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HomeMy WebLinkAbout0011 DESERT SANDS LANE - Health 1 Desert Sands Lane Barnstable A 355 001004 - r o ! � 2 . 4 Jun 29 2017 23:20 HP Fax page 1 rt 66-001 �O`f Commonwealth of Massachusetts . Title 5 Official inspection Form ^ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address ' James Higgins 3, Owner Owner's Name information is BARN-Iy,�, r MA„ 02637 6-26-17 r required for every Cummaquid fV ° page-a CltylTown 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 ``,���ttilllllpgp on the computer, �I' f' OF useonlythetab 1. Inspector. • ' �y% key to move your o �A M E S G cursor•do not James D.SearS '. " use the return y ke . Name of Inspector (►y Capewide Enterprises �_•.o "o.:Q Company Name i,' F'• T E•G 153 Commercial Street y�'��in rsrn nmp��`,o`°� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number R . B. Certification I system at this address and that the � •f that I have personally in the sewage disposal ste s I certify e inspected d Y Pe Y p 9 P. Y . 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 6(310 CMR 15.000)..The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I 6-27-17 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original 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. tbins.Ooc-rev.6116 We 5 Official Inspection Form:SubsLrface Sewage Disposal System-Page 1 of 17 ,Lo IDS Jun 29 2017 23:20 HP Fax page 2 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name information is required for every Cummaguid MA 02637 6-26-17 page, CitylTown State 2lp 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: Note:Tank should be pumped and cover's raised. The system is a 1500 Gal. Tank D Box and four chamber's. 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): t5rns.doc•rev.&16 Title 5 Ofridel hspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Jun 29 2017 23:20 HP Fax page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name information is required for every Cummaquid MA 02637 6-26-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/'alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced [] Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official inspecllon Form:Subsurface Sewage Disposal System•Page 3 of 17 Jun 29 2017 2320 HP Fax page 4 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name information is required for every Cummaquid MA 02637 6-26-17 page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) Z. 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 coliforrn 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge orponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . ❑ ® Liquid depth in rgE> 1 is less than 6" below invert or available volume is less than Yz day flow 4. g jO el-1 im C Mns.doc•rev.6116 Title 5 Official Inspection Form:Subs oface sewage Disposal System-Pape 4 of 17 Jun 29 2017 23:20 HP Fax page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y` 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name information is required for every Cummaquid MA 02637 6-26-17 page. City[Town State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due.to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd= 10,000gpd. ❑ ® The system.falls. 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 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section 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 I I 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. t5lns.doc-rev.6/16 Title 5 Official Inspeclion Form:Subsurface sewage Disposal System Page 5 of 17 L ' Jun 29 2017 23:20 HP Fax page 6 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name information is . Cummaquid MA 02637 6-26-17 required for 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 El ® Were any of the system components pumped out in the previous two weeks? Y ® ❑ 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? ® El available 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 backup? ® ❑ 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) 1310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6116 Title,5 oBldal Inspection form:Subsur'ace Sewage Disposal System-Page 6 of 17 Jun 29 2017 23:21 HP Fax page 7 Commonwealth of Massachusetts Title 5 Official Inspection Form li Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name information is Cummaquid MA 02637 6-26-17 required for every Stale Zip Code Date of Inspection page, CitylTown D. System Information Description: The system is a 1500 Gal Tank D Box and four chambers. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes S No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes S No information in this report.) Laundry system inspected? ❑ Yes S No Seasonal use? ❑ Yes S No Water meter readings, if available (last 2 years usage{gpd}); 2015-216,000GaI 2016-109,000Gal's Detail: Sump pump? ❑ Yes S No Present Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No u Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged'to the Title 5 systern? ❑ Yes ❑ No Water meter readings, if available: 15tns.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Jun 29 2017 23:21 HP Fax page 8 Commonwealth of Massachusetts R. . ..U Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Hi ins Owner Owner's Name information is Cummaquid MA 02637 6-26-17 required for every State Zip Code Date of Inspection page. CitylTown D. System Information (cont.) Last date of occupancyluse' Date Other(describe below): General Information Pumping Records: NA 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): Wns.doc•rev.6116 - Tllle 5 Offidal Inspedon Form:Subsurface Sewage Disposal System•Page 0 of V Jun 29 2017 23:22 HP Fax page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dispoeal System Form-Not for Voluntary Assessments r 11 Desert Sands Lane Property Address James Higgins Owner owner's Name information is Cumma uid MA 02637 6-26-17 required for every State Zip Code Date of Inspection page. CitylTown D. System Information (cont.) Approximate age of all components,date installed (if known).and source of information: 2002 Permit # 2001 -305, Were sewage odors detected when arriving at the site? ❑ Yes ® No Sewer locate on site Ian): Building p g 57" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipping is 4" PVC SCH 40. Septic Tank(Locate on site plan): 47 Depth below grade: feet Material of construction: ®concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years N Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ElYes [INo Dimensions: 1500 Gal. Precast H-10 3„ Sludge depth: f51ns.cloc-rev.6116 Title 5 Official Inspection form:Subsurface sewage oisposal System-Page 0 of 17 Jun 29 2017 2322 HP Fax page 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name Information is required for every Cummaguid MA 02637 6-26-17 page. City/Town State Zip Code -Date of Inspection D. System Information (cont.) Septic Tank(cont.) 8„ Distance from top of sludge to bottom of outlet tee or baffle 41' Scum thickness 8, from to of scum to to of outlet tee or baffle Distance p p 11 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? Asbuilt-Plan -Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level, Tank at 47" below grade w/both covers at 30 In and outlet tees. No sign of leakage or over loading. Tank should be maint pumped and cover's should be raised. g g p p Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from lop 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 151ns.4oc•rev.6r16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Jun 29 2017 23:22 HP Fax page 11 Commonwealth of Massachusetts t Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form- 11 Desert Sands Lane Property Address James Higgins Owner Owners Name MA 02637 6-26-17 information is Cumma uid required for every Citytrown State Zip Cade Date of Inspection page. D. System.Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle conditlon, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: ' Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No Title 5 otrwial Inspection Form:Subsurface Sewage Disposal System•Page 11 or 11 t5ins.doe•rev.6116 Jun 29 2017 23:23 HP Fax page 12 Commonwealth of Massachusetts s . Ville 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name „ information is Cummaquld MA 02637 6-26-17 required for every page Clty/Town State Zip Code Date of Inspection D. System Information (coat.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets.equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x 16'-5' below grade w/cover at 29". Box is clean and solid w/two line's out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No" Alarms in working order. ❑ Yes ❑ No" Comments(note condition of pump chamber,condition of pumps and appurtenances, etc): •If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 6 Official Inspection Form Subsurface Sewage Disposal System°Pago 12 of 17 Jun 29 2017 2323 HP Fax page 13 Commonwealth of Massachusetts Title 5 Official Inspection Forte Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owners Name information is Cummaquid MA 02637 6-26-17 required for every State Zip Code ' Date of Inspection page. City11 own D. System Information (coat) f Type: ❑ leaching pits number leaching chambers number: 4 leachin❑ alleries num ber:99 ❑ leaching trenches number, length: Cl leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelafternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leaching is four infiltrators wlstone. Chamber's at F-6" below grade. Ck D Box and camera out to chambers No sign of over loading t 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 l5ins.doc•rev.6116 Title 5 official Irspectlon Form!Subsudsoe Sewage Disposal System•Page 13 or 17 Jun 29 2017 23:23 HP Fax page 14 Commonwealth of Massachusetts Title 5 official Onspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins -- Owner Owner's Name information is Cummaquid MA 02637 6-26-17 required for every State Zip Code Date of Inspection page, City/Town 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.): 151na.do-•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Jun 29 2017 23:23 HP Fax page 15 Commonwealth of Massachusetts rA Title 5 Official Inspection Form subsurface Sewage Disposal,System Form Not for Voluntary Assessments r 11 Desert Sands Lane Property Address James Higgins Owner Owner's Name Information is Cummaguid MA 02637 6-26-17 required for every CltylTown State Zip Code Date of Inspection page. 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 'DRIVE w�Y h 13 a8"-s- t 13 -s ; 3V t5ins.doc•rev.U16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Jun 29 2017 2324 HP Fax page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane Property Address James Higgins Owner Owners Name information is required for every Cummaquid MA 02637 6-26-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No 10,+ 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; 5-4-2000 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: T.H.on Design plan 10'+ no G.W.. Bottom of chamber's at around 6' below grade. Bottom of chamber's at around 4'+ above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Offidal nspectim Form Subsur'aos Sewage Disposal System•Pape 16 of 17 Jun 29 2017 23:24 HP Fax page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Desert Sands Lane. Property Address James Higgins Owner Owner's Name Information is required for every Cummaguid MA 02637 6-26-17 page. Cily(rown 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 t5lna.dw-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 (TOWN OF BARNSTABLE c_ LOCATION .DLL Se 4 ,tAA SEWAGE # POOL 30S VILLAGE ����^ST��Ie ASSESSOR'S MAP & LOT�� 001-60 INSTALLER'S NAME&PHONE NO. P k SEPTIC TANK CAPACITY LEACHING FACILITY: (type) i' (f (size) (q) NO. OF BEDROOMS UII.D OR OWNER P , rrDATE: az COMPLIANCE DATE: z7 0:02 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 ant.Leaching Facility(If ar y wetlands exist within 300 feet of leaching facility) Feet Furnished by D LOT NO. : 1 ADDRESS : 4 r '• L- OWNERS NAME: Oki f el L, ;/�s;t SEWAGE PERMIT NO. : 76QINEW: ..