HomeMy WebLinkAbout2159 MAIN ST./RTE 6A(BARN.) - Health 2159 Main Street
Barnstable
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Commonwealth of Massachusetts o?c3 DAD
Title 5. Official Inspection Form
i Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments
y ,/
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
required for
Is every East Greenwich
required for eve RI 02818 8/1.2/2019 �~
page, City/Town State Zip Code Date of Inspection n.7
tw:r
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. Inspector ector Information
on the computer,
use only the tab Douglas Brown
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services Inc.
use the return key, Company Name
350 Main St.
Company Address
West Yarmouth MA 02673
Cityfrown State Zip Cod_e
reuun 508-775-2825 S14297
Telephone Number License Number
B. Certification
I certify that:I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true,,accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
8/20/2019
Ins or's Sig na ure - Date
The system inspector shall submit a copy of this inspection'report to.theApproving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DER The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 0281& 8/12/201_9
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
System is in working condition.
Y 9
2) 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Fla Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn . PO Box 518
Owner Owner's Name
information is required for every East.Greenwich RI 02818 8/12/2019
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):,
❑ distribution box is leveled or replaced ❑'Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑'Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) 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.
a,
a. 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:
t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts `
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is East Greenwich RI 02818 8/12/2019 required for every '
Cit !Town
page. Y State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fall 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 aseptic 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.
c. Other:
4) 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich Rl 02818 8/12/2019
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than'/z 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 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
k
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 18
Commonwealth of Massachusetts
,9 Title 5 Official Inspection Form
G Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 02818 8/12/2019
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
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 backup?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® 0 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 .Official Inspection Form
�� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .
2159 Main St. Barnstable, MA 02668
Property Address.
Tom Quinn PO Box 518
Owner Owner's Name
information is East Greenwich RI 02818 8/12/2019
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information .
1. 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): 110x4=
440gpd
Description:
Number of current residents: ' 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes"'® No
information in this report.)
Laundry system inspected? Z Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d 2017=526gpd
9 ( Y 9 (gp )) 2018=480gpd
Detail:
Note irrigation system in use on property.
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�^ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 02818 8/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes; discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: ,
No Records
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information Is required for every East Greenwich RI 02818 8/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of.System:
® Septic tank, distribution box, soil,absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
f
❑ 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):
.Approximate age of all components, date installed (if known) and source of information:
2014 Per BOH Records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
2911
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +10'
feet
Comments(on condition of joints, venting, evidence of leakage, etc:):
Line was checked with sewer camera and found to be clean, properly pitched with no sign of root
intrusion.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection` Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518 -
Owner Owner's Name
information is East Greenwich RI 02818 8/12/2019
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: _ 1911
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: .
1500Ga1
Sludge depth: 4-5"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 1-2
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 were dimensions determined? Estimated
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
150013al tank.in good condition.PVC tees in place and clean. Tank at normal operating level. Covers
19" below grade.
t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
F
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
lo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 02818 8/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:. Date
Comments (on pumping'recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: f
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
i
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
!% 2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 02818 8/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont)
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
9. Distribution Box(if present must be opened) (locate on site plan).
Depth of liquid level above outlet invert Oil
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.):
H-10 DB-3 with 1 line in and 3 lines out in good condition. Box is clean and level with minimal solids
carryover. Outlet inverts equal with speed levelers in place. No sign of overloading or hydraulic.
failure. Cover 24 below grade.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 02818 8/12/2019
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑;Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 3-50013al
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
ii Title 5 Official Inspection Form
M1 e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is East Greenwich RI 02818 8/12/2019 required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
3-500Gal Chambers with stone in a 12.83'x33.5'x2'Trench. No standing effluent in chambers during
inspection. No evident stain and soil was clean. No sign of overloading or hydraulic failure.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer.
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official InspectionForm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`,e,y 2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is East Greenwich RI 02818 8/12/2019 required for every .
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
I
Commonwealth of Massachusetts
.q (pi Title 5 Official Inspection Form
.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 02818 8/12/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont)
14. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
.� Title 5 Official 'Inspection Form
F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 02818. 8/12/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground +5.Below SASwater: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
14
If checked, date of design plan reviewed: Date
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Engineers Letter
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
Engineers letter and plans on file at BOH from 2014. Showing a minimum of 5' separation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page..
