HomeMy WebLinkAbout0085 MAIN ST./RTE 6A(W.BARN.) - Health 85 Main Street/Rt. 6A, West
A = 111-008-001 Barnstable
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No. 4210 1/3 BLU
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name /
information is West Barnstable V MA 02668 01-30-2020
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 614P4 3&9"-
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
� Company Address
Teaticket Ma. 02536
Cityrrown State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
02-02-2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
I conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist..Any failure criteria not evaluated are
indicated below.
Comments:
This 4 bedroom home has an H-10 1500 gallon septic tank and a D-Box feeding three 500 gallon
leaching chambers with stone. At the time of the inspection no visible failure criteria was found.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
(I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
° Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.� 85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is West Barnstable MA 02668 01-30-2020
required for every
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
' ❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
' I
4) System Failure Criteria Applicable to All Systems:
r
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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 16
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is West Barnstable MA 02668 01-30-2020
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
i
❑ ® 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
F and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
t
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
C questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
t. .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.; 85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ 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?
t ❑ ® 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
t 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?
t ® ❑ 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is West Barnstable MA 02668 01-30-2020
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
rGPD
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 44plus
Description:
i
r
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
_ Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
f
information in this report.)
Laundry system inspected? ❑ Yes ® No
i Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
f 3
1 ,
t
I Sump pump? ❑ Yes ® No
Dec. 2019
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i 85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is West Barnstable MA 02668 01-30-2020.
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
' Gallons per day d
P Y(gP )
. Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
tLast date of occupancy/use: bate
4 Other(describe below):
s
J
3. Pumping Records:
I
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
i • '
❑ Privy
r
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
}
Approximate age of all components, date installed (if known) and source of information:
11-02-2015
r
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 40"feet
Material of construction:
t ❑ cast iron ®40 PVC ❑ other(explain):
I
Distance from private water supply well or suction line: town water
feet
i
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
f—
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 32"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
l
f
9 '
i
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Standard H-10 1500 gallon
Dimensions:
Sludge depth: 2
+ 34"
Distance from top of sludge to bottom of outlet tee or baffle
y} Scum thickness 211
Distance from top of scum to top of outlet tee or baffle 5„
Distance from bottom of scum to bottom of outlet tee or baffle
14"
r How were dimensions determined? 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.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
i
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Main St Rte 6A
u—
Property Address
i Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
�
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
e ¢
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
{ Capacity: gallons
I r
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
f
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
I
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
d
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
0„
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
s
i
f + i
1"
t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
e
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
! - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is
required for every West Barnstable MA 02668 01-30-2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
fPumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
I ,
i
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
4
Type.
❑ leaching pits number:
® leaching chambers number: 3
E
❑ leaching galleries number:
❑ leaching trenches number, length:
' ❑ leaching fields number, dimensions:
i ❑ overflow cesspool number:
t
! ❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
i _.
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Main St Rte 6A
V
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection no visible failure criteria was found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
,
I
Ia
3
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
i
L -�
r
Commonwealth of Massachusetts
• �� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Main St Rte 6A
L,-
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy locate on site Ian
r
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
k
i
t �
9
t
5
I
I.
I 1
+4t
4
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I
1
f
k �
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
<l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.� 85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
�— 13 t/I f-l-dvo i,J 5 C--11 el-, v
I
i .
t
I
i
t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
TOWN`OF BARNSTABLE
LOCATION M M 41 5 i RT.&A\l SEWAGE#;t015 y 324
VILLAGE. WEST hil Wj �A+SSESSOR'S M�-AP&PARCEL 1
INSTALLER'S NAME&PHONE NO.I.Aac'wtD€ &TE"f seZ LLC_ 54.477:
SEPTIC TANK CAPACITY 15 D 0 C_,A�k"A1
LEACHING FACILITY;(type)(3)JCO tzAl,CMktge�S(size) 33:5,X 1.a-2 /
NO.OF BEDROOMS
OWNER 'TRAI SiLVFkMAd
PERMITDATE: 11-a-do15 COMPLIANCEDATEi
Separation Distance Between the;`
NO 1.
Maximum Adjusted Groundwater.Table,fo the Bottom of Leaching Facility CSSE1NO _ `Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
a r i site or within NO&et of teaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching:facility) �f�3. .Feet
® r
FIIRMSHEDBYl.�Qlkaaij � I.�ITEI�PQISEC. LL
%
r7eo
y14;a,sr Q
g-+F= 36,3'
06
R�• d 533
3
i
W;: ►��r I CA 19.9'
�6
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4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
' 15. Site Exam:
® Check Slope
i
® Surface water
® Check cellar
I
® Shallow wells
Estimated depth to high ground water: 14 plus feet
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
t
® 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:
I augered a hole at a lower elevation and I shot it with a transit to show 4 plus feet of seperation.
