HomeMy WebLinkAbout0083 KEVENEY LANE - Health 63 f6 veneyl'ane A
Barnstable, P
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No. 2`''2 is Fee 06150
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
r Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
RppYication for Misposar 6pstem Construction hermit
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) [Vomplete System ❑Individual Components
Location Address or Lot No. 7 3 X{ 1/�� � rC OAV Owner's Name,Address,and Tel.No.
Assessor's Ma /Parcel Q 1 _L C,-O e ® ��u� �{ `� P B//
P 3 < '>G ^f1�Jt('. A I ve-vc &/ e , 44 c ?t
Installer's Name,Address,and Tel.No. J'o l�� Designer's Name,Address,and Tel.No._$:0P W A 14-4 AS
yn 14xT, A-1 0It Z�0 A16VA1XCkIMC, 123/CIA -6/) y,4AMvI PoAr
Type of Building:
Dwelling No.of Bedrooms k Lot Size4 sq.ft. Garbage Grinder( )
Other Type of Building Q w ,_,L L /N J� No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date — t!3 ;lDo2 O Number of sheets Revision Date
Titler�(/ e
Size of Septic Tank A "®0 0,41-,L-0 A)S Type of S.A.S.
Description of Soil
r
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 provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar of alth. p
Si Date
Application Approved by01 Date I bx v
Application Disapproved by Date
for the following reasons
Permit No. 2o,10 Date Issued v
�.a.}R,+q„' t`'i.L._..• 'F «.-Al w:
o
:THE COMMONWEALTH OF MAS'SACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,-MASSACHUSETTS
l lYltAtIDII:.fOC Disposal 6pBtPIYC COYCBtCttttI0n Pert ttit- Y
Application for a Permit to Construct,( ) Repair( ) Upgrade('"r-'Abandon( ) 5,C-/omplete System ❑Individual Components 0
Location Address or Lot No.q 3 X{ I/e.N 41 ,C 0" Owner's Name,Address,and Tel.No.'Tx7-4"T t- v�
Assessor's Ma /Parcel Q + v t V c @ ,W C, V�W,
Installer's Name,Address,and Tel.No. J—a H/V Designer's Name,Address,and Tel.No j`f/���il(!�
yyt Ffj` iiv pK L L0Ns> 1�+0 ULb'� 0A1&A1JYkJAZ- .91,3`^4-Gr4 y,��edrN lei` `
t r a
Type of Building: w i• \. `/
Dwelling No.of Bedrooms Lot Size/4 � �✓� 4—ft.' Garbage Grinder( )
Other Type of Building h,, ,L L //V J�, No.of Persons .�.--' "'""`•"""""`Sfiowecs("-`) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow p�'idead ' ' gpd
Plan Date O -- /3.10,2 O Number of sheets jj Revision Date
Titled
Size of Septic Tank ���C' (•'t�dk ,VS Type of S.A.S` L� -41
Nil,
Description of Soil
E.VL
Nature of Repairs or Alterations(Answer when applicable)`'
st / ► /V-5
,-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 Certificate of
Compliance has been issued by this Bo d"`of ealt�tT
... Si ed 1 Date
Application Approved by /, , Date 111//(,12 u
Application Disapproved by Date
for the following reasons t
Permit No. ca a tl 3{o Date Issued 1( ///,41 u
THE COMMONWEALTH OF MASSACHUSETTS
�+ BARNSTABLE,MASSACHUSETTS
Certificate of,,Compliance
pliance
r '
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned by > � ?�
at 2? has been constructed in accordance tia
with the provisions of Title 5 and the for Disposal System Construction Permit No. 20-20"'J Wdated
Installer Designer
#bedrooms Ld Approved design flow V VJ gpd
The issuance of this permit shall not be construed as a guarantee that the system will no•on as designed.
Date 7, Inspector V hN v.S,
`r
No. �dt a—�_ 6r� Fee /.'ry.,
THE COMMONWEALTH OF MASSACHUSETTS
J U PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Nspo80I *pBtem Construction permit
Permission is hereby granted to Construct( ) Repair( ) Upgradeq-,") Abandon( )
System located at ke
r ..
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction /must be completed within three years of the date of this permit. '
Date It /2 u Approved by
w
ToNvn� of Barnstable
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ot
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1nst"al lei,"L 'N' Si nor Celqi fileatki11 Ffind
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Addrew x T e r n,
k t t� W . ISS(ted a Baernu t in.sta
based,.on a s9tgn d vr:I'!'L*4datcd
� l �f ci� ��k' '�. '1"1 u ( 3 ,t4Cencx : bove N`¢G} ll.;i�alkied s��;4stantial' ' accar3:71 , o
� i ,, .�ct� 'r i€ t m : l e %.,o t � Mtns, sv%,.h us. Waiml. rcloc4tion of a
dr:stuibutdon 'box �nd,,V scp Et ink, Sri , rams if r t�tr�'6) a�'a i, s c..�rt an the b ;i;s
we f fbuttd sati Af 1fuct ryy
c t that the septi gist an t ihji or thn c . ;
,s t r than . d er .€ lb a part y , t° h n Any,c m ore
an xemsiontir
rtr : c - t � girt l'aL � : ' trtf" twui ) Ilk3 .�
I c t� r whit the . 'item rc&&Anc. b. K �, a can tc t i:�� M t ance the tc ens f
ti l. a�3rk :I lrhtt �F } l� t: lc}
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Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaguid Ma 02637 9/16/11.
