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0057 COUNTRY CLUB DRIVE - Health
57 COUNTRY CLUB DRIVE,BARNS 1✓ TOWN OF BARNSTABLE LOCATION —'5�7 61Q i y;z2:l Igo 1 SEWAGE# ,=54 t VILLAGE eL&A&,+qa L� ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. 1 r: 1 SEPTIC TANK CAPACITY (YaO-4r-A-C-. W-/O LEACHING FACILITY:(type) —i (size) �X—L- NO.OF BEDROOMS � 9 All-�o 1/OWNER 1 L-Ld 4C PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �J Feet FURNISHED BY E `47 �rJfiwr��h� 1L 461 ib yam, l/vev l / zS 7 dri`ve- No. o� �' �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: +, Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliration for Disposal �&pstpm Construction permit Application for a Permit to Construct( ) Repair(e Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No.6-9 &Xjn 0 r;.Lf Owner's Name,Address,and Tel.No. vr0ff-Off - `�y`� �LYVYI ! j W24,f-A4s, �► - Assessor's Map/Parcel 3S,p 141V 159 • C Installer's Name,Address,and el. o. 5-o's /�8-99�o Designer's ame,Address,and Tel.No. 8 �� /a� frc�c,., Type of Building: J Dwelling No.of Bedrooms 3 Lot Size ° ! sq.ft. Garbage Grinder(. ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) .530 gpd Design flow provided 3 t/ gpd Plan Date el.10,0 n ,�pT{Sj Number of sheets Revision Date Title ,'�c5'i Y�/!ln-i At.Q -rl V �� Size of Septic Tank tgw0mQ 1 ) Type of S.A.S. i" &SX M,93 �a- sp�j�6t,Q P�Ngy��icA� Description of Soil S�,,,Q Nature of Repairs or Alterations(Answer when applicable) / is V,,nk Is ° Date last inspected: 2�greement: `` 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 >theEnvironment e a not to place the system in operation until a Certificate of Compliance has been issued by this Board Signed -� Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ggf L4� b( Date Issued No. :2 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes L PUBLIC HEALTH-DIVISION-- TOWN-OF BARNSTABLE, MASSACHUSETTS . ' 01pplitatiotf for Disposal 6pstrin Construction Perron Application for a Permit to Construct( )' Repair(. Upgrade( ) Abandon( ) a rcomplete System ❑Individual Components ' Location Address or Lot No.,517 �.'Gvt?�r,-i dqU ,r ivc, .Owner's Name,Address,and Tel.No. �5Zir-34-;? ✓V-o Assessor's Map/Parcel Installer's Name,Address,and el.No. j01 j Vd s=�`33Co Designer's am�e,Address,and Tel.No. S 3�0� VS-0/ /o C�vr�s�tzx�i lZi1�• �. . Type of Building: r Dwelling No.of Bedrooms 3 Lot Size ' sq.ft. Garbage Grinder( ) - Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures x ! » Design'FWW(min��.."required) 3 i 3U .r,.1/ !/-1 gpd Design flow provided 3(/2 gpd Plan Date y '(Dp yy) j� _ OI rNumber of sheets / Revision Date Title T .5- /4 Alec»/�T��, a lL� e �`/1�/rr(I.1CLtr#/� RA Size of Septic Tank I�Ugce� I4 l o Type of S.A.S. iE14 015 a4r' o -5 Q ,X Description of SoilN4� 4 y Nature of Repairs or Alterations(Answer when applicable)/ULv f-/ p /,Spp ,p�s'c yzlr box �� - aeP leao-A (_26//Wm&S / n 6, /,2. '/t> 5'L V g. au 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-eo7d d not to place the system in operation until a Certificate of ,-~ r f, Compliance has been issued by this Board of Heatft- } Signed / Date Application Approved by / G Date I-,,L r- r 5 Application Disapproved by Date . for the following reasons , Permit No. gQI L4- bf Date Issued` 5 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(.>4) Upgraded( ) Abandoned( )by ar>Lo !i& LY'15�2'�Ylo/� ire- at _ Ilk has been constructed in accordance with the provisions visions of Tit e 5 and the for Disposal System Construction Permit No.O��K^d�t✓� dated Installer n5/_41) /G 4 1"ns r/C.� /C��"�, fir!L Designer 1,2 ,/► J i #bedrooms _3. _ _ Approved design-flow � - - gpd _ The issuance of this permit shall not be construed as a guarantee that the system will nct"o as desi�ned. Date (t� Inspector No. 5` Y-Q.fL� /"" "'" Fee ( y y " THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstrm Construction Permit Permission is hereby granted tonvl) ruct( ) Repair( Upgrade( ) Abandon( ) System located at 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 Approved by MAY-29-2015 20:14 From: To:15087906304 Pa9e:1,11 FROM :down cape engineering ine 'FAX NO. :130B3629OW May. 29 2015 07:29AM P1 L E Services, T�®rears�,6:t®tax,lfDin a�:ac►r - • Jkgtpaer A;�ae SgA•,�67r4f4� Pax_ SOR••740-4304 • 1i��att�° -�, Sg�e��e�e�aa� �(�'41y ���e.�se�°'s��>E,11�etr��.350-.,�Y " s a3 iceda Pamut to inaaa a ( aye) (ins+t�.el: J st�pti�system ar Co _ I _ ,�+Wi --V'•based ma a,ciedFp&-Ayer►by _ T certify tlattiu,aa#,a s&.m.Tef''esa=cd.abme was iuAanvA 968timfifillY Rcotaflkg'ta ' tbr; de-,dig4 whieh joy iaal'udc ani_ffoz aP uV(-d,chltagG Mictz OS laterial:rOlOc tieR(Yti ire distr x NW,,sgdv,-tank. _ T �c fafy-l'hit tl-o she �y't�ts�u xef7..encecl Amu v it"L 110-ri.with uttr t[i en 10' [atexni�elnaalion fif tl,.a�IA.ti;rir�ii y vertice l_relorsti.�n oy cvn} �n?aT af,ttu:qaptiL;gstwn)but is atconl"hnoo wW Slurc&Y.oa:A ,eEdA tfrnS. PiR ,?8vigi0�. oY Cf"it C�39^ &,iguew to f l]U w. r yLt0 OF DANIELA. OJALA H . { tEtile S Is > ) CIVIL �No.4SW2. 0.cOf TfEf` r � �: �slONAt.6� • tes�ri Sao� tAf�x T7esia�eu'ti St�►��1-.ere) t ,Avl� 4�]C7R1Y :ioARAr5 t AaV .iSIz[ At.�c�ll 1D1�+14 Ulf. =' �C " �17 f&'txA CT+i �a i�t r u U-� IMS. i�T�l4'it. ii�,�'�i',liV�",�RV'Ir1� _��;I"i719��]�9'• � r�DIC�ISXCi�I'. '1�'��.1`�ll�`1t41'Yf. 7 Loom L — - Y . .. .. � ,/✓'\(\mom\Y�++�] ..-_. � r ® Photos 350/044/- Use Code: 1010 .e Sketches - Map/Block/Lot: 350!/044/ � w- _24 - Y a. R;�.�: , ,� h - CAs Built ards:Click card#to view ___ m.w_ __._ ...