HomeMy WebLinkAbout0218 WILLOW STREET - Health 218 Willow Street
W. Barr
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS .
21pplitation for -Misposaf 6pstem Construction permit
Application for a Permit to Construct( ) Repair W Upgrade( ) Abandon( ) ❑Complete System eindividualCom� ponents
Location Address or Lot No. 21 g to itkw '4j�-_ Owner's Name,' dress,and Tel.No. MR"
Assessor's Map/Parcel 0 1 ZYv�cl ,/�'pJ$
Installer's Name,Address,and Tel.No. F(Zie.Sf ,�S Designer's Name,Address,and Tel.No.
Po: Bd�71 Mve5'tz..'g YKILLS M4, cueFt$
Type of Building: so �S
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ep-Aa P_ }�(� P y� � fox LJ 1
e" a 093
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
i
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board o
Signed Date
Application Approved b
rr rr y Date '>I ) �
Application Disapproved by Date
for the following reasons
Permit No. a 0 �-� ' (0 a' Date Issued
j- -
t No! i d Z ,y , Fee
r-'te -
THE COMMONWEALTH OF MASSACHUSETTS Entered in compu ,�;,Y s
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for Misposal *pstPm construction permit
r�
y. Application for a Permit to Construct'( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ZIndividual Co ponents
Location Address or Lot No. (,m i« y Owner's Name,Address,and Tel.No. #ej .e� (y}j�r Ivyy�,�
S IT I�� i tx,3 �: �:1V, T," T
Assessors Map/Parcel � _�,a r�%\Z!V ., /SS Go
Installer's Name,Address,and Tel.No. c. 451 _S Designer's Name,Address,and Tel.No. `
Via, Ba� ?D m4P-srv,%S m -s r4=a. aiivf
Type of Building: y 1Ab`:o 5
Dwelling No.of Bedrooms 4 'I ,-RR Lot Size sq..ft. .rGarbage Grinder( )
Other Type of Building _ No.of Persons Showers( ) Cafeteria( )
Y Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
t Plan Date Number of sheets Revision Date
Title1
Size of Septic Tank Type of S.A.S.
Description of Soil
.t t
Nature of Repairs or Alterations(Answer when applicable) .x-i c� �� y�'. �•R�r, L,)t
AML4 A 0l
r'
i
_ Date last 4ispected,
- -
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 4
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health__. j
Signed _ �„ Date -11 1
Application Approved by Date sa a 1/?
Application Disapproved by Date 1 /
for the following reasons
Permit No. 11) o 1/ ' �� '1 Date Issued
F
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
P pR w e (Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by if#t(— vty!J.
at V 9 {A),V{tg-.j <-,V, has been constructed in accordance /
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer �°4 S U21 a1 & Designer r
#bedrooms p1/ Approved design flow b ,tj gpd
The issuance of this permit shall not be construed as a guarantee that the system will-funcctio as designed.
Date �? 1 Inspector
No. l l A 2 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
L 'fin Mispo8al 6pstem Construction j3rrmit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at Z Itlit.
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction/must be completed within three years of the date of this permit.,
/
Date $^( Z t/� / Approved by
/ 01 V
No � F—S
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for Misposal �&pstpm Construction Permit
Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) []Complete System ZK/dividual Components
Location Address or Lot No.2Wo Owner's Name,Address,and Tel.No S"o� 737- ?730
w, /3oPars�47s1'� Chi/�f /'u
Assessor's Map/Parcel
In ]ler's Name,Address,and Tel.No�S o�P Designer's Name,Address,and Tel.No.,0 -y9r-s-3i3
Cow
33-0 Ll Si Gab '�
Type of Building:
Dwelling No.of Bedrooms Lot Size y3 7>O sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures '
Design Flow(min.required) "?,�t!1 gpd Design flow provided ✓� 3a gpd
Plan Date��/Zi Number of sheets Revision Date
Title
Size of Septic Tank fro p Type of S.A.S.
Description of Soil
b
Nature of Repairs or Alterations(Answer when applicable)_��� Zvi`sue/pro Z rz.%,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date y�
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No f9q3� _ O Date Issued N
t ? r•F�F,�5 �t'.F+,.,,s'^- -�.. ',► .,� � ... "s.^{ .'1,�. q,_ f,�,,, r c:*.::•r&ky .•^i..r-•ti 7`c- d "�
€J r,•.;. P P,,,F:+r-'' a"."�'"-�s.•-..�n.rrvr•'...gr �+ {.nak.+'.'r.:'vti,Y'." '�.ca'
µ� No k Fee A)16
W THE,COMMQNWEALTH OF MASSACHUSETTS Entered in compater: YeI
PUBLIC HEALTH DIVISION - TOWN .OF BARNSTABLE, MASSACHUSETTS
i ra
4plication for Wop,0'sal pstem,Construction Permit
X
Application for a Permit to Construct( ) Repair(G'�Upgrade( ) Abandon( ) ❑Complete System 0,11rdividual Components
Location Address or Lot No.280 sT. Owner's Name,Address,and Tel.Noa`o8
/3v�.rsf�
Assessor's Map/Parcel /_7
Installer's Name,Address,and Tel.No>3 d-'r-rJ-- �a�� Designer's Name,Address,and Tel.No.
/�..�� �/' S% Y�.r...rr�nrr..rr`lf - /.9'l r'/iisss�'o . � /s.-•as�.✓,,.a ..:�+.
Type of Building: t
Dwelling No.of Bedrooms Lot Size �K�7 ys p sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) "� 4d gpd Design flow provided 3 30' gpd
Y Plan Date /zi Number of sheets 2 Revision Date
Title
'Size of Septic Tank ,/s"a47 Type of S.A.S.
Description of Soil
l
Nature of Repairs or Alterations(Answer when applicable) ii s,. //
.n, -,0
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate:of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
f:
Application Disapproved by r Date f
- . for the following reasons
Permit No 6 Date Issued cT�•J
r
1
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed Repaired - ,/ Upgraded
r
> g P Y ( ) P (�1 ( )P�' t
Abandoned( )by
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated T-il_A aJ
Installer9 oy'-z0'Z;z, " Designer Q
#bedrooms 3 Approved design flow gpd
The issuance of this permit shall not be c strued as a guarantee that the system will function as �signe .
Date Inspector
--- ---
'- --- ow- � " /X Fee N ! t-�
THE COMMONWEALTH OF MASSACHUSETTS a
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
i
Misposal *pstrm Construction Permit
Permission is hereby granted to Construct( ) Repair(!i� Upgrade( ) Abandon( )
System located at
l ..
and as described in the above Application•for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
'k
Title 5 and the following local provisions or special conditions.