I
i
i
I Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc,rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
# Commonwealth of Massachusetts
Title 5 Official Inspection Form
yy1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 85 Main St Rte 6A
Property Address
Ira Silverman
Owner Owner's Name
information is required for every West Barnstable MA 02668 01-30-2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
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i ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
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® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
I
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I
i
1
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
t .
TOWN OF BARNSTABLE
LOCATION 9,5 M 41� J Si 6KT&A1 SEWAGE# P-01�
VILLAGE WEST OAM. ASSESSOR'S MAP&PARCEL 111 /,008/001
INSTALLER'S NAME&PHONE NOCAPEAJME G— J i 8lLi 4(ser, LU_ 5-08-477-&'17
SEPTIC TANK CAPACITY, j 0 0 C,M _4AJ .
LEACHING FACILITY-(type)500 GAL C�.11d443ALs(size) 33,5
NO.OF BEDROOMS
-
OWNER -TPA SqLVERt4Ad
PERMIT DATE: I I.-;L-ac,l-15 COMPLIANCE DATE: I,A__J- aQ(5
Separation Distance Between the: NO 4&.W.
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 055E]kVk-b Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Q 5,5 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) 103,1 Feet
FURNISHEDBY(f)AIaE4,,fDi: GyTiap !l LLC
f
A'�
A- 7 - Li3 �o 6-1 =X7.3
a-8 =590�' r�Ua=a- ►� t
gV3 = 31,
& - 36.3'
�"$= 33 i
� P
Fee
THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppfication for Misposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair(x) Upgrade( ) Abandon( ) >�Complete System ❑Individual Components
Location Address or Lot No. 85 t1OM.41,0 S c (A T<-A) W 5 Owner's Name,Address,and Tel.No.
AAA sk G'A E20 L. S I L V'ERA4 A
Assessor's Map/Parcel ` 06 g I (Lys}/IJ 5 i C PL 6A W fl;-r a AAA15T
Installer's Name,Address,and Tel.No. 509-'171 • 9877 Designer's Name,Address,and Tel.No.50T-c9.73-Q 3 77
dAPeZ.1t8C L-i.G 3G ncG/ �Z�Zti�1�Div
S i N1 o4S aS S C R/ Ill h4 kl1F
Type of Building:
Dwelling No.of Bedrooms Lot Size 35.000 sq.ft. Garbage Grinder( )
Other Type of Building RC;510 6;LYtt Xt_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 4go gpd Design flow provided 4 5, = gpd
Plan Date (_C -7 '9 .,IQ f 5 Number of sheets ( Revision Date
Title Q S MAW S c` ('Prr!�A) W&S ( �}�t?ll��d�3 tZ
Size of Septic Tank d 76�) Type of S.A.S. �j j CC.b ON G1441106'-5
Description of Soil F!IC E 5A"0 CZ 474' PCAI'V
Nature of Repairs or Alterations(Answer when applicable) 'ZAJ_e>1XLL, IU&e ) 14 16 l S00 6nALW0 5
-rAh)K__ _M NEW 14 ao) U-MX, - i_(3) Soo &A-c O H--xo U446-406
Gi-(,cr.�cP,rSly $
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date �h-�
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. .�6 Date Issued
C _
At
NO. � l>'A Fee
THE COMMONWEAL T;fWOF�,MASS�ACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION -TOWN�OF_BARNSTABLE, MASSACHUSETTS
0[pplitation for his osar pstem Construction Permit
Application for a Permit to Construct( ) Repair( "Upgrade( ) Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. 85 "X I A) ST P-T6 W B Owner's Name,Address,and Tel.No.
ffm . dAtao(- st LVF-RMAN
Assessor's Map/Parcel 06S Nj' I" 5 a C.A L+)efr T A kRNST
Installer's Name,Address,and Tel.No. Jr'08 -q7 7 - 8877 Designer's Name,Address,and Tel.No.509--oZ-7 3 -O 3 77
dAPa,JIDG c_ariE0-PWtc5t55 L-<-C- -ZG C-
153
S T- M S A19514 C 24 E.
