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HomeMy WebLinkAbout0208 COUNTRY CLUB DRIVE - Health 208,Country Club Drive Barnstable A= 349—046 I� 1 s I i P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every 4 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: - / 6 q10 key to move your cursor-do not Trevor Kellett use the return Name of Inspector key: TK Septic Inspections Company Name 38 Vacation Lane Company Address West Yarmouth MA 02673 City/Town State Zip Code . 508-579-5502 S113744 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 4.15.15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every Q 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system-, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years.old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insi•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code Date of Inspection- B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired., B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water'levei 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): l ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1: System will pass unless Board of Health determines-in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of.a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is required for every Cummaq uid MA 02637 4.12.15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure'criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) 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 El ® 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 '/2 day flow t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy.is below high ground water elevation. ❑ ® Any portion,of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of,a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the Well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact-the Board:of Health to determine-what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant'threat, . or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. . t5ins•3/13 Title 5 Official lnspedion Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? a ® 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? • ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 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 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code Date of Inspection D. System Information Description: . This system consists of a septic tank d box and 2 infiltrators Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail.- Sump pump? ❑ Yes ® No Last date of occupancy: current Date 1 Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): canons per day(gpd) Basis of design flow(seats/persons/sci t:, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No f Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Tibe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 208 Country Club D"r Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q 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,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Otfidal Inspection Form:Subsurface Sewage Disposal System•Page a of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is required for every Cummaguid MA 02637 4.12.15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2005 per boh Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): " Depth below grade: 1.2 feet Material of construction: ❑ cast iron ®40 PVC El other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 5 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: 1500g Sludge depth: 2„ t5ins•3/13 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is required,for every Cummaquid MA 02637 4.12.15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" 2 Scum thickness Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank is water tight and structurally sound with tees intact and liquid at the outlet invert, system does not need pumping Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•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 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code- Date of Inspection D.-System Information (cont.) I Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as-related to outlet-invert, evidence of.leakage, etc.):. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons; Design Flow. gallons per.day. Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: bate q• Comments(condition.ofalarm and float switches, etc.): *NAttach copy of current,pumping contract(required). Is copy attached? ❑ Yes ❑ No • t5ins-3/13 ._ Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q 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 even 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 level and watertight with 2 outlets and no carryover Pump Chamber(locate on site plan): Pumps in working order: ❑" Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber,,condition of pumps and appurtenances, etc.)-. *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins+3/13 Title 5 Official Inspection Forth: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 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries . number: ® leaching trenches number, length: 2, 56 ft ❑ leaching fields number, dimensions. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching at the this property consists of 2 infiltrators foot field of stone there is no standing water or high staining in the stones of the leaching Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number arid 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•3/13 Ville 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)., Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 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 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name , information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a View of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A + 3 I O B O Al)22.5 A2) 16 A3) 52 B1) 18 62)24 133)62 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 208 Country Club Dr Property Address ROBB[NS-LECLAIR, DENISE Owner Owner's Name information is required for every Cummaquid MA_ 02637 4.12,.15 " page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 35 . feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS shows GW test hole on site at about 35 feet 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 208 Country Club Dr Property Address ROBBINS-LECLAIR, DENISE Owner Owner's Name information is Cumma uid MA 02637 4.12.15 required for every q page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information is required for Cummaguid MA 02637 08/18/09 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. ImportantWhenfillin A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not use the return Name of Inspector. key. Aardvark Environmental Inspection Company Name P.O. Box 896 " Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 SI3742 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: 0. ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority t 08/18/09 Inspector's Signature.• Date i 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. USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s y< 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information is required for Cummaguid MA 02637 08/18/09 every page. Cityrrown 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: e f I B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑ 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. ND Explain: ❑- 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 r pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 official Inspection for Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information is Cumma uid required for q MA 02637 08/18/09 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: R . ❑ 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 s ❑ obstruction is removed ND Explain: C) °Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water °f❑ 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, 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 watery. supply. ❑ The system has a septic tank and SAS and the SAS is within`50 feet of a°private water supply well. USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of,15 , 1 Commonwealth of Massachusetts t JD Title 5 Official Inspection F& Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 208 Country Club Drive M i. Property Address Thomas Moran Owner Owner's Name information is q required for Cumma uid MA ' 02637 08/18/09 every page. City/Town State Zip Code - t Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): , ❑ The system has a septic tank and SAS and the SAS is less than 1-00 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 coliform, bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: E D), System Failure Criteria Applicable to All Systems:' - You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El a ® ,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 El due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded El ® or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less ,than 1/day flow El ® 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. USGS•12/07 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of.15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information formation is Cumma uid required for q MA 02637 08/18/09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt.): Yes No ❑ ® Any portion of a'cesspool or.privy is within'a Zone 1 of a public well. ❑ Any,portion of a cesspool or,privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure ® criteria exist as described in 310 CMR 16.