Provided:Construction ust be completed within three`years of the'-date of this permit.^
Date % �� / Approved by 1
Town of Baknstable
QFtHE Tp�
Rebulatb yT Seryyces
I kha'rd V.Scali,;lnterim Director
snxrrsrnac c
Public Health Dvisi®irt t
Thornas,McKean,Director
'200 Main Street,Hyanrais,IN IA 0260I
Office: 508-862-4644 Fax. 503-790-6304
'Installer&Designer Certification Form 7
Date: SewacTe Permit# ►- Assessar's l� ap\Parcel 1 ` 06
P 4-c<- t 1 c
Resigner;
installer:
Address: )Z 1�1 CCr s ;e Ic/ jZend Address: 3 C 't fix
nil: �+ - alas"issued"a pertnit to install a
(date) (installer)
septic system at Z80 t�!1 ,,4 S-1-, L based on a design drawn by
(address)'
1'f)der ;d% f:�_zs dated`:.. _3t tt
(designer)
jev , sls (�zE
V I certify that the septic system referenced above was installed substantially acctirdiho to
the'design; wvhich flay include minor approved changes such,as lateral relocation of the
distribution box and/or septic tank. Strip out (if required);was inspected and-the soils
were found satisfactory.
_ I certif} that the septic system referenced above was installed wi;th major changes (i.e..
treater than10' latcral relocation of the SAS=or any,vertical,relocat
ion,of any component
of the septic system) but:in accordance with State'&,l.,ocal I2egtti 3tions. Plan revision or.
certified as-built by designer,to follow. Strip 6u. r(if reeluirt.d) was'inspec ted and the.soils "
were found satisfactory:
I certiR,that the "system referenced above was constructed in r. '*�" ".with the terin s
of the BA approvAI'letters (if.applicable) �N
�r
sta ler's Signature) U eC V1L
gip.35�fl9
O
(Designer's Signature) frix i7esigne axe)
PLEASE RETURN TO BARNSTAI LE PUBLIC HEALTI-I DIVISION. CER.TIFICA'rF,
OF COMPLIANCE WILL NOT BE 1SSUE1) UNTIL BOTH THIS FORM AN.D"AS-
BUILT CARD.ARE RECEIVED BY iHE:BARNSTABLE PUBLIC HEALTH DIVISION
THANK YOU.
Q .scpti..D.esigner Ceftification Form Rev 3-14-I 3.doc
Engineers note:This certification is li ited to an as-built inspection of systern,components as installed prior to backfill.The "
engineer did not supervise constriction of-the,systern.The installer assurnes responsibility for all materials,workmanship,backfilling
to specified grades v lh proper compaction and Eettinq riser 'covers as showfv.oti.the design plan.
cog
CERTIFICATE OF ANALYSIS Page: 1
.� Barnstable County Health Laboratory
Report Prepared For: Report Dated: 10/14/2008
Karen Mallcus
Barnstable Health Dept. Order No.: G0849584
200 Main St.
Hyannis, MA 02601
Laboratory ID#: 0849584-01 Description: Water_-Drinking Water
Sample#: Sampling Location ;218 Willow Street West Barnstable,MA. Collected: 10/6/2008
Collected by: K.Malkus Received: 16/6/2008
Routine+Ammonia
ITEM RESULT UNITS RL MCL Method# Tested
Ammonia ND mg/L 0.20 EPA 350.1 M 10/8/2008 - -
Nitrate as Nitrogen 1.7 mg/L 0.10 10 EPA 300.0 10/6/2008, .
Copper ND mg/L 0.10 1.3 SM 3111 B 10/9/2008
Iron ND mg/L 0.10 0.3 SM 3111 B 10/9/2008
Sodium 29 mg/L 1.0 20 SM 3111B 10/9/2008
Tota].Coliform Absent P/A 0 0 SM9223 10/6/2008
Conductance 270 umohs/cm 2.0 EPA 120.1 10/6/2008
pH 6.4 pH-units 0 SM 4500 H-B 10/6/2008
Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physici n.
Approved B
( erector)
r.:
ORIGINAL
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
CERTIFICATE OF ANALYSIS
Page: 1
,1 Barnstable.County Health Laboratory
`s�cttvs;fi Report Prepared For: Report Dated: 10/14/2008
Karen Malkus
Barnstable Health Dept. Order No.: G0849584
200 Main St.
Hyannis, MA 02601
Laboratory ID#: 0849584-01 Description: Water-Drinking Water
Sample#: Sampling Location 218 Willow Street West Barnstable,MA Collected: 10/6/2008
Collected by: K.Malkus Received: .10/6/200,8
EPA 524.2- Volatile Organics by GUMS
ITEM RESULT UNITS RL MCL Method# Analyst Tested Note
Dichlor3difluoromethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Chloromethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Vinyl chloride ND ug/L 0.50 2.0 EPA 524.2 yn 10/6/2008
Bromomethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,1,1,2-1 etrachloroethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,1,1-Trichloroethane ND ug/L 0.50 200 EPA 524.2 yn 10/6/2008
1,1,2;2-Tetrachloroethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,1,2-Trichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 10/6/2008
1,1-Dichioroethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,1-Dichloroethene ND ug/L 0.50 7.0 EPA 524.2 yn 10/6/2008
1,1-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,2,3-Trichlorobenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,2,3-Trichloropropane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,2,4-Trichlorobenzene ND ug/L 0.50 70 EPA 524.2 yn 10/6/2008
1,2,4-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,2-Dibromo-3-chloropropane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,2-Dibromoethane(EDB) ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,2-Dichlorobenzene ND ug/L 0.50 600 EPA 524.2 yn 10/6/2008
1,2-Dichloroethane ND ug/L 0.50 5.0 EPA 524.2 yn 10/6/2008
1,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,3,5-Trimethylbenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,3-Dichlorobenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,3-Dichlor:opropane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
1,4-Dichlorobenzene ND ug/L 0.50 5.0 EPA 524.2 yn 10/6/2008
2,2-Dichloropropane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
2-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
4-Chlorotoluene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Benzene ND ug/L 0.50 5.0 EPA 524.2 yn 10/6/2008
Bromobenzcne ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Bromochloromethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Bromodichloromethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Bromoform ND ug/L 0.50 EPA 524.2 yn 10/6/2008
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
4 get CERTIFICATE OF ANALYSIS Page: 2
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 10/14/2008
Karen Mallcus
Barnstable Health Dept. Order No.: G0849584
200 Main St.
Hyannis, MA 02601
Laboratory ID#: 0849584-01 Description: Water-Drinking Water
Sample#: Sampling Location 218 Willow Street West Barnstable,MA Collected: 10/6/2008
Collected by: K.Malkus Received: 10/6/2008
EPA 524.2- Volatile Organics by GUMS
ITEM RESULT UNITS RL MCL Method# Analyst Tested Note
Carbon tetrachloride ND ug/L 0.50 5.0 EPA 524.2 yn 10/6/2008
Chlorobenzene ND ug/L 0.50 100 EPA 524.2 yn 10/6/2008
Chloroethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Chloroform 3.1 ug/L 0.50 80 EPA 524.2 yn 10/6/2008
cis-1,2-Dichloroethene ND ug/L 0.50 70 EPA 524.2 yn 10/6/2008
cis-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Dibromochloromethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Dibromomethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Ethylbenzene ND ug/L 0.50 700 EPA 524.2 yn 10/6/2008
Hexachlorabutadiene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Isopropylbenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Methylene chloride ND ug/L 0.50 5.0 EPA 524.2 yn 10/6/2008
Methyl-ter:-butyl ether ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Naphthalene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
n-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
n-Propylbenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
p-Isopropy[toluene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
sec-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Styrene ND ug/L 0.50 100 EPA 524.2 yn 10/6/2008
tert-Butylbenzene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Tetrachloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 10/6/2008
Toluene ND ug/L 0.50 1000 EPA 524.2 yn 10/6/2008
Total xylenes ND ug/L 0.50 10000 EPA 524.2 yn 10/6/2008
trans-1,2-Dichloroethene ND ug/L 0.50 100 EPA 524.2 yn 10/6/2008
trans-1,3-Dichloropropene ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Trichloroethene ND ug/L 0.50 5.0 EPA 524.2 yn 10/6/2008
Trichlorofluaromethane ND ug/L 0.50 EPA 524.2 yn 10/6/2008
Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician.