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, i
use only the tab 1. Inspector: �)
key to move your VVV
cursor-do not Ricky L. Wright `
use the return key. Name of Inspector
•
B & B Excavation, Inc.
Q
Company Name
14 Teaberry Lane
Company Address
Sandwich MA 02563
Cityrrown State Zip Code
508-477-0653 S14595
Telephone Number License Number
B. Certification n e=
r X`
certify that I have personally inspected the sewage disposal system at this address and tb�,a,�t the-"
information reported below is true,'accurate and complete as of the time of the=-nspection. 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 i.340jof
Title 5(310 CMR 15.000).The system: .�
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
+� 9/16/11
Inspector's ignature 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 DER,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•09/08 Title 5 Official Inspection Form:Subsurface Sewa Disposall System-Page 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Kevene 83 T
G„M y Lane s
Property Address
Thomas Shack
Owner Owner's Name
information isequired or every Cumma uid Ma - 02637 9/,
16/11
page. City/Town 4 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):
r I,
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
f -
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments .
83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaquid Ma 02637 9/16/11
page. City/Town. State Zip Code Date of Inspection
B. Certification (cont.).
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 pipes)are^replaced -❑ Y ❑ N ❑ ND (Explain be
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced- ❑ Y ❑ N f ❑ ND (Explain below):
❑ The system required pumping more than 4times 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•09/08 Title 5 Official Inspection Form: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
°M 83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is Cumma uid Ma 02637 9/16/11
required for every q
page. City/Town 7 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 septictank 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 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:
9
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No to each of the following for all inspections:'
Yes No C -
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•09/08 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 83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaquid Ma 02637., 9/16/11
page. Citylrown 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:
El ® 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.
El ® - 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection' Form
Subsurface Sewage Disposal System Form -Not for Vol untary'Assessments
83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaquid Ma 02637 9/16/11
page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
9
Yes No ,
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ 0. 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?
Was4he facility owner(and occupants if different from owner) provided with
El ® 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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example:,110 gpd x#of bedrooms): 440
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Keveney Lane
GSM •
Property Address
Thomas Shack
Owner Owner's Name
information is Cumma uid
required for every q Ma 02637- 9/16/11
page. Cityrrown 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? [if yes separate inspection required] ❑ Yes ® No
Laundry system:inspected? El Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
: 9 ( Y 9 (9P ))�
Detail:
t
Sump pump? ❑ Yes ® No
Last date of occupancy: August 2011
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
Industrial waste holding tank present? ❑ Yes ❑ No .
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
f
Commonwealth of Massachusetts
HEUSEM51W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is Cumma Uld
required for every q Ma 02637 9/16/11
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: q
® Septic tank, distribution box, soil absorption system y
El Single cesspool
El Overflow cesspool
El 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys
tem em•Pa Page
- 9 P Y 9 17
r
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,
°M 83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaguid Ma 02637. 9/16/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
15-20 yers est.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet ,
Material of construction:
❑ cast iron Z 40 PVC ❑ other(explain):
>20
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):,
At time of inspection building sewer appeared to be in,good shape no signs of leakage or blockage.
Septic Tank(locate on site plan):
6" r
Depth below grade: feet
Material of construction:
®_concrete ❑ metal ❑,fiberglass ❑ polyethylene ❑ other(explain)
t
If tank is metal,'list age: years
Is age confirmed by a Certificate of,Compliance? (attach a'copy of certificate) ❑ Yes. ❑ No
Dimensions: 5.8x5.8x10.6
Sludge depth: Err
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts `
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Vol u ntary'Assessments
83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is Cumma uid Ma' 02637 9/16/11
required for every q
page. City/Town State Zip Code Date of.Inspection
D. System Information (cont.)
Septic Tank(cont.)
`
Distance from top of sludge to bottom of o 32"utlet tee or baffle -
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance from bottom of scum,to bottom of outlet tee or baffle no scum
How were dimensions determined? scour stick.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection tank appeared to.be in good shape tees present no sign of backup.
Grease Trap (locate on site plan):
Depth below grade: Peer
Material of construction:
concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from Acip 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-09/08 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
83 Keveney Lane
Pro Address Property dd ess
Thomas Shack '
Owner Owner's Name -
information is
required for every Cummaquid Ma 02637 9/16/11
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 bepumped 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.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
83 Keveney Lane'
M
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaquid Ma . 02637 9/16/11
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
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.): f
=At time of inspection d-box appeared to be in-working order.No sign of leakage or carryover.