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
- ,T Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
yy�
tl� 2159 Main St. Barnstable, MA 02668
Property Address
Tom Quinn PO Box 518
Owner Owner's Name
information is required for every East Greenwich RI 02818 8/12/2019
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
rage 1 of L
• s
- . TOWN OF BAMSTABLE
LOCATION. g-44 S C1 t2,i 6 A- SEWAGE# g 1 •640
VILLAGE. CzpIJ;� � ASSESSOR'S MAP&PARCEL 037 4
INSTALLER'S NAME&PHONENO.,?��gw—t�jtom " 5r65--_7'71-1311
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)-"=,iu It i(--F- (size) M. k o•QX-4-
NO.OF BEDROOMS
444
OWNER QUA tic;
PERMIT DATE: 1*•I�E COMPLIANCE DATE: L
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility Of any wells exist on ,
site or within 200 feet of leaching facility) N r Feet ,
Edge of Wetland and Leaching Facility(If aay wetlands exist within
300 feet of leaching facility) N Fk Feet
FURNISHED BY G/ow�+ -CaP. Il n f i v►..
3�6 .
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Town of Barnstable.. -- P#-
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gyp' ' Department of Regulatory Services
Public! •� � Division" Date
�A s639 tied 200 Main Street,Hyannis MA 02601
lFD MA't�
A .. 4 • - 00
Date Scheduled Time
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— / Fee Pd.
Soil Suitabzlty,Assessment for Sewa e Disposal
Performed By: fi�I`e� /"�C .�?�f� Ski Ir-'Z
Witnessed By:
+ LOCATION& GENERAL INFORMATION
Location Address Z$j 9 /on f,•� sue— Owner's Name l tf yy
lydr,.s b(e PD /Sox
Address
P 2 5 7 — O tCv rv- ie ► 4✓�
Assessor's Ma /Parcel: i Engineer's Name (jL A I
._ ,vieSL!t!�g I 1
I NEW GQNSTR!JGTI!2IJ izcFHu�Z_ � —��'— 1Telephone#
Land Use AlVl 4 e,- slope! r
P �(90) � � Surface Stones
Distances from: Open Water Body 3 ft Possible Wet Area / g '2_S'Q ft
• ,�_ft Drinking-Water Well' (
Drainage Way, f 0 ft Property Line i 5� t Other
ft
SKETCH:(Street name,dimensions of lot,exact locati(ns of test holes&perc tests,locate wetlands in proximityto`hoies)
Eq
Parent material(geologic) w r Depth to Bedrock --------
Depth to Groundwater. Standing Water in Hole: Weeping from Pit.Foie
Estimated Seasonal High Groundwater
DETERMINATION FOR SE.SONAL,HIGH WAT +R TABLE
Method Used: _ I
Depth Observed standing m obs.hole .: '`
P g in, Depth to soil mottles: in.
Depth to weeping from side of obs.'hole: in, Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level^ �r Adj,factor Adj.Croundwater Level
PERCOLATION TEST
Observation
Hole# �'� time at 9" /ZED Z
d
Depth of Pere - - Time at 6"
Start Pre-soak Time @ /C!+ tj !• Time(9"-6") ;
End Pre-soak k1
Rate Min./Incht +°
Site Suitability Assessment: Site Passed Site Fliled: Additional Testing Needed(Y/N)+ y
Original: Public Health Division Observation
g' . !lion Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one (1) week prior to beginning.
Q:\.SEPT[C\PERCFORM.DOC )_0 ...
DEEP.OBSERVATION HOLE LOG Hole# 1
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones-Boulders.
'Consistency,% ravel
d -Zo 14 ISL tLOj (LJj'z b�
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o lA Via, M.eoR-�j S`P / cs,,--
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DEEP OBSERVATION HOLE LOG Hole#
Depth from - Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,% rave
CA t,
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DEEP OBSERVATION HOLE-LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
..
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DEEP OBSERVATION HOLE LOG. Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
o si en I
Flood.1nsuron.ce_R.ate Max,.,
Above 500 year flood boundary No_ Yes ..
Within 500 year boundary No Yes
i
Within 100 year flood boundary No/- Yes
Death of-iNaturally Occurring Pervious Material
Does at least four feet of naturally occurring pervi us material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on, �t �9� (date)I have.passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required t ' ' ,expertise and experience described in 310 CMR 15.017.
Signature L. -�-- __._.."" Date I
I
Q:\.SEPTIC\PERCFORM.DOC
TOWN OF BARNSTABLE
LOCATION =4 i S 1Zf7 6 A- SEWAGE#
VILLAGE �(� Ott_$ ASSESSOR'S MAP&PA""RCEL al-3 -
S�
INSTALLER'S NAME&PHONE NO. � tZ� C e- ,� SPn5--7-71-9.3-11
SEPTIC TANK CAPACITY o�CQ 4&L- 10W
r � r
LEACHING FACILITY:(type)��tZ t� t4-- (size)
NO.OF BEDROOMS 4�-
OWNER OLLA 1,t to
PERMIT DATE: c=N- i 4--14- 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 Dow,., CND 11dr�v,r�.-�zr
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No. G ' Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
I PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS es
6
appfit tin for ispo Y O stent Construction j9erntit
Application for a Pt to)_<Cq4qtruct( ) Repair /U ade( ) Abandon( ) R/Complete System ❑Individual Components
Location Address or Lot No.,2 ksl Owner's Name,Address,and Tel.No.