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. r E) Large Systems: To be considered a large system the system must serve a facility'with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate'either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No 1-1 '❑. the systern,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 El the system is located in a nitrogen sensitive area (Interim Wellhead Protection El Area-IWPA)or a.mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered.a significant threat, t or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 4 f f Commonwealth of Massachusetts Tit le 5 Official Inspection' Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''r 208 Country Club Drive Property Address Thomas Moran Owner Owners Name information is Cumma uid required for q MA 02637 08/18/09 every page. City/Town State, Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping'information was provided by the owner, occupant, or Board of Health ❑ ® Were any,of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week'period? • Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined? (If.they were not available note as N/A) 4 ® ❑ - 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)] USGS•12/07 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts 3 Title 5 Official Inspection For ej Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information is Cumma uid required for 4 MA 02637 08/18/09 every page. Citylrown State Zip Code =Date of Inspection D. System Information Residential Flow Conditions: {' Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 `Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: f _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?, { a ❑ Yes ❑ No Industrial waste holding tank present? El 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): USGS'•12/07 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 208 Country Club Drive Property Address , Thomas Moran Owner Owner's Name information fo is Cumma uid required for q � MA 02637 08/18/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: r ® Septic tank, distribution,box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative.technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank. Attach a copy of the DEP approval. , k Other(describe): Approximate age of all components, date installed (if known)and source of information: 10 years Were sewage odors detected when arriving at the site? ❑ .Yes ® No USGS-12/07_ <. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M � 208 Country Club Drive Property Address Thomas Moran Owner owner's Name information is q required for Cumma uid MA 02637 08/18/09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) , Building Sewer(locate on site plan): Depth below grade: 1.6 - 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.): Septic Tank(locate on site,plan): Depth below grade: 0.7 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 Y Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 2811 • - 211 .. Scum thickness > , + 1 , Distance from top of scum to top of outlet tee or baffle 6� Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured r USGS-12/07 a Title 5 Official InspectionForm:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information is required for Cummaquid MA s - 02637 08/18/09 City/Town/Town State Zip Co deode eve page. b Date of inspection every P 9 P pe D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: x r Material of construction: ' ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):. ' USGS-12107. Y Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information is q required for Cumma uid MA 02637 08/18/09 every page. Cityrrown State Zip Code Date of Inspection. D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: ` gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order:- ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached?' ❑ Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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.): ' The box was level and tight with no sign of carryover. Pump Chamber.