Pump Chamber(locate on site plan):
Pumps in working order:. T ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
4, �I
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
Subsurface Sewage Disposal System Form—Not for Voluntary Assessments
83 Keveney Lane-'
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaquid Ma 02637 9/16/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits . number: 2(6x8) -
❑ leaching chambers number:
i
❑ leaching galleries number:
❑ leaching trenches number, length: }
❑ Teaching 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.):
At time of inspection.leaching appeared to be in good shape no sign of staining or hydraulic
failure.Leaching was dry at time of inspection.
r
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 y
Depth of scum layer
Dimensions of cesspool
Materials of.construction
Indication of groundwater inflow ❑ Yes t ❑ No
t5ins•09/08 Title 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
83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is Cumma uid Ma 02637 9/16/11
required for every 4
page. Cityfrown 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
j
Depth of solids,
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
-r
{
t5ins•09/08 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
c�M 83 Keveney Lane
Property Address
Thomas Shack
Owner
Owner's Name
information is
required for every Cummaguid Ma 02637 9/16/11
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
F31
R I Q (7,- f
)33`
/ V F
7 �.
6
G ='2$ 6
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaguid Ma 02637 .9/16/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells F
>15 M
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record'
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked'with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Hand augered hole threw observation poit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
83 Keveney Lane
Property Address
Thomas Shack
Owner Owner's Name
information is
required for every Cummaquid Ma 02637 9/16/11
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
r
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION 8":�> V-4--yQAQo/ j-n SEWAGE # �LAsPecttlo-,
'�VILLAGE w.nn ASSESSOR'S MAP & LOT O I
� , a 4 v,
INSTP&±:EWS NAME&PHONE NO. �c lL �Clr�nvtell yZ£g-I'l�,SEPTIC TANK TANK CAPACITY
LEACHING FACMITY: (type) �7� �E ��'►S (size) l i3/�.
NO.OF BEDROOMS
BUILDER OR(CEO.R --k2 J -e
PERMTTDATE: 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
T
0 0
LN
1�
Zz I �
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
C # .` .
MAY 0 5'2005
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A ,
CERTIFICATION r F
Property Address: 83 Keveney Lane
Cummaquid MA 02637
Owner's Name: David Potter
Owner's Address: Same
Date of Inspection: March 29,2005 Job#05-61
Name of Inspector: PATRICK M. O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
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 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 � jHillii
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The systerM�����H OF j
__X_ Passes
Conditionally Passes = � TRICK
Needs Further Evaluation by the Local Approving Authority = M.
Fails
(��Inspector's Signature: Date: 3/29/OS '�� �Fg INco
The system inspector shall submit a copy of this inspection re ort 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.
Notes and Comments: System in good condition,leaching pits have 2'standing water.
****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.
Title 5 Inspection Form 6/15/2000 page 1
,Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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.
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 pass inspection if(with
approval of Board of Health)_:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
T41A G rncnartinn Rnr 411;i,)nnn 2
I
,Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
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
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 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,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
T41a C incnantinn 17^r 411 Vnnnn 3
Page 4 of I 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X— 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 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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this forma
_No_(Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of atributary 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.
Titles S Tnenartinn Fnrm�ii si�nnn 4
f
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
d
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_ _X_ Were any of the system components pumped out in the previous two weeks?
_X_ _ Has the system received normal flows in the previous two week period
_ _X_ Have large volumes of water been introduced to the system recently or as.part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
_X_ _ Was the site inspected for signs of break out?
_X_ _ Were all system components,excluding the SAS, located on site?
_X _ 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?
_X _ 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:
Yes no
_X_ _ Existing information.For example,a plan at the Board of Health.
_X_ _ 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(3)(b)]
s
Titles c Tnenartinn T7nrm��i ci�nnn 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL•SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 83 Keveney Lane,"Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Number of current residents:2
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): No [if yes separate inspectiorrrequired]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2003 112,000 gal.'2004—.,122,000 gal.=320 gpd.
Sump pump(yes or no): Yes
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL <`
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records: None
Source of information: Owner
Was system pumped as part of the inspection(yes or no): Yes
If yes,volume pumped:_1500_gallons--How was quantity pumped determined? Size of tank'
Reason for pumping: Inspect interior of tank. '
TYPE OF SYSTEM
X_Septic tank,distribution box,soil absorption system.
_Single cesspool
_Overflow cesspool f
_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
_Other(describe):
Approximate age of all components,date installed(if known)and source.of information: :,
Compliance date: 6/23/92
Were sewage odors detected when arriving at the site(yes or no): No
Title G Inenartinn pe% m </1;Ionnn 6 a
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line: -
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 6"
Material of construction: X_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10.5' long x 5.8'wide—1500 gal.
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: 5" '
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: 9"
How were dimensions determined: STICK WITH HINGE FLAP.'
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees intact and clear,liquid level at bottom of outlet invert.Tank pumped as part of inspection,
recommend pumping every three years to properly maintain system.
GREASE TRAP: No (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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage, etc.):
Titla 9 1ncnartinn Rnrm 6/I si,)nnn 7
Page 8 of l 1
P
VOLUNTARY ASSESSMENTS L
OFFICIAL INSPECTION FORM-NOT FOR V O U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) '
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter Y
Date of Inspection: March 29,2005
r_
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) ` * (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene " other(explaih):
Dimensions: ~_
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (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.):
Distribution box at leachinsz pits paved over,inspected box with pipe camera.Has equal flow to both
outlets. t
PUMP CHAMBER: No (locate on site plan): '
Pumps in working order(yes or no): Y
Alarms in working order(yes or no): .