Approved B :
(Lab ector)i
� 0;6- ICST
ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
;4 Page. 2
CERTIFICATE OF ANALYSIS
M,
g9SSA ' Barnstable County Health Laboratory
Report Prepared For: Report Dated: 9/29/2003
Order Number: G0322802
Susan M.White
825 Main St.
West Barnstable, MA 02668
Laboratory ID#: 0322802-02 Description: Water-Drinking Water
Sample#: 22802-02 Sampling Location: Willow Street,West Barnstable Collected 9/12/2003
Collected by: S.White Spring Received 9/12/2003
Test Parameters
ITEM RESULT UNITS MCL Method# Tested
LAB: Metals
Lead 0.006 mg/L 0.015 EPA 200.9 9/15/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates <0.1 mg/L 10 EPA 300.0 9/23/2003
LAB: Metals
Copper <0.1 mg/L 1.3 SM 3111E 9/19/2003
Iron 0.1 mg/L 0.3 SM 311113 9/19/2003
Sodium \.29 mg/L 20 SM 3111B 9/19/2003
LAB: Microbiology .
Total Coliform Absent P/A Absent 309 9/13/2003
LAB: Physical Chemistry
Conductance 267 umohs/cm EPA 120.1 9/12/2003
pH 7.0 pH-units EPA 150.1 9/12/2003
Note: Sodium level above the average.-Those on low,sodium diet may wish to contact physician
Approved By.
(L irector)
<3 e3
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
CERTIFICATE OF ANALYSIS Page: 1
`g Barnstable County Health Laboratory
Report Prepared For Report Dated: 12/22/2003
Order Number: G0323453
Thomas Madden
P O Box 612
Hyannis, MA 02601
Laboratory ID#: 0323453-01 Description: Water-Drinking Water
Sample#: 23453 Sampling Location: 132 Old Route 132,Hyannis Collected 11/5/2003
Collected bv: T.Madden Received 11/5/2003
Test Parameters
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Sulfate 5 mg/L EPA 300.0 12/17/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates <0.1 mg/L 10 EPA 300.0 }l; '-.:;,:11/6/2003 "
..LAB: Metals.
Copper 0.1 mg/L 1.3 SM 3111B 12/16/2003
Iron 0.2 mg/L 0.3 SM3111B 12/16/2003
Sodium 12 mg/L 20 SM 311 lB 12/16/2003
LAB: Microbiology
Total Coliform Absent P/A Absent 309 11/6/2003
LAB: Physical Chemistry
Conductance 146 umohs/cm EPA 120.1 11/10/2003
pH 6.1 pH-units EPA 150.1 11/10/2003
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By: � rl Uy,
(tab Director), i
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PRO 1`ibi�-z!`�
P
1/ PARCEL ' 4
AU6 Z 4 2004
`O fi(3WN Of BAR,NSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 218 Willow Street
W. Barnstable .
Owner's Name: Valdo Kiiss
Owner's Address:
Date of Inspection: — G
Name of Inspector:(please print) W 111 i am E_ • Rob i nson Sr.
Com;panyName: William E. Robinson Septic Service
Mailing Address: P O Box 1089
_Centerville, MA
Telephone Number: (s08) 77 s-8776
CERTIFICATION STATEMENT
I certify that 1 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 CNIR 15.000). The system:
!°asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:� `� Date:-7 4—Uy
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health Dr
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 tile
DEP.The original should be sent to the system owner and copies:sent to the.buyer,if applicable,and the appro.ving
authority.
Notes and Comments
I "
****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 6/15/2000 page 1
R
. w
Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address: 218 Willow Street
W. Barnstable
Owner. Valdo Kiiss
Date of Inspections
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass.'section need to be replaced or
repair d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer es,no or not determined(Y,N,ND)in the for the following statements.If`not determined"plcase
explain.
Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, xhibits substantial infiltration or exfrltration or tank failure is imminent.System will pass inspection if the
existing is replaced with a complying septic tank as approved by the Board of Health.
•A metal eptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating at the tank is less than 20 years old is available.
ND expla'
Ob ervation of sewage backup or break out or high static water level in the distribution box due wbroken or
obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval o Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND expl in:
e system required pumping more than 4 times a year due.to broken or obstswcd pipe(s).The system will
pass in pection if(with approval of the Board of Health):
broken pipc(s)are replaced
obstruction is removed
ND explain:
III
Page 3 of I 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 218 Willow Street
W. Barnstable
Owner: V ldo Kiiss
Date of Inspection: .
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 fai' g 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
ystem 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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syste . 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 I 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 front 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 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.
Other:
3
Page 4 of l l `
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART A
CERTIFICATION(continued)
Property Address: 218 Willow Street
W. Barnstable
Owner: Valdo Kiiss
Date of Inspection: —
D. §ysteT Failure Criteria applicable to all systems:
You ust indicate"ycs".or"no"to each of the following for all inspections:
Yes o
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
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 I00,feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or,privy is within a Zone I of a.public well.
�. Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Kmter
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
indicates that(lie 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.]
(Yes1No)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 a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
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 sm-face drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or a mapped
Zone I of a public water supply well
If you ave answered"yes"to any question in Section E the system is considered a significant thrcal,or answered
"yes"i Section D above the large system has failed.The o%Nmer Orr operator of arty large system considered a
signific nt 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 218- Willow Street
_ W. Barnstable
Owner. Val do Ki i g�
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Ycs 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 7.
Were as built plans of the system obtained and examined?(If they were not available note as NIA)
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?
d �_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
thbaffles or tees,material of construction,dimensions,depth of ,li uid depth of sludge and depth of scum?
