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HomeMy WebLinkAbout0229 PERCIVAL DRIVE - Health '29 Percival Drive West Barnstable A = 110—001 004. I a I /10Commonwealth of Massachusetts 00/.do# owe) :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 229 Percival Dr J Property Address . IN If William Lento Owner Owner's Name ' M" information is r> required for every W. Barnstable ✓ MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the 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 16.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluat' by the Local Approving Authority 3-1-18 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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 1 C , r Corrmmonwealth'of`Massachusetts :a=1 Title 5 Official Inspection Form ( ' , ' Subsurface Sewage Disposal System Form _Not for Voluntary Assessments. 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System`Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. - Comments: System is in good working order with no sign of failure. r 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form hI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Jf!a 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 r Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form -` 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is W. Barnstable MA 02668 3-1-18 required for every ` page. City/Town ' State Zip Code Date of Inspection B. Certification (cont.) ' 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ' Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: A i D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Ye's 'No ❑ ® Backup of sewage into facility or system,component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposwi System-Page 4 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form � f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l a�' 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have.determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 , Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form ASubsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 �3% 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. CityfTown 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? " Z ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: ` Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts a= Title 5 Official Inspection Form ' ,�� Subsurface Sewage Disposal System Form Not for Voluntary Assessments �_J;!✓ 229 Percival Dr _ Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 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 ears usage Well 9 ( Y 9 (9pd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3-2018 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts .a=�l Title 5 Official Inspection Form } ,�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr ` Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town • State Zip Code Date of Inspection D. System information (cont.) r Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: ' Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract- ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I i Commonwealth of Massachusetts :a Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 24" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts a=1 f011 Title 5 Official Inspection Form "A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a� 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) 1 y Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness - 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle.condition, structural integrity, liquid levels as related to outlefinvert evidence of leakage, etc. Q 9 :) Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from,top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts ,a=1 Title 5 Official Inspection Form ' �i;. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;,_�.J ✓ 229 Percival Dr Property Address _ William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity:p Y 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 I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 17 Commonwealth of Massachusetts a=1 F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . � Jy 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan):' Depth of liquid level above outlet invert 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 was video inspected and in good working order with no sign of back-up from field. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form w-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_s�!✓ 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching.pits number: ® leaching chambers number: 4-Flodiffusers ❑ 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.): Flodiffuser field in good working order with water level and stain line at 3" below inlet invert. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts :a=�l 0 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -'Not for Vol untary'Assessments t JS 229 Percival Dr Property Address William Lento F Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town ' State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions , Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): s - t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form N 4�114 Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately We[ o O 1 rid: r '. Ift A, Ad r i 43- a_� 13mo3. TY 03 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts :a=�l Title 5 Official Inspection Form f ' 'N Subsurface Sewage Disposal System Form =-Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: i t . ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells y Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ,® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins,doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I - Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form l' �W�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 3-1-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ` lCommonwealth of Massachusetts. . Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 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. A. General Information ODD 1. Inspector: �� I Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the 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 Evaluatio y the Local Approving Authority 5-15-15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 page. City/Town State Zip Code Date of Inspection ' B. Certification (cont.) Inspection Summary: Check A,B,C,D or 1 always complete all of Section D A) System Passes: t ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon Y p completion of the replacement or repair, as approved the P PP by 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):. I • y F e t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection, Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑` Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to'a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ° El 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 Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a'surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and.SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This asses system if y p the well water analyses, 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: 4 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 ` ' f ❑ ® 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 %day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts _ W Title 5 ,Official .Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L h 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. h ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000.gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question:in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 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? IVA , . ® ❑ 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? • ® m 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: ` y Number of bedrooms(design): { 4. Number of bedrooms (actual): 4 DESIGN flow based.on 310 CMR.15.201(for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M °r 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Well 9 ( Y 9 (9Pd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy, 5-2015 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? r ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 L Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is W. Barnstable MA 02668 5-15-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: f `-j Source of information: Owner--pumped 5yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: - ® Septic p tank, distnbutlon box, soli absorption system ❑ Single cesspool ❑ Overflow cesspool - ❑ Privy ❑, Shared system (yes or do) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comment s (on condition of points, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12° t5ins-3113 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 s 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 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 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert; evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y El 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barristable MA 02668 5-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be,opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from flodiffusers. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts _ f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, M 229 Percival Dr Property Address William Lento Owner Owner's Name information is W. Barnstable MA 02668 5-15-15 required for every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-flodiffusers ❑ 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.): Flodiffuser field in good working order with water level and stain line at 4" below inlet invert. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions . Depth of solids Comments (note condition of soil;signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 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 L, cr �� t o2'R -19 flue 3 3 ! F t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 229 Percival Dr Property Address William Lento Owner Owner's Name information is W. Barnstable MA 02668 5-15-15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam- ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' 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: pate Z. 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: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I — J Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 229 Percival Dr Property Address William Lento Owner Owner's Name information is required for every W. Barnstable MA 02668 5-15-15 page. Cityrrown 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 COIMI MONT%, ALTH OF-VLASSACHUSETI'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.• :t)EPAR.'ITNsE?,TT OF.°ENVIRONMENTAL PR�OTECTI ' T TITLE 5 ✓J OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS.ME3VTS StM-SURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFI CATI ON Property Address- 0oZ Z2t/� T-14 Owner's Name: PIP Owner's Address: _ ,a vacn�� •Date•of Inspection: �U "7 Name of Inspector. (p;ease priest Company Name b MAilina Address: . Telephone Number: - -g CERTIFICATION STATEMENT 1.certify that l 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 ani:lDEP -approved system inspector pursuant to Section 15.340 of Title (3.10 CMR 15:000). The system. r � Passes ConditionaIl_y Passes co y i e s Further Evaluation by the,Local Approving Auth rity r Inspector's Slate:. Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or. DEP)within 30 days of completing this.inspection.if the system is.a shared system or has.a design flow of 10,000 gpd or Beater,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. Notes and Comments ****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. Title..5 Inspection Form 611512000 page I Page 2 of 11 . ,OFFICIAL-INS.PECTION:v—OR_-i 7 N.QT FOR V4DLTJ--NTARY ASSESS IENTS- SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORI-i PART A. CERTIFICATION (continued) `Property Address: 4ztl , Owner: Date of inspectioon:_ QQ Irpecion Summary:,Check' c I • A..,B',C,D or B/A1YAIS cnmpleta:aII of Section D .. A. System Passes: I have not found any information which.indicates that any ofthefailure criteria described in 310::CMR 15.303 or in 310 CMR 15:3N exist.Anv failure criteria.not evaluated are indicated below. ' Comments: B. System ConditionaIIy Passes: One or more system components.as described in the"Conditional Pass"section need to.be replaced or repaired.The system, upon completiop of the replacement or repair;as approved by the Board of Health,will pass. Answer yes,no or not determined(Y-,_NjND)in the. for the following statements. if"not determined:'please explain. The septic:tank is metal arid:over 20 years,old or the septic tank(whether metal or not)°is structurally