(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: 0 Yes ". ❑ No USGS 12107 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System, Page 11 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information is q required for Cumma uid MA 02637 08/18/09 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.). Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 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: 2@56'x3' - ❑ leaching fields number, dimensions: , ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: - $. Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of, vegetation,etc.): The system has two 56'long by 3'wide trenches with flow diffussors. There was no sign of ponding or failure in the stones. USGS•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15` Commonwealth of Massachusetts up Title 5 Official Inspection orm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information'Is required for Cumma id u MA 02637 8. 08/1 /09 -every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): - Privy(locate on site plan): Materials of construction: Dimensions Depth of solids s , r Comments(note condition of soil, signs of hydraulic failure, level of pondi% condition of vegetation, etc.): USGS•12107 * Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official 9nspection Form . t1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 208 Country blub Drive Property Address Thomas Moran Owner Owner's Name information is Cummaguid MA 02637 08/18/09 required for State Zip Code Date of Inspection every page. GyRown t D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. } ♦ rdle 6 Oifiaal mspe�on Fam Subs�u(aoe Sewage Visp 14 of 15 USGS•12W i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments x 208 Country Club Drive Property Address Thomas Moran Owner Owner's Name information is Cumma uid MA 02637 08/18/09 required for Q , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water Z Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 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) E Accessed USGS database-explain: x You must describe how you established the high ground water elevation:_- USGS maps show an elevation of over twenty feet. y USGS•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 N' TOWN OP BAyRNSTABLE ✓ LOr�''.�IT10N �. ' 6VAER_V C�V SEWAGE #f�� s (3 VILLAGE Cu tM A4 �✓ G# ASSESSOR'S MAP & LOT3 q 6 IN;;I'ALLER'S NAME`&'PHONE NO. SEPTIC TANK CAPACITY I S' 0 /�.' 'r I"LEACHING FACIL=: (type) 7AJ- TrcAxEQft 5 (size) a X 5 0- NO.OF BEDROOMS-- BUILDER OR OWNER 16 tM Mo IQ- A-1 U , PERMTTDATE: - 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) Feet Furnished by .ter ei S x p c = ¢ = ay qq L No. GS G �-�. :� —\ - - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migo!ml *potent Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.d 0&-' F04-*'Y C 14,6 Vl?, Owner's Name,Address and Tel.No. Assessor's Map/Parcel 09/A 10''")-Y/ `)," 1*&'-' Installer's Name,Address,and Tel.No. 3Gd�- v Designer's Name,Address and Tel.No. Type of Building-1 Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow t G Y S 3 S C-1 gallons per day. Calculated daily flow gallons. Plan Date M ti^C t'1 o;-cc f Number of sheets Revision Date Title Size of Septic Tank ( $00 Type of S.A.S. fG 14,r h t'Sn r c.d- tbo L9-� Description of Soil S" So,7 L oa� Nature of Repairs or Alterations�(Answer when applicable) S$ 'ti Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee ' sugd by this Board o eal Signe Date Application Approved by Date �S Application Disapproved for the following reasons Permit No. S Date Issued 0 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , m / LI DATA A' No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .. ,r r e.rA.w, `�• Yes ._,,,1 '-PUBLIC HEALTH DIVIS-ION;A T"N.OF BARNSTABLE. MASSACHUSETTS r ' � plication for i� oga p�ten� �on�truct%ri permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( TM) O Complete System ❑Individual Components - Location Address or Lot No. 'c" r y n v � �Lf,rj �J� Owner's Name,Address and Tel.No,.:� Assessor's Map/Parcel 3 y L/ ' G� (��u �t.�- /y y 44 4 41 ,r Installer's Name,Address,and Tel.No. 3 G d V 7�7 Designer's Name,Address and Tel.-No.; Type of Building: sS� �f Dwelling No.of Bedrooms -5, ry (� Lot Size sq.ft. y�` Garbage Grinder( ) Other Type of Building '� No. of Persons __t Showers( ) Cafeteria( ) Other Fixtures _ Design Flow G S k ! gallons per y. Calculated daily flow' - gallons. , ---;Y Plan Date tyi `�r ,,`i « Number of sheets f Revision Date` _ rr;. 