•_. . im �. Town of Barnstable Barnstable Regulatory Services Department A • 1ARDi8TABIE, • 1 O D Public Health Division 200 Main Street; Hyannis MA 02601 2007 Office: 508-862-4644- Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012 1010 0000 2851 4037 January 19, 2015 Mr. & Mrs. Edward P Keogh PO Box 284 Cummaquid, MA 02637 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at`57 Country Club Drive, Barnstable, MA was last inspected on 12/05/2014 by Reid C. Ellis, a certified septic inspector for the State of Massachusetts. The inspection of.your septic system showed.that the system "Failed" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: Y Backup of sewage into facility or system component due to overloaded or clogged SAS. You are ordered to repair or replace the septic system.within sixty (60) days from the date you receive this'.notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. - PER ORDER OF THE BOARD OF HEALTH as McKean, R.S. CHO Agent of the Board of Health TM/sc Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\57 Country Club Dr Barn Jan 2015.doc Y' Commonwealth of Massachusetts �. C Title 5 Official Inspection Form Subsurffs S wage Disposal System form -Not for Voluntary Assessments GM , 57 `4 V Cldb Drive P. O. Box 284 Cumma uid MA 02 7 q 63 Property Address Edward P &Carol R Keogh Owner Owner's Name information is every Cumma Uld required for eve q MA 02637 12/05/2014 page. CitylTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not REID C. ELLIS use the return Name of Inspector key. ELLIS BROTHERS CONSTRUCTION Company Name 23 ENTERPRISE ROAD Company Address J r YARMOUTH PORT MA 02675 Cityfrown State, Zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes Fails ❑ Needs Further Evaluation by the Local Approving Authority D Inspe tor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ?1° '`'_ da L, :' ° t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Cuntry Club Drive, P. O. Box 284 Cummaguid MA 02637 Property Address Edward P &Carol R Keogh Owner Owners Name information isequired or every Cumma uid MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: V A/A t 13) System Conditionally Passes: ❑ One or more system components as describeJ in the"Conditional Pass"section need to be replaced or repaired. The system, upon comp etion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" , 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 exfiltrat on or tank failure is imminent. System will pass inspection if the existing tank is replaced with a ccnplying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is str icturally 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 belo ): t5ins•3/13 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 57 Cuntry Club Drive, P. O. Box 284, Cummaquid, MA 02637 Property Address Edward P &Carol R Keogh Owner Owner's Name information is q required for every Cumma uid MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): //4-2- F] Observation of sewage backup or break oul or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a t roken, settled or uneven distribution box. System will pass inspection if(with approval of Board ol 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 imes a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluat on by the Board of Health in order to determine if the system is failing to protect public health, c,afety or the environment. 1. System will pass unless Board of Healt i determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioi ang 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 bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � M 57 Cuntry Club Drive, P. O. Box 284 Cummaquid MA 02637 Property Address Edward P &Carol R Keogh Owner Owners Name information is Cumma Uld required for every q MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Boar ofalth and Public Water( Supplier, if any) determines that the system is functi ning 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 tr butary to a surface water supply. ❑ The system has a septic tank and AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and AS 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 ana ysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the F resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no othE r failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the round or surface waters ❑ � 9 due to an overloaded or clogged SAS or ce sspool esspool ❑ ❑ 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/day flow t5ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 57 Cuntry Club Drive, P. O. Box 284, Cummaquid, MA 02637 Property Address Edward P & Carol R Keogh Owner Owner's Name information is Cumma uid required for every 4 MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ IV Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ L7 An y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ / The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the and of Health to determine what will be necessary to correct the failur . E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"o "no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a niti ogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped one II of a public water supply well If you have answered "yes"to any question in Sect on E the system is considered a significant threat, or answered"yes" in Section D above the large sy,tem has failed. The owner or operator of any large system considered a significant threat under Secti n E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The ystem owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 57 Cuntry Club Drive P. O. Box 284 Cummaquid MA 02637 Property Address Edward P&Carol R Keogh Owner Owners Name information is required for every Cummaquid MA 02637 12/05/2014 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No / ❑ Pumping information was provided by the owner, occupant, or Board of Health V❑ 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) V, ❑ Was the facility or dwelling inspected for signs of sewage back up? 7� ❑ Was the site inspected for signs of break out? ii✓ ❑ Were all system components,-excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: _ Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments wM 57 Cuntry Club Drive, P. O. Box 284 Cummaquid MA 02637 Property Address Edward P &Carol R Keogh Owner Owner's Name information is required for every Cummaquid MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yeso information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes L1 No Water meter readings, if available(last 2 years usage(gpd)): Detail: n Sump pump? ❑ Yes No Last date of occupancy: ` t Commercial/Industrial Flow Conditions: Z v-lAt Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Tit le 5 Official Inspection Form:Subsurface P Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Cuntry Club Drive, P. O. Box 284 Cummaquid MA 02637 Property Address Edward P &Carol R Keogh Owner Owner's Name information is required for every Cummaquid MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, dii&Wl; bex, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Cuntry Club Drive, P. O. Box 284, Cummaquid MA 02637 Property Address Edward P &Carol R Keogh Owner Owner's Name information is required for every Cummaquid MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, dat installed (if nown)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes , No Building Sewer(locate on site plan): ���_ Depth below grade: feet Material of construction: ❑ cast iron W40 PVC El other(explain): Distance from private water supply well or suction line: I , 77 feet Comments(on condition of joints, venting, evidence of leakage, etc.): —77 Y� Septic Tank(locate on site plan): Ile- s- Depth below grade: feet Material of construction: L1 concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) f/ If tank is metal list a e: years Is age confirmed y a Certificate of Compf/nce?(attach a copy of ce Ificate) ❑ V s ►❑ No Dimensions: 19 -Ilk Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 4, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 57 Cuntry Club Drive P. O. Box 284 Cummaquid, MA 02637 Property Address Edward P&Carol R Keogh Owner Owners Name If information is Cumma uid required for every q MA 02637 12/05/2014 a page. CitylTown State Zip Code Date of Inspection 'w D. System Information (cont.) 14 Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 4 Scum thickness Distance from top of scum to top of outlet tee or baffle C2 Distance from bottom of scum to bottom of outlet t et tee or baffle How were dimensions determined? �-°`� � � Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structur integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ydt, e— A Z,i S�' G, X7 Grease Trap (locate on site plan): Depth below grade: feet Material of construction.- El 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 ou let tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Cuntry Club Drive, P. O. Box 284, Cummaquid, MA 02637 Property Address Edward P &Carol R Keogh Owner owner's Name information is required for eve Cumma uid MA 02637 every q 12/05/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as rela ted 9 Y, q to outlet invert evidence of leaks e 9 , etc.).* Af Tight or Holding Tank(tank must be pump d at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day. Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switc ies, etc.): *Attach copy of current pumping contract(re uired). Is copy attached? ❑ Yes ❑ No i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'wM 57 Cuntry Club Drive P. O. Box 284 Cummaquid MA 02637 Property Address Edward P&Carol R Keogh Owner Owners Name information is required for every Cummaquid MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): / Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chambe , condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Cuntry Club Drive, P. O. Box 284 Cummaquid MA 02637 Property Address Edward P&Carol R Keogh Owner Owners Name information is required for every Cummaquid MA 02637 12/05/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: fit _ ' " /L? A leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions.- El overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of r vegetation, etc.): - K JaC� /ls -I/ fi� l� ' OV4 . � Cesspools (cesspool must be pumped a - ar of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 57 Cuntry Club Drive P. O. Box 284 Cummaquid MA 02637 Property Address Edward P &Carol R Keogh Owner Owner's Name information is required for every Cummaquid MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): /v Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hyd aulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 57 Cuntry Club Drive, P. O. Box 284 Cummaquid MA 02637 Property Address Edward P &Carol R Keogh Owner Owner's Name information is required for every Cummaquid MA 02637 12/05/2014 page. Cityrrown State Zip Code Date of Inspection 4.,j D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate ;rhand-sketch public water supply enters the building. Check one of the boxes below: in the area below ❑ drawing attached separately d � 6: a 9 u Vb r 'z � � e�v?m elva Idoo, !Sins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal system-Page 15 of 17 Commonwealth &Massachusetts u Title 5 Official Inspection Form A Subsurface SeWage Disposal System Form-Not for Voluntary Assessments 57 Cuntry Club Drive P. 0. Box 284 Cummaquid MA 02637 Property Address Edward P &Carol R Keogh Owner Owner's Name information is required for every Cummaquid MA 02637 12/05/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope �&-,6,e- Z, ❑ Surface water , ❑ Check cellar �� �0°`1— Tg, r ❑ Shallow wells �'✓ Estimated depth to high 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: 141 2- V,7 Yo must describe how you established the high ground water elevation: l1 �`� s lJ� ti Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 57 Cuntry Club Drive P. O. Box 284 Cummaquid MA 02637 Property Address Edward P &Carol R Keogh Owner Owners Name information is required for every Cummaquid MA 02637 12/05/2014 page. Cityrrown State Zip Code Date of Inspection E. Re ort Completeness Checklist Re Summary: A, B, C, D, or E checked