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): .
t
Title C rnenantinn Rnr A/I S/innn 8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)'
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_X_leaching pits,number: Two 6x6 pits.
leaching chambers,number:
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.): Pits have 2'standing water with no high stains.
CESSPOOLS: No (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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of.vegetation,etc.):
PRIVY: No (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.):
Title i inonartinn i nr Aii,;i,)nnn 9
Page 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
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.
y
" #83
49 22
Garage .
79 54
21 17
CA covers 6a grade
Edge of Pavement
Tif1a Tnc—A finn Pn—4/i,;iinnn 10
-Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 83 Keveney Lane,Cummaquid
Owner: David Potter
Date of Inspection: March 29,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
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)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el. 10 and topo map shows property above el.30.
Titla G Tncnartinn Rnr 411 vInnn 11
_ (Sr
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection . (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
. f
COPY
COMMONWEALTH OF MA.SSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID.B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIRCATION �y
Property Address: 8 3 Ke V 6 n e y Lch e- Name of Owner /'1 car
C #" o. q c� Address of owner: eQ. f'o;� 3 7
Date of Inspection: oZ/02 y/od y0.r p✓ / or+ M a. &, 6 7S
Nano of IrmPector:(Plea Print) Troy Williams
am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000)
Company Nam: Tro. Yrlliams So tip Inspections
Mailing Address: 19 Hummel Drive, So. Dennis, MA 02660
Telephone Number: (508) 385-1300
CERTIFICATION STATEMENT G
1 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:
V/Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
4upectoes Signature:!__Z r, ��� Date: a
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
RIFBARINSTABLE
ED
MA2000
TOW
EPT �
revised 9/2/9R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART'A
CERTIFICATION(contirxied)
Prop"A
owner: 83 Keveney Lane, Cummaquid, MA
Date of Inspection: Mary Smith
February 24, 2000
INSPECTION SUMMARY: Check A, B, C, o/ D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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 t e replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health, will pa
Indicate yes; no,or not determined(Y,N,or ND). Describe basis of determination in all.' tances. If "not determined",explain why not.
The septic tank is metal,unless the owner or operator has provide he system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed wit n twenty(20) years prior to the date of the inspection;or
the septic tank, whether or not metal, is cracked,structurall nsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the xisting septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static w er level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven dis ution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipets) replaced
obstruction i emoved
distributio ox is levelled or replaced
The system required pu ping more than four times a year due to broken or obstructed pipe(s). The system will pass
Inspection if(with ap roval of the Board of Health):
roken pipe(s)are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Addres::
83 Keveney Lane, Cummaquid,MA
QWfer: Mary Smith
Date of Inspection: February 24, 2000
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 stem is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE W rH1 3 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT:
— Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or alt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH NO PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS TH UBLIC HEALTH AND SAFETY AND THE ERVIRONMENT:
The system has a septic tank and soil bsorption 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 an soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank d soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic to and soil absorption system and the.SAS is less than 100 feet but 50 feet or more from a
private water supply wet unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that the
well is free from pollu. n from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Meth used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR?A
CERTIFICATION (continued)
.83 Keveney Lane, Cummaquid,MA
Property Address: Mary Smith
Owner: February 24, 2000
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either"Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 0 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine hat will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due-to an overload or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or su ace waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet inve ue to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last ear NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption Syst , cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy. within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or ivy is within a Zone I of a public well.
Any portion of a cessp or privy is within 50 feet of a private water supply well.
_ = Any portion of a c spool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable we quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bac ria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: ^
You must indicate either"Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria abo
The system serves a facility with a design flow of 10,000 gpd or gre er(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the ollowing conditions exist:
Yes No
the system is within 400 feet of a surface dri ing water supply
the system Is within 200 feet of a tribut to a surface drinking water supply
the system is located in a nitrogen nsMve 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 she upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further intorma' n.
revised 9/2/98 Page4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 83 Keveney Lane, Cummaquid, MA
Owner: Mary Smith
Date of Inspection: February 24, 2000
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yeses No
�/ _ Pumping information was provided by the owner,occupant,or Board of Health.
None of the system components have been pumped-for-art least two weeks and-the system has been-receivinglnormal 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.
JC/ _ The system does not receive non-sanitary or industrial waste flow.
y _ The site was inspected for signs of breakout.
