �_., ,_� i_� �_.i ___ __.� i_. � � .�;, `..... , • �, ... « TEST PIT DATA
_ t r�
, Ci.�.-�1 ; ., , ---� \�!, ,-;G ;, ---, �--, --, f �� ;�<� _ �; 2 -o � THE-DESIGN ENGINEER.
I �OUTLET TEE �� �_.
, y 4 LIQUID LEVEL
» ',s :z:: ,.. BOTTOM OF TRENCH
I _ FT TRENCH
10 0 i BOTTOM 0 RENC
t
4-
92.76 t v
� r
r
9 .76 (--,.MINIMUMB EL EL. 2 E LEVEL _ C �
POINTS WH R PIPES
ro BE RESET ON A LEVEL STABLE ,. 10. NON-SHRINK GROUT TO BE USED AT ALL PO S E E I ES
BASE. FIRST TWO FEET OF OUTLET PIPES _ .
C ? L J Ci /
�J
SLAB FOUNDATION t __->�, two` ---' :
, 17 STRUCTURES 1N ORDER TO PROVIDE
I � _ _ R .. 1 89 ENTER -0R LEAVE ALL CONCRETE
TO BE LAID LEVEL _.;� _� PE RC. NO
_._
, »
25 0
« «
WATER TIGHT SEALS.
-1 -0 0 0
D
DONA MI RAN
:WITNESSED ED BY.
O
vtEw
E S
CROSS SECTION , „R
12 -10
' N MA AS COMPLIANCE WITH DEED
NO TERMINATION HAS BEEN DE 0
N ! DETERMINATION
Y DAVID MASON, C.S.CPERFORMED B OR ZONING REGULATIONS. OWNER APPLICANT IS TO OBTAIN SUCH
. . END VIEW / '
SEPTIC SYSTEM PROFILE
DETERMINATION FROM APPROPRIATE AUTHORITY.
• JUNE 18. 2007
N.T.S. LEACHING DETAIL
DATE.
,12. ALL SEPTIC SYSTEM COMPONENTS ARE BEING INSTALLED TO
GROUND ELEV.. 98.0 t
E
_ N.T.S. WITHSTAND H-10 LOADING UNLESS UNDER PAVEMENT, DRIVES OR
TRAVEL WAYS REIN H-20 LOADING SHALL APPLY.
. NO GW OBSERVED �
ELEV. WATER.
• I
PERC. RATE: < 2 MIN./IN.
13.) DOUBLE WASHED CRUSHES STONE SHALL BE FREE OF ALL DIRT,
r, .�. DUST AND FINES.
200.00. _
.. I
DEPTH F PERC.. 4 INCHES DE 0 ® 6
-' I T REMOVE ALL LOAM
14. THE CONTRACTOR WILL BE REQUIRED RED 0 SUBSOIL
N FOR AREA FT. N
DECK.
TP #1 TP #2
AND UNSUITABLE MATERIAL BELOW AND 0 E 5 0 ALL
PROPOSED a' OVER EXCAVATION ,
SIDES OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL
« « WITH CLEAN COARSE SAND .FREE FROM CLAY FINES OR OTHER
, AS REQUIRED •, 00 I- ;_ '
A. LOAMY SAND A. LOAMY:SAND UNSUITABLE MATERIAL IN ACCORDANCE WITH 3.10 CMR 1.5.255(3).
z;xx",
YR43
. f BATH 1
« 10 YR 4 3 „ 10
BA - � 7 � 97. t
PROPOSED 12 x30 BEACHING 05 I� 9 .58 05
_ B___LOAM SAND _ __ Y DESIGNENGINEER, F ANY-DISCREPANCIES
B. LOAMY SAND t 15. CONTRACTOR SHALL-N•OT!!= DES G 0
__. IC!R hf TN 3!>!II _ 1 _
W ROOM 1 I FOUND IN SITE `CONDITIONS FROM THOSE SHOWN PRIOR TO
,- i 1 2.5 YR 6 6 ! 2.5 YR 6/6 OU D
97 _ / „ ,
PI, E INV. IN - 94.r6 - „ - -
( ) BED } 96. 2 � 13 , 6.92 t CONTINUATON OF WORK.
t
a
_uF ,I� ,^n, ra,�.�: ... ROOM
1 _.. 4 .� !._ � T 1 Cl: SILT LOAMY.
(" -1 C1. SILT LOAMY , 16.) PROPOSED PROJECT 1S LOCATED WITHIN.