unsound, exhibits substantial infiltration or exfiltratiori or.iank 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. . ND explain: Observation of sewagP.backup-or break out.or high static.water level iri,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 obstruction is-removed distribution box is leveled or repladed ND explain: 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.ofthe.Board of.Health): broken pipe(s);are replaced' obstruction is:removed ND explain: Pace 33 of 11 OFFICIAL ENSPECTION FORM -.NOT'FOR VOLUNTARY'ASSESSMENTS SUBS7:IRFACE SE�i-AGE:DISPOSAL;•SYSTEM INSP t' 'ION F RM PART:A i1 CERTIFICATION(continued) Property Address: ? w ' .Owner: Date oflnspaciion: 07 C. Further.EvaluatiOR 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) tb2t 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 Z_ System will fail unless the Board of Health(and Public.,Wate'r:supplier,if any).determines that the system is functioning in z 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 sun ly..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 ofa 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 aDEP certified laboratory, for.coliform 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, provided that no other failure criteria are triggered. A copy of the analysis:must be attached to this-form:. 3. Other: 3 Page 4 of. 11 ;. Q.FFICIAL INSPECTI.O1N<FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM-INSPECTION.FORM PART A CERTIFICATION(continued) . Property.Address:- Owner:, Date of.Inspection: . D. System Failure.Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the•fallowing"for'all inspections: Yes No — Backup of sewage into,facility.or system component due to overloaded or clogged SAS or.cesspool Discharse•or :onding of effluent to the.surface:of the ground.or surface waters due to an overloaded or clogged SAS,orcesspool Static liquid leveI:in the distribution box above outlet.inver'due to an"overloaded.or clogged SAS or cesspool. V, 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. Any.portion of cesspool-or.priyy 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 i.private water supply well. Any portion of a-cesspool or-privy-is.-less than 1.00 feet but.greater than.50-feet.from a private water supply W611 with no acceptable.water quality analysis..[This system passes,if thew ell water analysis, performed at:.a DEP certified laboratory,for coliform.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,provided"that no other failure criteria are triggered,A copy of the an a lysi"::must-beattached to-this form.] A. (Yes/No)The system fails.I have determined that.one or more of the above failure criteria exist as" described in 310 CMR 15303,therefore"the system fails."The.system-owner should contact the,Board of Health to determine"what will be necessary to correct the failure: t E. Large-Systems: To be considered a large-system the system must:serve:a.facility-with a design flow of 10,000.gpd to 1.5,000 5pd- You must indicate either"yes' or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 Protectiorj Area—iWPA) or a mapped Zone II of a public water supply well If You have.answered".yes"to any question in Section the system is considered a significant threat, or answered" yes"'in Section D"abo.ve the large system has failed.The owner or ooerator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3,10 CMR 15.304.The system owner;'should contact the appropriate'regional office of the Departm- ent. Page S of I OFFICIAL INSPECTION FORM—NOTFORVQ _NART MENTS SUBSURFACYSEWA'G.E DISPOSAL SYS'TE1VI`IiVSPECTTON FORiYI P:A.Rt.3. CPIECK'LIST Property Address: Owner- Date of Inspection: Check if the following haye:been done..You must indicate"yes"or"no"as to each of the following: Yes. v/ Pumpinc,. w o. owner,. Boardof Health. /�ere 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 larze volumes of water been introduced to the system recently or as,part of this inspection'? t 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 badk up ? ` Was the site inspected for signs of break out ? i Were all system componznts, 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/bafr'les or tees; material of construction, dimensions, depth of liquid,.depth of sludge and depth of seum? . _✓ 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 siteihas been`determined based on: Yes no Existing information. For example, a plan at the Board of Health. Determined in the fleld.(if any of the failure criteria related to Part C is at-issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)l Page 6 of l 1. OFFICIAL INSPECTION FORM—:NOT FOR.VOI1 I i T: R ':ASSESSMENTS. SUBS..,_UR.FAC E�SIWAGEDISP.OSAZ SYSTE M- INSPECTION FORIM PART.C SYSTEM-INFORIMATIOi I Property p rty Add:res5c �A Owner: Date:of Inspection: (e� FLO W'CONDITIONS RESIDENTIAL (� Number of bedrooms(design): / Number of bedrooms(actual),:. DESIGN flow:based on`310 CMR 15.203 (for example: 110 gpd,x n of bedrooms): ( Number.of current residents:. ' Does residence have a marbage grinder(yes or no): (7 Is laundry on.a separate:sewa-e system(yep or no):;,A if yes separate inspection required] Laundry system inspected(yes.or no),: ® Seasonal use: (yes or naa: Water meter readings; if ay ilable(Iasi 2 years usage.(gpd)): , Sump.pump (yes orno)_ r%��, ✓`(J �%Last date of occupancyL't COMMERCIALIIND USTRIAL Type of establishment:. Design.flow(based on 310 CIDER'I5.203):- gpd Basis of-design flow(seats/persons/sgft,etc.): Grease trap present(yes or-no): Industrial waste holdino"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/use: OTHER(describe): GENERAL INFORMATIOi Pumping Records .Source of information: Was system pumped as part ofth'.�nspection(yes or no): gallons—How was uani ed determined? If yes, volume pumped; q ty p p Reason.for pumping: TYPE OF SYSTEM _Septic tank, distribution box,soil absorption,system Single cesspool Overflow cesspool Privy _ Shared system (yes:or no)(if yes, attach previous inspection records,.if any) _Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) Tight tank. _Attach a copy of the DEP approval _.Other.