_ 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:
_ Existing information. For example, 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(
/ 115.302(3)(b)]
The facility owner(and occupants,if different from owner) were.provided with information on tha.prnpermaintanance�f
SubSurface Disposal Systems.
revised 9/2/98 page soru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Owo�Y Address: 83 Keveney Lane,Cummaquid,MA
Date of Inspection: Mary Smith
February 24, 2000
FLOW CONDITIONSRESIDENTIAL:
Design flow: /10 g,p,d./bedroom.Number of bedrooms(design): Number of bedrooms(actual):
Total DESIGN flow yyo
Number of current residents: ) (h,Ore P-.-
Garbage grinder(yes or no):—a5
Laundry(separate system) (yes or no):A/O; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):jV0
Water meter readings,if available(last two year's usage(gpd): E pu0 J(oaS
Sump Pump(yes or no): NO
Last date of occupancy: n«V P e-cf
COM MERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_ apd (Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)—
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of Information: �f
P�.tzt� 9//f /9R o<,r rM7'D o6 i�+cfi� �'.-sr,., Lio�y.e. owntr
System pumped as part of ins ecuon:(yes or no)_,!ft(o
If yes,volume pumped: gallons
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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: .fK
Lc.tic.L. p, �s wc,* �w c`-s- fiu:
Sewage odors detected when arriving at the site:_(yes or no)_,yD
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address`, 83 Kevene Lane Cumma uid MA
Owner: Y q ,
Date of Irupection: Mary Smith
February 24, 2000
BUILDING SEWER:
(Locate on site plan)
r�
Depth below grade: 8 +
Material of construction: cast iron Z40 PVC_other(explain)
Distance from private water supply well or suction line N/19
Diameter
Comments:(condition of joints, venting, evidence of leak e,etc.)
SEPTIC TANK:
s ti t P tie+.
(locate on site plan)
Depth below grade:�r
Material of-construction:Zoncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age ls.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 7.�>c/1
Sludge depth: !�
Distance from top of sludge to bottom of outlet tee or baffle:.2 i8 �r
Scum thickness:T4;" 1 a y c.r
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: Pro 16..
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structuraHMagrity,
evidence of leakage,etc.) �r c c is . /c o, A 4- �� ����
YVc_ ,
a �� �
— C;
rL n
✓a l
w w
1
vrt�
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(e lain)
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 r baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Page 7or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Addfeu' 83 Keveney Lane, Cummaquid,MA
Data of Inspection: Mary Smith
February 24,2000
TIGHT OR HOLDING TANK: (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(expl n)
Dimensions: _...._.
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes N:7Z
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switch )
10,
DISTRIBUTION BOX:_/
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note-if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box;etc.)_ _ /J aw was
4 C-Lt S IA/
~ '�^ 4 - h w at o ✓
_ ox
wor
L,
C�cc�✓v. 4�0 ,1 67r '0C JL »+s »f wui_lo^ ✓ C- slry c .
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 appurtenanc ,etc.)
revised 9/2/98 Page sorit
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM WFORMATION(continued)
Property Address: 83 Kevene Lane, Cummaquid,MA
Owner: }
Date of inspection: Mary Smith
February 24, 2000
SOIL ABSORPTION SYSTEM(SAS):,
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type X 6 r L«.
leaching pits,number:�— 8 ' C.ll, Pr�S w •"f"� �G S�u Ham- o.SS J w.e
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(not col ftion of soil,signs of hydraulic failure,level of/ponding, damp soil, condition of vegetation, etc.)
r tt -T a. oZ'O 1^- w/La��'-�r c-C c." iL
I I G.✓ !A 1 t-✓ I t� 1 �' N�Cl J r•. M.1.'�'1 T �✓P 4
D f Lf l ov y I �- "7rA (.�✓t �„r � l../ L. r n�t
I. /hi �✓EJiS T �.Jcr-�- �,✓v. c( r)rcSe.n-�- w f-
cEssPo •_ .�-1,t �-i�t � ram' ; HJs p���i�... /"
locate on site plan)
Number and configuration: r
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
in (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,level of p/ig, ndition 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,eon on of vegetation, etc.)
revised 9/2/98 Page 9eru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOM FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 83 Keveney Lane, Cummaquid,MA
Date of Inspection: Mary Smith
February 24,2000
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
A E = 9cl
AF =
A G , 79 '
aE = 22 � B
�^ 30
G H =�1 '
C 3°
C =2.8 �svo f wut,�
1 � Q
F_r�
G�ru.ci Q.
7-
�
2
6 p;4 C-
"Pi
. revised 9/2/98 Page toorit /
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Address: 83 Keveney Lane,Cummaquid,MA
Date of Inspection: Mary Smith
February 24, 2000
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
SD(IJ 2 sz
Observation Wells checked A/C lq , Cy aJ
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water ✓
Check Cellar
Shallow wells
Estimated Depth to GroundwaterOlDf Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site JAbutting property,observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
wl t i .s /e5 L a �- b h %Y t^ a-flJ••tal w f'l, w I.,�
r
L/; Su a.1
f r,<.. ti a�rco� o_� �� l,`�'r.� p ' rr�slJ�c1�'os, IJG�S �• 9 �.
Uo�'�r►+ a c/ yo s �- �o i HI a_.S l 2 . 5 C n J� G��-3 �o }- /a c.u�t�
revised 9/2/98 Pact 11 of 11
TOWN OF BARNSTABLE
1-9CATION 23 Kc vep) Lc:( e SELVAGE # - 7
VILLAGE ) Vw L `N ASSESSOR'S MAP & LOT 3 "j-61
,!INSTALLER'S NAME & PHONE NO;�
SEPTIC TANK CAPACITY 1 500
LEACHING FACILITY:(type) Pit"i v(size) q l� l
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER (lJ7J 1 �
BUILDER OR OWNER ✓ C� `1 I l 6�I
DATE PERMIT ISSUED:
DATE COMPLIANCE 'ISSUED:
VARIANCE GRANTED: Yes No L/
r
; c
C'
2 � �
(V W N W N .