Type of Building:
Dwelling No.of Bedrooms Lot Size 3 S,000 sq.ft. Garbage Grinder( )
Other Type of Building RC;5t D 6_ajTj A..(`_ No.of Persons Showers( ) Cafeteria`C-7" --
Other Fixtures
Design Flow(min.required) 440 gpd Design flow provided c gpd
Plan Date - r• �- Q ",l p/ S Number of sheets ( Revision Date
Title M A 1 iU 157- K 4.A) W _6A -02 -rAa cZ
Size of Septic Tank (��Q Type of S.A.S �� -00 C-WtGC ,0 N Gl- utB�s
Description of Soil Il� •�C��t _S( j�(}�l�/
r
Nature of Repairs or Alterations(Answer when applicable) -Zj(1 S:%C;(o (V� a) �4-/6 /.SD(p 6A"ILI S Ic-
1 TAN)V. In tJ t— J N-ao D 60X. -MT) 5oo 0 H-Xo uA44a+10JG -
Date last inspected: _
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed f Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. F_)C. J T Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by CA?6:w(b
at S S MA/N S-t- (P--T 6 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No��')5 -S e14 dated �( , -Ij
Installer CAPEIJLnG FX��Q(� (,(.�„ Designer .. < &111J A-.)&� Z�L�
#bedrooms Approved desig��w t.f•C. o gpd
The issuance oft is perHt shall not be construed as a guarantee that the system will fuhctid as designed.
Date �- { Inspector
t
No. � J S 3� ( —. r Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Vsposal .6pstem Construction permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at Q(S MA w S:r— (R-r (,A)
1 8#4 9 ST48 u::,�
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be c pleted within three years of the date of this pe it.
Date / 5 Approved by
l
4�.
!12/08/2015 18:2b bo"(;Mjb f
■
in
in
Town of Barn e
Regulatory Sep lei
Thomas F. Geiler,l r
• MR1'18TABLE.
Public Health -� pion
MAW.�A �sw. �,� Thomas McKear itor
�En r 200 Main Street, Hya A 02601
.Fait: 508-790.6304
office: 508-862-4644
Date: 12-5-15 Sewage P
ermit#c�O - � Assessor's Map/parcel I I
Xnstaller &Designer Certification Form
Designer:
G installer: Ga uu;ide. Lniz� fis.e 5 LL<- I
;y �;or1 :Cy Ni�;hw� Address: l
�3 Go,�;r►e�crat .S�re�k
Address: ? —�
o Z6
wcr am H R N astiQe�, N It
02_' y y
Eokerpase-s was issued.a permit to install a
On
- (date) (installer)
65 Per GA based on a design drawn by
. septic system at (address)
bckobe.(' 0
���erin� , T�nG. _ dated__ ;
(designer)
1 certify that the septic system referenced bedhests substantially
a to
ccording
the design, which may include minor was installed
as ateraleocaii
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 ways installedal eo acth major tion of anyhcoin nent
greater than 10' lateral relocation of the SAS or any vertical
of the septic system) but in accordance with State & Local Regulates ect land the soils
certified as-built by designer to follow. Stripout( an revision or
if req `rOFcr P
were found satisfactory.
JOHN L.
cHUP:C!'I!_L
� JR.
Cl!Il
(1 lstaller's Si, iattire)
No 4100.7
esigner s Signatur
(Affix esi er s mp Here)
PLEASE ItE DIVIS
TU O BARNS TABLE PUB D UI-rLELT$OTH T IIS FORM AND AS-
OF COMP LIANCF. WIL NOT BE ISS
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
;necccnilication ronwdoc
Town of Barnstable Fit /4 8#s' ^,��
111E
Departiment of Regulatory Services
>�STABIA i Public Realth Division Date V /AM
�
�A �blfl 200 Main Street,Hyannis MA 02601 �,�/
rFll A9A't A
Date Scheduled
- Time �lM Fee Pd. inti.
Sail Suitability Assessment for Sewage Disposal
Performed By: M t C�aaei� �i,m w►l-e l t t 1 C�C Witnessed By: 0j d Iq,
LOCATION& GENE;RAL INF'ORMATION
Location Address 9 5 ` ` (PT
6A) Owner's Name _T" S r 4_Vr.WAV
Address $j M A t 0 Sr,. W 13
p &W ion � eR4jS— rQ i.cdc
Assessor's Map/Parcel ' I (�p '®v 1/ Engineer's Name d kQ J e-
NEW CONSTRUCTION REPAIR __ Telephone# �()� q 70 0 -273-0 37
Land Use R t!S dan:�/a l d we it Slopes(go). 3 — •/' Surface Stones N
Distances from: Open Water Body 7/`S O ft Possible Wet Area 7100 ft Drinking Water Well 10 ft
Drainage Way [ S 0 ft Property Line eft Other ft
SIMTCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes)
sec_
A tfot ch ed �la�
Parent material(geologic) V r(�/ash ��0'/t, Depth to Bedroelt_
Depth to Groundwater. Standing Water in Hole: n L7 GS Weeping from Pit Faee 7 16�J/, 13Gs
U
Estimated Seasonal High Groundwater
]DETERARNATION FOR SEASONAL IIIGH'WAT]ER TABI.,Ii
Method Used: 04SP[f[a,10A p��
Depth Observed standing in obs.hole: 7 1 68 In, Depth to soil mottles: 7 I.60 ln,
Depth to weeping from side of obs,hole: l In, Groundwater Adjustment ft.