'f .. Title Size of Septic Tank. l C' Type of S.A.S. Description of Soil, S o'' S� L ` _. Nature of Repairs or Alterations(Answer`when applicable) ` Date last inspected: ! ' i t Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code"and of to place the system in operation until a Certift- cate of Compliance has bee�t-issued thisaBoard �Ieh, - Signe ___ / Date y �1�� Application Approved by Date Application Disapproved for the following reasons Permit No. ' 1 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS - Certificate of Compliance THIS IS TO CERTIFY, that the.On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded( ) Abandoned( )by 1' I t, at G�- ('c t ;�� N l t /).' �^f ( t % ' f✓LL %`' has been constructed inj accordance with the provisions of Title 5 and the for Disposal System Construction Permit NO.. 5 ' dated Installer A` Designer The issuance of this P ///e }ta/ot be construed as a uarantee that tes stem it n do as desi ned. Date J g Inspectory g i THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION - BAR NSTABLE}MASSACHUSETTS xi!5po!5a[ *p$tem"CongtrUction i3ermit Permission is hereby granted to Construct( )Repair O Upgrade( )Ali'andon System located at ,T G ('c / 0 ( t ; ( _ �_ I ;J and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions,,or special conditions. Provided: Construc�ti/o`n must be completed within three years of the date of this ermit. Date:__ 1/ 4 /U Approved bye.. I 41 SWEETSER ENGINEERING P.O. BOX 713—SOUTH DENNIS — MASSACHUSETTS 02660 TEL(508) 398-3922 FAX(508) 398-3063 LAND SURVEYING—ENGINEERING —TITLE 5 SEPTIC SYSTEMS SEPTIC DESIGN PROPOSAL PAGE 2 PROPERTY SURVEY AND FLOOR PLAN SKETCH Please fill out this form,including the floor plan sketch,and return to us with the signed proposal and retainer. This information is necessary to properly prepare your Septic System Design. IF YOU ARE PLANNING AN ADDITION PLEASE INCLUDE THAT INFORMATION ALONG WTTH THE FOUNDATION DIMENSIONS AND LOCATION FOR THE NEW ADDITION. Total#of Rooms Year Round Home Seasonal Home Owner Occupied Rental #Bedrooms ,Q� Family Room/Den Living Room /�L Dining Room #Bathrooms Washer/Dryer l L Dishwasher 5 Garbage Disposal y C5 Gas Service ��"4 Town Water In-ground Electric Wires*res* In-Ground Oil Tank* k�In-ground Sprinkler* Jj In_ground Gas Pipes* x Please note on sketch where located. Sweetser Engineering assumes no responsibility if in-ground components are, damaged during Soil Testings, Inspections, Locations of and/or Installation of New Septic System. Cellar: Full Partial(Crawl) Slab Wells: Main Use Irrigation Only (please provide location of all ivells) PLEASE USE THE SPACE BELOW AND THE BACK OF THIS SHEET TO PROVIDE US WITH A ROUGH SKETCH OF. THE EXISTING FLOOR PLAN(ALL FLOORS). Also include any items that should be avoided,IF FEASIBLE,i.e.shrubs, trees,patios,electric lines,tanks,etc. IF YOU ARE PLANNING AN ADDITION,PLEASE PROVIDE THE LOCATIONAND FOUNDATION DIMENSIONS. �4� L TOT I.w R+h 3, ..54 re—e__+ * � �2 rj t•�ry t Ton of Barnstable P# �v D S °f tt+E Department of Regulatory Services ' aresra, Public Health Division Date " 200 Main Street,Hyannis MA 02601 Fee Pd. Date Scheduled ' Time Soil Suitability AssessmentforSewage A osal Witnessed By T: Performed By: LOCATION & GENERAL IN ORTION Location Address RDti � Owner's Name ^ �� A W Gl/I^""" +M A, i Address Zo S �v���y C.��✓� , �2 �� D y� Engineer's Name Assessor's Map/P$rcel: J 1L J NEW CON I lON REPAIR Telephone# Slopes(40) Surface Stones Land Use • Distances from: Open Water Body ft Possible Wet Area_____— ft Drinking Water Well ft Drainage Way ft. Property Line ft Other ft SKETCH:($treet name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ' I I Depth to Bedrock Parent material(geologic) Depth to Groundwater. Standing Water in Hole: Weeping from Pit Pace Estimated Seasonal High Groundwater D#,TERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: in. Depth to call mottlt;s: In. ___ � Depth Clbserved standing in obs.hole: in, Groundwater Adjustment Depth to weeping from side of obs.hole: Adj.factor,, .. Adj.Groundwater Level Index Well# Reading Date: index Well level -- PERCOLATION TEST _ vatt:�..�. '�' Observation Time at 9" Hole# Time at 6" )depth of Perc Start Pre-soak Time.@ - End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed; Additional Testing Needed(YIN) Original: Public He$ith Division Observation Hole Data To Be Completed on Back-------- ***If ercolation testis to be conducted within 100' of wetland,you ut first notify the P prior to beginning- Barnstable C44'servation Division at least one(1)wetyk p n•xcFpr 1('%PFRCFbRM.DOC 'DEEP OBSERVATION HOLE LOG HQIe# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Strucre,Stones,Boulders. Cons stenc ravel DEEP OBSERVATION HOLE LOG. Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc % ravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc Gravel 'DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi tenc ra el Flood Insurane Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No— Yes Within 100 year flood boundary No— Yes Depth of Natutally Occurring Pervious Material Does at least fo r feet of naturally occurring pervious material exist in all areas observed throughout the area proposed fbr the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on. (date)I have passed the soil evaluator examination approved by the Department of environmental Protection and that the above analysis was performed by ride consistent with . the required training,expertise and experience described in 310 CMR 15.017. Signature Date Q:WP71CWERCVORM.DOC Town of Barnstable Regulatory Services _ Thomas F. Geller,Director MAMPublic Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 0 yU Designer. G - ��'y Installer. JJ(,vS �" 1. 0f , Addressi .6 Address: ? S MA � 3-7 pn 5 _ ' __J_P M©R i N was issued a permit to install a (date) (installer) septic system at 26 �v,�wn C'C,e��3 t�Ls based on a design drawn by (id dress) p dated •vCs (designer) _ZI certify that-the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. STETSON EDVkAR! L .5 . KELLifzY e) (Affi - p Her 1? E O BARNS LE PUBLIC HPULTH Ip ION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTIO THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUIILIC HEALTH DIVISION. THANK YOU. Q:I•iealth/Septic/Desiper Certification Form ; ASSESSOR'S MAP NO. PARCEL f L O C W T 10 N RO G?�""' •°� •��� f l A G E PE R M I T NO. VILLAGE `�7a� H S T A L L E R'S N A IR E A D D R E S S ASSESSORS MAP NO: 3yW B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Rota= - ZS 3� Gov tic� Ll.0 B D� a � 1 gr � ... Fas:No .. �1 f.. .. __ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Applutttinn for 31ispaiial Works Tonstrnrtinn f unfit Application is hereby made for a Permit to Construct (�/Or Repair ( ) an Individual Sewage Disposal System at: tj ........� "!z:�' - . ...C?!� ! .. ...... ?...._..................._......_..__ Loca Addr sor Lot No. poor aet_._............... .•• ...__........ ._.. r..... ............_.... Owner Address ......................... .................... ess InstallerType of Building SizerLot _, ..__ .._..Sq. feet U Dwelling—No. of Bedrooms........ ............................Expansion Attic ( ) Gauge Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ............................................................................••------.........._....._:._........--•-•---.....................----_.... WW Design Flow...........o6j�,!�___._.---_________gallons per Perso �y. Total o_yv........ ................. ?ga llp s —Liquid ca aci �___• Ions L h-. ...� Width. Diameter.....- _�.... Depth--- Septic Tank __ Disposal Trench—.No......_--:.......... Width./.....�........... Total Length...................• Total leaching area....................sq.ft. 3 Seepage Pit No......`;Lrn...... Diameter.._,,,1 _...... Depth below inlet-3-_.-�;......... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by.��.) .c.1 t/ �'�C Date.... ..D .... Test Pit No. 1 9!: ,M. .minutes per inch Depth of Test Pit.,/Z—.! ?..... Depth to ground water .. -A) J f� Test Pit No. 2_4____________minutes per inch Depth of Test Pity V_.... Depth to ground water/ .... lU a ..... .. Description of Soil................... J •- W ...................••----...-.------....._...............-•-•---........----......._..........__..........---.........•-•---..........•---...--•- ......-••-•........................•---••-------....._......_.........__....._......................_...........----........--••--........._.__.........----•--•........---._...__.........--------••--- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ..-•----•----.....-•---•--...--•---------------------------•-•-•--•-._....--••-••-----......-•-------.......---•---•------.....-•••-•--..........--••-•-•----............----------..._-•--....__•••_... Agreement: The undersigned agrees to install the a edescribed Individual Se ag i osal System in accordance with the provisions of TITLE 5 of the State Sanit ry ode—The un signed r r ees not to plac the system in operation until a Certificate of Compliance has ssued by the r h th. 14 O Y kited.