pection Summary D(System Failure Criteria Applicable to All Systems)completed ystem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file N t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Departiment of egWatoAy.Servaces Public Healih,DuvdSzon Date fin h1 200 Main Street,Hyanals MA 02601 Date Scheduled Tiime+,T ]FeeFd, ' Soil Suitability Assess ent fog Sewage Disposal Performed-By: pah` ` 6On;a `y e Witnessed By: Location Address , Owner's Name &unqr-\1 Cab �r,cle- ` Address [�1�-ins v�nGL�1r11�1 � Assessor's Map/parcel: 36,,, J L/ Engineer's Name c)o wn (ape— NEW CONSTRUCTION REPAIR / Telephone# Land Use: La `Np-? Slopes(%) V- S// Surface 5tonas ILI Distances from: Open WaterEody 140� ft Possible WetArca�l � A Drinking water Well Dral'nage Way / ft Property Line ft Other ft SICEi'TCH-1(Street name,dimensions of lot,exact locations of test holes&pert tests,'locate wetlands in pznxhnity to holes) IV ,T3 V G��c�ai -�,` �l �z�G • Parent material(geologic) Depth to Badmak Depth-to0roundwatcr: StandingWaterinHole:_�"/1 '. Weeping from pltFnea' Estimated Seasonal glgh groundwater /"� ,Method Used: w - Depth Observed standing in obs.hole: lug ;Dvptta:to,,s.Q11:Ra?ttluttt. ltt. Dopth to weeping from side of obs,hole: In, arouudwatorAdjusttiii nt in Index Well ltcading DAkc: lndox Wc117pYa[ _ Add.t t tdr, .�., r A ,proupdwater Laval PERCOLATION TEST Dale— Time Observation Pe? C: Ir e5(417�� - ro' lqb� Hole# Tlmv,at 91, ... ...,_ Depth of Penn. ` Time At 6" Start Pre-soak Time @ TI=(9"-0) Rud Prc-soalc ` Rate Mindlucll !/��i Site Sultability Asaessmcot. Sito vAssed 5itq Failed: Additional Testing'Needcd(:X7N) N original: Public Health Division Observation Holy Data To Bo Completed on B ack---�----- ***If paxool2doi a testis to be coaadiacted witbl a 100' of wetland,you must-first-Aotlfy the. Barnstable Conse)pvatio)l Division at least one(1)week prior to beginning. Q:1SMTlC F-RCFOR.M'.DOC _ _ tl DREG'.oBgM!()-.XU,0PA6Uq LOB Depth from Sail Horizon Soil:Texture ShclColor Soil.. Ofhcr Surface(in.) , (U§bA) (MunselI) Mottling ,(Structure,Stones;Boulders, an i`tan�y.96'Gravcl) (DY�3l� 10 2y-IBC cl log—lq 2 5 y 7lA Depth from Soil Horizon 'Soil Texture Soil Color Soil Other Surface,(in.) (USDA) (Monsell) Mottling (Structure,Stones,Boulders. Consistency.'Yo 0mve 5;L 2,1 y wiz I -Iqz Z 2.-\i 7G(a Depth*on7 Soilnwizon Sail Texture Soil Color Soil Other* Surface(in.) (USDA) (Munsell) Mottling (Struotuxa,Stoncs,Boulders. Co i to c Gravel) Depth from Soil Hodzon Soil Texture Soil Color gall tither Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Ca si ten b y t ' Flood lnm-AftC��� Above 500-year fiaad boundary No Yes 'witliln500 year houndnry No, 'Yes ' - - Within 100 year flood boundary`IVoV- Yts- Doptla of n.turaRy.Occurrink-Pervious LY1atar%aY Does at least four feet of naturally occurringpelwious tne.terixl exist in all areas observed throughout the area proposed for the soil bsoiptibn system? y� If not,what is the depth of•ilaturally occurring pervious matoriall Cei-dficatioln I certify that on l 2- (date)I have passed the soil evaluator e=Tnination approved by the Department of Environmental Protection and that the above analysis Was performedby me consistent with . 'the required.tralning,expertise and experience described in�10 CVM 15.017. Date Signature • Q:ts.�lyrlc�r�lz.cnanM.nac • e SUBSURFACE �SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of propertyy� owner's name �--z5�&.�r� h�?��.>, �► � - ' Date of Inspection a , PART A CHECKLIST ,r-� •(/ �^ g Chec if the following havei been -done: • � .ate Pumping information was requested of the owner, ant, ,andB�oard c 1 Health. -None of the system components'=have been pumped for at least two week: and the system' has been Ireceiving normal flow rates during that period. Large volumes of .water have not been introduced into the system recently or as part ofthis inspection. V/ As built plans have _been obta fined and `examined. Note}i they' are no available: with N/A. Ll The facility or dwelling ^ i was : ns pec ted for signs of sewage back-up. .� The site was inspected for signs of breakout. Ll All system. components,; excluding the SraAs, have been located on the �.. site. The septic tank manholes were uncovered o erred and the 'interior P , of the septic tank was inspected for condition of baffles -'or tees, material of construction, dim nsions, depth of liquid, depth of sludge, depth of scum. L The size and location of the,. SAS on the site—has been determined bas on existing information or ap:px;o;ximated by non-intrusive methods. The facility owner (and �ccupa,.' , if different fro owner) were provided with information on the proper maintenance of SSDS. A WA f - W WA - k a,...) VET -A L ` p A vA ILIA, .- copy *'.n> r � .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 'FORK ' J PART B , SYSTEM INFORMATION �► , FLOW CONDITIONS If resident.ialr., r ..-L4z numbers of f�be ` drooms = number of!_current residents -.�l. garbage grinder, yes or nog � 1'aundry connected to systemlv �-vos or no seasonal use, yes or no If nonresidential , calculated flo''W: Water meter readings, if availabl : q2- Last date of Occupancy r GENERAL INFORMATION Pumping records and source of information: System pumped as part of insIpection, yes or no if yes, volume pumped Reason for pumping• TYP Of system r Septic tank/distribution box/;,oil abs&-ption system Single cesspool , Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all com onents'. Dateinformation: i1- .alled, if known. Source of -------------- Sewage odors detected when arr ;_v_ ng at: the sit e, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:. (locate on. site plan) ' depth below grade: material of construction: concrete �m etal FRP other(explair all , dimensions:_ LCV �( N p sludge depth ° distance from top of sludge to bottomipf outlet tee or ��baffle ' scum thickness _ distance from top of scum toltop of outlet tee or baffle _ distance from bottom of scum t-.o bottom..of outlet tee o ' baffle 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 leaka a recommendations for repairs, etc. ) It DISTRIBUTION BOX: <' (locate on site pi n) depth of liquid level� .1above outlet invert Comments: , .