Index Well It Reading Date: Index Well lM1e1 Adj,Netor��� Adj,Groundwater Level s '
PERCOLATION TEST Date 1�-S-� 'line
Observation
Hole# j
IJ y Time at h" ---
DepIli of Pere S•"`J /2. Time at 6" _
Start Pre-soak Time @ ' , 0'3 AM _ Time(9"-6")
�1
End Pre-soak 1 /7 f1M
Rate Min./inch ✓
Site Suitability Assessment: Site Passed V Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Coinpleted on Back-----------
***If percolation test is to be conducted within 100, of wetland,you must first notify the.
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:\S EPTIC\PERCFOIZM.DOC
DEE,P.OBSERVATION HOLE LOG Hole# I t Z
Depth from Soil Horizon Soil Texture Sdil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,,Boulders.
Colisilltency.%t3ravel)
0-30 F/Ly
LoQ�. --
Sy''- 16& C F% e S' d 2SY 4/6
DEEP OBSERVATION HOLE LOG Dole#_
Depth from Soil Horizon Soil Texture Soil'Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
onsisten % ra
DEEP OBSERVATION HOLE LOG Dole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%O e
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency,
' a
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
Within 500 year boundary No �!, Yes _
Within 100 year flood boundary No.—V Yes _
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? —Y&16
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on 10-•-17-11 (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training,expertise and perience described in 10 C M 15.017.
Signature Date 16•2$-/:5
Q:VS E1'TI0PBI2CPOAM.D OC
I
FRECE111V177"D
Commonwealth of Massachusetts
Executive Office of Environmental Affairs 1997 :Department of cEnvironmental Protection -
Wllllam F.Weld Trudy Coxe
GovernorArgeo 8yry
u. �r Paul Celluccl David B.Struhs
canmb.aner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/�_r�f- CERTIFICATION
PropertyAddrese: 85 Route 6A, W Barnstable Address of Owner. Peter Winchester
Date of Inspection: C-_,-7_.17— 9'7 (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6
W.E. Robinson Septic Service ;
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,aa:nrate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sew disposal systems. The system:
. 's
_ Conditionally Passe,a
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Wil i Date: C— '7- 9
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 tke Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
-1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will, pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)5WI049 a Telephone(617)292•SM
4w1 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddrese: 85 Route 6A, W Barnstable j
Owner. Peter Winchester
Date of Inspection: �'��_ L3/I
B]SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system requite pumping more than four 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
obstruction is removed
C) THER 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 the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supp)y well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for ooliforn bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddresm 85 Route 6A, W Barnstable
Owner. Peter Winchester
Date of Inspection: 4
D SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage into facility or system component due to an 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ Any portion of a cesspools 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) GE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The o r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req ' eats of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 85 Route 6A, W Barnstable'
Owner. Peter Winchester
Date of Inspeotion:
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
_iIVone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
411L built plans have been obtained and examined. Note if they are not available with N/A.
14he facility or dwelling was inspected for signs of sewage back-up.
system does not receive non-sanitary or industrial waste flow
I The site was inspected for signs of breakout.
77
-L,All system components,excluding the Soil Absorption System, have been located on the site.
J/fhe septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or .
tees,material of construction, dimensions, depth of liquid,depth of sludge, depth of scum.
4/Phe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
VThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
propertyAddrese: 85 Route 6A, W Barnstable
Owner. Peter Winchester
Date of Inspection:
FLOW CONDITIONS
RESIDENTw:
Design flow: t 0 Ions
Number of bedrooms:-3—4)
Number of current residents:
Garbage grinder(yes or no):_4 D _
Laundry connected to system(yes or no)�..5
Seasonal use(yes or no):Z✓6
N/A well water
Water meter readin®e,if available:
Last date of occupancy:,i/—;,7!q q
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:sgallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER.(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) ✓�=5
If yes,"volume pumped: r,-6 f gallons
Reason for pumping:e�
TYPE OF SYSTEM V/I
Septic tank/distribution box/soil absorption system
mgle cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: ` 3 a
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85 Route 6A, W Barnstable
Owner. Peter Winchester
Date of Inspection:
SEPTIC TANK
(locate on site p
Depth below
Material of n:_oonc:ete_metal_FRP_other(esplain)
Dimensions:
Sludge depth:
Distance fro top of sludge to bottom of outlet tee or baffle:
Scum thi
Distance top of scum to top of outlet tee or baffle:
Distance m bottom of scum to bottom of outlet tee or baffle:
Cc en
(row ndation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
eviden of leakage,etc.)