(describe): Approximate age of all components,date installed(if own)and source of information: Were sewage odors:detected when.arriving at the site (yes or no) 5. f .Pane 7 of 17 OFFICIAL INSPECTION FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SE'�VA;GE_DISPOSA.L`SYSTEM INSPECTTOIV F:0I2iYM PART.0 SYgTFM-INFORiNLA.TSON(continued) Property Address: Owner: Date of Inspecticn: 0 _ BUILDING SEWER(locate on site plan) /11/� Depth below grade: Materials of construction.,_cast iron _40 PVC_other(explain): Distance-from private watersuppl-y well or suction Iin,e: Comments(on condltion.ofjoints, venting, evidence ofleakage, etc.): SEPTI N � C TANK:—(locatt.on site plan.) (,L/'/0) P Depth below grade: Material of construction:. concrete .metal—fiberglass Polyethylene _other(explain) If tank is metal list age:— Is age:confirmed by a Certificate of Compliance(yes or no)'.`:_(attach..a copy of certificate) , Dimensions: /0-" _ Sludge depth: 1 �� Distance from top of sludge to bottorn of outlet tee or baffle:.�� _ Scum thickness: Distance from top of scum to top:of outlet tee or bafile: Distance from bottom of scum to bottom'of outlet tee-or baffle: How were dimensions determined: p Comments (on pumping recommen tdya ions, i et and outlet tee orbaffle condition, suctural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): T ,/tr GREASE TRAP- (locate on site plan). s Depth below�Qrade:_ Material of construction:—concrete meta!—fiberglass_polyethylene_other • (explain): — • Dimensions: Scum thickness: DistaL ance frorri top of scum_to top of outlet tee or baffle: Distance from bottom of scum to bottom'of outlet tee of baffle: Date oflastpumping: Comments(ori pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 1.1 OFFICIALINSPECTION FORM—N*0T.:FOR.YOLU-N'TL -Y--ASSESSMENTS SUBSURFACE SEWAGE DISPOS:�SYSTEM INSPECTION FORiYI PA--RT C. . SY STEIYI INFOR-MATION(continued)- . Property Address: PA r Owners Lffia Date of Inspection: a TIGHT or HOLDING TANK:✓k(tank.in.ust 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/day A1arn present.(yes or no):. Alarm level: Alarm in working order(yes'or no): Date of last pumping: Com.ments�(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be'opened)(locate on site.plan) Depth of liquid level above outlet invert: Comments (note if box is.Ievel and distribution-to outle., qual;.any evidence of solids,carryover, any e.videnee of aka�e into 0 out f box,,ete.): - ' o� PUMP CHAMBER:: .(locate on site plan): Pumps in working.ordei=(yes or no): Alarms in working order(yes or no):. Comments(note condition of.pump chamber, condition of pumps and appurtenances, etc.); 'Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT.FOR.VOLUNTARY ASSESSMENTS `SUD URFACE SE TA E ISPOSA.L�SYSTEM INSPECTION FORM PART C SYSTEM INFORR'YIATION(continued) Property Address: C 166 AIA- Owner: Date of Inspection: �. SOIL ABSORPTION SYSTEM. (SAS): l/ (locate on site plan, excavation not required) If SAS'not located explain why: Type leaching pits,number:. leaching'chambers,number: leaching-galleries, number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool;number: innovative/alternative system. Type/name of technology: Comments (note condition of soil.signs of hydraulic failure,l-eveI of ponding, damp soil, condition of vegetation; etc > >r � 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 or.no): Comments (note con dition-ofsoil. signs of hydraulic failure,.level ofponding, condition of vegetation, etc:): PRIVY.-AL(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.): 9 Page 1 Q of l 1. OFFICIALINSPECTIONTORM--...NOT FORYOLUINTARY ASSESSMENTS . SUBSURFACE SEWAGE:IIISPOSAL SYS`IT_N.INSPECTION FORM: PART-C" SYSTEKIN.FORPILATION(continued). , Property Address: pp{�Y/ fl f�/ �l� /vu�YN ff Owner: (,C/ Date of Inspection:. o� SKETCH OF SEWAGE DISPOSAL_SYSTEM Provide a sketch of the-sewage disposal system including ties to at,Ieast two permanent reference landmarks or benchmarks.Locate all:wells within 100 feet:Locatd.where public water supply enters the buildinla. s [c✓ 1 . 1 t L Taae 1 i of 1 1 OFFICIAL INSPECTION FORINK —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION'FORM .PART C SYSTEM:INFOR11fIA TIOTi(continued) Property Address: 4fi � n Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to 'ground water J�_.'f,et ' PIease indicate (check)all methods used to determine the high ground water elevation: Obtained from-system design plans on record-I'f checked, date of design plan-reviewed: Observed'site (abuttin,-property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.locaI excavators, installers-(attach documentation) ✓Accessed USGS database-explain: You must describe how you established the high ground water elevation: iM 11 Permit Number: ,r� Date: Completed by: el HIGH GROUND-WATER LEVEL COMPUTATION e Site Location: ��1� � �,'';aif Lot No. Owner: G�'yJ Address: Contractor: Address: Notes: / _ .fly', ,5ri`��.� STEP .1 Measure depth to water table to nearest 1/10 ft. .............................................................................. .Date f/Z3,4 month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OA Appropriate index well................................ Z� " _ OB Water-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... 0?— p `,7 month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) 1. determine water-level adjustment .......................................................................................... STEP 5' Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water �'� levelat site (STEP'1) ............................................................................................................. Figure 13.--Reproducible computation form. 15 i Fume IF L ra*l�. Page 1.0 of 11, OFFICIALI31iSPECTION TORiVI-.?`t0I FOPS VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYS`I'E_MINSpECT7tflN FORM PART,C SYSTEM:JNF0RMATION(continued). Property Address: c 9J ij)��� JI Owner: (ICJ i Date of Inspection:. SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. I� - ape)n �.1 �. -3' &Y- . I J DEED RESTRICTIONBk 22483 P� 18 —0-664-58 b 1 1--20--2007 09 : 3Ocx y WHEREAS, of (owners name) (address) is the owner of -J 0��ti ,: % �•- �,� . located (address) MA (hereinafter referred to as ;7tA t and being shown on a plan entitled "Subdivision of Land in MA, Property ofZ�,� .� s et al, duly recorded in Barnstable County Registry of Deeds in Plan Book `'�/ , Page 99, ; Or on Land Court Plan Number WHEREAS, �� h� .