L� �fn
Assessor's Map/Parcel.B� fjf`Fdt 6� l Dm d?u1M
Installer's Name,Address,and Tel.No..S0$-90/- 9:399 Designer's Name,Address,and Tel.No. _
��V'}616�7� �OrT3fr2.^Cf'iC�rl,jyie t/sXrjVS+V M P
in' /I ,1ric
G,. "(V G�Co�
Type of Building:
Dwelling No.of Bedrooms Lot Size 1-39 *KfW5 sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 9(46 gpd Design flow provided YSI-S gpd
Plan Date"t;ctf,j I , dy{T Number of sheets
j IJ
Revision Date
Title -r�� �S� l e PIS 04 a16-1 h �o k 6 A �n a"e..
Size of Septic Tank �c/�Og� H/U / Type of S.A.S.43) Cx1�r�Q Jj-d U �� 3A$1C I-a.S3 Q
Description of Soil 6R2 Q`f:'& / d 60 a,` l CSC
Nature of Repairs or Alterations(Answer when applicable) .SS
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 d not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
y Signed _ __....._. Date
Application Approved by "�- 42f Date 2 <<
Applcation Disapproved by Date
for the following reasons
Permit No.- J(��U�.� Y Date Issued
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es
,1 PUBLIC HEALTH DIVISION - TO;INN OF BARNSTABLE, MASSACHUSETTS
Zipplic i n fdr ispo Y Opstem ConstCUttion 3pErmit
Application for a Pe it to o struct ) Repair •r-U oade'( ) Abandon( ) R/Complete System ❑Individual Components
Location Address or Lot No.,2)Sj , j / ' Owner's Name,Address,and Tel. "-"-
Assessor's Map/Parcel ydrnSR `��- ►
Installer's Name,Address,and Tel.No: 9 3 9 9 Designer's Name,Address,and Tel.No.
k�l�fh� G�vr�sfi vc1�t ,:t x+c yS�r�dusEry fit t�ccvn )apE•r�ineer"i�'► ,-Ln
f o G[i C��Co7S
Type of Building:
Dwelling No=of Bedrooms '' Lot Size /•3g *K•(2_5 sq.ft. Garbage Grinder( )
Other _Oype of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.re�quired) 9 y� gpd Design flow provided - �S�S gpd
Plan Date"u rt 1 oZ, a o1� Number of sheets / n Revision Date %
Title-T'i p_ �"S;I°&_ pjc"-i c.�-�. o?l S� /'loll-k- 6 A �.:Xcrl)S�cC. Je_ II
Size of Septic Tank Type of S.A.S.43 S�Y)!�nC U-,?U mi (S 3 .SX a�oFj3lC�
Description of Soil 6" Ci., ,Sp
r
Nature of Repairs or Alterations(Answer when applicable)
3 k� o n� cf cu •SQL ` j h
n if
Date last inspected: �f e
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore?, escribed on-site sewage disposal sy m
accordance with the provisions of Title 5 of the Environme Code d not to place4h_-ystem in operation until a Certificate of
Compliance has been issued by this Board of Heal i
l Signed Dates /
Application Approved by 12r Date [ i
Application Disapproved by y Date r
for the following reasons
Permit No. 'I")f 'o ® Date Issued J "
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( Repaired Upgraded( )
Abandoned( )by r .(-6n.56)c +�nn , 1 nc
Q ,.
at o71Sg C 01 e 6 A kLe has been constructed in accordance
with the provisions of Title and the for Disposal System Construction Permit No. G(�' 0 U dated- .1
Installer e)or�o10 i. an S�ck K-T i a rl ,Tr,e_ Designer r)odo o f �
i
#bedrooms Approved design flow ASS gpd
The issuance of this perm shall(n)tbe construed as a guarantee that the system will ncti a 'geed.