No...,� .- :. 3 Fns..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTHP : '
.:'c vatlon Dept
TOWN OF BARNSTABLE
,� lirtt#tla for i u l irk Cnong ` r rrMl
"I
Application is hereby i t de for a Permo Construct ( ) or Repair (�) an Individual Sewage Disposal
S stem at: /�i 'r-,w X . n
c%
`.•`.olv` T._ �dress1.......................... 5.R ...or Lot No. ...._.._........
W � Owner Address
Installer Address
Type of Building , Size Lot...................... Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other a —Type of Building ---------------------------- No. of persons............................ Showers
( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------•-----------•-------•-•-------- ---------•---------------------- ------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity..........--gallons Length................ Width................ Diameter------.......... Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.--................. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit---.............--.. Depth to ground water.....................--.
44 Test Pit No. 2................minutes per inch Depth of.Test Pit---................. Depth to ground water.............--.........
a -------------------------------------------------------------------------------------•------'--''-......................................................-•--
0 Description of Soil.................................
x
V .....-------•-•----------•-----------------------------------•--.....----------------........------------------.----------------------------...----------------------------..............--..._---.-----
UW -----------------------------------------------•------•-•----------------------------------•.....------------. ------------
Nature o�R,pairtor Alttera�ns—�A`nssweg when applicable,71- .................YS1^L--''` -------------------------•-•----
-•----------------------------------••--------------------------------------------------"--------------•------•----------.....-----------------------------------------------------------------•--------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issue,. th Sard o h
Si n
----- ------ .................
Date
Application Approved By ..............
<`.,.`"'.,,, ................------...................... ............................ --- 4
�t�Dat
Application Disapproved for the fo owing reasons: ... ....................
---------------------------------------- ---------------- --............................................-- -- ---- ----------------------- -- ......................................... .........--..........................
Dale
Permit No. .....--�d- ��- Issued ................................... .........................
Date
No....al .: `:_.. Fzs............................
..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD.-OF- HEALTH
TOWN OF BARNSTABLET��� -6
Appliration for Diopoottl Works TontrurfUan rrmit �' -") 9�
Application is hereby made for a Permit to Construct ( ) or Repair (l ) an Individual Sewage Disposal
System at: c !/ /'/✓ P Y 4;,A
..�f..: _ ........ �--------------------------- ---- '`' ` '-"' '�...
r- / Location-Address or Lot No. .. -...........................
.. --. .-..
...._A:Z"W.,sT Z"t.-.Z................................ .........................---•-•----...... .....................0......................
Owner Address
a ram '._....... ......... .------.... ................
pq Installer Address
Type of Building 3 Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
WOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------•-------•--------•----------•---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------__-- Width................ Diameter................ Depth................
x Disposal Trencz—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
F-I Percolation Test Results Performed by.......................................................................... Date........................................
a
11 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit 1\o. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
a' -------------------------------------•------------••------------••------.....--•-------•-----------.....---•----•--------------•......-•-----•-----•---------
0 Description of Soil..................................................................................
-------=----------•-•-•---------•-••-------....-----------------•--•-........................
W
V ..............................................--------•-----------••-...•-----------------------•-------.......------•----••--••---------•---•----------•--------.....----••=•-----..._.........--------
------------•- _ --------------------------------------------------
U Nature of Re airs or Alterations—Answer when applicable�?.�r-__-----l�_..�_%Sf__���____-1--k __••__-
o 'p C lF 14 A/ 4 v i
------------------------------------------------------------------•••------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued-by the.board of,.health.
Signed `
/ Dale
Application Approved By -------------- ''--
Application Disapproved for the fo owing reasons- --------------- ------------------------- -------- ------------------7...---------------- ----------- ------------------
------ --- --------------------------------------------..................................... ........................................................................................................ --------------------------------- ----
Dace
PermitNo. . .... 1---Z.. . Issued --------------------------------................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
&r#ifirate of Qlantylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
by ....--- .. ................................................
Ins[aller
---------------------------------------------
at ------------ ............. -- .............'- .....-- --' -......�--y--------G `� `
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..--....... ..-...rc .7. ..... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE'CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
D
DATE------------------ ........................ ------------------------------- ---------- Inspector ------------......
V_---- ---------------------- -----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
qq TOWN OF BARNSTABLE 3 c2
No..,L��..: .
71 FEE........................
�i��o��t� ork� �on�/frion l�rntif
iL G /.f L9d S�
Permission is hereby granted -142
-----------------•-------•-------------------
-----------
--.....................
.. .........
..-------.---.........._
to Construct ( ) or Repair ( ,j an Individual Sewage Disposal System
at No. �' .. v��/ ..�..:'�------------------------------/�! ^�-r------------------•..........-•-----••----•-•---•---....
--......
Street ��
as shown on the application for Disposal Works Construction Permit No,%r�.: _ Dated..........................................
f •-------•---.....--•-.........�- ........................................................
