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Home My WebLink About0059 GRANITE LANE - Health LA Granite Lane, Barnstable = �I s ° I II d I Commonwealth of Massachusetts W Title 5 Official Inspection Form07 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments o 59 Granite Lane MD Ilk, Property Address David Darval Owner Owner's Name information is Barnstable Ma 02630 - -17 required for every 1211 page. City/Town State Zip Code Date of Inspection C-0 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information / on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation Q Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 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 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails. ❑ Needs Further Evaluation by the Local Approving Authority 12-11-17 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 vs 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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: ® 1 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: System was in working order at time of inspection. 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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): ❑ brokenpipe(s) are re laced Y N ND (Explain below): i P ❑ ❑ ❑ ( P ) ❑ 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 Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c, 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El E Liquid depth in cesspool is less than 6" below invert or available volume is less than /day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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 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 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, 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 Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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) ❑ ® 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) _4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 561/GPD t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 page. City/Town State Zip Code . Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2015- 112,000gallons 2016-91,000 allons Sump pump? ❑ Yes ® No Last date of occupancy: Nov 1st Date Commercial/Industrial Flow Conditions: Type of Establishment: NA A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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: Owner-date of last pump is unknown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4.N 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 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: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 6 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: 1500gallons Sludge depth: 7" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 E Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 page. Cityrrown 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 27 Scum thickness 4 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 12 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap(locate on site.plan): 'Depth below grade: NA 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 l5ins-3/13 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as 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: NA 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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 0 11 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 in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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.): NA * 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 Form:Subsurface Sewage Disposal System•Page 12 of 17 II Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 59 Granite Lane M Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (4) 500 gallon ❑ leaching galleries number: ❑ leaching trenches , number, length: ❑ 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.