Date y r Inspector
---- ----------------------G -------- ------•-- ---------------------'----------------------------------------- ------(�-------------
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pstem ConstCUction J)Prmit
Permission is hereby granted to Construct(.k) Repair Qi' Upgrade( ) Abandon( )
System located at 0?/157 & & (p 80_C, to We—
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:Constru tion r ust be completed within three years of the date of this permit
Date �/�I l Approved by
r t . - Town of Barnstable P#
Department of Regulatory Services
f : BAMNSTAUM Public Health Division Date
es 200 brain Street,Hyan is MA 01601 r l jJ{
Date Scheduled . , t ime _ Fee Pd.
Soil uitabili/Qty Assessment for Sew s Q
Perfomred By: � Ay yj'Lid Qi16t witnessed By: .V
LOCATION&GENERAL INFORMATION-
Location Address - -
Oaner'sName
2159 Main StreetiBgj&A 'omas P.Quinn
Assessor's Map/Parcel: 2 3 7/3 9 4 0 Engineer's Name
NEW CONSTRUCTION
� REPAIR /� �,dnrpdge Surveying Engineering, LLC �
Land Use a 1 resv i��4.+ Slopes(%) 'T Surface Stones._
Distances from: Open Water Body_kA`ft Possible Wa Area R41-ft Drinking water Well&A _ft
Dminage.V,ray—MANI-I ft Property Line Other ft
' 1
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
LOT
-g Ts It
t"
Parent material(geologic) 4�A�l.L_ Depth to oedrock Depth to Groundwater:Standing Water in Hole:___.Owc Weeping from Pit Face 0W1:3
Estimated Seasonal High Gioundwater
DETERMINATION FOR SEASONAL
+H'IGy HH WATER TABLE
Melhod Used: `;Depth Observed standing in'obs.hole: ,40in1�ep t li�rsoil mottles: - in. _
Depth to wccping.from side of obs.hole: - in. Groundwater Adjustment ft.
Index Well . Reading Date:. Index Weltlevel Adj.factor Adj.Groundwater bevel_
PERCOLATION TEST Date Tim e
Obsen•alion
Hole.`.' _. Time at 9" !i1`i; ._ ..
Depth of Perc �o_ - Time at 6' 1 it C - -
Start Pre-soak"Time @ iW t��S_7{_ Time(9":5") lltiv,,
End Pre-soik
Rate MinAncll � -
Site Suitability Assessment:. Site Passed. V00'- Site railed: -Additional Testing Needed(\'R`).
Original: Public)leapt Di%ision Observation Hole Data To Be Completed on Clack--------
***If percolation testis to he conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIOPERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole# 4L
Depth From Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Molding (Structure,Stones,Boulders,
Consist"6,%Gravel) `
o � q `- V i$'tlz l�ta 1F�ir
AO
'w�n lc�Air
SSA
DEEP OBSERVATION HOLE LOG Dole# Z
Depth from Soil Horizon Soil Texture Soil Color Soil - . I I .Other
Surface(in.) (USDA) - (Munsell) Mottling (Structure,Stones,Boulders.
- - - - - - - -- `Consistency.%Gra4l) - -
. . . T/t59a
DEEP OBSERVATION HOLE LOG Bolt #
Depth from Soil Horizon - Soil Texture Soil Color Soil Otter
Surface(in.) - (USDA) -(Munsell) Mottling (Structure,Stones;.Boulders.
- -Consisrency,%Gravel)
DEEP OBSERVATION HOLE LOG Hole
Depth from Soil I lorizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) - (Munsell) Mottling (Structure,Siuncs,Boulders.
- - - Consistency,%Graven -
Flood Insurance Rate Mau: /
Above 500 year flood boundary No— Yes i
. Within 500 year boundary No ✓/ Yes
Within 100 year flood boundary No—VI Ye, -
Depth of Naturaltv Oeci rrine Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorptionsystem'1
If not,what is the depth of naturally occurring pervious material?
Certification
1-certify that on :Tat^' (date)1 have paswd the soil evaluator examination approved by the
Departuncnt of C,nviromnctilal dcctio❑and that the above analysis was perl'omted by me consistent with,
the required traitung,exp ise an s ncc des c 'bed in 310 CMR 15.017.
Signature Date
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Q inS EPTICd'E RCFORbt.DOC
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RRR-15-2014 21:59 From: To:150e7906304 Pa9e:1/2
FROM :dQun cape egginearing inc FAX NO. :15083629880 Apr. 15 2014 09:46AM P1
Public Health Division
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AR -15-2014 21:59 From: To:15087906304 Paee:2/2
FROM :down cdpe engineering inc FAX NO. :15083629880 Apr. 15 2014 09:46AM P2
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downcape.com 0
down eape eevineern't, 107t, 2159 RTE. 6A
civil engineers PREPARED FOR
land surveyors TOM QUINN
9 J9 Maln Street ( Rfa 6A)
YARMOU THrol?T MA o26 95 SCALE: 1 30' APRI L-14. 2414
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ELDREDGE SURVEYING
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1 036 Main Street
Chatham, Massachusetts 02633 i C
February 11, 2014 1
Ms. Donna Z. Miorandi, R.S.
Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA 02601
Re: 2159 Main Street
Dear Ms. Miorandi,
Enclosed please find the completed Town of Barnstable Soil Suitability
Assessment for Sewage Disposal Form for testing performed at the above
referenced property. These are transmitted in accordance with 310 CMR
15.018(2).
Please call me should you have any questions regarding the enclosed.
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Very truly yours,
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C' EL f%REOGE SURVEY/NO
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cott F. Arno d, P.E.. S.E. #12667
Enclosure
Y:\Clients\Whitlock H.Jerry-111710T Barnstable BOH Soil Form.doc
508-945-3965; Fax 508-945-5685; email: office@E5E-LLC.net
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Town of Barnstable P
gyp` °W o Department of Regulatory Services
&UMSrABLF,: .Public Health Division Date
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200 Main Sheet,Hya is MA 02601
FD
r��, Date Scheduled une Fee Pd.
6
Sg4Ltability Assessment for Sew s
Performed By: -:6tak �� �(3�j� ,�o��Witnessed By: V
_ LOCATION&GENERAL INFORMAI�ION r.
Location Address p,,,,�(�.� Owner's Name
2159 Main Street��A�1�Jlomas P.Quinn
ress
Assessor's Map/Parcel: 2 3 7/3 9 40 Engineer's Name
NEW CONSTRUCTION REPAIR 'I elept'ionr#—dge 'Surveying Engineering, LLC
Land Use _1DaNT1SP - Slopes(%) � Surface Stones �
Distances from: Open Water Body J A ft Possible Wet Area�� ft Drinking Water Well&Ak ft
Drainage Way rbFf .R Property Line �1 ft Other ft
SKETCH:(Street name,dimensions of lol,exact locations off test
ghoolles&perc tests,locate wetlands in proximity to holes)
t,
LCT 4
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d' P
Z 1 �'
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Parent material(geologic) 6`44AIA1✓ U— Depth to Bedrock NOAJ6 Y'Y7
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Llbu'z
Estimated Seasonal High Groundwater
DETERMINATION' - ,R SEASONAL HIGH WATER TABLE
Method Used: _ p�'jb�]��
Depth Observed standing in obs hole: �w\t i ,1G]��UUn 4eplFi fo soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date° Time
Observation
Hole# �fG Time at 9" tQ�
Depth of Perc 99���®'6 id I Time at 6"
Start Pre-soak Time @ ppW t�,� Time(9"-6") AIU u
End Pre-soak lL%
Rate MinAnch Z
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole# 4.
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
b-�P°° A lbw �kzv it lef-L k9cw 'qmu le
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DEEP OBSERVATION HOLE LOG_ Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
6-5 it A L044&y 4fidup tgfi zZ r,xtr -CAI e
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DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Sc•il Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
DEEP OBSERVATION HOLE LOG _ Hole# _
Depth from Soil Horizon Soii Texture Soil Color Soil Other m~
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
Flood Insurance Rate Mao:
Above 500 year flood boundary No— Yes
Within 500 year boundary No 'V/Yes
Within 100 year flood boundary No_V11 Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? )4:-:t7—
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on L00 (date)I have passed the soil evaluator examination approved by the
Department of Environmental tection and that the above analysis was performed by me consistent with
the required traw' xp tse an x i cc desc ibed in 310 CMR 15.017.
Signature Date WSO I A
Q:\S EPTIC\PERCFORM.DOC
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SUBDIVISMN PLAN OF LAND IN BMYSMOU,MASS.
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LO,CA ION SEWAGE PERMIT NO..
L VILLAGE�
090
INSTA l E 'S �E & ADDRESS
C� /o
B ,U f'L D E R OR OW ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �Q •- 'h "7 �
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THE C HEALTH
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Appliration -for Riipoiitt1 Workii Tonitrurtioo Vrroiit-
Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
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�l = ------------------------------------------------------- --------------------------------------------------------•---------------------S6--------------.
Location-:Address 1 or Lot No. ti
--`r --------------------------------------------------- ------- -
Ow er dress
Installer
Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...-_ '....................................Expansiop Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a
Other fixtures ---- ---------------------------------•------------------------------------------------------------------------•--------------------•-------------
W Design Flow.....I b7o.:cj..........................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.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.---._-.-----_-sq. ft.
z Other Distribution box ( ) Dosing tank ( ) 10, 41, 761 .