/ 9 P g P
-,/ 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:
Yes .no /
_ 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(3)(b)J
S
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 218 Willow Street
W- Barnstablg _
Owner:
Date of Inspection: - - O
2-7
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual): . a
DESIGN flow based on 310 CMR 15.203 for example: 110 gP
d x#obedrooms):3 — 6
Number of current residents: N 6,
Does residence have a garbage grinder(yes or no): X-
Is laundry on a separate sewage system(yes or no):Ll-0 [if yes separate inspection required]
Laundry system inspected(yes or no):/It,
Seasonal use:(yes or no): A,b
Water meter readings,if available(last 2 years usage(gpd)): well water
Sump pump(yes or no):�'0
Last date of occupancy:
COMMERCIAL/INDU RIAL
Type of establishment:
Design flow(based on 3 0 CMR 15.203): Rpd
Basis of design flow(s is/persons/sgft,etc.):
Grease trap present(y or no):_
Industrial waste hold' g tank present(yes or no):—
Non-sanitary waste ischarged to the Title 5 system(yes or no):_
Water meter read' s,if available:
Last date of occu cy/use:
OTHER(des• be):
GENERAL INFORMATION
Pumping Records
Source of information: 19 -�t 5�
Was system pumped as part of the inspection(yes or 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)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):zt, 0
6
•Page 7 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 218 Willow street
W. Barnstable
Owner:_
Dale of Inspection: b vC
I
BUILDING SEW R(locate on site plan)
Depth below gr de:
Materials of c swction:_cast iron _40 PVC_other(explain):
Distance Go private water supply well or suction line:
Comments n condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: I
Material of construction:_✓concrete_metal fiberglass_polyethylene
_othcr(explain)
If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no):
certificate) —(attach a copy of
;
Dimensions: 7 �, 1 d ti G
Sludge depth:
Distance from top of sludge to bottom of outlet Ice or baffle: Or
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_ c f
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: B e_N
Comments(on pumping recommendations,inlet and outlet tee or baffle conditiofi,structural integrity,liquid levels
as related to oust invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction:_con rete metal fiberglass_polyethylene_other
(explain): —' _
Dimensions:
Scum thickness:
Distance from top of scum_t top of outlet tee or baffle:
Distance from bottom of sc m to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet lee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 218 Willow Street
W. Barnstable
Owner:
Date of inspection:
TIGHT or HOL ING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below gra e:
Material of cons ction: concrete metal fiberglass_polyethylene other(explain).
Dimensions:
Capacity: gallons
Design Flowrof
allons/day
Alarm presen
Alarm level: rking order(yes or no):
Date of last p
Comments(c 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 level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working ord r(yes or no):
Comments(note con lion of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of]I
OFFICIAL INSPECTION_FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 218 Willow Street
W. Barnstable
Owner: Valdo Kiiss
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required)
I
If SAS not located explain why:
Type
leaching pits,number:_
1 ching chambers,number:
aching galleries,number: y �ee L
6
E�iceachingtrcnches,numbcr,Fen—gth:a,—,%r� ..-5 3
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): S_
`l , Furs r 6'r6 A
v
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 Ar no):
Comments(note condition of soil,sig s 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 s il,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 218 Willow Street
W. Barnstable
Owner: Valdo Kiiss
Date of inspection: = 4 "
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
bench arks.Locate all wells within 100 feet.Locate where public water supply enters the building.
%. rti
as
(W lJ
1
G
� 1
3
10
I
Page 11 of it 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:218 Willow Street
W. Barnstable
Owner.
Date_of Inspection: —
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells -
Estimated depth to ground water L feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
pecked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you blished the high ground water elevation:es
6t5- Y77 A 5
11
CERTIFICATE OF ANALYSIS Page: 1
'= Barnstable County Health Laboratory
Report Dated: 07/03/2002
Report Prepared For:
Kiiss,Valdo&Imbi Order Number: G0215509
Valdo Kiiss
237 Red Top Road
Brewster, MA 02631
Laboratory ID#: 0215509-01 Description: Water.-Drinldng Water
Sample#: 15509 Sampline Location: 218 Willow Street,West Barnstable Collected: 07/01/2002
Collected by: Imbi Kiiss 155-8 Received: 07/01/2002
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 1.5 mg/L 10 EPA 300.0 07/01/2002
LAB:Metals
Copper <0.1 mg/L 1.3 SM 3111B 07/03/2002
Iron 0.3 mg/L 0.3 SM 3111B 07/03/2002
I
Sodium 26, mg/L ".72-01 SM 3111B 07/03/2002
LAB: Microbiology
Total Coliform Absent P/A Absent P/A 07/01/2002
LAB: Physical Chemistry
Conductance 267 umohs/cm EPA 120.1 07/01/2002
pH 6.4 pH-units EPA 150.1 07/01/2002
Note: rj:S ample has higher-than,averaae level of Sodium. Those on low sodium diet may wish to consult physician.
Approved By:
(Lab Director)
7�3�ZooZ
i
e
9
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
o
Commonweafth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Wililam F.Weld Trudy Coxe
Gow"M Boost"
Argeo Paul Celluccl David S.Struhs
U.Governor ComtnhNorrr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION
Property Address: 218 Willow S t, W Barnstable, MA Address of Owner. David Scott
Date of Inspection: L`—/ 7—S 7 (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_L,�saes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Zo Date: —q
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
V I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMIZ 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11103/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556.1049 a T61eph0n6(617)292.5500
ice,Printed on Recycled Paper
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Address: 218 Willow S t, W Barnstable, MA
Owner. David S Ott
Date of Inspection: 4/—J'1—
B1 SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed `
distribution box is levelled or replaced
s The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
tbroken pipe(s)are replaced
/ obstruction is removed
1
C) THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
03nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is.within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE,SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for 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.
9) OTHER
'' (revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
property Address; 21.8 Willow St, W Barnstable, MA
Owner. David Scott ---
Date of Inspection:
D) SYSTEM FAILS:
Id
determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_i Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(e).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
lcoliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El I E SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone U of a public
water supply well)
The owns or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
me to of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11103/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
property Address 218 Willow S t, W Barnstable, MA
Owner. David Scott
Date of Inspection:
Check if the following have been done:
_kfumping information was requested of the owner,occupant,and Board of Health.
one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
L/As built plans have been obtained and examined. Note if they are not available with N/A.
_'Phe facility or dwelling was inspected for signs of sewage back-up.
_ZZThe system does not receive non-sanitary or industrial waste flow
_ZThe site was inspected for signs of breakout.
Y'All system components, excluding the Soil Absorption System, have been located on the site.
d/The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
VThe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 218 Willow St, W Barnstable, MA
Owner. David Scott
Date of Inspection: L1 I /7'q?
FLOW CONDITIONS
RESIDENTIAL:
Design flow: L dns
A.
Number of bedrooms:.5-
Number of current residents:/
Garbage,grinder(yes or no): .`
Laundry connected to system(yes or no):�5
Seasonal use(yes or no):t,V d
Water meter readings,if available:
Last date of cccupanry:-�/�- 7-S
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallonsiday
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING"RECORDS and source: of information:
C-/171 %�1 Z Jq(� S
System pumped as part of inspection: (yes or no)_
If yes,`volume pumped: gallons
Reason for pumping:
TYPSYSTEM
Septic tank/distribution box/soil absorption system
single cesspool
Overflow cesspool
Privy
Shared system(yea or no) (if yes,attach previous inspection records,if any)
Other(explain)
` APPROXIMATE AGE of all components,date installed(if known)and source of information: /G-is. '!2
f _
Sewage odors detected when arriving at the site: (yes or no) A,v
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertYAddress, 218 Willow St, W Barnstable, MA
Owner. David Scott
Date of Inspection: G�-I -c-7
SEPTIC TANK:
(locate on site plan)
Depth below grade: 0 - //
Material of construction:vconcrete_metal_FRP—other(explain)
Dimensions: Z
Sludge depth: `/_6 ' /O�
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thiclmese: 3
Distance from top of scum to top of outlet tee or baffle: v ,
Distance from bottom of scum to bottom of outlet tee or baffie:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) Ys rP �b c
G"E TRAP:_
(locate\\ n site plan)
Depth ow grade:
Material f construction:_concrete_metal_FRP--other(explain)
Dimenaio
Scum
from top of scum to top of outlet tee or baffle:
Distaa from bottom of scum to bottom of outlet tee or baffle:
Comm ts:
(reco elation for pumping,condition of inlet and outlet tees or baffies,depth of liquid level in relation to outlet invert,stnichual integrity,
evidence f leakage,etc.)