DATE............... -
C t r ............................. Board of Health
--�------�-� ------
FORM 36508 HOBBS♦!WARREN.INC..PUBLISHERS
SEPTIC SYSTEM PROFILE
TEST HOLE LOG
8 M ® T.O.F 121.94 NOT TO SC ALE DATE: 8/14/20 T.H. #1+2 T.H. #3+4+5+6 9/3/20
T.H. #7+8 9/29/20
/ TEST BY: MIKE O'LOUGHLIN
WITNESS: DAVID STANTON
ASSUMED PERC RATE T.H.#7+8 C2 LAYER MED.- COARSE SAND > 5 MIN.
(2) WAY CLEANOUT
HOLE
To GRADE WITH TEST # 1 TEST HOLE # 2 TEST HOLE # 3+4
WITH PLASTIC HAND-
HOLD COVER TO GRADE 011 120.2 EL _ C). 119.7 EL 120.4 EL
COVERS TO WITHIN AP LOAMY SAND
6" OF FINISHED
12„ FILL 119.2 EL 12„ FILL 118.7 EL 18" 10Y 3/4 118.9 EL
COVER TO WITHIN 6 GRADE
CELLAR FLOOR OF FINISHED GRADE BW LOAMY SAND BW LOAMY SAND BW LOAMY SAND
" 36» 10Y 5/8 117.2 EL 36" 10Y 5/8 116.7 EL 42" 10Y 5/8 116.9 EL
IT, , 112.0-111.0 F.G. PIPE TO BE -LEVEL MINIMUM 2 PEASTONE OR
FOR 2' OUT OF D-BOX GEOTEXTILE FABRIC 5' OVERDIG TO B E C1 C1
C1
111.0 F.G. 109.0 INSPECTED BY SANDY CLAY LOAM SANDY CLAY LOAM FINE SAND
REPLUMB To NEW DESIGN ENGINEER 2.5Y 6/4 2.5Y 6/4 2.5Y 7/4
LOCATION AS SHOWN 110" TEE
ON PLAN WITH PLUMB ING ETAIL 3' 5' OVERDIG 23' X 43.5'
r7
14" TEE
PERMIT FOR WORK 112.5F 107.0 REMOVE FROM TOP OF
109.0 GAS B AFFLE 107.75 107.41 TOP ® 106.0 168" 106.2 EL
107.58 C-2 LAYER TO 168" 1A5.7 EL 68" 114.75 EL
0 0 0 0 0 0 0 0 0 0 o EXISTING GRADE, AND
H-20 0 0 0 0 0 o a B B o o REPLACE WITH C LEAN C 2 C 2 C2
D-BOX 105.0 g o o o g SAND TO EL. 106.0 SANDY LOAM SANDY CLAY LOAM SANDY CLAY LOAM
a 103.0 2.5Y 6/3 2.5Y 6/3 2.5Y 6/3
/ - 1500 GALLON H-10 103.2 EL 228'
a MONO SEPTIC TANK 17 204" 204" 102.7 EL 101.4 EL
6 COMPACTED STONE „(3) 500 GAL DRYWELL H-20 NO WATER ENCOUNTERED NO WATER ENCOUNTERED NO WATER ENCOUNTERED
2 OR COMPACTED BASE WITH 3/4 - 1 1/2" OF DOUBLE WASHED STONE 8.35' T.H. # 7
NO WATER
4' ON ENDS AND 4' ON SIDES � g4.65 ENCOUNTERED TEST HOLE 7 12.83' X 33.5' TEST HOLE # 5+6 # TEST HOLE # 8
�- 119.0 EL 108.9 EL 109.69. EL
0 0
FILL
42" 115.5 EL 3" 108.65 EL 3„ 109.44 EL
C SANDY CLAY LOAM A LOAMY SAND A LOAMY SAND
52" 2.5Y 6 3 114.68 EL 12" 10Y 5/3 107.9 EL 12" 10Y 4/2 108.69 EL
o
C2 FINE SAND BW LOAMY SAND BW LOAMY SAND
98" 2.5Y 7/2 111.03 EL 38" 1OYR 5/8 105.74 EL 38" 10YR 5/8 106.53 EL
C3 C1 C1
O SANDY CLAY LOAM SANDY CLAY LOAM SANDY CLAY LOAM
2.5Y 6/3 80" 2.5Y 6/4
102.26 EL 88" 2.5Y 6/4 102.38 EL
136" 107.71 EL
C4
C2 C2
- FINE SAND
2.5Y 6/4
f06 MEDIUM -COARSE MEDIUM -COARSE
SAND SAND
BenchrnAr k se fo4
194" 102.89 EL 168" 2.5Y 7/3 94.9 EL 168" 2.5Y 7/3 95.69 EL
108 MAG SET NO WATER ENCOUNTERED NO WATER ENCOUNTERED NO WATER ENCOUNTERED
108.4'1
Drive l01,94
CB OH FND
102 GENERAL NOTES
lu 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION -0F ALL
UNDERGROUND AND ABOVE GROUND UTILITIES PRIOR TO ANY EXCAVATION
OR CONSTRUCTION.