Percolation Test Results Performed by.......................................................................... Date.--------------------------------------
Test Pit No. 1-----------;....minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...---.-.------..-.-___.
Gr, Test Pit No. 2................minutes per inch Depth of 'Pest Pit..............-----. Depth to ground water...-._-.-_---_------.___
tx ------------------------------------............................... -----------... ------------...----.....--•-----.---------------------..-_...
ODescription of Soil-------------------------------------..................................................... •-----------._..... ---------------••---- -----------------------------
x
V ._ -----------------------------------------------------------•--.....-....----------...---.....---._....-----------...-------------------•------------------.......-.---------------•---------------------
W
x -------- -
U Na re of Repairs or Alt rations—Ans er when applicable._..-. .--_.-. --.-.-�. .` -w...- -
-----.----
Agreement• ;
The undersigned agrees to install the afored scribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanita y ode— The undersigned further agrees not to place the system in
p p
operation until a Certificate of Compliance has n issued e board of health.
E�
Signed-- /
Date
ApplicationApproved By--------•----------------------------•-•-•-------------------••---......------..........------•-
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------•------
....-•-•-----••--•-------•----------•----••----------------••----------------•----•-----••-•••-----•••-•-----------------------------------------------------------------------------------------------
Date
PermitNo.........................................................
Issued..... ............................................
Date
------------
`--- -
No. 1_.7 Fas.... .`!...._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
7o, ,�... ............OF..... ...../..hny �.
Applirtttiun -fur Bitipuuttl Works Towstrttrtiun Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S tem at:
i� ,
Location-Address or Lot No.
i
_ --••----_ --.--
W Owner - dress
-- --------------- -•.-...................
--•- --------
Installer Address
U Type of Building ,t Size Lot............................Sq. feet
Dwelling—No. of Bedrooms--._`'....................................Expansion Attic ( ) Garbage Grinder ( )
p.., Other—Type of Building ---------------------------- No. of persons..-________--__-__-__---_. Showers ( ) — Cafeteria ( )
QI Other fixtures -----------------------------
W Design Flow-----I _�..........................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.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area-.----.-___-_--_-_sq. ft.
z Other Distribution box ( ) Dosing tank ( ) le- -/- 76
.Percolation Test Results Performed by-------- ------------ ---------------------------------------------------- Date----.----------------------------------
W
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--------.__.--.--..-.._.
GZ4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.-_.-.---__-_-_-.-_._.-
I ----------••-- ------- ------------------••--•-------------•----••-•-•--------•------------•------.._..---------...-•-•---•-------------------------.-----
GDescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
V .-----------------•---------•------------•--------------------••---•••-•-----------•------•-•----•-........---•----•-----•-----------•------•---------•--•-------------------.--------------------------
W
U Nu/}J��7}}rye of Repairs or Alert/eyrationyps—Answer when applicable...... ± 7�,e �... -f- ...... .�4C_--�./--� !-`_-.._-___...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanita y ode—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issued e board of health.
Signed..... --•-- . ..... .. --_--------------------- .... l-7 ---••--
ate
ApplicationApproved By--------------------------------------------------------------------------------------------------- -------•---••---------------------------
Date
Application Disapproved for the following reasons:----••--------------------------••----------•--•-`-----------------------------•--------------------------------
. ------------------•...-----------•-------•--••--------------•-•-------....---•-------••••••-----•----••••---•----•---------------••-----•----.•---•---------------------------------------------.-----
Date
PermitNo......................................................... Issued------ -��..�---------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............. ... .............OF....... ..................
i -
i T-rrtif irateof Tontplittnrr
tTHIS TO�JRTis e Individual Sewage Disposal System constructed ( ) or Repaired (�
by'- 1 L.d=
nstall r
��'! < --- -.
-----------------------------------------
{�-v;� _
has been installed in accordance with the provisions of .6rtie XI ofe State Sanitary Code as described in the
application for Disposal Works Construction Permit No .... 7 _______________ dated -_— -_6_______.........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............/_�..... �C Inspector = C'
. .. A.
r - - _THE COMMONWEALTH OF MASSACHUSETTS
BOARD O 4HE�LT
i 4F
N =ti FEE------ --------------
e
Permis ion is herebyygranted--- --- --------- = �- -----------------------------------------------------------------•••--
to Const c ( ) or L�epa�( arn Indi dtt ewag� Disp sal ystemN
at No. Lfis� ? f /'''_ _..------••-------•....--
S r{eet q,•., �
as shown on the application for Disposal Works ConstructionP F lo_________ --- I)4t d;-----_.r�.i................................