Gken
TRAP:_
(ln site plan)
D w grade:
M o oonstruction:_concrete_metal_FRP_other(ezplain)
Dns
Sea.
D top of scum to top of outlet tee or bade:
D m bottom of scum to bottom of outlet tee or baffle:
Cts:(re ti n for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integ ity,
e o leakage,etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85 Route 6A, W Barnstable
Owner. Peter Winchester
Date of Inspection:
TI HT OR HOLDING TANK:_
( on site plan)
Depth low grade:
Mate ' of construction:_concrete_metal_FRP_other(explain)
Dime ns:
Capaci gallons
Design ow: gallon/day
Alarm evel:
Cc nts:
(oo n of inlet tee,condition of alarm and float switches,etc.)
DIStofi
ION BOX:_
(loc plan)
Depd level above outlet invert:
Com(notand distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER_
(locate n site plan)
Pumps' working order:(yes or no)
Comme
(note co of of pump chamber,condition of pumps and appurtenances,etc.
(revised 11/03/95) 7
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddrem 85 Route 6A, W Barnstable
Owner. Peter Winchester
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits,number:_
leaching chambers,number:
—
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: Lf''
Depth of solids layer.
Depth of scum layer: —� I
Dimensions of cesspool: 61 (�
Materials of constriction: /s
Indication of groundwater: A,O
inflow(cesspool must be pumped as part of inspection) r7 L S Z ►Q fB j� �G
11
C 1 —�
Comments:(note condition of soil,signs of hydraulic failure, level o ponding,condition of vegetation,etc.)
P _
(lots on site plan)
Ma rials of construction: Dimensions:
De of solids:
nto: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11/03/95) g
I'a
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 85 Route 6A, W Barnstable
Owner. Peter Winchester
Date of Inspection: % 9+�
SI(ETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
hi
1
a �
i
a
� • r
DEPTH TO GROUNDWATER
Depth to groundwater: 1 L feet
method of determination or approximation: 6
(revised 11/03/95) 9
PROP. VENT WITH CHARCOAL FILTER TO ABOVE GRADE GENERAL NOTES
TOP OF FOUNDATION= 35.0''E' FINISH GRADE OVER D-BOX= 34.3'±
FINISH GRADE OVER CHAMBERS= 35,0' - 33.7'
PROVIDE EXTENSION RISER SLOPE @ 2% MIN. OVER SYSTEM 3/4"TO 1-1/2" DOUBLE WASHED
WITH COVER OVER INLET& REMOVABLE WATER-TIGHT COVER OVER STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
OUTLET TO WITHIN 6"OF F.G. RISER TO WITHIN 6"OF FINISHED GRADE 4"SCHEDULE 40 PVC INSPECTION PORT WITH ACCESS METHODS SHALL BE 1N ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
FINISHED GRADE + + MIN SLOPE 1% BOX TO F.G. (SEE NOTE 19) 2 OF 1/$ TO 1/2 DOUBLE WASHED CODE AND ANY APPLICABLE LOCAL RULES.
' F.G. OVER TANK EL.= 35.0 - 36.0 5"DIA. OUTLET(S)
@ FOUNDATION= 34.T± STONE OR GEOTEXTILE FILTER FABRIC
2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
20" MIN:ACCESS
COVER 3 TYP. 9"MIN. PLACE RISERS ON ALL DESIGN ENGINEER.
( ) 36"MAX. 4.00'MAX TOP OF SAS= 30.00'
PROP.SCH.40 " CHAMBERS WITH 3. 4"SCHEDULE 40 PVC PIPE WITH WATERTIGHT JOINTS SHALL BE USED IN DISPOSAL
PVC SEWER PROP.SCH.40 4 PVC TEE SEE NOTE 20 29,00' SEE NOTE 20 _ + Ih�iLET PIPES TO 6"OF SYSTEM UNLESS OTHERWISE NOTED.