� as the owner of said lot has (owners name) agreed with the Town of Barnstable Board of Health to a restriction as to the number,._of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; ' WHEREAS, the Town of Barnstable Board of Health, as a pre-condition-to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a-single family home on this property, is requiring that the agreement for the,restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, dear NOW, THEREFORE, does hereby place the (owner's name) following restriction on his above-referenced land in accordance with his agreement with the Iav mof BarnstahlaB d-of-be�a whiel�festrietien shal{ run with the land and be binding upon all.successors in title: Le may have constructed (address) upon the lot a house containing no more than f',��� (y) bedrooms. agrees that this shall be-permanent deed (owner's name) y� , restriction affecting'; q located ony4e�C:"7/Ae5:?^ � %�`MA, and . being shown on the plan recorded in Plan Book �i-3 , Paged __ 1? . Or on Land Court Plan For title of�� /�'� >,; see the following deed: Book %P q/, Page . 'Or Land Court Certifcate of Title Number Executed as a sealed instrument J day of 11 -�,.. .� Owndrs signature Owner's signature Owner's signature COMMONWEALTH OF MASSACHUSETTS . ss 20 Then personally appeared the above-named known to me to be the person who executed the foregoing instrument and acknowledged the same to be_free act and deed, before me, L Notary Public My commission expires: (date) deedr TOWS 0 RPMST"LE nn n LocA`Y'IOI+I YJI.LA(�, - .�a rn �:�e �AS5ESSt}R'S`l�# P&b.t}T 3NST�iI.I.ER` NAB&PI OR SfiPT1C TANK CAF'ACTC X /J�00 LEACfffNG ACII*MI. 0 NO (3FBSI} tXlPhS OR OWi�TER - EtJII.DER. PERAdITDATE CONIPIiANCE DATE-. Separation Distai►ce' reen"ihc Maxuium Adjusted Groandwatsr Tate to the$ottom of i,eacfitng Facility Feet Pnw►ate�itater 3upply; e11 and Laacbiag)x>cihty E iiuy w� exist on:sits ur vinttun?AiI feet of leaching fatty) Fcet.:. Edge of Wand and I�eachtng#�aa`lity(If anY wetlands exist witW4300`feeto teacluta factlitj►) Feet: \ well e- to kd- ,'�66' 80- 331�1 ~ 009 4-3- P-7 ' 63 101 'R-,ser v � s>OwiqOF l�at~ ' ioN 'V1LLAdE,_.W- ct !n S. e ASS S OWS MAC'&. II�tSTALLBl3'S rt &.1pHon No s c x L cAQAcM LEACgi�1+iG f+�►CI �"I"Y t +p . (size) . IT Dkm- Saptuation a� li&4 Betv� eta a' Maxlmumd djuse�d;_GR'puuciwacee'!'abie to, tlac k)cyitontcs iref��hin l�artlity, i�lv tc; inBj:C Scapply UYcU1`a�icl I;c chink 'acll�ty a�►y {8195 exist ergo. as s9te ar wlthi�n:200 feet of laiclumg fucitity) t?c1�ti^cy�U�leWantl tied L.eactntt l: ciltay 4Yt'nny wetlnnd�exit ivitlaiiiQO fcct`F lenalaing Pacjixry) 1 .F, l -�- 33�� , © � A -F-336.. OP r F F TOWN-OF BARNSTABLE t� P C LOCATION A le fC,-64 l it SEWAGE # ? VIiLAGE � ASSESSOR'S MAP & LOT Jose INSTALLERS NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(t� ) �'~' (size) NO. OF BEDROOMS RIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �¢ G DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No '✓ L �1 Y - 4 Ir q3--_03 _ No Dl . 3 HEALTH-coo BOARD THE COMMONWEALTH OF F TS TOWN OF BARNSTABLE App iration for Di-ripm3al Norks Tonotriirtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: C; -------------------`'....o..- ..........................................`✓.. �. .............. -------------•--------•----•----.....----- ------•--...-----•------......---.....---- //, j�ocation-i\ddress or Lot No. Owner Address a --------------•------- . :a�- ... Installer Address U Type of Building 3 Size Lot..._ —/-Sq. feet Dwelling— No. of Bedrooms.-,--------- Attic ( ) Garbage Grinder ( ) a Other—Type of Building _�Jtpf1..�!`93: To. of persons----------�-----__-__-. Showers ( ) — Cafeteria ( ) Other fixtures - ----------------------------------...------------------------------- ----------------------------------------•------------------- W Design Flow................�..�P...Q_.__gal lons per person per day. Total daily flow................,�3_��..__-___-__-_.gallons. WSeptic Tank—Liquid capacity./ - tons\® Length________________ Width---------------- Diameter................ Depth-_--______---_-- x Disposal Trench— N ... Width..... .... Total Length----SXf4--- Total leaching area....................sq. ft. .___ Seepage Pit No ._ . . �___ .............. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results2 erformed b --------------------------------------------------------- Date........................................ W M„� Y Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water---__...__._____-.___.-. G% Test Pit No. 2................minutes per inch Depth of Test Pit-_._____-.-______- Depth to ground water--..-__.-__-___--______- a .,..�.�__.... _ M1-----___------- ______ 0 Description of Soil.......... --------............................................... U .........................................................................................................................................•-5------------_------------------------------------•----------- W ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---...........------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Di ' al System in accordance with the provisions of TITLE 5 of the State Environmen I C e The u r ' ed further agrees not to place the system in operation until a Certificate of Complian ri issued oard of health. / w Sle ......... .. ... .......— ------------------------------- �/ '� ce S . Application Approved By ............... ...... Dace F: Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------- ........... ........................ .. ........................................ ......................... . -- . ... - - ... ........................................ D. Permit No. .:---73— //....t�.�7j...................: w �� !l/ Issued ............ ....- -............. .............te...... Date irio 00y Fxs.. ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Avv iratinn for Dijrvn!3tt1 nr1w Tomitrnr#inn rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ll c mac' . .... ✓✓ 2r r t�C .. .......................... ... .... ...... / Location•Address or Lot No. -- f ..........1- ,/� r % --------------------------------•-•----- --------------------------------------•------------------•----------------•--•-------------------- W ! Owner Address Installer Address Type of Building Size Lot.... feet Dwelling—No. of Bedrooms__,r_________________-___---_--__-.._.-.Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building __1-^s_��! �•rahTo. of persons._--______ram___....._.. Showers ( ) — Cafeteria fixtures --------------------- ----------•---------.---_--------------------------------------- ------------------------------------------------------------- W Design Flow________________.................... a...........gal lons per person per day. Total daily flow............... 3. ...........gallons. WSeptic Tank—Liquid capacity_/9allons 'oLength................