NZ
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddreae: 218 Willow St, W Barnstable, MA
Owner. David Scott
Date of Inspection: L/-/ 7
TIGHT OR HOLDING TANK:_
(locate=mde:
plan)
Depth
Material of n _concrete_metal_FRP_other(esplain)
Dimensi
Capacity gallons
Design w: gallons/day
Alarm 1:
Comments:
(condition f inlet tee,condition of alarm and float switches,etc.)
V
DISTRIBUTION BOX._
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) d
PUMP HAMBER:_
(locate o site plan)
Pumps working order:(yes or no)
Commsa 1.
(note oondrn of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 218 Willow St, W Barnstable, MA
Owner. David Scott
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,but may e b approximated PP by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits, number:
leaching chambers,number:_
leaching galleries,number:
leaching trenches,number,length: /
leaching fields, number,dimensions:
overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etcJ 1&]i- /_
i 5
,7 7
rz
POOLS:_
(loca on site plan)
N and configuration:
Depth- of liquid to inlet invert:
Depth o solids layer.
Depth of scum.layer:
of cesspool:
Mate of construction:
Indicatio of groundwater:
in
(cesspool must be pumped as part of inspection)
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:
(locate on site plan)
Mate ' of construction: Dimensions.
Depth solid-:
(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
OL
(revised 11/03/95) g
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
property Address: 218 Willow St, W Barnstable, MA \\
Owner. David .Scot-: I
Date of Inspection:
I
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (L I
1
• O
v J
/+
DEPTH TO GROUNDWATER
Depth to groundwater: /�'-+ feet
method of determination or approximation: 6 A
(revised 11/03/95) 9
LOCATIOPI SEWAGE PERMIT NO.
* Zes la3-R 63
VILLAGE A ^ i5's
1 N S T A LLER'S NAME A ADDRESS
D U I L D E R OR OWNER
i� L,-bN�A S�
DATE PERMIT ISSUED Bak
DATE ' COMPLIANCE ISSUED
f
I -
t �
I
L)v She �� -
.o
I
f
1AAA
� ... ................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
. ...
Appliration for Uiipnsa1 Works Tonotrnrtiun Prrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
VMR
-
• ocafon-Address A o Lot No. .............
.......... _._. ._..... i.. �. .........................
O er ................................Address
Installer Address -f- ��
QType of Building Size Lot_�P�.??. .__._.__ -feet
V Dwelling—No. of Bedrooms.........��.................. .Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ................................
w Design Flow............J.�_.Q....................gallons p � per day. Total daily flow.......... .. ._............__.ga,11ons.
WSeptic Tank—Liquid'capacityOO gallons Length..&: ! Width.'../O ��.—_�15iameter................ Depth .'7..- '
x Disposal Trench—No. .....I.............. Width_--.3........_.... Total Length...jR-a`�-.--..... Total leaching area...'&;0.....sq. ft.
Seepage Pit No-------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (L,,' Dosing tank ( )
aPercolation Test Results Performed by.....s ,._.�'� > F}' ..;.� L.+_. Date.. - . .�_ .��.....
a Test Pit No.3....�.Z'minutes per inch Depth of Test Pit•.1�-3.�_..... Depth to ground water.._. . .
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ------------- ----------------------------._........---•-----•----. ---•----------------------------------------
-----------•------..-
O Description of Soil..o..� ........ Sol t...�.--4� b�................. .................................................
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 iI'L LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by boar heal
Si �c�...
Application Approve ..... ....... /y
Date
Application Disapproved r th ollowing reasons:--------•.....................••----------------------------....:------........................................
---------------------------------------------------------•----------•-----........--•---........-•--------••--••---•-•.....•----••-------•-•---•••-•-•••--•••-•••••••-•-------•••......---•••......•---
Date
PermitNo....................................................... Issued_.......................................................
Date
f"•'ti
....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
F?_A-)
............ ..... .... .............__OF........................................................................................
Appfiration for Dhivaaal Works Tomitrurtion Famit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
L L D W
......................................... --------------------------------------------------------------------------------------------------
Location-Address or Lot No.
..........)
-7.......................... ............................................... ...................................................................................................
Address
..........................................I .I e----"-------------------"....... - d--d-r-- ------
. Installer Address. C
PQ Type of Building Size ------Sq. fm
Dwelling—No. of Bedrooms._._..... ...............................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Other fixtures ............................... . - ......... --------------
Design Flow............L.I C, aapr;: ga Ions.
....gal ons per perm) eV ay. Total daily flow------------------------------------- -
------------- Width.t'::.K0.'Diameter________________ Depth
P4 Septic Tank—Liquid captcit/.11...."gallons , Length............... ? Depth ..`_. ._.
Disposal Trench—No. ____________________ Width___.._.__._.______.. Total Length_.'`. ..........Total leaching area.3A_?.......sq. ft.
Seepage Pit No_____________________ Diameter.__._.__.__..____.._ Depth below inlet_.______..._...._._. Total leaching area..................sq. ft.
Z Other Distribution box (L-) Dosing tank ( ) - _�'q - a /
Percolation Test J�esul� _Z. Performed by.....ow. ....d1?_)JFA_1ZA) I... Date..'��...........................
.... . ... ..............it..
ti
...............
Test Pit No—I................minutes per inch Depth of Test P Depth,to ground water..
Test Pit No. 2................minutes per inch Depth of Test Pit_______.___________. Depth to ground water-______________________-
Oil ...... .....)1�.................................................................
0 W Description oI f�-5S oRil,.ii._Cui, -- _ ��0;A
;K)- ----------------------------------------------------------
U ....................................................................................................................................................................................................
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable............................................................... ...............................
......................I................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
S' d.....
------------------------ .......... --te---------------
•
y---X ........
Application ApproGX�,By__..<� .... --------
.. .. . .. . .............. ...............................
ry
Application Disapprov for t e following reasons:................................................................................................................
......................... .................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Tntifiratp of Tom;lHattrr
THIS IS TO CERTIFY, That the Individt lS Disposal,6',stem constructed'(�6r Repaired
by .......................... ...... ......... ........................................................................................
j-'Z7----ft---------
..
...............................................................................................