�./REFAIR: DATE ISSUED:_ DATE INSTALLED: -Z7 oz, iNSTALLERS NAME INSTALLATION OF: PLooedi -6AV j- T (M,4 WATER TABLE: FINAL INSPECTION BY: DRAWING OF INSTALLATION ON REVERSE SIDE: Arc of R � D rs s ,4b �� x No. computer: THE COMMONWEALTH OF MASSACHUSETTS Entered in com p Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 3pprtcation for 10igpogar *pgtem Congtruction Permit Application for a Permit to Construct Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. / �j' Owner's Name,Address and T .No. yes � Assessor's Map/Parcel �Z l� ✓� /�1'�'�PD Installer's Name,Address,and Tel G Designer's Name,Address and Tel.No �� X1 ^�! / Type of Building: Dwelling No.of Bedrooms ` Lot Size Z sq.ft. Garbage Grinder(A140 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow O gallons per day. Calculated daily flow gallons. Plan Date C Number of sheets Revision Date Title / / Size of Septic lank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 provisio of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- pate of Compliance has been i s by ieod, f HeSignDate 4 Application Approved by Date Application Disapproved or the following reaso Permit No. "`� Date Issued wNow--....�"(�•/�.,/ �, J{ ��,. ,.,z'� - «.��;q �. � -` Fee THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer:- Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS r '(pprication for.]Digpogar, *pztem Construction Permit Application for a Permit to Construct pair( )Upgrade( )Abandon( ) ❑Complete System • ❑Individual Components Location Address or Lot No. / �e S / ,�� Owner's Name,Address andTgl.No. Assessor's Map/Pa cel y/ /p / �� (S'lC Y (�4Z*Q" Installer's Name,Address,and Tel.No. Designer's 3Name,Address and Tel.No.. X(IM / � Qc Type of Building: Dwelling No.of Bedrooms Lot Size 2'11'1460 sq. ft. Garbage Grinder( A/40 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flower gallons per day. Calculated daily flow gallons. Plan Date `� �`� Number of sheets Revision Date Title / C Ar/ of,6-1 /o;t J-AAW Size of Septic Tank /^SL'r'n Type of S.A.S. Description-of.Soil Nature of Repairs or.Alterations(Answer when applicable). d 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 provisio of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss e y i .odd of He th Sign Date v` V Application Approved by Date Application Disapproved or the following reaso� r 1J1 Permit No. Date Issued �. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,.MASSACHUSETTS Certificate of Compliance THIS IS TO CE ,that t e O -s' S wa a Di osal/Sy m Constructed ) Repaired ( )Upgraded( ) Abandoned( b l at It W, ted nstructed in accordance with the pr°�v�jsions�of T SAa e f al System Construction Permit N . ''' Installer //�l v I I v ' a`— Designer The issuance o this p rmit shall not be construed as a guarantee that the systjill function as de" Date o1`7�0 7-- Inspector ( 7n r No. -------------------------Fee----- .---- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Zi!5po!5ar *p.5tem Con.5truction Permit Permission is hereby gr to {tMonct.- ) e ya�ir( )Upgrade( )Abandon( ) System located at 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:Co77S10 ctio must be completed within three years of the date of this Date: 2- Approved by t i TOWN OF BARNSTABLE r_ LOCATION DP Se r+ �01 d S SEWAGE # IDDI VILLAGE �'�ur�s7��J� ASSESSOR'S MAP & LOTmjz: 0I1 0-W INSTALLEdS NAME&PHONE NO. P k� SEPTIC TAfi1K CAPACITY 150 U LEACHING FACILITY: (type) (size) A NO. OF BEDROOMS - - QOR OWNER '`� ��^S�'•ATE: a z. COMPLIANCE DATE: =-76 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 whin 200 feet of leaching facility) Feet Edge of Wetland anN Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I ;eA A+b D. Town of 13ar11stabie 11 Department of Health,Safety,and Environmental Services �,m<r Public Health Division Date . 367 Main Street,I lyannis MA 02601 3 BARMABILA _ - MA88 ,Date Scheduled April 4 �p�t► 2000 Time 10:00._AM . Fee Pd. $100.00 Soil Suitability Assess»zelzt for Sewage Disposal ...........