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HomeMy WebLinkAbout0113 BOULDER ROAD - Health 113 BOULDER ROAD, a y _ wj Wr „ < , r r .G • .. .. ., .. >: � .. -., a ,,.- 1, A J r - w:+y',.`�- -..�:.:.. - �G_.•�. _ _ — ... 1f.?. 3- a SCE. yi a� • v y ". f - r- ♦ O w 31S-- od v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name Information is Barnstable ✓ MA 02630 3-21-20 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the and of the form. � c�(11UH OF�rl 4i S'o Important:When A. Inspector Information <S/ /yyd3 _�� �''�-; filling out forms on the computer, _ JA 10 F. use only the tab James D.Sears _ rn key to move your Name of Inspector = �' cursor-do not Jim The Inspector Man A%cl� use the return I ���� -- — Company Name �Jy (F'••.. ...• •, % key. P.O.BOX 784. �'�iin,�i�itN sPw\ao�• Q Company Address West Yarmouth_ MA __ _ 02673 City/Town State Zip Code 508-364-4398 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system Inspector In full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails IAa� _�CLJ2,edJt,e� _ 3-21-20 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the 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. 161nsp.doc•rev.7/28/2018 Title 6 Official Inspection Form:Subsurface Sawage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 Boulder Road Property Address Kathy + Ken Dorman Owner Owner's Name information is required for every Barnstable _MA 02630 3-21-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal Tank D Box and two pit's. 2) System Conditionally Passes: ❑ One or more.system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is Barnstable required for every _ MA 02630 3-21-20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/2&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is Barnstable MA 02630_ 3-21-20 required for every _ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *�This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ivy 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is required for every Barnstable _ _ MA 02630 3-21-20 page. City/Town ^J State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in Qa2Mwl is less than 6" below invert or available volume is less than %day flow P/ ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section C.4. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply Cl ❑ 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 t5insp.doc•rev,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 f c Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner _.___.._......._ Owner's Name information is required for every Barnstable MA 02630 3-21-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name Information is Barnstable MA 02630 3-21-20 _required for every page. Citylrown State Zip Code Date of Inspection D. System Information 1. 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 Description: i 1500 Gal.Tank D Box and two pit's. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage na 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken_ Dorman__ _ Owner Owners Name information is required for every Barnstable MA 02630 3-21-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: - — Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): --- Grease trap present? ❑ Yes ❑ No Water treatment.unit present? ❑ Yes ❑ No If yes, discharges to: -- Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is Barnstable MA 02630 3-21-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1988 Permit#88 -252. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 30"feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH -40. t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts -- Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is required for every Barnstable MA 02630 3-21-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 30" 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. Precast H-10 1„ Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle 291 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and outlet cover at 30"w/inlet at 4". Inlet tee w/outlet baffle. No sign leakage or over loading_ tsinsp.doc•rev.7/26/21118 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name - — information isBarnstable _ MA 02630 3-21-20 _ _ required for every page. City/Town State Zip Code Date of Inspection _ D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: - Scum thickness Distance from top of scum to top of outlet tee or baffle ------- Distance from bottom of scum to bottom of outlet tee or baffle — — Date of last pumping: Date — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: I Material of construction: ❑concrete ❑ metal ❑fiberglass El polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ^ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is Barnstable MA 02630 _ 3-21-20 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: -— Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 3' below grade. Box is clean and solid w/two line's out. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 cn\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r _tv 113 Boulder Road Property Address Kathy+ Ken Dorman_ Owner Owner's Name information is Barnstable MA _ 02630 3-21-20 required for every _ _ page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (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: t5insp.doc•rev.7/26/201a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •'' 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is Barnstable MA 02630 3-21-20 required for every — .._. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal.precast pits w/riser's. Pit#1 at 6' below grade w/cover at 16". Pit#2 at 7' below grade w/cover at 14" 1'water in pits. No sign of over loading. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form .' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Boulder Road Property Address Kathy + Ken Dorman _ Owner Owner's Name information is Barnstable MA 02630 3-21-20 required for every — - — page. CityJTown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 113 Boulder Road _ Property Address Kathy+ Ken Dorman Owner Owner's Name - information is required for every Barnstable _ _ MA _02630 3-21-20 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Q 13-1 - V7 r -3 2 T I if 50 ACE C A s �� 0 P,r.#t '� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 116 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is Barnstable MA 02630 3-21-20 required for every _ __ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 16. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 15'+ Estimated depth to4high ground water: 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: Lot Higher then the road. Bottom of pit at 12' below_grade. Bottom of pit at 5' higher then road level. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f Commonwealth of Massachusetts �. Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L,L 113 Boulder Road Property Address Kathy+ Ken Dorman Owner Owner's Name information is Barnstable _MA 02630 3-21-20 required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t j. + 15-4- � t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page I of 18 t7- (;0MM0NWI;n1;I'LI c)r MnssnCLlvsl�'l"I's rost,,,oF 3 1999 1',XI,CtYI'IVE 0F.FIC1', 0.1' iNV1Lt0NMI�,NTAI IIt"; z DEXAlVl'M ;,N'I' O.F ENVllMMEN'1'AI, PJtO'I'l;C ON1 wIN'I'f R. S'f 12.(;i;'1', ROS'1'ON NIA 02109 (617) 292,-Ci�d)D 350 MAIN STREET TRUDY COX , WEST YARMOUTH, MA Secrel.nry a ARGEO PAU 508-775-28001, CELIAIC(A �.+� !�V DAVID R. STRUI1:S Governor (.;nnnnissinner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 64 PAR 1 PROPERTY ADDRESS: 113 BOULDER ROAD, BARNSTABLE ADDRESS OF OWNER: DATE OF INSPECTION: JULY 14, 1999 VALENTE, PAULINE NAME OF INSPECTOR : JAMES D. SEARS I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A& B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: 50E3 775 2t300 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 systerw X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS c INSPECTORS SIGNATURE: ' DATE: A.1 7 The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) 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. NOTES AND COMMENTS: SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. NOTE: REVISED REPORT SEE ATTACHED LETTER13 o l HN0FQg9' r �I revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 INSPECTION SUMMARY: Check A, B, C, orD: A] SYSTEM PASSES: YES I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A 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. 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,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is 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. 