............. ---------- .....................
has been installed in accordance witl-rihe provisions of TITLE 5 of The State Sanitary Cod as escribed in the
applicatioii'for Disposal Works Construction Permit ................... dateIYC71
:' --------- ---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE__..._...... C1 0&1............................. Inspector.v---------; ....................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................._1
OF..................................................................................... F&E........................... ...............
Disposal Worku notrudion Famit
Permission is-herebygranted------------------- . ... ...... ..... ......................................
<j,-) or Rep�L;:�
divl �XV Disposal System
to Constr .wage
at .........
-------g;i�f---- -------------------------------------------------------------------------------------------------
Street
as shown /thhp Ii.cation for Disposal Works Construction Permit Nq ......................... Dated__..____._..__..__.__._____..._____.......
.. ..................................................................................
Board of Health
DATE. ......I................
FORM 1255 A. M. SULKIN, INC.. BOSTON
T.
t
fiIGN? GFtC)UtfUCOMi �IIkT;:IUtr
�5 1'e P.
Address;. +
Contractor Address
6 a '.
'��
STEP l Meaaure .depth to water ,table `
f
to 'nearest. 1/10 t.
ix date
STEP 2 : Using 1,'ater=Levc1. Ranye. Zone
and Index We1,F Map locate
site and .determine:
we) ) . . . . . a 5
A) Appropriate. 'index
B) Water-level range zone I- ~
STEP 3` Using .monthly -report-_'ICurrent
Water Resources Conditions"
determine current depth to.
waster :level 'for.: index well
mo. yr
STEP 4 Us in Table of Water-level
Adjustments for index well
STEP 2A current' depth to `
water. level for index w.e) 1
(STEP 3) , and •water .l,ev.el
zone .(STEP 201 detcrm .-se
water.-level adjustment. • • • -
STEP $ Est inate-,depth to h i gh wat'er
by s.A racting the water- '
level adjustment -(STEP
from measured di•pth to water r II
level at si.t.e (STEP 1) . . � _�J
filGti GROUND-4,'111ER Lf \DEL CU!11'illh1 IUt: ,
te ocation: . ot No
_ _.. .
Owner: Address: --
Contractor: — - Address:- - ---- .
Notes:
STEP 1 Measure depth to water.. table
to nearest 1/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . � / /811------- .
:date
:STEP .2 Using Water-Level Rang,e. 7-one
and Index Well-. Map locate
site and determine
A) Appropriate index well _..__
B) Water-level range. zone . .
STEP '. .3. .Using monthly report'!Current
Water Resources Conditions
determine. current depth . to. .
water level:. f.or index:wel l ,,..tp/8
mo yr
r.STEP 4 Using Table of Water-level
Adjustments for index well
STEP. 2A current depth to
water level. for index w.el.l ,
(STEP 3) , and water-:level -
zone .(STEP 2B) determine 1► CP'
water-level adjustment, . . . • • - • - -
STEP .,'':Est inate depth to h`i.gh water "
by subtracting the water-
level adjustment (STEP 4) -
'from measured dept h to wit er � 1
)eve) at si.t.e (STEP 1 ) . . . . _. .
con'lpIcIcd by
' `. . . HIGH GFtQ.UND-.1,'n1ER lVEL. CO'4i'UIAFI0lr
Site Locat ion: �l-^� .._..,_�._
Owner;
Address:
Contractor: _Address: - ^_
Notes.
STEP l Measure depth to water table ( o
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
to nearest 1/10 ft.
date
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
5�35 w
A) Appropriate' an is a dex well . . . . . . . . . . .
B) 1"'at er-l ewel range zone . l $ -
STEP 3. .Using monthly report''Current
Water Resources Conditions"
determine current depth: to
water level-:.f or: index well
,mo yr
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--A ev.el
zone :(STEP 26) determine 1�
water-level:.adj.ustment . . . . . • . • . • • . . . .
57EP $_ E.st.inate depth to high .water
by subtracting :the water- 44
level adjustment (STEP ..4.)
from measured depth to woier rr i
. level at site (STEP 1 )
l:i� -
�' , ' u f11GH''GROUt�U 1,'l1CR 1 C11Lt_ COHI'U1151;I,Utr'
5 i t e Lpc;a t 1 an ���..� ��� � .����� � lot N o
Owner, A�+�i,rc.ss;
Contiractor• _Addre�s
N teS�
1Q ' � ' +^—*----- i "!'""^" "`�,': f—+--r" r '.I "'T'T•"�'�—�'_5+i'k•rrT,l ry r
� ,^,J•a �,�t �'i;' a Cr t ` t � I a4.• tf r.
STEP 1 Measure depth., to water •cable
ft
to nearest 1/TO :�. = _
s � r date
STEP 2 ; Rls i ng Water Level Range:
d��'1 nd'ex ocaxel
p d
site: and deter,�n�ne�
ryY '�s r M {( -• 1 G J� { �,}1 � :.I 1 �Sa �� a L.x',1
ur a"� z '.,r !:' ," '' /`':.Jr t i t Ir f r t ;xili a t r fS r r ✓ Yp A
�kt t � a, s z:} a J s r I I f 1 Iva : I � � r• 4 ,f xr ?t`, '� , i 9t YY, :
� r r r ''A) Approp:r�at,� �ndex wE l � °�' h• �Y` f `J � �, y' '�r„
Y r r d -�•, � I :r � r , i.I,. 1' t , s � :�"�ly���''e.»x�� 1! n r� r!F i'��A 4 14�4�' ti 5:
r
STEP>1 3 . Using mon'thly,:report
f k , ►,; ,, 4 I rl, a 4 k. ,yx T y } a -.,t�?r`IIY} r r .,r 6 .:
R Water esources 1Cond 1
H'
z
,�"�;,• r 4 det�,r��ne� d
curren� ': epth;
a�,t
r I 4 . . .0 y - lri I I r
yra �! 14 �Fft rr I /r�,,,� ,r. }�Z�SI�n+ �F °4Y't a r�.-1 d b� y�; Tr
I` V5
:. ,, a r .• . ., c' rhryla t� a I ,.�� �.