L -----------•--
DATE......... --------------------------------------------
Board of Health
FORM 1255 H0613S & WARREN. INC.. PUBLISHERS
SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES
MARKED WITH MAGNETIC TAPE OR NOTES
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION.
PROVIDE MIN. 20" DIAM WATERTIGHT 1. DATUM IS APPROX. NGVD
FIRST FL. EL. 74.2' ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE Railroad
2" PEASTONE OR GEOTEXTILE
\ TOP FOUND. EL. 73.16' FILTER FABRIC OVER STONE 2. MUNICIPAL WATER IS EXISTING {e o a
71.0' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 69.0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. W° �ooe
PRECAST H-10 BLOCKS OR 4. DESIGN LOADING FOR ST & D'BOX Lo s
RISERS (TYP.)
+I PRECAST RISERS UNITS TO BE AASHO H-�• 500 GAL. UNITS
2'0 4"0SCH40 PVC MORTAR ALL
'••' H-10 TO BE H-20. P
..,. PIPES LEVEL 1ST 2' COMPONENTS Ca e Cod
�4' (�.P) INV S EL. 64.0 4' Community
ENDS SIDES 65.0' 5. PIPE JOINTS TO BE MADE WATERTIGHT. Game College o
CRAWLSPACE 10" 1500 GAL H-10 14" ➢o�aoo�° Pond
69.25 TEE SEPTIC TANK TEE ° ° ° ° ��00 0 00®Tm �
�QQ 0 �EnEl ° ° ° 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE
69.0' o ° o ° ° ° 6" MIN. SUMP >o�a�o�o� oaooMoa�a® aa000a000 WITH 310 CMR 15.000 (TITLE 5.)
° ° ° ° o o o Qa�a��a0�� �a�0� � ° c 0 0 0 0 0 0 0 0 0 o OO � OO � ODOO � 0000 � 00 � '00000000 ��� G
GAS BAFFLE::` ° ° ° ° ° ° 12" MIN INT. DIM. o°o°°°°°o ° o^o °_ > o ° ° o �®�aMMEj®FPEj aMO�a In�O�� °°°°°°°° o o 0 0 0 0 0 0 0 0 0 o °°°°°°°° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 3 a
oa000000 a0000000
4 LIQ. LEVEL (ACME OR EQUAL) 64.27 64.10 ° ° o ° 62.0 NOT TO BE USED FOR LOT LINE STAKING OR ANY o0
OTHER PURPOSE.
o°o 0 0 0 0 0 oY o o 0 0 0 0"0^o'o•oo 0 0 Exit
o°O°O°O°o°O°o°O°o°o°o°o°o°o°o°O°o°o°o°O°O°o°O
° °^° " " '°'�^°°°°°°°°°°°°°"°"°"-^°°?°°°° 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. H-20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
ALL AROUND PRECAST STRUCTURES (3) UNITS REQUIRED {e 6 #6
70f* 6" CRUSHED'STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 33.5' X 12.83' 9. COMPONENTS NOT TO BE BACKFILLED OR RpU
COMPACTION. (15.221 [2]) 5.0' CONCEALED WITHOUT INSPECTION BY BOARD OF Servjce Rd'
HEALTH AND PERMISSION OBTAINED FROM BOARD
( 2 % SLOPE) ( 7 % SLOFE) ( 1 % SLOPE) J OF HEALTH. LOCUS MAP
MIN. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR
FOUNDATION 25' SEPTIC TANK 65' D' BOX 12' LEACHING CALLING DIGSAFE (1-888-344-7233) AND NOT TO SCALE
FACILITY 57.0' BOTTOM TH-1 VERIFYING THE LOCATION OF ALL UNDERGROUND &
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF ASSESSORS MAP 237 PARCEL 40
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS WORK.
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM 11. ANY UNSUITABLE MATERIAL ENCOUNTERED VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE
SHALL BE REMOVED 5' BENEATH AND AROUND THE IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR
PROPOSED LEACHING FACILITY. BY HEALTH INSPECTOR
ROUTE 6A 12. EXISTING LEACHING FACILITY SHALL BE PUMPED
PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED
BY THE BOARD OF HEALTH REVISED DURING A PUBLIC
- --x 70.79 AND REMOVED OR PUMPED AND FILLED WITH CLEAN HEARING HELD ON AUG. 4, 2009
LEGEND _ - 71 - - - - SAND.