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 pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced 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):. broken pipe(s)are replaced obstruction is removed revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • CERTIFICATION(continued) Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JUYLY 14, 1999 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT 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. 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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 and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 D] SYSTEM FAILS: N/A You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to Determine what will be necessary to correct the failure. Yes No 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 over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No N/A Pumping information was provided by the owner,occupant,or Board of Health. X None 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. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout.' X All system components,including the Soil Absorption System,have been located on the site. X 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: X Existing information.Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 g.p.d./bedroom for S.A.S. Number of bedrooms(design) 4 Number of bedrooms(actual): 4 Total DESIGN flow Number of current residents: 1 Garbage grinder(yes or no): YES Laundry(separate system) (yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): Sump Pump(yes or no): NO Last date of occupancy: N/A COMMERCIAUINDUSTRIAL: N/A Type of establishment: Design flow: Gpd(Based on 15.203) Basis of design flow 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: 1998 System pumped as part of inspection:(yes or no) YES 1998 1,500 Gallons Reason for pumping TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known)and source of information: 1998 PERMIT#88-252 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: (Locate on site plan) Depth below grade: 30" Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,500 GALLONS Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: N/A NOTE:OUTLET COVER NOT OPENED Scum thickness: Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How dimensions were determined TAPE&AS BUILT 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.) TANK AT WORKING LEVEL,INLET COVER 4"BELOW GRADE ONE INLET TEE NOTE:TANK PUMPED AFTER INSPECTION GREASE TRAP: N/A (locate on site plan) Depth below grade: 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: 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.) revised 9/2/98 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 TIGHT OR HOLDING TANK: NIA (Tank must be pumped prior to,or 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 Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: N/A (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,) DISTRIBUTION BOX IS 12'X 16",V BELOW GRADE ONE LINE IN,TWO LINES OUT PUMP CHAMBER: (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 8 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type Leaching pits,number: 2 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, - Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) TWO 1,000 GALLON PRE CAST PITS,BOTH PITS HAVE RISERS COVERS 6"BELOW GRADE. PIT#1-2 WATER,Pit#2 6"water NOTE:LINE FROM BOX TO PIT#2 NOT ENOUGH PITCH,MAY WANT TO CHANGE LINE AT SOME TIME CESSPOOLS: N/A (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(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: N/A (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.) revised 9/2/98 g 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM*- include ties to at least two permanent references landmarks or benchmarks locate all wells within t 00'(locate where public water supply comes into house) c> � id �J r revised 9/2/98 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 113 BOULDER ROAD, BARNSTABLE Owner: VALENTE, PAULINE Date of Inspection: JULY 14, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water, Check Cellar Shallow wells Estimated Depth to groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed). , NOTE: LOT HIGH NO GROUND WATER PROBLEM I revised 9/2/98 11 350 MAIN STREET TEL: (508)775-2800 WEST YARMOUTH MA 02673 (800)698-3993 FAX:(508)778-9628 Septic Service Mechanical Services Pumping & �..