(note if level and distribution is ; qual , evidence of solids carryover, evidence of leakage into or out of ;;box, recommendation for repairs, etc. ) f • t• PUMP CHAMBER: (locate on sit p an) { i -pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances recommendations for maintenance orj airs etc , — SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFO TION continued I% SOIL ABSORPTION SYSTEM (SAS) : (locate on:site plan, if possible ; excavation not .required, but may be approximated by non-intrusive methods) I'f ,not determined '.to be ;present , ex;_.,la in c51 Type: leaching pits and number f uz� L�Am_ leaching chambers and number leaching galleries and number leaching trenches, number, length _ leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of 'hydrau is failure, level of ponding, condi►t'on o vegetation , c mmendations for maintenance or repairs,etc. ) A)SCESSPOOLS (locate on site plan) : number and configuration depth-top of liquid to inlet inver.,t 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 hydrauli?c: failure, level of, .ponding, condition of vegetation , recommendations for maintenance or repairs, etc. PRIVY: (locate on site plan) materials of construction dimensions depth of solids -- Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determin'e;d (Y, N, or 'ND) . Describe basis of ,:. determination in all instances. Shf "not determined" , explain why not) Backup .of sewage into facility? Discharge or po'ridin'g' of, e f fluent to the sur surface waters? face of the ground or Static liquid level in. the distribution box above outlet invert? 4Liquid depth in cesspoo]. inv flow? ert or available volume< 1/2 d. J, Required q pumping 4 times or snore in the last year? number of times pumped --- , Septic tank is metal? cracked+? structurally unsound? substantial infiltration? substantial exf"M tration? tank failure imminent? Is any portion of the SAS , c'�sspool or." privy: -AL below the high ' g groundwater elevation? within 50 feet of a surface water? , Az� within . 100 feet of a surf ace water supply or tributary to a surface water supply? /V/ t within a Zone I of a public ? . within 50 feet of a border ' nd` ��e vegetated g d wetland or salt marsh and privies onl y, ,n_,ot the SAS) ? ithin 50 feet of a private water supplly well? less : than 100 feet but greater than 50 ,1.feet from a private water supply well with no acceptable water. gtiality analysis? If the well has been analyzed to be acceptable, attach co for coliform bacteria volatile copy of well water analysi organic compounds, ammonia nitrogen and nitrate nitrogen . 5 i 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL .SYSTEM: include ties to at least two penmanent references landmarks or benchmarks ocat:e, all `wells within. 100 ' �5A ` Via F DEPTH TO GROUNDWATER depth to groundwater method of determination or approxIr �, t on: 4ip1 P to�.�.r�e .n�a �T2sflie a�cnac 1, f we, P , SUBSURFACE SEWAGE DI.81NOSAL SYSTEM INSPECTION FORM PART D CERTIFICATIb'k f Name of Inspector ` /� Company Name Company Address A / Certification Statement t I certify that I have personally tr)spected' the `sewage disposal system at this .address and that the informat'i.on reported is true, accurate and complete as of the time of inspect`i,(-.,n. The inspection was performed and any recommendations regarding upgr�);de , maintenance and repair are consis ent with my training and ex:� rience .in the proper function and manit Hance of on-site sewage disposal systJerns. C Vek one: I have not found any information which; indicates that the system fai_ to adequately protect public -;ea-;-th or the environment .as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are .as stated in the FAILURE CRITERIA .section ,of this -form. I have determined that the system fail :, to protect public health and the environment as defined in _21.0 CMR 15.303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature Date original to system owner . Copies to: ff Buyer (if applicable) k Approving authority . E . TOWN OF B STABLE o LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP&LOTIJ 3� INSTALLER'S NAME&PHONE N/Oy.!i"I 5,hm aeat SEPTIC TANK CAPACITY .LEACHING FACILITY: (type) lay (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Z Feet Private Water Supply Well and Leaching Facility (If any wells exist • on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) •--� Feet Furnished by--M;5 Ida ' 00 f,.OP , 27� froKt 37 S� 1 TOWN OF BARNSTABLE LOCATION 2( C&nkt� Club Or SEWAGE # O J' Z�12 VII L,AGE��d^M!491 a ASSESSOR'S MAP&LOT `50 nN q, INSTALLER'S NAME&PHONE NO. I►� SEPTIC TANK CAPACITY y)®0 LEACHING FACILITY: (type) k_-I (size) t'2 T X 0 / NO.OF BEDROOMS BUILDER OR OWNER (_ PERMITDATE: =10 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility Feet Furnished by . i+ors PA-N /%*— ' r y r OO � Z FE$.._........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w/ ...............:............................OF..............................-..---.......---------._...---....I.._..................__. Appliration for Uhgpoiia1 Works Tomitxnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at -• - _. .. = ........................ _.....___---•--------.-•._...______-----.•------••----•-•••.._.............................__ . aattio -Ad s �j or Lot No. .. tttttt.//..SA.Be�._. c .._.._.6.. ._ dl_r�_-_- - ner Address .......-- ••-•-•--- Installer Address Type of Building Size Lot______.......... _...._S , U Dwelling—No. of Bedrooms____._...______......................Expansion Attic ( ) Garbage Grind a Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria !� Q' Terixtures .---•----•-----------•----------------- -Design Flow__ __ -.....