__ ' Paved _ .._--
IL _ - - _ - W-8 y, 2. SEPTIC SYSTEM IS TO BE INSTALLED IN COMPLIANCE WITH 310 CMR
0 ----11� �CF 15.00:TITLE V.
z l - Parking -
n- �G -
i � ,� I REQUIRED B Y L ,
3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION.
J - �► 4 AND I FINAL INSPECTION BEFORE B A�KFR L DIG F PAN
i� �� WALK-IN
GARAGE 5. CONTRACTOR TO PROVIDE 48 HOUR NOTICE FOR ANY REQUIRED
i� M CLOSET ATTIC INSPECTIONS.
1 ' . $ �"Q}. 6. THIS SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE
1 I DISPOSAL.
TOP OF ALL SYSTEM COMPONENTS SHALL BE MARKED WITH
MAGNETIC MARKING TAPE OR A COMPARABLE MEANS IN ORDER TO
o ONCE BURIED.
BATH BATH ND UNSUITABLE OR DIFFERING FROM THOSE FOUND
LOCATE THEM
8. IF SOILS ARE FOUND
ros BEDROOM IN SOIL LOG CONTACT DESIGNER AND THE BOARD OF HEALTH.
to
• 9. IF AN OVERDID IS REQUIRED BY PLAN, OR IF UNSUITABLE SOIL IS
,� E o BEDROOM A B LAYERS.'. F CLEAN GRANULAR SAND MEETING 310CMR 15.255(3)
EDRO ouND +
Garages --- e \ E 10. ALL 4" PIPE CONNECTIONS AT SEPTIC TANK AND D-BOX SHALL
ETAIL A s
BE MORTARED IN PLACE. IF USING 18' PLASTIC RISERS, THESE TOO
i # �e SHALL BE MORTARED OR SEALED IN PLACE.
j I Paved W SERvPcE
Drive \ BEDROOM DESIGN DATA
DAILY FLOW: (4) BEDROOMS X 110 GPD = 440 GPD
BEDROOM
SEPTIC TANK: 440 GPD X 2 = 880 GPD
USE: 1,500 GAL. H-10 MONO SEPTIC TANK.
i p , DISTRIBUTION BOX:
\ Brick ;`,, 1 ,1 I USE: DB-6 H-20
SECOND FLOOR SOIL AB SORPTION SYSTEM: 440 GPD s .74 = 594.6 SOFT
PATIO ,
1 l T.�.M2 �''i3 \ USE: (3) 500 GAL DRYWELLS H-20 WITH DOUBLE WASHED STONE
T01-12LS4 \ 1 NOT TO SCALE 4' ON ENDS AND 4' ON SIDES
(,4ssumed) ti `I j
SIDEWALL AREA: 92.66 X 2 = 185.32 SOFT
BOTTOM AREA: 12.83' X 33.5' = 429.81 SOFT
T.H.N3 15.13 SOFT
f � ; TOTAL AREA:
E G 120.98 T.H.06
S m
N NOTES
T.H.M4
\W �< 1. LICENSED PLUMBER TO OBTAIN PERMIT AND RELOCATE PLUMBING TO
GARAGE EXIT FRONT OF BUILDING UNDER CELLAR FLOOR AS SHOWN ON PLAN.
BREAKFAS 2. ENGINEER TO INSPECT OVERDIG BEFORE PLACEMENT OF SEPTIC SAND
NOOK
IFT 1LE LIVING AND THE SAND TO BE USED FOR FILLING AROUND SAS SHALL
\ 102,64 MEET SPECIFICATION OF CMR 15.2.55(3).
G //
Stockade Fence 4 164 foes BCHB FND '+i 3. REMOVE THE SEPTIC TANK AND FILL IN (3) EXISTING LEACHING
--1 PITS, OR LEAVE PITS IN PLACE TO USE AS DRYWELLS FOR
N e3•o_ i�, 1 ROOF DRAINS
106 4. SEE DETAIL (A) FOR 4" PIPING AND 2-WAY CLEANOUT TO GRADE.
foe FAMILY KITCHEN
VARIANCE
LIVING
DINING
`n Lot t
o y FIRST FLOOR
Map 351 o �C NOT TO SC ALE
Parcel 13 r
Ays v a HEALTH AGENT APPROVAL DATE
SURVEYOR: PROPOSED SEWAGEPLAN ENGINEER:
u TERRY WARNER LA STEPHEN HAAS
W LOC ATION:
o Q 73 KEVENEY LANE
B ARNSTAB LE, MA.
LL1 �d ATE Y a PREPARED FOR:
o PAUL REVERE
U Z o ANN 1 = 20 DATE: 10 13 20 '
'LIJ ' No. 87 WAHNE2 JOB NUMBER: REVISION: / `ca
LLl Scale: I.20 9 ,a SHEET NUMBER:
MAP: 351 PARCEL: 13 ��'`'. �; f� $��
} v #.
3 R� 6P 0 20 40 bo J. 0 LOUGHLIN INC . r .
1�� liD 714 MAIN STREET
_ 1
W YARMOUTH PORT MA 02675
LOCUS '
508 362-4942