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was dry when viewed with a stain line 2" up from the bottom. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 59 Granite Lane M Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 page. CityTTown 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 DRIVEWAY I r I A1-28'6" B1-25' A2-36' B2-33' EXISTING DWELLING A3.56' 133-52' A4-63' 134-55' GRANITE R Ap I B NEW ADDITION 3 4 I DRIVEW — — - — - - - KARWRQAt-- - - - — - - — - - t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 page. CitylTown 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: No GW @ 144" 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: 6-30-98 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: Plan on file with BOH. 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 f Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 59 Granite Lane Property Address David Darval Owner Owner's Name information is required for every Barnstable Ma 02630 12-11-17 page. CitylTown 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 i M t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Borrower:David and V FCCtORPLAN SKETCH rginia Danral File No.: V032712 S Prop2e Address:59 Granite Lane Case No.: 'l UY: Barnstable State:MA Zip:02630 Lender:Homeward Residential Inc. 22.0' In w nn . /h 14.0' Bedroom Office FIRST FLOOR C S 14.0' 25-0' L.ed EnPoreh Bath I Open. Sun c Patio '16-0' Room 16-0' 46.0' Kitchen ,p• 4.0 23 0' 7 0' 14.0' S Dining Kitchen 17.6bdroom Living \ 28.0' 22.0' Bath_ .I S Living Bath Bedroom B.DOpen PorcHB-0' € 21,0' � SECOND FLOOR 48 0 Bedroom Family. Bedroom 21.0' c � 21 A' Bath IBM 46 0' NOT TO SCALE SKETCH CALCULAiIONs Perimeter Area F-1 Al: 14-0z 16.0= 224.0 A2:21.0x 8.0= 168.a A9 A13-`48.Dx 26.0= 1248.0 A4 18-0x 2.0= 380 First Floor 1676.0 A5':.48:0x 21:0= 1008.0 AS Second Floor 1008.a Totil Living Area 2684.0 J _j P,O.Box 455 Forestdale,MA 02644 Phone 617.775.4415 Fax 508.833.8789 TOWN OF BARNSTABLE 9 LOCATION 6 :TC 4,44, SEWAGE # F 8 VILLAGE ASSESSOR'S MAP & LOT-3i 6 0Y3 INSTALLER'S NAME&PHONE NO. &C-A-d-,FsL - -:5 SEPTIC TANK CAPACITY /5'-00 O� LEACHING FACILITY: (type) S�o c2S�Y (size) IYIX x L3 NO.OF BEDROOMS BUILDER OR OWNERS PERMIT DATE: 6 l COMPLIANCE DATE: 'T - 2 - 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 ;l 0 63' TOWN OF BARNSTABLE LOCATION ' r�h , 4—e . L •: . SEWAGE 5 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPAC= /" 4' 0 LEACHING FACII.ITY: (type) (size) x NO.OF BEDROOMS A BUILDER OR OWNER C— a PERMITDATE: COMPLIANCE DATE: S Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by w' w > • 7—30-- ?r7 I 3D e � v j� �.^.� No.- s x t FEE —F 02 f COMMONWEALTH OF MASSAC14USETIS Board of Health,�&i ajQ 7fib - MA. APPLICATION FOP, DISPOSAL S YSHM CONSTRUCTION PERMIT Application for a Permit to Construct T"'Repair( ) Upgrade( ) Abandon( - ❑Complete System ❑Individual Components Location �` Lj e- . r Owner's Name r Map/Parcel# 316 A,3 Address 2 Cr �`� Let. 2amir Lot# 39 Telephone# Installer's Nameff C - '� r� vJ Designer's Name � Address 8 �o� .S P 0 C C Address Telephone# oZ Telephone# Type of Building �Gve%��/,. Lot Size sq.ftl Dwelling-No.of Bedrooms .S Garbage grinder ( Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 0 6 — 4 X" O f3 !• I /� h�a�c/.b The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree,5 to not to a the cyst n n operation until a Certificate of mpliance�hass been issued by the Board of Health. Signed 2 Date Inspections ,v 3Y-. �sp-��r.......r-+'r�.F.�r.�_ 3 r�y.�E.a -�..i.,.r•r.....• a`}� t .,. .y...w, ../{•Mw'r�.i.i.-R ..'N"t+...