________________________gallons per person per day. Total daily flow....`3_3_ ........................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....:................ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. _ Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_--___--_.________-__._. Test Pit No. 2................minutes per i Depth of Test Pit.................... Depth to ground r.. .................... a 0 Description of Soil....... -- .... ......... ........................:. ......... .... -/--'-p-`` U ----------------------------- ---- -- - -- ------- - ------- ---- ------- - W -=---=--------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--••-•---...._.....---- UNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------•----------------------------------=------------------------•----•-----•-------------------------•----------............................................................... Agreement: The undersigned Pagrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary C de—The undersigned further agrees not to place the system in operation until a Certificate of lollowing as bee issued by the board of h th. 44� .. •€ 1 �.. .. ......................---------- �� Date Application Approved BY '----------------------•----------..._........._-------_.. DDateApplication Disapproved fo theasons----------------------------••-------------------------------------------------------------------------------•--- ..............................................-------•-•-----•-----•-•-------------•-•---••-•----------•---------------•--•-----•------•--•-•----------•••---------------•-•--•----•-------••---------- Date PermitNo......................................................... Issued....................................................... t Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... �rr�ifirtt�.e laf f��ant�li�nrr T I CERTIFY, That the Individual Sewage D' osal System constructed ( or Repaired ( ) by ...." ------ ------ -------- ........ ... .. ....... ---- ----.................-------------------•...._._.._ nstal at.•� .......�._ -- - --- ---- ------------ has been installed in accordance with e provisions of T 5 f State Sanitary Coe s d cr ed in the application for Disposal Works C, ruction Permit No.- ►•---�-- -----•----------- dated---- ----- --- ---•............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................................................................... Inspector........................................................:............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (�2. ...........................................OF..................................................................................... �a No FEE. Permissionis ereby granted_.. --..................... ---•-- . _-• ------. -----•----•......................................................... to Constru or Ream ( ) a 1 is al at No �� - ------------ Street as shown on the application for Disposal Wo onstruction Permit No..................... d •---------------------------------•---- ... •-•• ----------------------..__...... B r Health DATE............................................. :................................. - FORK 1255 HOBBS & WARREN.,,INC., PUBLISHERS f i Fizz........... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ...................._OF......................1.11................ Appliraffou for Uh4paiial Works Toustrurtiou "amit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal syst at o7z cam . .. ...... ..... . ............ ...... .............. ........................................................... ...... ...... ftti d or Lot No. ..... .... ......... ................................................................................................... 0 er Address 1`1 1.4 ............. ................................................................ ...... ...... Installer Address U Type of Building Size —........... e 3 S Dwelling—No. of Bedrooms......_Ila........:......................Expansion Attic Garbage Grin_�e Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Other.-fixtures ......................... .......................................................................... Design Flow.....'.7_?.fQ.......................gallons per person per day. Total daily flow...... W - - -.._-gallons. 1:4 Septic Tank—Liquid*capacity.............gallon's Length................ Width._............__ Diameter---------------- Depth:__.._.......... Disposal Trench—No..................... Width.................... Total Length.__................. Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box Dosing tank Percolation Test Results Performed by........................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit....._....__........ Depth to ground water.___........_......._._. 44 Test Pit No. 2................minutes per in Depth of Test Pit.................... Depth to ground .. . ................... __. 1 ' 7/ ............ ------- ........ ...... ...................................P4 ..... ............. .. ............... ..................... ......... ........ .. .... 0 Description of Soil......_. ....... .... ......... ............ .......... ......... ...... . ...... .... ............. ...... .......... ..... .. .......... . . ................ ...... ... ...................... .................................... ............. ------ ..................... _. .- -1. .. U W ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable....___......................................................................................... ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT!Z- 5 of the State Sanitary Co e—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as bee i sued by the boar of 115AUh. e ...... ...... ----------------------*........ ----------------------*----Date ---- ApplicationApproved By.......... .................................................................. ........................................ Dite Application Disapproved for he ollowing reasons:........................................................................................................------ ........................................................................................................................................................................................................ Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...................................................................................... Tntifiratr of Toutpliatta TH I,V� � CERTIFY, That the Individual Sewage D* osa System I S tem constructed �®rRepaired by t ....... ..................................................... ............................... .. ... . ..... a 11 ey .... .. .......—A- ...�5 vt ...Z�4 .............................................. -------------- has been installed in accordance with provisions of TI he State Sanitary Co ril,-d in the application for Disposal Works C dated__..._...' . ..... uct 9 ion Permit No.__ .... .............. ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0 ........................................ OF..................................................................................... NO.O.d. .. FEE../O...................... Permissionis eby granted..-. ... ........................ --- -------------------------------------------------------------------- to Constr c r Repair, e s at No ... ......... .......... .............. ...... ....... eo�44 ------ ....... ................ .................7.................................. Street "Vz as shown on the application for Disposal Wo onstruction Permit No..................... jr,_7 .7--------- ........................ ................................................. ... ................................................ B Health DATE............................................................................""', FORM 1255 HOBBS & WARREN. INC., PUBLISHERS APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION t,OT 2-b Cc�uNZ!� ('L + r� �►� _��F►2.,vs � c F NO. n/339 V �VILLAGE. AOZN5-r 4r4 ,L DATE_g1�/� APPLICANT ':Ru.5.S j- • G r a� c) FEE a,f ADDRESS P,O, "I'X 9� �uYnsikblr Wi rt TELEPHONE NO. ��,�-3 06 1(Non-refundable) •ENGINEER_ ��,� ra-pt �F.'sg.14S4 R r NG _TELEPHONE NO.� G:)_ 45,4/ DATE SCHEDULED �� /y9 Z. (Applicant's signature) . . • • • • • • o 0 0 0 0 o • o •o o o 0 0 • • e • . . . o o o • o • • • . . . . • e • • • • • • • e • • • • o • • • • • • • • • •o • • • • • o • • o • • • • • • SOIL LOG •SUB-DIVISION NAME �►tb,�wiu,^,�Weih' S DATE APT 9 9Ts2 TIME � '?z c7 EXPANSION AREA: YES1,,"N0 �,, _ _ � /� P� ENGINEER. : . .TOWN WATERZPRIVATE WELL G rr�Q2� BOARD OF HEALTH EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: t N c - . LoT �!p C ri PERCOLATION RATE: TEST HOLE NO: a ELEVATION: TEST HOLE NO: ELEVATION: 2 .3 3 4 Cam / 4 5 .5 7 7 C r, 8 8 C-o.6 P', 9 9.' `°10 10 5 d►.,l . 12 �, c� � 12 / 13 13 i4, 14 14 15 15 U=f 16 70-z- 16 -SUITABLE FOR SUB-SURFACE SEWAGE : LEACHING FIELD EACHING PITS LEACHING TRENCHES UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS ; NOTE : ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON P TEST APPLICATION ORIGINAL: COMPLETED IN ENTIRETY BY P . E . AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT .SFrTtnty _ ar_� —SEPTIC TANK — _ „D"BOX — — LEACH TOP QF FON �)Z.I+-4 4 ocA," - GG3v+2a e_—a -rc.> W rr"I A.T "2"OF 1/aTO 42" ' ( '4° U1~ Ffwal .ea Ga�.e4AC, . \ASHEOSTONE IN OUT IN- OUT IN- SEPTIC r // T - ELEV. TANK ?S rJL i�.-IZ./ G+ ELEV. ELEV. ELE' N raS•1Q -- 2.S / / S�•.q� t 54 ff ELEV. ELEV. M.' 9_ 0 p 11=V. Zfr�OF th" JV2.. WASHED STONE PLAJ" VtFw Q / r d� / �� 0 �V — >~ErncavE, n�,Y ue'jrau,-rx>P,L GP I c_Qu n I T Ei Grp w,rc•,t u to �'i. c31=- / — 'N'pt .:._ _L..- •� 1 �; ,r� TEST HOLE LOG i` - 1 119 (- �.�.tfZ3Ar-! 7 i3 .+..l " i+F c7�t.7 FiJIE'\/• a d ! M•9.1-. G3Cf �:�11L� a1r` / ! / per ' T .TEST BY K-tt �., .r3R�.t2.w4: �.sTa. c�'>~"t-Y[w�t�•+.�-� E>r.�r._,D! wrn-:,n.a Y3 1~t,i-6�t• rafr'wc.u�:�. 1 "� / ,y �'�,,.';_/'" ,• ! / �,/ TEST DATE 1/9 (�2 WITNESS DESIGN BEDROOM HOUSE IA,Z i T.H. as 1 �). T.H. # 2 Cd,1 ZC->' CDC> AL ELEV. CJC?' ELEV. �T"4.'tit �1 �. mat LC3Fsty N O t�+cp i � ,`` � C••I.s' ri• 'L PERC RATE �^®`�" MIN/IN. DISPOSER I DISPOSER `,_ ! / ' �, t i Ell ct `a I -- FLOW RATE 3�(GHL./DAY ) '7.�'3c; I +� � . CIl�Y SEPTIC TANK 3?t� x (1.�s►= _ 4Ci_— i , (} s + v+ REQ'D SEPTIC TANK SIZE LEACH FACILITY rSIDE � BOTTOM LL�.S.c Iota)+I"aC ;tx(21 e Z-1'? G/D. /a:)•=�+•(3 Ie\_r c, r� TOTAL z.__S C�. 5 6/t> USE. ._ _._ _. ________ ___..___..�._ LEACHING —)� N 1 p FCrT� 1G>wi, x tZ_ C. x Z•a �>CLr���vGc�vJ �,� T "t`Cci1J. �� ��-I ►�j r WATER ENCOUNTERED -- --- ----_-- _- - R ...".... NOTES: (UNLESS OTHERWISE NOTED) ! E "kj 1. DATUM (MSL) + TAKEN FROM----- _•------•-•---- t��f 1 `? QUADRANGLE MAP 2.MUNICIPAL WATER------_.. +� ------•_----AVAILABLE 3.PIPE PITCH: IW'PER FOOT 4. DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO -_- F(�IG7 -..44 5. MIN. GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. -Q----DISTANCE AS CERTIFIED 6.PIPE JOINTS SHALL BE MADE WATER TIGHT �' - ,�= eta 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS.STATE ENVIRONMENTAL CODE TITLE 5 �l� ^�� 1 HEREBY CERTIFY THAT THE BUILDING SITE PLAN O� ARN16 �G ARNE !i HOWN ON THIS PLAN IS LOCATED ON THE H. ALA OUND AS SHOWN HEREON & THAT IT Locus � �� L �I r+ �n,�ta, c .lf_ IS ^tz� f aii ) NFORM TO THE ZONING BY LAWS OF THE ���J�I a��C {���M��u4�- ��15'1'1✓'1.2G:(-tr,�r..► Tm 1It'>= c.t.e�r,�tc.�.—lo.-+ `!ti1n.-r 'nay < qy2 , WN OF ___ 'Lict, FtnNT tb¢� �aaT"sF-A�'rt�et�YR.�c�D �g REG. PR F E HEN CONSTRUCTED. DATE _�T E Cs O ti -n.