----• ---.. ...1.ate../ //_.... Application Approved By- ......... :.......:_..................... __......---.......... 1._.(. 5�.... Date Application Disapproved for the following real ................•----..................----•--••-•---•----•--.._...---•-----......._..-••-••---•....--- ........................................................................................._............._.......................................................................................----- .'!��?. a `70� / Date Permit No..... _�..7SJ._ .._.._...._ Issued................... --------------__........._ nie •----�n�..-�....w,E�...j,.�„r• +'...x-""e.-:.+'a�i/'+^�''�—w`�'•-w 4•.-;�w+t3�dc�"""-`•.,s�r,7�'�"'+a'...:...;,?�.dr�..rt_a.y..,f ;t•F i s...:. •+y;,6*•:,. `) Y M1fw No -?07 FxB.. THE COMMONWEALTH`OF MASSACHUSETTS BOARD. OF HEALTH \q\ ` Applirationjor .�i asal Works r rZ onstrur�tio Prrmit Application is herebymade for a Permit to Construct oRePair an Individual Sewage, Disposal System at: ......... .G-c?T....... .. .._................w... Loeat�y/p�p Addresqso or Lot No ... tab al...^ � ,.........`.... .... ...._C................. .... _.^... ......................................................-........................._ .. - OwnW Address ....................... 1.....�?Ji2.................... ......................................................... Installer, Address Type of Building Size Lot,.35..h�3...-Sq..-feet. Dwelling No. of Bedrooms.::......y.............................Expansion Attic ( ) Garbage Grinder ( ) '04 4 Other—Type of Building No. of persons............................'Showers — Q Other fixtures ...................... ; ----------- ........... ------------- .... --...... Cafeteria W Design Flow........... ..... . ,gallons per person erday. Total da �oDiamete.V. _-.....Depth �ons W Septic Tank—Liquid capacrty4�.gallons Length j ep x Disposal Trench—No....:..—. :.._.. Width................... Total Length.................... Total leaching area.....................sq..ft. Seepage Pit No....... Diameter...., 0...... Depth below inlet:S ...... Total leaching area. ..sq. ft. OtherlDistribution-box Dosing_tank Percolation`Test Results Performed b . Date Test Pit. No l.Z.Z—..min utes per inchX Mepth, of Test Pit.., :�� . Depth to ground,water 6...`zAS f=, Test Pit No 21�{�-Z�--mmutes per inch Depth of Test Pit�`t!.Y` Depth to ground water,/ �/.'/./.5?1U 1 ... .... Desc�riprion of Soil.....Q ..: � � �..,..j _ .� l`t1ls 4r�.:.._.. am..... :0 ...... ...... .............................................................. W a $ . � UNature of Repairs or Alteritions ,Answer when applicable.......: : � t �, Agreement The,undersioedlagreeskto�instilI th or�edescribed Individual.Sewlag�e1Disp�osal System-in'accordance with , the pro visions of ,ITtE °5-of the State Sanittgy Code The undersigned further agrees not to place the system,in ' operation until a Certificate of Compliance has been issued by the board of/ Wth. S e L._.._... 't v f _ ..._... Date Application Approved By....- > '" ... .._ - ..........2 .Z,,/..l.... � 1 s Date Application Disapproved for'the f ollouring redsofn ........ ........ ....... ......... .....--................................... . ................................. ^-^ - -K .... ................�c 7— .........................................Date } _ Permit No..:......... .�0 Issued...' .. .. ` .......................... THE COMMONWEALTH'OF MASSACHUSETTS BOARD: :OF. .HEALTH j �PrtifirMtP of TII1Itp1talttP ; THIS O CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired.( ) b ......... ...........v 0 - y ........__u ........................ ..._. .... ... .--- ... ............ .. .........................._t ll ��ra ,... ... has been install e in accordance witli the provisio�of TITIF j of The State Sanitary Code s d 'bed in the application for Disposal Works Construction Permit No.._......'��.....�_OZ..._ dated........r.7 .... ....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A`GUA ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE ............. ' / ........ ......... .................... ............ Inspector......... ...------ ....-- --._.... ...-•-•-• ••................... THE COMMONWEALTH OF MASSACHUSETTS 1' BOARD OF HEALTH FEE: .. Disposal arks Tonstrurtion ramit Permission is he by granted.--U ? MVP.P.----- .......••-••--•.........•••-••-•--•----•...........•••••.........................^ to Construct ( or Repair ( ) an Individual Sewage Dis System at No......... d.....�.... o... r ......�' �.� street - as shown on the application for Disposal Works Construction Perna V-*70.. Dated r'7)2.!