PVC SEWER BREAKOUT EL= 29.50
FINISHED GRADE
2" DROP MIN. _ +L 4. TO PREVENT BREAKOUT,THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
_ MIN.SLOPE Q 1% 6 3 " '3 9 L - 1 CJ±
" " MIN.SLOPE
� o 0
- 3 DROP-MAX. PROVIDE WATERTIGHT_ ELEVATION =29.50 FOR DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESSA
�-�33.3'± 13
4"PVC IN FROM JOINTS(TTYP. 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
\_ " 0 O 0 C� O �l CJ
14" 32.25' SEPTIC TANK 4 PVC OUT TO THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
*33.4'± • LEACHING FACILITY °° op o
ALL TEES MUST BE CENTER CD> �-{ o 0 0 5. SLOPE ALL SOLID PIPE AT 1.0/o MINIMUM.
32.50 UNDERNEATH RISERS 12" 6" po I i o o 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
29.40' MIN. 29.23` 2' o 0 0 00
48" OUTLET TEE - 0 0 0 0
- .. o 0 00 0 7• LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
6 CRUSHED STONE o o --� o FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
AS BAFFLE OVER MECHANICALLY oo 0 0 0 00 0 0 C_J o NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
33.V OFFSET TO FND. COMPACTED BASE ___ AND DESIGN ENGINEER.
3 OUTLET DISTRIBUTION BOX 4'0 8.5' (TYP) 4.0 4 0 4.83' 4'0 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM. BENCHMARK ELEVATION OF 35.00'
6"CRUSHED STONE TO BE INSTALLED ON A LEVEL STABLE 33.5' �P•) ESTABLISHED ON THE FRONT, LEFT CORNER OF THE BULK HEAD,AS SHOWN ON PLAN.
OVER MECHANICALLY BASE. FIRST TWO FEET OF OUTLET - < 20.00' -
COMPACTED BASE C C PIPES TO BE LAID LEVEL. 27.00' GROUND WATER ELEV.-
12.83' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
PROPOSED 1 ,500 GALLON CONCRETE SEPTIC TANK 5'MIN. f THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
'_ " ' "- ' " (Dimensions per Wiggin CROSS SECTION VIEW 3-500 GALLON H-20 CHAMBERS CHAMBER END VIEW 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
LENGTH 10 6 WIDTH 5 -8 DEPTH 5 -8
'CONTRACTOR TO VERIFY EXISTING !�► pin Precast Corp., Pocasset, MA) tt L� TYPICAL CHAMBER PROFILE p �* TO THE DESIGN ENGINEER.
ELEVATION PRIOR TO ANY WORK& SEPTIC TA PROFILE FILE " � � DI STR� UT� `-' `-' DETAIL H-20 CHAMBER DETAI La7 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC.STRUCTURES SHALL BE MADE WATERTIGHT
NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE
11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
TEST PIT DATA SUCH DETERMINATION FROM
..:.- c/} • ` i ,>�,; REGULATIONS. OWNER/APPLICANT IS TO OBTAIN S
IN, #t �,�'�/ .. 14845 APPROPRIATE AUTHORITY.
- PERC NO. _
l I ; rX INSPECTOR. David W. Stanton R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED
\ c� ` \,t ► " UNDER MORE THAN 3 FEET OF COVER OR LOCATED UNDER PAVEMENT, DRIVES, OR
EVALUATOR. Michael Pimentel, EIT,CSE
- TRAVELED WAYS IN WHICH CASE THEY SHALL WITHSTAND H-20 LOADING.
C.S.E.APPROVAL DATE: Oct. 1999
13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
DATE. October 5,2015
O p
TEST PIT#: �' 1 14. . WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE-
\ -o \ � •-.. ?•5.._ ....- _ - ...�. ` � ,�� -..+�_ MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. .
Y O t -- ELEV TOP= 34.00'
\ \\ \ L \ ,� • _ _ ,,�• - I���t��� REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
\ ELEV WATER= <20.00' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). !