�.'CO Heating & Plumbing Installation Fire Sprinklers Since 1930 RE: Septic Inspection - 113 Boulder Road During inspection, we found one line from the d-box has not enough pitch. If, in time , the line is replaced, the d-box should also be replaced due to age. Once the line is removed, the d-box may be broken. Revised report due to page 2 wording and pages 7 & 8 being typed wrong. Inspection report conditionally passed 9-25-98. Met with Jerry D. of the Barnstable Board of Health 12-12-98, reviewed report, system passed. Revised report 7 14, 1999. TOWN OF BARNSTABLE LOCATION�,g.r �,1��>,� �r,1 SEWAGE # 86 —2-5—L VILLAGE lAV4J,,i j 6l a Vi 11A ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. f l y,)v,1 Ole') !a 4' SEPTIC TANK CAPACITY . 15 oo LEACHING FACILITY:(type)-7-_)-e- r_12 o i s (size) ►e�-�c� NO. OF BEDROOMS 'PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ►QJ 1 ttc— 1��O �i t DATE PERMIT ISSUED: 3 DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No ,r `� ��� .. �N O "� � o. �.. � a � - �� Q �' _� a No .� FEW.. ........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® 0,F HEALTH 1�3 '.........OF...... .._ .. Applira#inn for DispoliFal 19orkg Tnnstrnrtinn ramit Application is hereby made for a Permit to Construct ( r Repair ( ) an Individual Sewage Disposal System at: = - Location- ddress • Lot ..-•- .._.......-••------•---- 17,f-Z_ .... Q-:r- __-_-----------•-------- Ow r Address a ............................... f'^...................••..................... •--•---••------.................................................................................. W Installer Address U Type of Building Size Lot_____ Sq Dwelling—No. of Bedrooms............. ........................ Attic ( ) Garbage Grinder ( ) a Other—Type of BuildingNo. of,, ersons.....•...._...r_.___ _ Showers — ( ) -------------•-----------••- --------persons_ - - •----- -------(---->•-----,Cafeteria......---- d Other fixtures ................... -----------------•-•- ••----------------------•------------ W Design Flow...........'�:. .........................gallons per person per day. Total dail flow............................................ alIons. WSeptic Tank—Liquid capacityP�e-..�----gallons LengthkP.-.!�t _ WidthA5��-. . Diameter---------------- Depth.6.-._�_�..". x Disposal Trench—No. .................... Width.................... Total Length.................___ Total leaching area........ ___.__sq. ft. Seepage Pit No.___-•-_--i--------- Diameter... U".. Depth below inlet.... [__ `.:__ Total leaching area��4-_..sgX 6ro Z Other Distribution box DosiI tank '-' Percolation Test Results Performed by. 9�-�4 ___ JG.f `= � __! -Date...C>-- �n - 17 a Test Pit No. 1.___ _.._._minutes per inch Depth of Test Pit----1?-�'_________ Depth to ground water... _ _.- minutes per inch Depth of Test Pit._.. .....__.. Depth to ground water...........`............. (s, Test Pit No. 2_______________ _ �,+ O AL: -�`-�' 1�'�' � r�:a��c?o L 2'- �' ��;�i-I_l.�-•F--.e �p� 3� Descriptionof Soil.............................................•--------------......-...I•• ----•-----•----------------•. ..M -p--� -`�••---------.... U Nature of Repairs or Alterations—Answer when applical,................................................................................................ ----------------------------•-----------------•-•--•-----------•--------------••----------•-••_-•--•------------•--•-----••-•-•------------•••----••-•--••---•-•----•-•••--••••-••-----..._..........._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 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. _ Si ed-------•-••-•------ ....... ................................ D to Application Approved By.......... ........................... = �- Date Application Disapproved for the following reasons----------------•-------------------------------------------------------:--------•............................ - ................................................................................................................--------•---•-•-----------------•--------•------------•-•------•----••-----•-•---------- Date PermitNo......................................................... Issued-------------�a/.io.....-----....... ate 2� F a -� ........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® O� HEALTH ....................":"...---......OF...... -- '-'�� ......-----........••---............. AllpfirFatiou for Uhipaaal Workii Cnonstrurtion ramit Application is hereby made for a Permit to Construct ( -.�'Or Repair ( ) an Individual Sewage Disposal System.. at: ................................... L ...c- . = ._... ------------- --�...................... ...... ----...