`-'^� *t"""-^'p.... ,. it, _ . - No:�I �O F ;�' S k r`� FEE Board of Health APPLICATION, FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to ConstructepairO Upgrade( Abandon( - ❑Complete System ❑Individual Components Location S �'�A�� r Lj N e, Owner's Name �. AI M Map/Parcel# 316 /1-13 Address S Cr. n C I M _ _ Flrn i 7' Lot# 39 Telephone# Installer's Name A�, /,j <Q �� Designer's Name 1 e L Address �o,_t� f � �� Address Telephone# 4 Telephone# Type of Building Lot Size sq.ft Dwelling-No.of Bedrooms SI Garbage grinder ( ) Other-Type of Building No. of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soils) e Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS tn The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree to not to a e the sys operation until a Certificate of mpliance hasp been issued by the Board of Health. >. Signed Date 6 1 Q \ Inspections i No.- V FEE > f Board of Health, MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) lzrcomplete System t The undersigned here certify that the Sewage Disposal System; ConstructeV<Repaired ( ),Upgraded ( ),Abandoned � a,.-) ( ) by.. �)v'Yx v AV � at has been installed in accordance with the.provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. f dated Approved Design Flow (gpd) Installer t- C' c C(�(1 �, Te r "� Designer: 4: 0 t2 C \ 1 Inspector: Date: / The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. 9 g - (g. ryt. .. FEE COMMONWEALTH OF MASSAC14US ETTS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(V Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at J 1 t' C ��, _ C A i t �1+ , � 1A a Ic as described in the application for Disposal System Construction Permit No. , dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health i t TOWN OF BARNSTABLE LOCATION 6-9 Ct4gi,7C49>t e SEWAGE # 8 VILLAGE .%-2 sJ,9b C ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. ./ter- SEPTIC TANK CAPACITY /5'-00 O� LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER �m PERMITDATE: 6AS9 8 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 i J Jo J),J 7 . .Db X i o 63' r 1 I J (�a S6 D, T . fax SoZ 9 TROY WILLIAMS SEPTIC INSPECTIONS C 400 X Certified by MA Department of Environmental Protection ID F D 8) 585-1300 19 Hummel Drive South Denrs, MA'02660 A 4, UqCOMMONWEALTH OF MASSACHUSETTS E ti EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS COPY DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617-292.5500 1ti ILLIAM F.WELD TRUDY CORE Governor Stcretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A / CERTIFICATION Property Address: `5 y V�'�` �' �e �v�. �vrNS �a 'Acddress of Owner: I � /3v /c, /mil; I ar�dl 17�v� �oc Gc Date of Inspection: � (If different) Name of Inspector: Troy Williams CSa wh I am a DEP approved sY�tem inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) e, Company Name: Troy Williams Septic Inspecti0.ns Mailing Address: 19 Hummel Drive, South Dpnnis , MA 02660 Telephone Number: —r5 0$T3 8 5-13 0 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Vse Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: 7 /3 O The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,D00 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltratipn, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. _ (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: httpJtwww.magnetstate.ma.us/dep SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: cf Owner: Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) A,1 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A1/19 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revimad 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS: /,//,I You must indicate ei;,,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15:303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a ` public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. I (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: y �,—O`vi ' 'L Owner: „� c.