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No --- __- Width..... ----- Total Length....3�4--- Total leaching area....................sq. ft. Seepage Pit No.4 _:�7,ld... b(a eter------------------- Depth below inlet.................... Total leaching area..................sq. ft. rt .rU Z Other Distribution box ( ) I Dosing tank ( ) ~" Percolation Test Results Performed b ... Date........................................ W Mti Y Test Pit No. I----------------minutes per inch Depth of Test Pit------___--•--__-__ Depth to ground water..................... 44 r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p4 ;. ;...... •-------------------- •--- •--•--------- --- ------------------------------------------------- 0 Description of Soil..........`- -� `�- K.--....--••----------------------------------••- V ..........................-•••••---••••-•-••---••---••••••-•--••--•••••-••--••--•-•-•-•-•-----•---•-•••-•••••--••-•••---•--•------•••••••--•-----••••---•-------•••••--•••-•--•-•-••................•••- W UNature of Repairs or Alterations—Answer when applicable............................._.__-_.-_.............__._...._....................._...........__. ------------------------------------------------•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code 7ZThe undersigned further agrees not to place the system in operation until a Certificate of Compliance hlaybeen ssueddiby the board of health. �^ Sig ed . _`. ! - ------ -----------------------------------------------*------------- Application .,�-,. .-.--�__.. /f s"` ._ A roved B %, // ? .. PP Y .............. -- --!' ..' :,...... ............. ...................... Application Disapproved for the following rearons: .......... ---------------------------------------------------------------------------------------------------------------- e r:........................................ .. _... C� � 1 'r � Date Permit No. / Issued -------... ........ -� .... — --- �--------------------- f • �— Dare ----------------------------------------- --------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE y C�e>rtifirate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by .............................. . .........................................----------- -- Installer I R C I ✓fit at ~�.��----------------- --- ----- ------------------ l..�.r�,.,. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..�1.3.._�n_644�--------------- dated ..b .--. /-9:5_.-.-._- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ ,.....` ..� :=,...-...%..:�--------------------------- Inspector ---------- ---_ .�.r,.._...:.......:..._.......... -------------------------------------------------- ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No........ ... FEE.- 3 y TOWN OF BARNSTABLE )J u� ... ...��....... -•.....__...... Disposal Workii Tnnitrudinn ",,Writ Permission is hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System -•-.... ...... .................••--•---. -- -------•-•-----•-••••-----•-•-••-----•-•••••-----•-----•---•-•-•-•---•............. as shown on the application for Disposal Works Construction Permit Street No--_�---(-��Dated....�..� of ealtlh -/�'_j........._........ ------------------------• /_ DATE................ -;��' ---------------------------------- Boardl r FORM 3890E HOBBS 6 WARREN.INC..PUBLISHERS a " De liar tment of Environmental Managernent/Division of Water,Resources p WELL COMPLETION REPORT — �± WELL LOCATION GEOGRAPHIC DESCRIP`i' nN Address 1 Z t N S City/Town rl1 (E.rc��o f p�• � /hJSIc. P �4 ��/L Well owner _—I O (road/ Addressoy /n ./lt'ir+ S 7` r0 N 6 E W of 6?60 y (mi.in tenths) ' (circle) Board of Health permit obtained: yes ©` no Elintersect. w/(7�L_ L )f, WELL USE WELL DATA Domestic ©"Public❑ Industrial ❑ Total well depth 9 ft,, Monitoring❑ Other - Depth to bedrock ft. Water-bearing rock/unconsolidated material: Method drilled.(- 4 P 0�, / Uescriptlon 41!- Ste^ Date drilled ZZ Water-bearing zones: CASING nn 1) From To Type �r �/O /'y C 2) From To Length ft. DWJ.D.► in. 3) From To Length into bedrock ft. Gravel pack well: dia. Protective well seal: Screen: did. Grout_[D000 Other Slog r_length $ _from _tor/_ STATIC.WATER LEVEL(all wells) r , Static water level below land surface �O e( ft. Date 71h S. _Z_t__ WELL TEST(production wells) Drewdown ft. after pumping hr. min.at /S gpm How measured-Recovery— IL after—hr.. min. 0 LOG of FORMATIONS COMMENTS. . 8 Materials From To o 2 Driller J. ACc v O Firm ( di .r-1 : Address�Q 60X S'a City/Town Ltd f v I2tGt D.?G I Supervising`Driller Reg.if ' — Si natur o supervising registered well driller Please print rrrm/y BOARD .OF HEALTH- 'COPY No.------- ----------- Fee -- - ------------ BOARD OF HEALTH TOWN OF BARNSTABLE Zpprication-*rVell Cootruction3permit Application islelf hereby made for a pedrmit to Construct ( �, Alter ( ), or Repair (. )an individual Well at: ---- ------------------------------------------------------ ---------------------------------------------------------------------- ----------------- / Location — Address r± Assessors Map and Parcel Owner . Address Installer — Driller � Address Type of Building Maf lld4-4- A ze 4A Dwelling= a. s------------------------------------------------- Other - Type of Building ---------- No: of Persons-------------------------------------------------__ Type of Well --v e--------------------------------------------- Capacity---------------------------- ---------------------- --_ _—_— Purpose of Well---A C>AA-` 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 f Compliance has been issued by the Board of Health. Signed _ - - - - - date Application Approved By---- ---- - -- - --- — --- ---------------- ---------date—__-- Application Disapproved for the following reas s:------------------------—----------------------------___________—_______________ —_--- — --— — -- - --------- ------ ------------------ - -- -------- date Permit No.0 - -3 - ------------------------- Issued---------- ate BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, hat the Individual Well Constructed ( '�, Altered ( ), or Repaired ( ) j ----/(_�/,�L-= ------- - ---- Installer at- 3------ - - - - -- - -- ------------------------------------------------------------ - - has been installed in accordance with the provisions of the Town of Barnstable Board f Hea h ivate Well Protection Regulation as described in the application for Well Construction Permit No.w_- ___ Dated--------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----__----- — ——_——-- --— - Inspector------------------------—--------------- ---- --- No.