__Performed By: Witnessed By: LOCATION & GENICI RAL INFORIVIATI. N Location Address tot 12. Desert Sands Owncr s Name Arthur & Sharon Wright Cummaquid Address 101 Regis Road Braintree, MA Assessor's Map/Parcel: �� S! Engineer's Name Sweetser Engineering NEW CONSTRUCTION XX` REPAIR Telephone ll 508-398-3922 Land Use s Slopes(%) Surface Stones Distances from: Open Water Body ft. Possible Wet Area R Drinking Water Well R Drainage Way R Property Line R Other R SKETCH:(Street name dimensions of lot,exact locations of holes&perc le' ,locate wetlands in proximity to holes) ` �� y C � Parent material(geologic) Depth to bedrock Depth to Groundwater: Standing Water in Bole: Weeping from Pit Face Estimated Seasonal Iligh Groundwater )ETERMINAmION 'OTt SEASONAL HIGII;'VVA'1'EIt'T'ABLE Method Used: Depth Observed standing in ohs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustment R. Index Well N Reading Date: Index Well level Adj.factor Adj.Groundwater Level— PEACOLA ' ON TEST I)aic i imc e e ti Obs rvan o tole H Time at 9" Depth of Pere Time at 6" Start Pre-soak Time cr Time(9"-6") End Pre-soak t 4 T Rate Min./Inch - Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Yh4) Original: Public health Division Observation hole Data To Be Completed on Back Copy: Applicant DEEP.OI3SERVATION-ITOLE LOG hole # Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones,noulderes. Consistency.%Gravel► P DEEP OBSERVATION IIOLE LOG Hole# Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Iloulderes. Consistency.%Uravch DCCI' 013SCRVATIOIY`I�OI,E LOG I I0le# Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Iloulderes. Consistencv.%0 'ravel . . ... . DEEP OBSERVATION HOLE LOG I�ulc# Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Iloulderes. nsisl nc % 'ravel_ Flood Insurance Rate Map.• Above 500 yesr flood beunda:; No Yes Within 560 year boundary, No_ Yes Within 100 year flood boundary'No_ Yes Ven(h of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughoul the area proposed for the soil.absorption system? `If not;what is the depth of naturally occurring pervious material? q '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 me consistent with the required training,expertise and experience described in 310 CMR 15*.01T T. Signature Date 17'-0' 14'-0' I 1 1'-4" 5'-6" 16'-2" ." 6'-0" 5'-8' 1'-10" 3'-6" 3'-9" 6'-6" 3'-9" 5'-4" 6'-0" 3'-9' 1'-9" V-10" 14'-4" c G o N G G a leg SUNROOM P.T. DECK 0 a 1 1 C', 14' X 12' 14' X 10' M 9� 3 00 e G t N 11 � 31J1 5 l o -r. w r Ji �6'-0" CASED OPENING \ 3'-5" 6'-0" 4'-0• V o0 D C I ; CENTER. x' WITH� .r-- M. BATH Z " wINDo>N T i . H � co y 1 !;y ....... G BEDROOM2 , ,1> DINING AREA 1. U { i r R0�0 SV 14 ABOVE x.+-� r^ 13'-2"t x P'—o"t r,tr ' 13'-2"t x 13'-6"t KITCHEN y' MASTER BEDROOM a5�- V , *� :w 15'-8"f X 15'-0"t M Q W co CATHEDRAL CEILING _ ;. �, 11 2 ± X . 13 -Y6 is 0 0 ��� (� X / i c_,. -t~ATHEp(2AL CEILING -0" -0 i O 0 W W 3'-3" 2'-11" 4'-5" �� ; //J' 00 V1M1 UIJC x S ER ..� m---------------------- �-� 13" 1'-8" 4'-3" 24'-10 _ 5r 5 2,-0' —_-- ____._ _----- ._T 1'-9` 14' a'-5" 12'-0' 3'-1" 4'-0" 2'-8" 3'-2" 3'-2" z fO ��R -- - ---�. C� I F— o I I L r-r x r__r � (n o i, C .: ter-• ----------------- S'- O - 2'-0" 2'-0" 5'- r " 2 O o r, - `-12 -0 CASED OPENING •� aE c` �µ4A5E i -It _ �/ 4 ANY ME N P'(,K:BRf D N i _.. kc) S , cl t0 10 11 - 2'_8" 2'-6" 2'-6" 2'-6" 3 10" o LIVING ROOM • 19'-0"t X 13'-6"f N Pro 1 I '" Dgi N t COPIES FACE OF STUD 9 4 S PLAN (L ——— —_ JI FACE CATHEDRAL CEILING - r S�� STUD OF of C HEARTH 6" MIN. STEP o CENTER " o �^� a1 WITH fROVIDL 5/8" FIRECODE GYPSUM I (J �I o as WINDOW WHERE GARAGE ABUTTS DWELLING00 Q U I MAINTAIN 2" MIN. CLEAR FROM r— —-� • t F a x•�� o MASONRY TO FRAMING MEMBERS I I V `,�I N — 12 <v Qm W B "ROTO" SV 14 ABOVE —T - 3 HEAT HEAT Q t O _ o • - I r 4 I o A t J 2 CAR GARAGE 24'-0"t X 23'-0"f I I o COVERED PORC I A U 9'-8" � 6'--4 �1/2" I Q i -3ri a I — -- — ----- STEP -- r---------------- ----------------� d Iut O i I I I U I I I I j I I I I O 19'-0. X 7'-0" O.H. GARAGE DOOR) 19'-0" X 7'-0" O.H. GARAGE DOORI 9'-o" P.C. 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