--) .;- �; � 95.59 �# TOP OF ,
o FSE P'L•INIPE-D AND e 777VIOT:'
-- C'i BED / /b`/ ASSESSORS MAP109 PARCELQ1 EXTENSION007
9 9 ) ( LEACHING FIELD
1
NEW D-Box
ROOM
F SEPTIC SYSTEM UPGRADE.. . : • , 17. THIS PLAN IS TO BE USED ONLY OR SE C S STE U G DE
„` FIENGINEERINGWI NOT ASSUM ANY LIABILITY FOR THE
,. . .„ • L, IPT F21� C t G� KCJ. WILL E
9 �`
USE OF THIS`PLAN OTHER THAN ITS INTENDED PURPOSE.
'5 ---- -- ------------ 92.67 f
k., : , 6 N FLOOR LAYOUT
64 92.67 � 64
= o SECOND
18.) SEPTIC SYSTEM TO BE INSTALLED A MINIMUM OF 150 FEET FROM ALL
l _ MEDIUM AND'
N.T.S.
�2. MEDIUM SAND , 2. MED U S EXISTTNG WATER WELLS. THERE ARE NO WATER WELLS WITHIN 150
M 4 2.5 YR 6 4 FEET OF THE PROPOSED SEPTIC SYSTEM.
2.5 YR 6/ /
- - - 97
I
"EXIST
N N
+
.4 - .- .4 7 F rn � rn
DECK �-_-- ---- - 6. REVISIONS.
E 134 86.83 134 8 83
TP P_1 ., WA NO GROUNDWATER
� �" NO GROUNDWATER 1�` ., 9g
9$ � . OBSERVED OBSERVED
` 9
98
37,5 + BATH
1 KITCHEN
ROOM
� beck - � 1
+ ('3
,o c; DESIGN DATA.
9 a
+
!
oC
c E.0 , 6 In
1 3 BEDROOM DWELLING
0
a r
9
TM
FAMILY
± N DESIGN FLOW. 110 GPD PER BEDROOM
C
apes s Trail
15 0 DEN
6 P
6 ROOM
11 x ; = PD "
• Bedroo
m
0 3 0 330 G
Exist. 3 e PROPOSED SEPTIC SYSTEM UPGRADE
DECK
� SEPTIC TANK.
i- _ PREPARED FOR.
k � 33Q, GAL X 2009� - � GALS.- DESIGN CAPACITY
/ Dec
LL USE EXISTING 1.000 GALLON SEPTIC TANK
/ SIZE LOT S� FIRST FLOOR LAYOUT MR. GEORGE SELV/ITELLA
Q �
/ 0 3 REQUIRED LEACHING AREA:
? W 1 .02 ACRES N.T.S.
♦I w o: 330 GAL DAY 0.74 = 446 SO. FT.
ao /
m � LOCATED AT:
• 0 z
�, SIDEWALL CAPA►C1TY.
z o
*~' i in W 66 CAPES TRAIL
N in > 25.0 (LENGTH) X � (HEIGHT) X 2 = 1 .0 SQ. FT.
/ �x.► a � \� �� (WIDTH) X ?.�' (HEIGHT) X 2. = 51� SQ. FT.
BARNSTABLE MA.
_ I TOTAL SIDEWALL CAPACITY.= 151.3 SO. FT.
BOTTOM CAPACITY:
210.00� -±" SCALE: AS SHOWN DATE:09-17-07
Q 20 40 80 FEET
25.0, (LENGTH) X 12.83, (WIDTH) = 320.8 SQ. FT. t ,
EXISTING WATER WELL_C PROPOSED EFFECTIVE LEACHING AREA:
�H of Mgs9 PREPARED BY:
SIDEWALL AREA + BOTTOM AREA sc
o� ROBERTA. y KCJ ENGINEERING
151.3 SQ. FT. + 320.8 SO. FT. = 472.1 SQ. FT. s DRAKE
.CAPES TRAIL (50' WIDE) (472.1 SQ. FT.) x (0.74) 349 GAL/DAY 9 No 416az ROBERT A. DRAKE
0
349 GALS./DAY > 1330 GAL/DAY O.K. A9p�QISTEPS
66 GREENVILLE DRIVE
ORE DAL 2
, ., . . , , , , .. . . : , . , • Y .. , � - 1'i o� F ST E, MA 0 644
TEL. NO. 508 287 1253 FAX. NO. 508 477 5048
Drawn By. Designed By. Checked By. JOB No. 07092
, , e
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