Y: SOIL ABSORPTION SYSTEM
EXISTING CONTOUR 99- � -9-2- T 0
93 x 71.29 j�71.46 INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW
X 99.1 /' 71.23' \ I APPROX. GAS AND WATERLINE GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE)
EXIST. SPOT ELEV. '� I 3 LOCATIONS (SNOW) - NEEDS TO BE AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS
99 PROPOSED CONTOUR
71.28 90.65' 1 DIG-SAFED BE LOCATED MORE THAN SIX FEET BELOW GRADE.
x 72.28
99 1 PROPOSED SPOT EL I I I x 72.20 �;�so SYSTEM DESIGN.
TH 1 I
TEST HOLE I � GARBAGE DISPOSER IS NOT ALLOWED
x 69. I GRAVEL x 2.78
2% SLOPE OF GROUND DRIVE
I EXISTING 4 BEDROOM DWELLING
UTILITY POLE (72.57 DESIGN FLOW: 4 BEDROOMS ® 110 GPD = 440 GPD
72.76 USE A 440' GPD DESIGN' FLOW
FIRE HYDRANT 68.00 x 67. 70.29 .23 EXISTING
SEPTIC TANK: 440 GPD 2 - 880
NOTE: NOT ALL SYMBOLS MAY.APPEAR IN DRAWING x 66.53 I DWELLING ( ) -
TOP FNDN. )96 USE (1 H-'10 1500. GAL. SEPTIC TANK
EL.=73.16'
NOTE: EXISTING INVERT DISAPPEARS LEACHING:
TEST `HOLE LOGS INTO DIRT FLOOR OF APPROX. 3'
x 67 8 HIGH CRAWLSPACE. INVERT SIDES:2 (33.5 + 12.83) 2 (.74) = 137 GPD
x 66 73 70.21 ELEVATION MUST BE CONFIRMED
72.58
ENGINEER: SCOTT ARNOLD, PE PRIOR TO INSTALLATION OF ANY BOTTOM 33.5 x 12.83 (.74) = 318 GPD
�
PORTION OF SEPTIC SYSTEM
WITNESS: DONNA MIORANDI, IRS 0 ° DECK 17 72 8 TOTAL: 614 S.F. 455 GPD
DATE: 2/3/14 I BENCHMARK: USE SILL ELEV. USE (3) 500 GAL. H-20 LEACHING CHAMBERS (ACME OR EQUAL)
PERC. RATE _ < 2 MIN/INCH 7� 72.09 AT SLIDER, ELEV. 74.2' WITH 4' STONE ALL AROUND
CLASS I SOILS P#
14217 x 71.28 ' ; CESSP 0 .
x 67.26 x 11 0. 2
O "
ELEV. ELEV. , 10" O x 9 THE
off 68.2 ooff69.7' LO TREE O
A A x 87 71 APPROVED DATE BOARD OF HEALTH MA
LS LS x 42 70
6» 10YR 4/2 5., 10YR 4/2 R x E x 69.43
BU x 68.57 x 68.44
B B x 1 OIJLDERS TITLE 5 SITE PLAN
LS LS OF
cn X
s" N
60„ 10YR 5/6 63.2' 60„ 10YR 5/6 64.7' CTI L LOT 1 r: N 2159 ROUTE
OU 6A
PERC 10, co
.26 x 66. 0 1.39 ACRES J11 BARNSTABLE
C C .7 TH x 66.28 z
x6 52 x6 3 PREPARED FOR
X 28
Ms x -__ 12" OAK x 68.6 v � Z TOM QUINN
MS x 66.62
FIRM IN PL. FIRM IN PL. PROP. VENT WITH CHARCOAL FILTER 68.�C J x 67.74 J FEBRUARY 12, 2014
AND BUGSCREEN (FINAL PLACEMENT B x 66.88
CONTRACTOR WITH HOMEOWNER 9.9
15% GRAVEL 15% GRAVEL CONSULTATION) !O x 69.48 off 508-362-4541
& STONES & STONES x 69.62 ,p�SN nFwys�q? 7 fax 508-362-9880
X x 7
.4 >> " Q` DANIELA. yG DANIEL �Go I
downcape.com
2.5Y 6 4 2.5Y 6/4 x 73 OIVIL JA
A. �, down Ca►Ae eI! h7ferin h7C
58.5 x 68.20 j CIVIL OJ,+�LA �1
134" / 57.0' 13491 No.4G502 No.40980 (�
x 69.07 �� �F civil engineers
NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' s o,v TL G�� �� q °yob. ° land Surveyors
77
)� 1+*r ;---- 1b� t�� 939 Main Street ( Rto 6A)
0 10 20 30 40 50 FEET YARMOUTHPORT MA 02675
� �-D2 > DATE DANIEL,� A. OJALA, P.E., P.L.S.
1 --- - - - -- - -