-------�------------ .Fee-� ---------------- BOARD OF HEALTH TOWN OF BARNSTABLE { ApplicationfoOVelt Con!5tructionPermit Application is hereby made for a peArmit to Construct (V), Alter ( ), or Repair ( )an individual Well at: f.. 4 / N L i .--,J /GIJ GJ• Location — Address Assessors Map and Parcel - ------------------------=------------------- S��----�`,�_, �(r, s/ -----`'-- -'- ---------------------- Owner Address O j, ---------- / ---------------------------- ----------- --------------------------- Installer — Driller Address Type of Building Dwelling e- Other - Type of Building------------------------------------- No. of Persons-------------------------------------=-------------------- Type of Well-- ------------------------------ ------- Capacity----------------------------------------------------------------------------------- Purpose of Well--A`- v-r'- - - --------- 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 of Compliance has been issued by the Board of Health. Signed -- `` ``' --- - - - ------G � date Application Approved B � -- - m----------- -- --------------------------------------- PP PP Y—� -T� date Application Disapproved for the following reaKal------------------------------------------------------------------------------------------------------------------ ------------------------------------- ----------- -- - / ------/--------------------------------------------- / �" \date Permit Noll / -^- - - Issued ------------ 1-- / /! 3 - -- - date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance • 'THIS IS TO CERTIFY, That the Individual Well Constructed ( '), Altered ( ), or RepairedCU ( ) - -------------•------1------------------------------------------------------------------------------ ------------------ - -- - n Installer nolC�v. 1 �/ C� i� ------------------------------------------------------------------------ has been installed in accordance with the provisions of the Town of Barnstable Board of Hea th,Private Well Protection Regulation as described in the application for Well Construction Permit No.�_� __(__ ____ V 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 Con5truct ion Permit 0 No. -------------------- /� /� /� I Fee Permission is hereby granted--- �--------------------------------------------------------------------------- to Construct (�), Alter ( ), or Repair ( ) an Individual Well at: No. ------ 0-6 &,-" ----- ------------------------------------------------------------------------------------------------------ Street as shown on the,application for,a Well Construction Permit No. " �--�--- Dated--- • / Board of'Health J/ 1DATE----- ,-�------r--=------------------------------------------------------------ ENVIROTECH LABORATORIES Kb Mass. Cert.#:MA063 449 Route 130 Sandwich,MA 02563 • (508) 888-6460 CLIENT: Bill Lento LOCATION: 23 Percival Drive ADDRESS: W. Barnstable, MA COLLECTED BY: D.A. Scannell SAMPLEDATE: 11-19-93 TIME: 12:OON DATE RECEIVED: 11-19-93SAMpLE ID: DAS23 JOB#: NPW WP11 WELL DEPTH: 91, RESULTS OF ANALYSIS: Parameter Units Recommended limit Result Coliform bacteria/100 ml (MF Method) 0 0 pH pH units 6.0-8.5 6.49 Conductance umhos/cm 500 101 Sodium mg/L 28.0 10.2 Nitrate-N mg/L 10.0 <0.02 Iron mg/L 0.3 4.05 Manganese mg/L 0.05 Hardness mg/L as CaCO? 500 Sulfate mg/L 250 Potassium mg/L 20.0 Alkalinity mg/L 200 Chloride mg/L 250 Turbidity NTU 5.0 Color APC units 15.0 Background bacteria/100 ml (MF method) 200 EPA 601/602 * ug/L N.D. COMMENT: Iron level is not a health hazard, but may cause taste and staining problems Filtering system should be considered. * See report attached. YES NO X 0 WATER IS SUITABLE FOR DRINKING PURPOSE ORTPL�ERS TESTED. ��- DATE G� -S9 44 11-24-93 e: 19 PM ;C-P,(D ,DNATEB ANALYTICAL ENVIROTECH GROUNDWATER ANALYTICAL EPA METHODS 601 and 602 Volatile Organics (GC/PID/ELCD) Lab ID: 6454-01 Field ID: PAS 23 Batch ID: VG2-0272-W Project: Lento Sampled: 11-19-93 Client: Envirotech Received: 11-19-93 Cont/Prsv: 40mL VGA Vial/HaHSO4 Cool Analyzed: 11-23-93 Matrix: Aqueous CONCENTRATION REPORTING LIMIT PARAMETER (ug/L) (u9/L) i 5 Dichlorodifluoromethane BRL 5 Chloramethane 8RL 5 Vinyl Chloride BRL 5 Bromomethane BRL 5 Chloroethane BRL I Trichlorofluoromethane BRL 1 1,1-Dichloroethene BRL 1 Methylene Chloride BRL 1 trans-1,2-Dichloroethene BRL 1 1,1-Dichloroethane BRL I cis-112-Dichloroethene * BRL 1 Chloroform BRL 1 1,1,1-Trichloroethane BRL 1 Carbon Tetrachloride BRL 1 Benzene BRL 1 1,2-Dichloroethane BRL 1 Trichloroethene BRL 1 1,2-Dichloropropene BRL 1 Bromodichloromethane BRL 5 2-Chioroethyl Vinyl Ether BRL 1 cis-1,3-Dichloropropene BRL 1 Toluene BRL 1 trans-1 ,3-Dichloropropene BRL 1 1,1,2-Trichloroethane BRL 1 Tetrachloroethene BRL 1 Dibromochloromethane BRL 1 Chlorobenzene BRL 1 Ethylbenzene BRL 1 meta-and para-Xylene * BRL 1 ortho-Xylene * BRL 1 Bromoform BRL 1 1,1,2,2-Tetrachloroethane BRL 1 1,3-Dichlorobenzene BRL 1 1,4-Dichlorobenzene BRL 1 1,2-Dichlorobenzene C LIMITS QC SURROGATE COMPOUND SPIKED MEASURED RECOVERY 87 - 113 % .0 31 103 % a,a 30 30 31 105 % 83 - 117 % 1,2-Dichloroethane-d4 BRL = Below Reporting Limit. * Non-target compound. 36 method References: Method 601 - Purgeable Halocarbons and Method 602 - Purgeable Aromatics, 40 C.F.R. 1 Appendix A t ': � � �: f$ .5.. �. - � - � - •. � ,. r q;,E st xr.•° i �°c, 5ni 1 ��:a°9 }'��y..{i 9<rg•. � r,}1 5 _ t ".a., 7,�.r�� ` �� ._8+.q _—._..��__ I Z' -1;-------- 4Ce'gOO-------- ----__ _I I�-�--- — --- -'41-�_ 3'_-`�" - � �24 � '- -. j �• S t ye' 1 { s I j i * !4'. 945 .a'L rp 14aiu n ,y{, I _ Sz fq N )) tI '- y 9 f: 1 /:SLgr:D� ��"•. /�•' '�. �V.�.9��os. < '} PS -i 4'nf .. � � /--}-1 •,yy -, _:i ffff �6U1��[t?\ � ���- �� �/ `� �O �'�M,nS `t' 1 � 4' xS2{ 2 4" •' _.__— [o r I•h I. � 2-8 �5,-� 3 to I, .,�ro 9" -- -- -• — - - --- - �,r,r :F P, O�q I <J 'ice •s/ d 0 ' �.. wR` M .N .'tifa �-� •L�_ S �y { }-f'�'�--r a' AD X. wl t+' N 00 W.a O, `Y 2, Ov'rx.'e•cu N _1v .. 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BK. 413 PG. 99 LOT 23 SETBACKS FRONT = 30' I CER77FY THAT TO THE BEST OF MY PROFESSIONAL SIDE = 15' KNOWLEDGE, INFORMATION AND BELIEF THE DWELLING REAR = 15' SHOWN HEREON CONFORMS TO THE HORIZONTAL SETBACKS PROPERTY LINES SHOWN HEREON OF THE ZONING BY-LAW FOR THE TOWN OF BARNSTABLE. WERE COMPILED FROM AVAILABLE PLANS OF RECORD AND VERIFIED ' ON THE- GROUND. �PVSH oFMggs9cyG _ oa TERRY PLOT PLAN ANN THE DWELLING DEPIC7ED ON THIS U WARNER SHOWING PROPOSED ADDITION No.38721 PLAN WAS LOCA7ED ON THE GROUND IN BY SURVEY ON JAN. 16, 2007 AND EXISTS AS SHOWN AS OF THE DATE BARNSTABLE, MASS. OF LOCATION. SCALE.