t
ST r
.i WA EP � Us. Table of ter level r. I
``A'djustments `:for ii,de-�e�11
'STEP 2A current `deplt.h to - • rr � •`Y `
1
water•level .for index ,w.el1 ' , f
t 4 (STE,P,: 3) and`.water level I�R 't,+ 6 //
(STEP 2B).; determine t r �1 " , 1 A �► �•0 1, ,�` I
water, I eve t6dj6Stment5
/' r. � '4 r :.. .'( s � ,�.t, .y,: '' t ' Fi 1 {�,'✓;){' Y, Ir a , d �,yr It
Es't m ate depthghy'wat �+//��
�. �
I"a; {ar11'LL by sbbtcact ��:g thewl ter a` A ' tl. t I I � I+ >✓jy`;4`t >}4,� jk�4
i
{ � levelf adjustmcn� �(STEP ' .4) �' `
m�aSured `�Icpth to ,hater
rl
leve°) ,r
1 I P { t
5 1... .1
,�It ', , ( } ♦ 1 I f
4`lt`'S • .. ! r i '� G i r t f a T
S U
k i � • t > i s �' I �1 1 -� PA' iaJ s 1. y C r � 1* r l � y h 4C
�,• t T , _ 1,"F` , ' r ra` f {' b 4, - ! "e .:`!fir ! ' v 111 b x'i}�q� (
\Vf
,
s 4'
Ltt
e F BENCHMARK
COR./BOTT. STEP
EL.=22.05 WF
a.o
WF 0MI SL We
8.24 9.�3Y,, ^ trtetable,M 2668
♦ WF WF ♦ /ir` .81
O� WELL \ 6.94 ABANDONED CRANBERRY BOG a
' PRC FR Sg �`r0� \ x.23
C '4 WATERSURFBBG II WF WF / y 7 0
12.04 x 10.91 WF +6.33 7.71 9�
-
\ Y = . .., :..x..:12...:.a.`:'.. •.: .G:....;. u.14 'ED . 0 E�6.47 WF W�5
7 e26 0 �"V 6 5p�O vI -
\� ��`ee cnrolmoysters
p/ 12.ao.VW. +
.1c. I.-
RA 6
21.80 AE � ,v�"'•;aaape
16 3• , :;' OR/� `�"`- A Z° --- N� LOCUS MAP
21.56 FE ONE tJ
,S ..�.:10.30. . ., ,,:.•,,..,.: 9.99 ' MA Z 13.88 O
19 16.14 80116 4O 30 4 10.03 Y-.�-R2 x 12 1 FE / U
6 -ArcsOp `91 SP KE 0.
N T 2.28 �- ' /.09
B FFE Cn
'..., .C.:. 20.1e 5�V yd
E tea. 13. °.E ♦ �' Tom' FENG / 17.25
20.42 p„ 19.04 A$
g.2 �O T�C• ANK x g' x 19.07 18.02
x
20,60 N pp JO +•20.39• -F•21,77 x la7a
]9.91
x 20.59 x oHrox.) R 20.2 \ i 7
-`x 18.(opp
x 16.88 1v \
20.07
to 6) x ♦ DECK I p�oX•
20.22 H 2:03 l� x 21.29 w o x 16.51 \ ND
+ GA
NG STIIEX M
�. RAGE
' .62 B
22.05 HOUSE( 280) 21.36E 17.93.:'
T.F EL. 2 1f1 43,750 f SF
19.34 2P K9/ �c1' FF EL.=23.3t ;.''.:`';..
+'22. _ I CO- PY 20 1
�. v x �.Da
WORK IM1T DECK pR�
� 22.08 / �•' � I ..+ it :;O; ,18.86 K \
2 7 +22.27/
EXISTING LEACH P17 -�� O • , 16.09 EXISTING SEPTIC TANK
TO lase ,, VENT ::; x 21.31 / p ,� 12.65
TOP OF TANK, EL.=20.29
WITH SAND &PUMPED,NABOI°Dp ' T 11.63 a.19.5d 5p 9'Ap+ 0P� \ INV.(OUT)=18.96t
+21. 21.10 1e,92 697A / 5(P�,
2 �o TP-2 �-q:5a: -' s / / x 11.64 LEGEND
:I w.: .
G x 12.80
F 2 19 bo:: A 16.61 x 16.7o Q --10-- EXISTING CONTOUR
O 1 .36..'... ..•c '' •' i� OFFER F o OF MAs x 11.98 EXISTING SPOT GRADE
10 " u` �/ WATERSPICKET SO�j�BUFF- TOP 0 13.86 / �Q� `S9�y W EXISTING WATER SVC.
3 5 E. :,....:... .: ,
1e.72 `ST�N.• .'19.E + SALT M o PETER T. �, G EXISTING GAS SERVICE
_ - 15.82 x 9.53' o McENTEE �•H. {�- OVERHEAD WIRES
x 14.01 9 CIVIL109 cn WETLAND SYMBOL
15.4a
36 . ; No. 35
PROPOSED S.A.S. j EMA ZONE X 4 1 e / GISfE�`� Wz0,01� W��'�'ND FLAG
2-500 GAL CHAMBERS T 703 x�l�-��? 1s,lo ZON AE (E 1 B NK s J SS E�'� TEST PIT
SURROUNDED W/4' STONE U 1 A
y 16.4a FE A LE COASTAL �Z \ BENCHMARK
WORK LIMIT OF BARNSTAB 5.54 �I
PKBM ' 4. TOP MA PROPOSED SEPTIC .SYSTEM_ UPGRADE -PLAN
RSN
16,20^ 16.58 1 EDGE OF SALT . 280' MAIN STREET WEST BARNSTABLE MA
PLANREVISION 5 5 21
E >' �
EV / /
+ t5.6a �
A ALC S 5.99
AREA C TO S.A.S. EtC� Pr CORRECTIONeared for. Cape Cod Septic Services, 350 Main St, W. Yarmouth MA 02673
SALT MARSH
P P P
I 5.93 � Engineering by: SCALE DRAWN JOB. N0.
411,FEMA FLOOD DESIGNATION 5.38 OWNER OF RECORD
MAP NUMBER: 25001 CO532J BRUNCO, CHRISTOHER & MICHELE L Engineering Works, Inc. 1"-30' P.T.M. 122-21
EFFECTIVE DATE: JULY 16, 2014 15,54 (� 280 MAIN ST (Route 6A) ' 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
Zone AE (EL13) & AE (EL14) PARCEL ID: 134-009-001 WEST BARNSTABLE, MA 02668 (508) 477-5313 3/11/21 P.T.M. 1 Of 2
NOTE: TO PREVENT BREAKOUT, FINAL GRADE
SEPTIC TANK SHALL NOT BE, AT, OR BELOW, EL.=18.0
INSTALL RISERS & COVERS OVER INLET & FOR A DISTANCE OF 15' FROM THE EDGE GE
OUTLET AND SET TO 6" OF FINISH GRADE PROPOSED D-BOX OF THE PROPOSED S.A.S. EXISTING
HOUSE( 280)
• INSTALL RISER & COVER PROPOSED S.A.S. T.O.F.= 2.1t/
SET TO 6" OF GRADE INSTALL RISER & COVER OVER ONE CHAMBER AND =23.3t
T.O.F=22.1 f SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT 1 ^Ov
-F.G. EL.=21.3f F.G. EL.=21.3t F.G. EL.=21.8t F•G. EL.=21.8f "r
MAINTAIN 2% SLOPE OVER S.A.S. 24
49`3
' L = 48' Y
"S=1% (MIN.) p S=1% (MIN.)
4SCH40 PVC 4"SCH40 PVC 2" LAYER OF 1/8" TO 1/2" CP. /�� a0`L PROPOSED S.A.S.
6' DOUBLE WASHED STONE Z5 2-500 GAL CHAMBERS
B as qe as (OR APPROVED FILTER FABRIC) SURROUNDED W/4' STONE
14•• 6®B BBB
2' EFF. aaaaaaB S.A.S. LAYOUT
EXISTING 48" LIQUID DEPTH as®aaa® -3/4" TO 1-1/2" DOUBLE
LEVEL :BAFFUE
ROPOSED 4' 4.8' 4' WASHED STONE
cas INV.=18.00 P INV.=17.83
INV.=18.96 �O EFFECTIVE WIDTH = 12.8'3 OUTLETS INV.=17.50 GENERAL NOTES:
(VERIFY)
EXISTING SEPTIC TANK 2-500 GALLON LEACHING CHAMBERS
SURROUNDED WITH STONE AS SHOWN 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER.