SILT FENCE P \ \ 2� \ "`
Cam ) / `" "'" ' .� - - ```- _ < 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
�\ �' PERC RATE 2 mm.Anch
SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
PROPOSED INSPECTION PORT -: : * - .
co �Y - - ;`-� DEPTH OF PERC= 54 -72 16. PROPOSED PROJECT IS LOCATED WITHIN:
F.:
O f > LQCUSS _ ,,. ,, TEXTURAL CLASS: 1 ASSESSOR'S MAP 111 BLOCK 8 LOT 1
a r / • - a
PROPOSED 3-500 GALLON H-20Ul) ✓ ' f I t \
1 (6) _
d LEACHING CHAMBERS WITH AGGREGATE / s- = '" ! " - -- ,� - - OWNER OF RECORD: IRA F. &CAROL L. SILVERMAN
N -
,,,
/ / I \ ::`: .::.. 1j - ,,. . ' ADDRESS: 85 MAIN ST
� 011
PROPOSED 4' PVC VENT PIPE; I
EXACT LOCATION PER OWNER ` \
• � �- ¢r �`�- --.:.�. � WEST BARNSTABLE, MA 02668 �
Fill
WELL OFFSET 2j
,I,A - FEMA FLOOD ZONE X
'� 31.50 COMMUNITY PANEL# 25001 C 532
MAP 111,LOT 22 �Q
N \ /1 ,
r' \ G • o o - --4h Loam Sand 17. DEED REFERENCE: BOOK 11473, PAGE 130
,�
ti p
WITH � 9 , \ � ,.,w x �* .,. 10 Yr 5/8
EXISTING LEACHING PIT TO BE PUMPED & FILLED ® ��, g. N o A c \ • 18. PLAN REFERENCE: PLAN BOOK 245, PAGE 78
CLEAN COARSE SAND AND ABANDONED a .. ,.. ��
Q \ �` ,.
54" 29.50' 19: A 4"PERFORATED SCH. 40 PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION TO A
POSED 1 500 TP 1 \ I �" H F THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3 OF FINISH GRADE. A
PRO .. 2 _ O Pe
.. DEPTH O E
o \ \ HC 1 :n
w 34x0 0 -,
GAL. SEPTIC TANK . . � .�- ® �ii �x TOP O ALLOW OR INSPECTIONS.
� ,. , _ .. � N� � A REMOVABLE THREADED CAP SHALL BE PLACED ON THE T F E
�
EXISTING CESSPOOL TO BE -
,: � -r-.; � _ � \ G �, 20. IN ACCORDANCE WITH 310 CMR 15.401 -15.405,THE FOLLOWING LOCAL UPGRADE
/ h \
/. _ � �- -`- `� \ '-- O � DESCRIPTION HC-1 HC-2 �.. �-o
PUMPED AND FILLED WITH CLEAN = P 2 >, , -\ \ \ G� ` , APPROVALS ARE REQUESTED FROM 310 CMR 15.221 7 :
\ :. Fine Sand ( )
SAND AND ABANDONED „ y \ \ \ , - U COVER OVER THE LEACHING SYSTEM.
\ 6) TANK INLET COVER 1 39.0 54.5 ' 2.5Y 6/6 (1.) A 2.00 WAIVER(3.00 5.00) FOR THE MAXIMUM CO E E E LE CH G
PROP.
20 (2.) A 1.00 WAIVER(3.00 4.00)FOR THE MAXIMUM COVER OVER THE DISTRIBUTION BOX:
\ �
\ - COVER 2 36.V 48.T
\ TANK OUTLET O _
\ � D B07C BOX T � \ � \ ,
h �' \ �� \ \ 21. THE FOLLOWING LOCAL VARIANCE IS REQUESTED FROM THE TOWN OF BARNSTABLE S
36.8 44.8
fro LP �, � \ \ \� � CORNER OF STONE(3) CHAPTER 397: WELLS REGULATIONS;SECTION 397-81:
MAP 111 ��, ° \ \ \\ \ \ LOCUS PLAN . 1: A 44.5'VARIANCE 150.0'-105.5 FOR THE SETBACK FROM THE SAS TO THE EXISTING
�o 0 0 \ O
CORNER OF STONE(4) 49.6' SS.T
LOT 22 / � BUSH O �, \\ SCALE: 1"= 1000' - ONSITE WELL LOCATED AT 85 MAIN STREET(MAP 111, BLOCK 8, LOT 1).
CORNER OF STONE(5) 59.0 49.9
No Mottling, Standing or Weeping Observed
P �00 i \ \ �\ OF STONE 6 48.7' 37.3' g PI g
\� \ \ \ CORNER ( )
1 SWING-TIES SCALE=1"=20' DESIGN DATA TEST PIT DATA LEGEND
6•, SA \ PERC NO. 14845
tv #85 \ ' ' ' I \ 50x0 EXISTING SPOT GRADE
co CHERRY I
�, ;� EXISTING � � � INSPECTOR:- -David W.Stanton, R.S.