-L ...tr.......... .................�'�1: . ......................7" .................. ..... 1f6 Board o f Hea ` I DATE........ -- ........ •>. . FORM 1255 889 8 WARREN, INC.. PUBLISHERS - - wr R. J. Q'HEARN, INC. REGISTERED LAND SURVEYORS cswan =Rturt Qtn1E 2 REGISTERED SANITARIANS 35 cRouEe 134 'Sout4 1(bennis, r:=-Ma. o266o 394-1265 April 9, 1986 Gallus Construction 170 Trout Brook Lane Cotuit, MA 02635 Re: Job #3107 Lot # 50 Country Club Dr. , Barnstable Dear Sir: Two Soil. Tests were performed on the above referenced lot on May 24, 1985. The results are as follows: 0 - 18" Top and Sub Soil 0 - 18" Top and Sub Soil 18" 0 126" Fine Sand 18" - 144" Med Fine Sand No water encountered Percolation Rate less than 2 minutes per inch. ' These results indicate this soil will support an on site sanitary facility for a single family residence in accordance with Title V, the State Sanitary Code. Very truly yours, R. J. O'HEARN, INC. Richard J. O'Hearn, President I ASSESSOR'S MAP NO. PARCEL L 0 CA T ION .tear G ,� rd . e 1-0T5� - v (u2g A c E RE R M I T R-Q. 12. ( G . VILLAGE i I N S T A LLER'S NAI1E ADDRESS ASS f �E�27- B Ova ASSESSORS MAP NO: -3yq ; 614 BUILDER 0R OWNER ookfi A dvrH - I DATE PERMIT ISSUED I I i DAT E C0MPLIA 'NCE ISSUED r - 34 wticT►v! C(,hJ3 D , SOI L LOG DATE-. WITNESSED BY : X7., j �C- liz N ELEV.V. UANHOLES AND COVER TO BE 19UILT WITHIN <0 TOP OF NI O F FINISHED GRADE .DE .DAIO) ,'FINISHED 6RADEe - RAIN. 27 SLOPE c 11 % 47C.AST I RO 0 R Pvc S 10 C )1- 40 1!: IST 1!j P V C SCH. 40 PITCH 1/47/F T, L' MIN. 2" LAYER ��r"jet ic- X c /12'LE VE p PITCH 1/8" (12" P E A S TO N E T '02 IS T'LE VE L' to 'ST N T 0 I N V E R T iNVE N V E R T D, GALLON C) 40 el 3/4"- 1 112"D f A . I N V E R T C, x r 10, 4 1 SEPTIC TANK WASHED STONE I N V E R T C) r r.'lllI C3 MI N. 3/4 VV A SH ALL L INVERT 10 0 ALL AROUND . C cl.. E L E 0 c, 10 16 (L GARBAGE _j 0 ELEV. BOTTOM M I N. G R 1 N 0 E R k 6-0 Of A OF P IT -IS 0' \A 1 N -&- 4 S,\ E L E V. 17- t PROFILE OF GROUND WATER TABLE SAN I 'TA R Y DISPOSAL SYSTEM NOT 70 S C A L E No _Q E S I Q_N DATA r—�OQ * CONSTRUCTION OF SANITARY D 15 PO 5 A L BEDROOM5, SYSTEM SHALL CONFORM TO MASS . DESIGN FLOW - 15-l� GAL . DAY �ol 11 -1 -l000 ENVIRONMENTAL CODE TITLE V 7)(REVISED 7- 1 - 7 LEACH RATE .-, - MI N./I NC H AND THE TOWN OF --& � " :­ PROPOSED LEACH CAPAC;��-- C -Z-:S, Ac,- x HEALTH REGULATIONS. s- -/0 s 7-C 14 o SEPTIC TANK., DISTRIBUTION E30X AND LEACHING PITTO BE OF REINFORCED CONCRETE : ;707— G A L/D A Y 7 KAI N. CONC RETE STRENGTH 3000 PSI MIN. STEEL STRENGTH 2 q0 OOP S I H 10 DESIGN LOADING • DRIVEWAYS NOTTO BE LOCATED OVER SYSTEM UNLESS H - 20 DESIGN LOADING 13 USED. • ALL PIPES AND FITTINGSTO BE WATERTIGHT AND TO BE OF CAST IRON OR SCHED 40 P.V. C. SITE PLAN s OWING PROPOSED CONSTRUCTION SH. / OF —/ SHS. LEGEND L 0 C A T 1 0 N - A 0-,0 FOR : APPROVED 19 pp / BOARD OF HEALTH SCALE: DATE :--.-, BUILDING SETBACK REGULATIONS PER EXIST- ( NG CONTOUR R E F E R E N C E BUILDING INSPECTOR OR BUILDING PROPOSED CONTOUR -Z , DATE AGENT COMMISSIONER . :::7 —Z—)C__4. "ol MIN FRONT SETBACK EXISTING SPOT ELEVATION 17. 6 10q ...... . Al MIN. S ( DE SETBACK PROPOSED WATER SERVICE _W_ OF OF TEST HOLE LOCATIONS MIN. REAR SETBACK -V m CIVIL #A&27483 J . M. MONAHAN., JR. & ASSOCIATES IV 4 PROFESSIONAL LAND SURVEYORS L ENGINEERS JUL 6 loc'104,96 JUL n ISAR J N. ; TOP OF FOUNDATION ? ,r d 4 1�r CONCRETE COVERS iNSF�3:Ti h POW %1 .• � . 002 Cz• 4z_ov SCHCAXrEUIILtlRQB 4C ea- eSCaiEDULE 40 P_vCG.CON><7� �� \ P V_G 1E PtP Ma". P l PE - MIN. P1 TC M �-„esr L F1- CLEAN SAM O S AC311FI L • 1/.4 PER,Fr char Ar-V,t� •2'� t �� GAS SAFF E T INVERT 7 iavEteT ;i . ,, INVERT 9/. SEPTIC TANK go�z3_ ��rtiE pL_Ap_s3_ INVEXr INVERTGA . 149 .48 OtST / BOX INVERT _�S•CRt15t�ED S IONE EL' �' 8�,/z- ---------�8.. _../,/�GN <A CHAMBERS 7. PRO FI LE OF SEWAGE DISPOSAL SYSTEM AOJ• GROUND WATER EL__ SO I L LOG OATS . ?!!�/_�_Z o � o . Ti N E -_-• - _•-_• - No Sr-Al _ TEST HOLE EST HOLE - Z_-.. VEGETATIVE C*VER ELEV. .c�--�"z--- EL-•-V• --Sz=rsn-•-- DESIGN DATA f � : - < <,� r tr cat er No L �'''- % ♦I �, Soyf� Sa/[ NUMBER OF BEDROOMS . . . . S . . . . . . . . �t _ '\ ,•�; ` 2s I Svl� SGiL 28" ���-37r� - - 1. TOTAL- ESTtMI[TED FLOW _ - SSo - „- GALLONS/DAY �.- 1 -�/ LPL, S'2,/ BOrTUM, LEACHING AREA 7S- SO_FL/ZRENCl'i 30 t -- -- SIDE LEACHING AREA SO FT_JTRETICH � �7Elp - - - . ... . . . .. . . s/37'n �o/a»�L GARBAGE DISPOSA Ad'v' a .(SO% AREA INCREASE) LEACHING 9 i TOTAL LEACHING AREA ¢47 r i-G7=.. .. SO.FT_ 74C.fy �N•-• �+ Sr�/ PEOLATION RATE - . 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