H-20 RATED 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
TOP CONC. ELEV.=18.6t OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
NOTES: BREAKOUT ELEV.=18.00 LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW:
1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=17.50 EMT= aaaaa -310 CMR 15.405(1)(b): LOCAL UPGRADE APPROVAL
INVERTS, PRIOR TO INSTALLATION. aaaaaaaaaae 1) A 1' variance to the 3' maximum cover requirement, for up
2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE BOTTOM ELEV.=15.50 to 4' of max. cover. S.A.S. shall be H-20 and vented.
ON A MECHANICALLY COMPACTED STABLE BASE OR 4' 2 x 8.5' = 17.0' 4'
SIX INCH AGGREGATE BASE, AS SPECIFIED IN 310 4' OF NATURALLY OCCURRING -LOCAL REGULATION Chapter 360. Article 1 - Setback Requirements
CMR 15.221(2). PERVIOUS MATERIAL EFFECTIVE LENGTH = 25.0' 2) An 23' variance, S.A.S. to coastal bank(north), for a 77' setback.
3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' (MIN.) ABOVE G.W. LEACHING SYSTEM SECTION 3) An 25' variance, S.A.S. to coastal bank(south), for a 75' setback.
4) A GAS BAFFLE SHALL BE INSTALLED ON OUTLET TEE BOTTOM OF TEST PIT, EL.=9.7 = 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
SEPTIC SYSTEM PROFILE 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
ENGINEER BEFORE CONSTRUCTION CONTINUES.
5. ALL ELEVATIONS BASED ON NAVD88.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
SOIL LOG THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
DESIGN CRITERIA HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
DATE: FEBRUARY 22, 2021 (REF#TPT 21-33)SOIL EVALUATOR: PETER McENTEE SE-1542 7, WATER SUPPLY PROVIDED BY PRIVATE WELL.
NUMBER OF BEDROOMS: 3 BEDROOMS WITNESS: DAVID STANTONS R.S. HEALTH AGENT 8..THERE ARE NO WELLS WITHIN 100' OF THE PROPOSED S.A.S.
SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
DESIGN PERCOLATION RATE: <2 MIN/IN 21.2 A 0" 21.2 A 0" AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
DAILY FLOW: 330 GPD LOAMY SAND LOAMY SAND DIRECTED BY THE APPROVING AUTHORITIES.
DESIGN FLOW: 330 GPD 20.7 g" 20.7 g"10YR 4/2 10YR 4/2 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
GARBAGE GRINDER: NO-not allowed with design B B THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF LOAMY SAND LOAMY SAND CONSTRUCTION.
10YR 5/8 10YR 5/8 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
74 GP 19.2 C 24" 19.0 C 26" IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND
EXISTING SEPTIC TANK: 1500 GALLLONON CAPACITY REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
PROPOSED D-BOX: 1 INLET, 3 OUTLET (MIN.), H-10 RATED PERC
USE 2-500 GALLON LEACHING CHAMBERS IN SERIES MED. SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN
SURROUNDED WITH 4' OF DOUBLE WASHED STONE 2E5Y 6/6 36"/54" 2.5Y 6/6 280 MAIN STREET, WEST BARNSTABLE, MA
SIDEWABOTTOM. I .AREA: 2(12.8' + .8' x x 2 = 151.2 SF Prepared for: Cape Cod Septic Services, 350 Main St., W. Yarmouth, MA 02673
BOTTOM AREA: 12.8' x 25.0' = 320.0 SF
TOTAL AREA:..............................................................471.2 SF Engineering by: SCALE DRAWN JOB. NO.
9.7 138" . 138" Engineering Works, Inc. N.T.S. P.T.M. 122-21
PERC RATE <2 MIN/INN. OU HORIZON 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
DESIGN FLOW PROVIDED: 0.74 GPD/SF(471.2 SF) = 348.7 GPD NO GROUNDWATER ENCOUNTERED (508) 477-5313 3/11/21 P.T.M. 2 Of 2
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CAPE ASSOCIATES 218 WILLOW STREET PROPOSED THREE CAR GARAGE 09-20-2005 JBI'-O" ✓B Des��s
WEST BARNSTABLE MA.02668
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J REOPONSIBLE-FORHOT COMPLIANCE WITH IBL�. 2 EXALT BIDE AND I REINFORCEMENT-OF By LOCAL OI ALL CONCRETE FOOTINGS 3 ALL FOOTINGS SHALL EXTEND BELOW DESIGN
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NOTE LOCAL BUILDING CODER FOR
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FOR 817E CONDITIONS OR FOR THE USE OF THESE DRAWINGS DURING CONSTRUCTION, PRACTICES OF CONSTRUCTION,VERIFY DESIGN WITH LOCAL ENGINEER. WITH LOCAL ENGINEER AND BUILDING OFFICIALS.
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DESIGN CALCULATIONS '
SOIL, .,� TEST
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.:NUMBER 'OF BEDROOM S�.*.'.....
DATE ' OF SOIL-� JEST,
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TOTAL E�Tl MATED F L 0 W
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REQUIRED SEPTIC -TANK- CAPACITY. GAL
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LEACHING �AREA REQUIREMENTS
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9
-NOTES
WO'RkM4NSHIP, AND MATERIALS SHALL CONFORM
.ALL
TO � -D.,E.Q.'E. TITLE :5 :,AND "THE TOWN 0 F- FOR ' SUBSURFACE.
RUL 'Atli
ES D REGULATIONS DISPOSAI, .,
OF
SANIT
ARY � SEWAGE
SHALL BE
WITH REGULATION'S
:,,2�COMPLIANC�.-�
-DETERMINED 'BY BUILDING. : INSPECTOR OR BUILDING BUILDING
BUILDING SETBACK REGULATIONS PER
COMMISSIONER
INSPECTOR OR BUILDING
MMIS'SIONER
MfN, FRONT SETBACK '
3.EXISTI _GR
NG AND _ FINAL, ADES'. : SHALL REMAIN ESSENTIALLY
MIN., � REAR SETBACK
SAME
SIDE SETBACK
MIN.
APPRO
-HEALTH
I P ;4,�j
VED
BOARD OF �
w DATE AGENT
W
PROJECT LOCATION:
UOT
APPLICANT:
'57
SCALE*
OR. BY. DATE,
.,,.1 :,LE.'GEND
EXISTING
E
SPOT LEVATIONS �OOXO
REV.
APPD. BY,
JOB NO�-
ONTOUR - 00
EXfSTIN
SPOI�� ELEVATIONS
DRAWING
FOO-0
, , �4, `"�,,-_ , � �:R. 1V. 0 HEARN, INC.
FINAL �.c
ONTGUR
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L A
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oil
LOCAT p 'a BOX 1263"
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