HomeMy WebLinkAbout1443 MARY DUNN ROAD - Health 43 Mary Dunn qad FF
Barnstable,
A= 335 - 003
17
yubs Z
C
TOWN OF BARNSTABLE
LOCATION Iqy, Ley_ P&AW n04 SEWAGE#020,V
VILLAG4Je?6,e?V?W ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE
SEPTIC TANK CAPACITY 1600
LEACHING FACILITY.(type (size)
NO.OF BED MS
OWNER 4
PERMIT DATE: ! COMPLIANCE DATE: f j0 1 y
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Welland 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
[�.
lV 446,
60
Jolo
r i F /�
� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered incomputer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
No.
G4plication for Disposal �& stern Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.lyS/ Mn'44Y Owner's Name,Address,and Tel.No. �y
Assessor's Map/Parce1Mj 33s /"44eRl V4&1 8'j �/Y1l� h4 / �� RO•
3sta llei'DNameiAAddress,and TeL to 4:f4/ Designer's Name,Address,and Tel.NgQyjQ ^4.�6v-J
Type of Building:
Dwelling No.of Bedrooms 7 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.r uired) y(/U gpd Design flow provided Al S� gpd
Plan Date /G ! Number of sheets Revision Date
Title
Size of Septic Tank /Aag Q`f(. Type of S.A.S. !!
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)X/ew Z-V ;I ia'Pti�f; j 6ti IrilQ 3,
/ —ZV 42y 494&,Qjtr f—G4GId ��gn3�L3 J
Date last inspected:
Agreement:
The undersigned agrees to ensdea
ction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5mental Code and not to place the system in operation until a Certificate of
Compliance has been issued is Boar
gn d G° Date
Application Approved by Date
Application Disapproved b Date
for the following reasons
Permit No. ' Date Issued
NoLOA A 0 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
/ 3 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
1 litation for bis oBal 6 strip ConstrULtion Permit
c
It.
,- Application for a Permit to Construct( ) Repair( ) Upgrade( ), Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No./9 9,5 M 41e y , Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel/l 955- /"W,'-el 3 ��Ll cSy16//1?A.) /y<j3 1JItV
Installer's Name Address,and Tel.N05 dye /tielw/J Designer's Name,Address,and Tel.N94 y;o /40 4 fGv"
3i R-� �G� �� e'�1 il- E4s7 Sq-7,9w c
Type of Building:
Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ��(/U gpd Design flow provided 'y SS gpd
Plan Date v /&//y Number of sheets / Revision Date
Title
`. Size of Septic Tank-/ jy9 n Type of S.A.S. v n//b Ic e S
Description of Soil
Y
;Nature of Repairs or Alterations(Answer when applicable) /P/,C� /�� Z� �i�T�C� i�,r✓�, �, `�ju�( ijnp j ,
cJ 4 ec Ll /fey, c t 5
Date last inspected:
,Agreement:
The undersigned agrees to ensure the cons ction and maintenance of the afore described on-site sewage disposal system.in-
accordance with the provisions of Title 5 of the Env ronmental Code and not to place the system in operation until a Certificate of
'. Compliance has been issued by is Board o i eal .
gne C Date
Application Approved by (/ f/A Date ILK
v v
'> Application Disapproved b Date
{
for the following reasons
! Q, /
Permit No. 9' Date Issued
r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliattce
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(I/� Repaired(k*lf Upgraded( )
Abandoned( )by��11•�i.�i.1 I��Crt L
g at/4U.3 &4Ay /„ /A,, 440 has been constructed in ac%aalta0d
with the provisions of Title 5 and the for Disposal System Construction Permit No.�/ y"
Installer /1,Qd)%rl' ( /v?n fZA 1 4 i nil) Designer / 174
#bedrooms y Approved design flow gpd
The issuance of this a it sha not 'e construed as a guarantee that the system ctio as djesigno`d t/ ®
Date / Inspector
--------------9_____ ____________________________—________—______ _______________:�p"________________—
No. ��?'. a` -!'- - _ l Fee --(/J��
(/` _ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction i9ermit
Permission is hereby granted to Construct( P< Repair(tom U!p ade( Aban
don( )
System located at !/ O / A (//
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:Construct' J�/t be 'ompleted within three years of the date of this permit. /
Date / / _ Approved by f .�
•, ti
i
T6Wn ®f Barnstable
f1"E TQ� Regulatory Services
Richard V. Scali, Interim Director
9BARN B '�' Public Health Division
'39 i6 �� `
pTFa 39 Thomas McK11- n, Director
200 Main.Street,Hyannis,NIA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer Desi ner Certification Form
Date:- 2� 0� Sewage Permit#alustaller-
Address: Assessor's 1Map�Parcel
Designer: �FN5F Address:
� Q
t On q C*tXWA_k1 Jwas'issued a permit to install a
(date) (installer)
septic system at based on a.design drawn by
(add ess)
,o 10. dated o�
(designer)
I certify that the septic system referenced above was installed substantially according to
the design; which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designerAo follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I c ify that the system referenced above was constructed in con liance with the terms of
th IAA that
letters (if applicable) �\A OF A44�5
DAM C b
0 B.
s MASON 'K�!J
( stall ignature) o i
No.1066
FC,ST0"
esi ignature) (Affix Desi p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU:
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
I
ter, Town of Barnstable P# _
Department of Regulatory Services
. AM ; Public Health Division Date
�e� 200 Main Street,Hy s MA 02601
Fp
Date Scheduled s ime Fee Pd.