•...----....--------- Locationf ddress �r Lot No. ...... ------- � _ .. .. c: ?c s'�_..1 =..., ........ ...":--"% -.-..�--.------- owner Address .............................L.._-e,., ------------- ------------------------------ Installer Address 44 S^� Type of Building Size Lot.......................... . U �e't Dwelling No. of Bedrooms............................................�., g— Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures -------------------------- ----- . d ------•----•---------------------------------- W Design Flow..........�_5�!�5.......................... per person per day. Total daily flow......... . .........gallons. �.: W Septic Tank—Liquid'capacity`%C _gallons Length ?..__ ':. Width_ �...�.'. Diameter................ Depth&' x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........I.......... Diameter..'=...f.'s".. Depth below inlet.._ .:_t ... Total leaching area '_....sq/t.f I Z Other Distribution box (X) Dos' tank ( ) a Percolation Test Results Performed by__.__.et .? _._. _C�! rl �.. �:•Date.. ?!.._ .' � . M Test Pit No. 1.... :_._....minutes per inch Depth of Test Pit----1_ ._..._..... Depth to ground water... cz�U l -__. Test Pit No. 2....A'____.__.minutes per inch Depth of Test Pit....I.. `......... Depth to ground water---------:............. Descriptionof Soil.......................................................................1•-----.---------------------•-- C _I� o x ��` c 1 �� ----.....••---- s r-�t w,. �.�-1;;�V -.......................... ' .................................. W 'e {-, 3/G_-�P''"7 ;•/e�•'_l_)#��"[-?9 ..---_--`'-. _....C' ___.•'r•---1 �7T:2_!_ :._.l �,re?�L+_.✓ _._..--"'--_.__ 7t� r E\.!4,..�. �. ��- 1 U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..........................-----•---------------•-•----------------•----------------....----------...........-------------------------------•----------•-----------------------------....---•---••....-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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. sigued................. -•-----•------•--•-••-----•------------------ •------------ --•----.-•------- , / Dto Application Approved By-- ��. %'" ��''�— C�,/ Date Application Disapproved for the following reasons---------------------------------------•-•-------...--------•----------------•--------...._.................._. ...................•...............--•--...--•-----------•-•-------------------------........------....---•-••............----•-----------------...--•-----••--•-----•------•-•••--•-•--•...----•-••---- �. Permit No......................................................... Issued............�`-!� �..----au------ l�ate THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALTH ............. ,1............f ,. ="fir ....................... THIS IS TD__CERTIFY, That..the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by--------•--•-••--• L' z l -i e r� .............•-....------•----------------------•------...........-•---------------•---.....-------•---------...--•••---••---•-•-••-- C. shaller at. .5 {. 1 -��`-=`r'�` ( ....... ---------�...f......--------------••----....----------------•----------------...----------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code/as described in the application for Disposal Works Construction Permit No.___�- _J&-___-2 - dated-----(.__f _ � ................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GU4RANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �� .. .. u?,�n..... ......OF.......t:..�..........�......... C_L. FEE.._...r� .......... No. � .. .' .. 2 �i���a�aal �rk� �rra���rilan rrmi� Permission is hereby granted.......... f..: .s `.......................•-----...-•-•--------......-•---......----........---....---.•.. to Construct ( ) or Repair (_. ) an Individual_.Sewage Dispo S erm at No.......... r-�= ... C'��s: �c 6�� v,) i56� 'P �. -----------------------•-------...----------.......-----------•-••-•---••••......------......•••-----••--•--•------••-- Street as shown on the application for Disposal Works Construction Permit No._§.'.�....�_?Datteedd._ ___ ----------------- Board of Health DATE.-�•---•------��z�`--�- �.