►E. m_Ati► , 'e f, fCISTER��QQ C1 TV. ' wI Is REF: ---�1-A►.,f_r3lJ©1G 2'j_ 1�s�w. t '1 tdown Cape eftogIi(eer1#60 PREPARED FOR: CIVIL ENGINEERS LAND SURVEYORS CONTOURS (EXISTING) ------------- BOARD OF HEALTH J REG. LAND SURVEYOR (PROPOSED)-O-O-O-O- APPROVED DATE SI-A.3LZ MA / Yarmouth& Orleans,MA SCALE _ Q _Ct 9 7. DATE -1 C� SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES MARKED WITH MAGNETIC TAPE OR (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS ASSUMED o � 6q ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE 2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING Rile- ACCESS \ TOP FOUND. EL. 44.4' FILTER FABRIC OVER STONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. � 41.5' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 41.5' Sand i e�C PRECAST H-10 BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST NOTE: MIN. WALL THICKNESS 2" RISERS (TYP.) PRECAST RISERS UNITS TO BE AASHO H-LQ 2'e 4"0SCH40 PVC MORTAR AL Locu ) j �, PIPES LEVEL 1ST 2' �4, COMPONENTS INVERT IN 37.6T 4' 5. PIPE JOINTS TO BE MADE WATERTIGHT. o � ~ ENDS ° " 39.01'* 10" 1500 GAL H-10 14" I.o.. . .. SIDES 38.5 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE `' Dennis ' TEE SEPTIC TANK TEE \3 , 1�"'*'o' ° ° 38.26 8.01 ® ` ®® ®®® ®®®®- n ®®® ° ° ° WITH 310 CMR 15.000 (TITLE 5.) Pond c ` o,o,o°000° 6" MIN. SUMP p RRER� ERR ® °°°000 c GAS BAFFLE:. ' o�o°°�°° 12" MIN. INT. DIM. 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 0000000 ,4' LIQ. LEVEL (ACME OR EQUAL) ` 37.94 37.77 :°g°g°g°o 35.67 NOT TO BE USED FOR LOT LINE STAKING OR ANY •-•-•-._._. ------------- OTHER PURPOSE. >r• .......:•:.:.,.; - • .:.....•: -... WATERTEST D BOX " o°o°o°o°o°o°o °o°o°o°g°g°g°g °o FOR LEVELNESS °°°"°���°���'�'°°°°°°°°°°°������"�"S'�°°°° 3 4"-1-1 2" DOUBLE WASHED STONE 4' MIN. H-20 500 GAL. LEACHING CHAMBERS BY ACME PRECAST OR EQUAL 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PV Q 6" CRUSHED STONE OR MECHANICAL ALL AROUND PRECAST STRUCTURES (2) UNITS REQUIRED C- COMPACTION. (15.221 (21) OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' 9. COMPONENTS NOT TO BE BACKFILLED OR Q (2.5% SLOPE) ( 1 % SLOPE) 1 % SLOPE M CONCEALED WITHOUT INSPECTION BY BOARD OF m xit 7 MIN. ( ) 00 HEALTH AND PERMISSION OBTAINED FROM BOARD Route 6 FOUNDATION- 30' SEPTIC TANK 7' D' B LEACHING OF HEALTH. OX 12' FACILITY lA ELEV. 27.3' BOTTOM TH-1A 10. CONTRACTOR SHALL BE RESPONSIBLE FOR 4 2A ELEV. NO GROUNDWATER FOUND CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP 0" 41.3 p" 41.7 VERIFYING THE LOCATION OF ALL UNDERGROUND & TESTHOLE LOGS OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF �7 fl WORK. NOT TO SCALE R. FAIRBANK, P.E. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL 11. ANY UNSUITABLE MATERIAL ENCOUNTERED LOAM LOAM ENGINEER: UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS SHALL BE REMOVED 5' BENEATH AND AROUND THE ASSESSORS MAP 350' PARCEL 44 PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM PROPOSED LEACHING FACILITY. 18" 6" WITNESS: R.A. GIFFORD NOTE: INVERT OUT OF HOUSE TO BE RE-ROUTED & RAISED, VARIANCES REQUESTED: DATE: 9/9/82 INSTALLER TO CONFIRM FEASIBILITY PRIOR TO INSTALLING ANY 12. EXISTING LEACHING FACILITY SHALL BE PUMPED UNDER MAX. FEASIBLE COMPLIANCE 15.405: PORTION OF SEPTIC SYSTEM AND REMOVED OR PUMPED AND FILLED WITH CLEAN (1b): REDUCTION IN SETBACK TO CLAY CLAY SAND. FOUNDATION (20' TO 15') 114" 31.8' 66" 36.2' NOTE: PERC AT TIME OF INSTALL 5' REMOVAL OF UNSUITABLE SOIL REQUIRED REQUIRED. INSTALLER TO COORDINATE AROUND PERIMETER OF LEACHING FACILITY, TIMING WITH ENGINEER AND BOARD OF DOWN TO SUITABLE SOIL LAYER. REPLACE BENCHMARK NTH CLEAN MED. SAND, TO MEET HEALTH. 24 HOUR NOTICE REQUIRED. \ \ COR BULKHEAD SPECIFICATIONS OF 310 CMR 15.255(3) SYSTEM TO BE INSTALLED IN OLD 40 EL. = 42.35' RESERVE AREA. PROVIDE 40' OF 40 MIL LINER AT 5' 165.00, OFF SAS IN AREA SHOWN. TOP AT CLEAN, FINE CLEAN, COARSE 4 ELEV. 38.5', BOTTOM AT EL. 34.5't SYSTEM DESIGN. AND MEDIUM AND MEDIUM $ SAND SAND R2 TH1 40 GARBAGE DISPOSER IS NOT ALLOWED PUMP AND REMOVE SEPTIC TANK C. b _ EXISTING 3 BEDROOM DWELLING A� - / DESIGN FLOM!• 3 RFDRC)OVS Ca 110 GPD - 330 CPD " 27.3 162„ o 2 �o' 168 2A 2' 1 30 4 USE A 330 GPD DESIGN FLOW 28. N i 21.91 NO GROUNDWATER ENCOUNTERED / � / �` NOTE: INVERT TO BE A ! / SEPTIC TANK: 330 GPD (2) = 660 TEST HOLE LOGS RAISED TO EL 39.01 'S o �� / " USE A 1500 GAL. SEPTIC TANK DANIEL E. GONSALVES, SE 13587 o ! / 24 ENGINEER: # DECK � � � 42 SWEETGUM LEACHING: WITNESS: / DONNA MIORANDI, RS/ EXISTING DWELLING r W SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD , 12 19 14 I TOP OF FNDN ��' BOTTOM 25 x 12.83 (.74) = 237 GPD DATE: x <Y 7Ff1{R PERC. RATE _ z j / TOTAL: 472 S.F. 349 GPD O ' / CLASS I SOILS P# 14.601 \ C / USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) FAILED ELEV. ELEV. A� �� / WITH 4' STONE ALL AROUND I p" 42.8' p" 45.0' TH2 DECK / y A A A // LS LS 6 �s 44 - „ 1OYR 3/2 1OYR 3/2 �� / APPROVED DATE BOARD OF HEALTH MA 4 12 WATER LINE TO BE B B �s_ ANY°SPTIC SYSRIEM TITLE 5 SITE PLAN SL SL �rn / COMPONENTS OF 26" 10YR 4/4 40.6' 10YR 5/4 � PAVED DRIVE / 30 42.5 / 57 COUNTRY CLUB DRIVE C 165.00, LEGEND 43 -/ CUMMAQUID, MA / C SiL 99-- EXISTING CONTOUR / PREPARED FOR » 10YR 5/6 , X 99-1 EXIST. SPOT ELEV. / SiL $$ 37.7 [99]- PROPOSED CONTOUR I _ MR. & MRS. KEOUGH C2 198.41 PROPOSED SPOT EL. ! 12 �jpl��� Jam' \ �^ L// -� DATE: DECEMBER 30, 2015 10YR 5/6 LS WITH rH1 � _ J POCKETS OF } TEST HOLE N OF �t�OFMgs J �p��H OFM48. ��N OFi11ASS off 508-362-4541 MS & SiL Y �`��� Ss�o ��� sq�ti o`'� DANIEL 9c�� o���DANIEL 9cti� fax 508-362-9880 2.5Y 6 3 2� SLOPE OF GROUND © DANIELA. DANIELA. A �� �� A s� downcope.com OJALA OJALA OJALA C OJALA a` • • • CIVIL CIVIL 144" 30.8' 138" 33.5' `� UTILITY POLE No.40980 wn cQ a endiaelf?4,f, h7C No.46502 �, 02 1p �No.40980� �o � - R� t Fss\o °� ss�0� civil engineers PERCHED GROUNDWATER PERCHED GROUNDWATER yyo FIRE HYDRANT Scale: 1 = 20 c'S* ��`` Fss�o A G�� q suRv °� � o�uRv��,a� land surveyors ENCOUNTERED ® 138 EL. 31.3 ENCOUNTERED ® 108 EL. 36.0 NOTE NOT ALL SYMBOLS MAY APPEAR IN DRAWING 939 Main Street ( R to 6A) LICE # 1 4-360 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 14-360 KEOUGH.DWG