- c, Date of Inspection: /3(3 /� 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least.two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. II 441 _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: S C1 Gr-o-bl%e � t- �ti . Owner: 14t-, L , ` f - Date of Inspection: 3 U FLOW CONDITIONS RESIDENTIAL: Design flow: 4 o g.p.d./bedroom for S.A.S. Number of bedrooms: 9 Number of current residents: Garbage grinder (yes or no): Laundry connected to system (yes or no): 7 G S Seasonal use (yes or no):-,E S Water meter readings, if available (last two (2) year usage (gpd): / Sump Pump (yes or no):_I/v —� Last date of occupancy: COMMERCIAUINDUSTRIAL: /i/1' Type of establishment: Design flow:_ gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of iinnforma'on: /v u "A.,Ln 5t r" T O - System pumped ds part of inspection: (yes or no)J�/o If yes, volume pumped: eallons Reason for pumping: TYPE fJF SYSTEM �/ Septic tan -soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: y►- H w/ - �-e Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 10 . 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: G r� o • �c L h Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: /0 Material of construction: Zoncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: c5 ix °J L Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: oP Scum thickness 16 " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: </ How dimensions were determined: i-> 9 C- . Comments: (recommendation for pumping, condition of inlet and outlet tees or ba les, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc} 4-� C- r r i 1 c.-7" a 7-61 W B r c ,- ...J L-J u r^fn c. 6✓-k t f /Vy GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION (continued) Property Address: Owner: C— Date of Inspection: —2 /30 `! 7 TIGHT OR HOLDING TANK: N/19(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is ual, evidence of solids carryover, evidence of leakage into or out out of box, etc.)Aa c. 4, +_ s c K.� a o s �Yv r G s S PUMP CHAMBER:_/� (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C f SYSTEM INFORMATION (continued) Property Address: Owner: C 0 L K Date of Inspection: -� /30 Q 7 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: Qh b / `e- (1, c-{-oe-row . d S ta`,c leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) kc w M ,, . 4 .S d N �,t;r✓-e-A S u/ w C c� J� 2 cf ho IL O 4- i h y f/(rµ✓r .C_ CESSPOOLS: / (locate on site plan) D r✓ra fj -t-N.�S r(„ � �� s t' W c✓ S �� Jl� �Tl�..t Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /!9 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: - (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C C SYSTEM INFORMATION (continued) Property Address: V Gf—d- Owner: jam,, h G V� Date of Inspection: � �/ b 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) L Y64- �S; ok C2 �Zy (revised 04/25/97) Page 9 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: v �✓�``' L Owner: /— �L O Date of Inspection: 130 / / Depth to Groundwater — Feet adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) y 6t t.J O u 1 b G. ry.ct k : .ti.✓ h., C.A (revised 04/25/97) Page 10 of 10 V I ols it 01 1jarnstaUle Department of Health,Safety,and Environmental Servicen ,w f Public Health Division . Dale z, z f� �►� 367 Mein Street,Ilyannis MA 02601 l anrrarsarrt , Date Scheduled 3- -- 9 Thn67 Fee Pd.° _ Soil Suitability Assessment for Sewage Disposal Performed By: STl*7-520N �• /�/a e e S Witnessed By: LOCATION& GENERAL INFORMATION Location Address 5" �,,Yy ; ,✓ Owner's Name AA7ox.lo ,Y. S✓S/�•N �i: CAK/�ION Address 8,�,irvsTA BCE �''1A. Assessor's Mop/Pareei• Lrtghreer'e NOW L=D/.✓/tItI> t•' ,. NEW CONSTRUCTION REPAIR ri Telephone N .6 o6-3d7--5o75 Land use 2L3/DG7yT/A L Slopes(%) /0Z., Surthce Stones Distance,from: Open Water Body N/-7 11 Possible Wet Area N/I R Drinking Water Well :n • H Drainage Way A/4 • R Property Line 6a FT A Other R SKETCH:(Street name,dimensions of lol,exact locations of lest holes&pere tests,locate wetlands In proximity to holes) N 7-e_ �9 ea ' leg D r 7z�� 41Ie — -- _ 1� &WST7N6 �j DtVIUVA)a LOT X317 o�y 37 B71 Wzrr V v Z2a•aa' " I Parent material(geologic) Depth to Bedrock. I+ Depth to Groundwater: Standing Water in Hole: 14/10 Weeping from Pit Fete Estimated Seasonal High Groundwater N14 t I DETERMINATION FOR 8EASONAL40011VATER TAKE Method Used: Depth Observed standing in obs.hole: In. Depth to