--•----•--•---------------•---- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ' D O � AN O z � ...... _ a ® \ -- tti� O rn� c-o �Q 1 Po .4 Lo N COT. >� 4� rn LA g il;� g�ojj gR z ;� ° A n= Aill z i 21 • IXIST. I R co Ir NEW ADDITION FOR: DESIGNED/DRAWN BY: NOTE: THE PIAMS SHOWN ARe THOMAS A. MOORE DESIGN CO me sore PROPERTY OF T111 DESIGNER AND CAN NOT • I BE CORED,REPRODUCED z o z N rn �� KATHLEEN RAFTERY & KEN DORMAN P.O. BOX 2124 949 ROUTE 137 BECOPIED,REPRODUCED D O I- LIT THE EXPRESS WRITTEN 9pt`l'Of THE DpSIGNER 113 BOULDER RD. BARNSTABLE, MA. BREWSTEK MA. (508) 896-6403 CON U' —i DN) O a • G� z . c� • O R M glog TO z v rn , � r- 6 Z \\ O , \ � G \\\ D \ ------------_______ ___ —I -----� --------- ------1-1 r---------, Z I I I I I I I I I I I ----------- • __� `--i r-------------------' j I I I — NEW ADDITION FOR: DESIGNED/DRAWN BY: NOTptAN5 SHOWN An D THOMAS A. MOORE DESIGN CO,THE SOLE FROPERTYOF — L rn " THE DE5IGNER AND CAN NOT t BE COPIED,REPRODUCED Z o N ' - KATHLEEN RAFTERY & KEN DORMAN P.O.-BOX 2124 949 ROUTE 137 AND/ORALTEREDW uc;ED `0 O I THE E)M55 WRITTEN = ° GONSEPtrOFTHE0E51GNER 113 BOULDER RD. BARNSTABLE, MA. BREWSTER, MA. (508) 896-6403 ;1 TEST PIT #1 TEST PIT *2 F_F - r4-o ELEV= (.� GENERAL NOTES 7, - L' ALL ELEVATIONS SHOWN ARE BASED UPON 2. PITCH ALL LINES A MINIMUM OF 1/8`I /FT UNLESS OTHERWISE SPECIFIED. 000 0 0 J o 0 f 00000 nA � �, I ra :�t+�w►"s 00 O op O 0 3. SYSTEM SHALL BE CAST �, N -� --�- 0 00 0 0 000 � ALL PIPES TO AND IN THE SYS M r- �7 Cal ---" -- - -_-- -- -- -- -�- _--� --� -- -- � �- �0 00 00 �`) �o © o 0 0 0 000 ( IRON OR SCHEDULE 40 PVC. -o i 4. ALL SEPTIC TANKS DISTRIBUTION BOXES AND T,,1. �j ,ho I 000 0 0 O O O 0 0 000 -ti LEACHING PITS SHALL BE DESIGNED FOR H-20 WHEEL 000 0 0 0 C9 0 0 000000 LOADINGS WHEN UNDER PAVING. �- ---- ----- a` 000003 � O 0 0 0 0 000 i MV�U.a� �0 " 000003 0 O 0 0 0 0 000 5. REMOVE ALL UNSUITABLE MATERIAL BENEATH THE 14" 3- _ _ � 000 �J C� O 0 6) 0 0000 INVERT ELEVATIONS OF THE LEACHING PIT FOR 4'_0" fZ: LIQUID LEVELci TYPICAL DISTRIBUTION BOX 000 G _ 8c j u 0 O 0 0 0 OOCO A DISTANCE OF 1OFT AND BACKFILL WITH CLAY- FREE SAND GRAVEL HAVING A PERCOLATION RATE NOT TD 5C.4Lt-- ( -6-0 1 OF 2 MINUTES PER INCH OR LESS. . . J /I/OTE DISTRIBUTION BOX AND 6. THE BOARD OF HEALTH MUST GAL REINFORCED SEPTIC TANK BY BE NOTIFIED WHEN THE SYSTEM IS NEAR COMPLETION OBSERVATION PIT TYPICAL f;-Y�D GAL. SEPTIC TANK ACME PRECAST OR EQUAL. TYPICAL LEACHING PIT: AND PRIOR TO BACKFILLING. 7, UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS PERCOLATION RATE= 1 NOT TO SCALE NOT TO SCALE SHALL BE INSTALLED IN ACCORDANCE WITH TITLE 3E OBSERVATIONS BY -, - _r NOTE- TANKS REINFORCED THROUGHOUT WITH OF THE STATE SANITARY CODE AND ANY LOCAL BOARD OF HEALTH ELECTRIC WELDED WIRE WITH 24-1/2" RULES WHICH MAY APPLY ENGINEER: ARROW ENGINEERING INC. EMBEDDED STEEL RODS IN TOP 8 BOT- 8 CONTRACTOR IS TO NOTIFY ENGINEER, PRIOR TO THE DATE r - TOM. CONCRETE IS 4,000 PS.i TEST. INSTALLATION OF SEPTIC SYSTEM , OF ANY DISCREP- ANCIES BETWEEN TEST PIT RESULTS AND FIELD CONDITIONS, 9. ACCESS MANHOLES TO SEPTIC TANKS AND LEACHING Y-- - PITS TO BE BUILT UP TO 12 INCHES BELOW FINISH GRADE. } - TOP OF FOUNDATION I ELEV I IN RA ;+ -- r iNiSH GRADE FINISH GRADE OVER LEACHING/ b f I FINISH GRADE i OVER ,NK OVER D BOX AREA ELEV. _ t =- ELEV= FF.FV � � Ft FV : ; I , '• y 1 I EXIST. GROUND i -- - I _ _ t so i ,� INV.- - ., a, .z..:,-. WASHED STONE I I -- _ o _ - T 1_ I I NV.= GAL 4+ I NV. INV. - ..... . DIST BOX RF INFORCED i o x 4 x 1 } k CON RETF 1 E L.LVE., E _ c._ C � f� STABLE) °° ° ° ..... .° WASHED TON �- ._.._.... ;E�PTIC TANK BOTTOM TOM OF PIT °8 ° T i (�1 ���► I BF ; E VEt H y; I NV._ ELEV = =-- - TYPICAL SEWAGE SYSTEM PROR LE PRECAST LEACHING PIT`- (TO BE LEVEL a STABLE) "I NOT TO SCALE _ LEGEND MAP SECTION PARCEL coT - ADDRESS 1JISO)( l I EXIST CONTOUR ------- ..._.___ ____ _..___ 8 �* PROPOSED CONTOUR 8� du - EXI`iT SPOT ELEVATION 8 X (; PROPOSED SPOT EL EVAT ION 8 + O .r ' •a �'. .a 6z4 - v I PERCOLATION TEST x _- "-ZONING DISTRICT FLOOD HAZARDZONE I OBSERVATION PIT i DE`�IGN CRITERIA +' r NUMBER +")F� ;jEt''RC?OMS 2, �Nof �,� PROPOSED LOCATION OF DWELLING PERSON PER BFDROOM .2. o� `�� 8� SEWAGE DISPOSAL SYSTEM ROSEW GALLONS PFP PERSON PER DAY 55__ RAYMO+rD i LEACHING RF QUIRED -44O ANo 21583 / i LEACHING P!?0VIDEO - . _ �, s DISPOSAL APPLICANT: ENGINEER I } r�4'. I > aul «�L �✓� ARROW ENGINEERING INC. I x S1--WER DESIGN _, , , �, _ 1� fzu M J 1 CAPE DRIVESUITE B S H PE E, M A 0 649 MA SIDEWALL. o RORERT BOTTOM = r)'z x. �,3�) 2 _! 3 o ICY a H SCALE DATE: SHEET TOTAL= i >ON � AS SHOWN �b,� ��, IC3 DRAWN BY CHECKED BY APPD BY PLAN NO PLAN SCALE SE.E /r,l M