- 1"-40' FEB. 12, 2007 THIS PLAN IS FOR PLOT PLAN / TERRY A. WARNER, P.L.S. PURPOSES ONLY. 22 LONG ROAD HARWICH, MA. 02645 (508) 432-8309 THIS PLAN IS VOID IF NOT STAMPED AND SIGNED IN RED, 0 20 40 80 PROJECT N0. 07-103PP -7 'rop, , 0 )9�-�7, 4_H�13 ENCW m ARK T S T , , ,"H OLE .' . ; R E SUL T S 14AI 4�06 DA T E S E 0 BY� C 'OAJ IL 0,N/ WITNES Q 4C 14 �HIGH GROUND-WATER ADJUSTMENT- Zoy/-& Aff"Al C- )P..,/,Iz Ep7ilo OBSERVED WATER DEPTH Al"I INDEX WELL TE ST 'H& E TEST, OLE 2 A L H WATER, RANGE ZONE "CURRENT WELLDEPTH .-' , 7-Q;D 41 r1i A-.4 WATERADJUSTMENT � o DEPTH TO,WA ESTI MATED TER 6 A ESTIMATED ,. M X. WATER, Z LEV. .4 ovo .........*� -WATER — GROUND ENCOUNTERED,� ENCOUNT'ERED Q it ANHOLES AND COVER TO ' BE BUILT JO EV. T0P ,.0 46A, cm6 rig, WITH I N -�OF 'FINI Eb -D E 121 , SH GRA U N D A,T,10 GRADE M I N,' LOPE 2%' S� A F I D I A_ 4 D1 --PIPE P I P E MIN. 21' LAYEIR OF, AT MIN. P(TCH, 'At -:74, CH' I F E FT '/47 GA L INVERT� IN VE' AT I N'V ER ,' D I'S T ­ Y4 t,FZ2 D'I A .0 N rT ANk 1 N VE R T Ox D STONE Li 10 D, INVER N 'A PL,A�C'E �P TJ C ' INVER Q : WASHE 40 10 A06U.N ce 0, V, *:40 ............ TO .7 M AT ELE :111 R M ' �BASE T 110 MIN) '� AU6 4 10�GARBAGE , 4 A&O 20 MIN ,,GRIN,DER 0 72 oi�w �1LEV., f 01F, R 0 Ff,L -8 A,Lk�'�,_ Y AN I AR Y -D I 'S P 0:' S'TO , �C NOT,.: , ALE GN . ' DATA: D ES I CONSTRUCTION' OF SEPTIC ­ t*STEM 'SHALL,' CO FOR N TO -LICY m BEDROOMS : TH COkM , OF, AS S NVIRON MEN TAL"CODE9 TIITLE,,5�� Y GAL./bA AND THIE�- OWN, �B.OARD' OF ''NE'ALT14 ':REGULATIONS%, -4 �DESIGN FLOW NCH THE E CRGLEACH RAE: m M I N./I : T 2) SIGN, IS TO, BE STR I CYLY FOLLOWED .' so 0 BE"CONTA&ED PRIOR ' TO ANY:, CHANGE A SHORT Mi r 24 'SF 'PRO -AREA W P*D. BOT E AREA' .� Pe, _SF 3) TANK, -DISTRIBUTIO.N -BOX D LEACH ' �PROP DL SID SF :: -TO I N TAL AREA *3 e6 G UNIT 0 BE OF ' REINFORCED CON,CRETE 0 0 P S.I. MIN�, C 0 N CR E T�E. ST R E'N G T H z PROPOSED �EACHING CA PA CI TY 2 _ GPD Rt N G T H PS. I. "GPD MIN. �STEEL , ,''S'T y W40 . . REOUIRED ' LLACHING, C,,APACIT ..--- �DE$ I G N L 0 ADI aa�,v i G MIN , IRED'­SEPTI C �, TANK it Ive R�EQU -R ' -SYSTEM . ' 4) .DRIVEWAY NOT TO: BE ' LOCATED ' OVt S DESIGN LO ING ". . ..... �UNLE-SS IS" i�USED IV 8 ERTIG _FfTTI:NGS � 10 E ,:WAT, Mau:) 5) ,A LL PI PES , AND , �H T� BE C - 'OR.,.APPROVED, P.V.C. AGENT ,:-APP ROVAL ! DATE "AND', TO AST IRON 'HEALTH .' "TO EX CAVAT 10 N11 , : CONTRACTOR 70';'CONTACT D IG SAFE ,. : 72 HOURS , PRlbk CONSTRU T � SCALE ' S] TEPLAN N 20 Pee c"i Z,ON I N '�G DATA G E -N D LOCATI rr� 1, - - R - TE F0 R �DA iZ 0 N E, A S, SH-OWN :ON , :REVISI T E I S T H 0 L E, RE FE RE N C:E, '_ L'O LOCAT I O'N ONS :_ R E 0 U11 R E D:� AREA �' t.� -EXISTING ' SPOT ELEVATION 17.6 P404 CLI E T� S, 'RE SS. , "-CONTOUR EX18TING ,,' D . REQUIRED - R-ONITAGE _R b FRONT SE BAC k PROPOSED 'CONTOUR ` ' -- F T ' IF THIS� P OT TAMP 'BY :-CRAIG R.: ' SHORT, L A N DOES N BEAR A �RED THEN ' 'IT IS NOT ��A VALI'D , COPY' -WATER SER ' ICE N E, �R EQ U!.IR ED' :SIDE SE T'BA C K L I I "A SSUME NO RESPONSIBILITLY iFORATS CONTENT OR ' ..USE. , -S RVICE LINE R Eri U I R E D REAR S E T-BA C X c -8 1E E � HONE �:LINES ELECTRI L P EaT -E S HO R (;"RAI R PROFESSIONAL �-_ C IV I L ENGINEER ANE ` DE 14 tO�RY L 'NN 1-6 I-MA S S. 02638 FILE NO. I 11"B U I L' G : I N SPE CTO',R' ', APPROVAL T E , 6530 S H E ET 77--- - 0 4B _C H -MAWK : E LE -S T R E S,u 3 7zc Pr T S E N Ar7* -Hia DAT W 'E D y t' C 0&/4. 0 A.�� E.: 2L -44 4f I T N'E'S S B "HIGH -WATER -ADJUSTMENT : GROUND.''OBSERVED WATER DEPTH 4a- 17� 7 INDEX "WELL T E ST ,,H OL E &4. //,6 )*A*r I Id, 'WATER RANGE ZONE c 4L URRENT WELL.DEPTH .......... 'WATER ADJUSTMENT -4 ESTIMATED- DEPTH,"TO WATER 4 ESTIMATED 'MAX. W ATER ELEV. lot 4. GROUND WATER ER ENCOUNTERED ENCOUN TE R E D� TO MANHOL AN 6 cbVER , �TO : BE , BUILT E 8 OF WIT 'A� lf ELEV -12 -OF �F I N1 r H I N SHtD: GRADE ........ FOU4DAT E 0 , i'-.0RADE j4f F I N I S H' 2 % SLOPE X_Ky4prji4 2 r7 4 D I A. 4 �,D I A.� PIPE, IRS MI L A'Y E'R OF , 'MIN Pl'rum FT 2' LEVE PEASTONE Y2 1f;ju TCH 'MIN. pf A I NVERT - GALLON , INVER ca D I A,,.' 2 PTIC DIST 4 'SH E D , STON E INVER '147 z � tANK iS 7', I I I r 'i st \ Ago 'WAI 'ItNVER C INVERT$ INVERT ,,B 0 X E ON 0 A L P b U N D, PL A lb _RM SAS IE4 CL Ff 2�: OM AT 11C T T ELEV #A I N 4' 6AREIA GE 2 0' M I N.) A&- N 0 E R Aj, LEV ' 04 Z7 E PRO Fl L E : Or��l S I S P 0.S"A" Y S TE A,N.1 TAR _N T A T �, tCA N OT 0 D,E S 16 'SYSTEM SHALL: CONFORM TO� � CONSTRUCTION OF 'SEIPTIC -ENVIRONMENTAL ilITLE ��5 BEDROOMS �4- THE COMM. MA&S�. :50F .,AN D TH E­ TOWN 130 ARD , OF ' HE ALTH AEGULATIONS . -440' G AY DESli GN �''FLOW� AL./D' O - BE LOWED , ,:- 'i ,!LEACH i�tM I N-./l N CH 2) , THE DESIGN IS �7 STRICTLY ' FOL .:RAI IE Z�lt^i A SHORT , IS TO,-BE:' .CONTACTED PRIOR TO ANY, ':CHANGES.". _OP'D. :SO T �i�ARE PR A' SF 4 kc w PRO P,'D. S I'D E A R El'A . , AND , LE 31 SEPTIC TANK,DISTRIBUTION � BOX :' TOTAL ARL,A:=, . S F'MIN. CONCRETE , l$ T'RENGT-H .z� 39p,0 O,P SA PRO'ROSED -tEACHING CA PACI Y' GP(D I N,G UN IT -:(�TO BE , OF REIN FORCED . CONCRETE, too 0�7'ps. L' -LEACHING CAPAC T GPD S T 9 E N G I REQUIRE ST E Et H MIN. Y—! M I N'' D E S G N LoADIN'G E 'TANK GALLON' On is REQUIR' ' D e'SEPTI C DRIVCWAYS,., NOT, TO M 4)'. BE OC AT ED ,. OVER , tYSTE 5 UNL E,S S 1­120� DES I,G N, !L'OA D ING IS U S E D 0 5 ALL PIPES AN D FITT,INGS JO -BE -VATE RITO Hl oe APPRO R �VED:* P.V. 'DATE TO, SE -PROPO'SEb , , CONS TRUCT 10 N ' ­tAUTIO N : CONTRAC 11 TOR TO - CON TACT ,D [G-SAFE 7 CASTAPON" 0 c. H E ALT H E-N T APPROVAL �2 HOURS P Rl OR TO 'E CAVAT.10 W 11 S I T E , , PL 'N � OWING - SCALE 1' 301 ar-��aj P tO CAT -9RA S -E,G ZOMNG�� . DATA L EN D', '10:1 V-4 4 D;2 "WZ�S�7'�,Co FO R, DATE ap4zRl S�"4e X<movz -ION E S7 �H 0 L E, LOCAT Z 0 N E "R EFER E N C E LO T A-S .' , SHOW N' ' ON REVI'SIONS *- EXISTING � 'SPOT ELEVATION 17.6 R E,Q V I R E Dl' '-,AR EA-, , 92 16 ' EX : 't "REQUIRED - R-o NT A G E , ISTING C 0 N'T­0 U R S AD R IF S CUEN tT IF -THIS PLAN DOES N A !'RED _ NT �'S E TA.0 K PROPOSED . CON TO U �R A MP BY RAIG ., R. :__SHORT, AS NO -A �H E N IT -COPY 8k W T VALID 'RED : �,S I D,,E , S E FO U .' WATER 9 V(CE: 'LINE SUME 'NO �RESPONSIBILITLY REQU , TBACK R ITS CONTENT, OR U I tf RI C E LI 4E P S El K R E r4 RED ; REA BA - ELEPHONE Ll E:fli ' C' R ELIECTRIC 6� ES_' FE, N A L: E G I"N S: _77 A 41 Y-"% : 8 MAI 2 6 3 8 A" SS, Djj#N FILE lW.,j N SP E C TO R- P R 0 ALr ,DAT,E 10 Fr'l SHEET .,