soil mottles: In. Depth to weeping Rom side of obs.hole: In. Groundwater Adjustment A. . Index Well N__•„•. •ReodinR bate: Index Well level Adj.factor AdJ.Oroundweler Level_. PERCOLATION TESL' lObservallon Hole N Z_ Time N 4" Depth of Pero . ,,,,:;- 7 L Time et V. Stan Pre-soak Time® /o:3 2 _,7 Time(r.6") End Pre-took ,/1" _ Itate Min./Dnch 24G/YL iN /o Hew, Site Surtobility Assessment: Site Passed V"' Site Felled: Additional Testing Needed(Y" Original: Public Health Division Observation Hole Date To Be Completed on Back-� Copy: Applicant 1)I;I;N 011SI;IIVATION 11OL1;LOG 11o1e# 'r Ikplh Pam . Soil llorlf.Un Snll lexhrre Soil Color Sell after Surface(In.) (USDA) (Mansell) Molding (Structure,Slonet,noulderet. O'-Z" b rig /o Yz S y 3`�-/7" '�'� /o /le e C Sg n z �/.yfC, ,TgwO 5�3��7L" C 3 w�a affwr /b�'c �¢ le DEEP OBSERVATION NOU LOU"' Fr.� Soil Ilorlton Sall Texture Soil Color Soll er (USDA) (Munseil) Mottling (Structure,Slonet,Uoulderet. ' YA c y � /z U1;1;11 OBSERVATION 11OLC LOO Hole# z' Ucpllr from soil I lo►laon Soil Texlure Soil Color Sall Ulher Surface(in.) (USDA) (Munseil) Mo1111ng (Structure,Stones,poulderet. O��Z 3 ,�/, 4 � • L Ner,S/W,3 3 /oy2 DEEP OBSERVATION HOLE LOG 11010# hCo er w r,) Depth tram Soil Iloriton soli'fexlure Soil Color Soil Surface(in.) (USDA) (Munseil) Molding (Structure,Stones,dolrlderet. west /" •� F771 ' I Flood insurance Kale Man: ' Above 300 year flood boundary No Yet ✓ Wiihin 500 year boundey No— Yet Within 100yew hood boundary No___, Yet Depth of Naturally Occurrin`Pervious Malerlal Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorplion'system? Yin If not,what is the depth of naturally occurring pervious material? �erliticdlon � I certify thnt on L� B (date)I have passed the evil evaluator examination approved by the bcliartnicnt of Environ nental Prolection and tile(the above analysis Was perfonned by the consistent with LOCATION SCALE . ,/ . 30 . . . pATE T yE 3o PLAN REFEnENCE 1, 70' \ I sea I — — k Lug \ 3? 8 7/ -50 � -A- � rn��N o 0 77/ M 00 alsT. 1 `---- -rfl z &LEN. GP of ZZ'4 a♦' I .i-� 1'�-- - - �.•; 1�/'/ �,,) 7.j'� az `1 �o.voRT,dw� 7998 `/�2o�a ED r .�,eivEw.ny J lij 'eo / EL.. �1 TOP OF FOUNDATION --� CONCRETE COVERS __... 4CAST irn RpN 9'r n—mrrnr „, / N/.SG/ G2/hD� 77 OR SCHEDULE . 4"SCHEDULE 40 P.V,C. (ONLY) - P.V.C.PIPE MIN, g'MIN. LEACHING TRENCH (/)REQ. „ PITCH1/4"PER.FT. PIPE-MIN, I/8°- I/2°WASHED STONE 36 MAX. �-75;53' PITCH 1/4"PER.r% __ "oL 753� INVERT p'ld,i,C?.' Y- 8„E2. -7 7L GAS BAFFLE-v INVERT C7�CI;C_1Y • _„ '•° EL..�sr87, d•�C7%p •O 'CJ ICI-, --�" 4��74.3y SEPTIC TANK cL 9s,4�/ OE�7 �L =ra;=o',r:5;t5 C1;.L� d��,b, 24 ,:b INVERT ;pa!O,pcj•,;I % j, % 7✓�C� ...�CO GAL.. INVERT _ E2. EL......'...... DIST, INVERT Z 7..?� EL.. .�,, BOX EL,7`39 Precast 500Gal.Leach 3/4"-1V2"-� 6"CRUSHED STONE / (4)REQ. Chamber WASHED STONE ^/o Q PROFI LE� OF '•••I!, �" / //z GROUND WA TcR TABLE SOIL LOG SEWAGE DISPOSAL SYSTEM TYPICAL .CROSS SECTION DATE .Z6,,i��g TIME.!°-�ofr!`l . No scaLE ,fi LEACHING TRENCH . ' TEST HOLE I TEST HOLE 2 NO Sr"!E ELEV. .7B_8a.. .. E�_EV. ?¢Sz .. DESIGN DATA.: ySG3 F? r, ' NUMBER OF S „I WSHED" 36"MAX. 7¢z7 TOTAL ESTIMATED FLOW ..` � . ... GALLONS/DAY - _•_,,, . 8," /7'� �: 773q ceiaa, i7•' ug„ BOTTOM LEACHING AREA C36? / 3%9`/ �� ;dr O;Cj 4" 73.// , .. SOFT./TRENCH C.PiD, r, r „ \�: 7S,!¢ [osrry C� ,SIDE LEACHING AREA , ,Z�9 3Z... . SQ.F T./TR��CH//4Z,3' 24 7o,8G C,P,D. S3 " s'Nn S3 Cs n GARBAGE DISPOSAL ./V?^/L..(50% AREA INCREASE) s cogrrsE �3 76W TOTAL LEACHING AREA 758 /pU i 7a n 7z,9d°�q�rin¢ H ADD . C,ae�ces 7 �� PERCOLATION ?ATE �4'.�'RAN ?N��/iy I �8 yin,s lo8s� . . PER.INCH C" �. LEACHING AREA PER PERCOLATION RAT; ctv�3TLS�; .•.. S0.r i y S s LoAri S/ a c NC9. .9�vo WATER TwBLE /�' CL_8o / r� w�.7Z1�APPROVE�7 .. : . . . . . . .. . BOARD OF HEALTH GROUND i 7P..-WATER ENCOUNTERED - Of k ss� DATE.. o EDWARD WITNESSED BY : AGENT OR INsPECTOR GCTL/L�/ �liNN!!VG BOARD OF HEALTH � N yA� � No. 26100 s��'73N 4 ! s: ENGINEER �°ps 9f61STE p