MAP 111 /� ` I `\ \ EVALUATOR: Michael Pimentel EIT CSE - - 50 EXISTING CONTOUR
O p 6 4-BEDROOM ` 1 ' ,
"/ , `o° O NUMBER OF BEDROOMS (DESIGN) 4 Oct. 1999
LOT 21 / tv�'! DWELLING NN �� ` C.S.E.APPROVAL BATE 50 PROPOSED SPOT GRADE
TOF=35.0'+ o
I DESIGN FLOW 110 GAL/DAY/BEDROOM 50 PROPOSED CONTOUR
Q ' I oo, DATE: October 5,2015 0
\ TOTAL DESIGN FLOW 440 GAL/DAY TEST PIT#: 2
_ ❑/H/W EXISTING OVERHEAD WIRES
DESIGN FLOW x 200 % = 880 GAL/DAY ELEV TOP= 34.00'
Benchmark
f ' \ \ USE PROPOSED 1,500 GALLON SEPTIC TANK ELEV WATER GAS EXISTING G E
e ch Bn �
Corner of Bulk Head 8"YEW ` ��
1
..PROPOSED.CLEAN-OUT TO � �-- ;.�- GA a--; GAS OI`\ \ / PERC RATE
GRADE (TYP OF 2) 8"YEW Ps I - W W EXISTING WATER LINE
Elev. 35.00' 'p�� GAS
A rox.M.S.L. �i I t \ �A - DEPTH OF PERC=
GAS--` \ �. _
4\ � ( o� INSTALL 3 500 GALLON H-20 CHAMBERS w/.STONE �- TEST PIT LOCATION
5"YEW WELL o I I TEXTURAL CLASS: 1
SI DEWALL CAPACITY O O O PROPOSED 1,500 GALLON SEPTIC TANK
H + WIDTH 2 SIDES (2' HIGH) 0.74 GPD/S.F. = GALIDAY
I I p \ \ (LENGTH ) ( ) ( � ( )
\ \ \ (33.5'+ 12.83) (2) (2') (0.74 GPD/S.F.) = 137.1 GAUVDAY 0" 34.00' PROPOSED 4" SOLID SCHEDULE 40 PVC PIPE
I
MAP 111 BOTTOM CAPACITY Fill ❑ PROPOSED H-20 DISTRIBUTION BOX jl
O 'S, BLOCK 8 \
r'. 6' U.P. �. \ \ \ \ (LENGTH x WIDTH) (0.74 GPD/S.F.) = GALIDAY
S� LOT 1 \ \ �\ \ � � ' (33.5'x 12.83) (0.74 GPD/S.F.) = 318.1 GAL/DAY 30" : 31.50' PROPOSED 500 GALLON H-20 LEACHING CHAMBER
yL 35,000 S.F.± #35/580
\ \ t
/ Loamy Sand
TOTALS: 10 Yr s/a
B REV. DATE BY APP D. DESCRIPTION
\ MAP 111
3 54" 29.50'
BLOCKS - TOTAL NUMBER OF CHAMBERS PROPOSED SEPTIC SYSTEM UPGRADE
\ LOT 1 f / TOTAL LEACHING AREA 615.1 SQ.FT. i
TOTAL LEACHING CAPACITY 455.2 GAL./DAY PREPARED FOR:
\ - Fine Sand CAPEWIDE ENTERPRISES
C 2:5Y 6/6
1°
5 � LOCATED AT
_ 85-MAIN STREET (ROUTE 6A)
WEST BARNSTABLE, MA 02668
NOTES: � 'LO -
O° 6' SCALE. 1 INCH 20 FT. DATE. OCTOBER 28,2015
�o / 168" 20.00'
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF EACH \ �! / MAP 1 1 1
BLOCK 8 No Mottling, Standing or Weeping Observed � tr°F"fgssgcy o �0 20 ao so Fees
SEPTIC SYSTEM COMPONENT: \ \ i / / - / �o G� ONNOW
;-% LOT 2 JOHN 1. PREPARED BY: '
2. CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE �-_ RESERVED FOR BOARD OF HEALTH USE
PROPOSED LEACHING SYSTEM TO ENSURE CONSISTENCY WITH TEST PST DATA / cHUR IviLLJR. � JC ENGINEERING, INC.
SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF HEALTH IF 2$54 CRANBERRY HIGHWAY
SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. A
so T EAST WA►REHAM, MA 02538
3 ENTIRE PROPERTY IS LOCATED OUTSIDE THE LIMITS OF A DEP APPROVED ZONE 2 N 508.273.0377
AND ESTUARINE WATERSHEDS.
I Drawn B JC Designed B :MCP Checked B : JLC JOB No. 3282
SCALE: 1"=20' Y 9 Y Y
i
I