Q
So''Z uitability Assessment for S e Di p s
Performed By. Witnessed By-
LOCATION&GENERAL INFORMAXIO�N
Location Address
Owner's Name
�./ Address "rrlWVv
Assessor's Map/Parcel: �� �� Engineer's Name� �,
NEW CONSTRUCTION AIR Telephone#
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes perc tests,locate wetlands in proximity to holes)
w�.
52,
a
Parent material(geologic) - Depth to Bedrock
Depth to Groundwater:Standing Water in Hole: Weeping from Pit Face 4
Estimated Seasonal High Groundwater
DETERM_ INATION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: 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 Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time
Observation
Hole# Time at 9"
Depth of Perc Time at 6"
Start Pre-soak Time @ l.4 Time(9"-V)
End Pre-soak`
Rate M Anch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
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#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
�L
DEEP OBSERVATION HOLE LOG_ Hole#
Depth from Soil Horizon Soil Texture Soil Color So_il Other'
Surface(in.) (USDA.) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color F Soil Other
Surface(in.) - (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
` F ,
t
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)
Flood Insurance Rate Mai):
Above 500 year flood boundary No Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No Yes_
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pert/ riaI exist' all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the de th of atu rally occurring pe ous terial?
Certification I certify that on ® (date)I have pasF.sed the soil evaluator examination approved by the
Department of Enviro ental P o ctio d that the above analysis was perfo ed V me co' istent with
the requiredn expe ' ce a rib M017.,
Signature Date
Q:\SEPTIC\PERCFORM.DOC
Commonwealth of Massachusetts
Title 5 Official Inspection Form 33s. oo3
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 /1
w 1443 Mary Dunn Rd.
Property.Address
Paul Sheehan
Owner Owner's Name
information is required for q uid Cumma s� MA 02637 June 18, 2007
E� t ai�1 S
every page. Cityrrown T State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:
When filling out A. General Information }
forms on the CC
computer, use
. ,
only the tab key 1 Inspector:
to move your David D. Flaherty Jr., R.S. `.
cursor-do not t P
use the return Name of Inspector +�?
key. Flaherty Environmental Services
Company Name
P.O. Box 81
Company Address
Yarmouth Port MA 02675
ream. City/Town State Zip Code
508-362-1657
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by th Local Approving Authority
June 18, 2007
Insp or's Signaiurw Date
The system inspectors.hall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5insp 1443 Mary Dunn Rd Cummaquid.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name t
information is q
required for Cumma uid MA 02637 June 18, 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. f
Comments:
13 System
ste Conditionally Pa
sses:
) Y Y
❑ One or more system components as described in t "Conditional Pass" section need to be
replaced or repaired. The system, upon completi n of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) i he ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over.20 ears old*or the septic tank (whether metal or not) is
structurally unsound, exhibits subs ntial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the xisting tank is replaced with a complying septic tank as
approved by the Board of Heal
*A metal septic tank will pa s inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating at the tank is less than 20 years old is available.
ND Explain:
❑ Observatio of sewage backup or break out or high static water level in the distribution box due
to broken r obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass ins ection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
obstruction is removed
t5insp 1443 Mary Dunn Rd Cumma id.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is Cumma uid
required for q MA 02637 June 18, 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is.leveled or replaced
ND Explain:
❑ The system required pumping more than 4 time a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of a Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Req ired by the Board of Health:
❑ Conditions exist which re ire further evaluation by the Board of Health in order to determine if
the system is failing to p otect public health, safety or the environment.
1. System will pass nless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that th system is not functioning in a manner which will protect public health,
safety and the en ironment:
❑ Cesspo I or privy is within 50 feet of a surface water
❑ Cess ool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. Syste will fail unless the Board of Health (and Public Walter Supplier, if any)
determi s that the system is functioning in a manner that protects the public health,
safety d environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 et 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
s pply•
The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
r-►
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is
required for Cummaquid MA 02637 June 18, 2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Healt cont.):
❑ The system has a septic tank and SAS and the S 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 w er analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and th presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided tha o other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ 0 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
E N Static liquid level in the distribution box above outlet invert due to an overloaded.
or clogged SAS or cesspool
❑ Z Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow -
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the 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.
t5insp 1443 Mary Dunn Rd Cummaquid.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 .
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�1M 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is q
required for Cumma uid MA 02637 June 18, 2007
every page. City/Town State- Zip Code : Date of Inspection
B.'Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ Z 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.]
1
® 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 rge system the system must serve a facility with a
design flow of 10,000 gpd to 15,00 gpd.
For large systems,you must:indi to either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
El ❑ t 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 swered."yes"to.any question in Section E the system is considered a significant threat,
or answer "yes" in Section D above the large system has failed. The owner or operator of any large
system c nsidered a significant threat under Section E or failed under Section D shall upgrade the ,
system ' accordance with 310 CMR 15.304. The system owner should contact the appropriate
region I office of the Department.
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is q
required for Cumma uid MA 02637 June 18, 2007
every page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 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?
❑ 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 1443 Mary Dunn Rd Cummaquid.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is q
required for Cumma uid MA 02637 June 18, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Number of current residents: 3
Does residence have a garbage.grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d '06: 187 gpd; '05:
9 ( Y 9 (gpd)): 220 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: present
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15. 3): Gallons per day(gpd)
Basis of design flow(seats/pers s/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holdin ank present? ❑ Yes ❑ No
Non-sanitary waste ischarged to the Title 5 system? .. ❑ Yes ❑ No
Water meter re ings, if available:
Last date of ccupancy/use: Date
Other(d scribe):
t5insp 1443 Mary Dunn Rd Cummaquid.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is Cumma uid
required for q MA 02637 June 18, 2007
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
I
Pumping Records:
Source of information:
owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ cesspool
Single
9
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
probably 1976, as builts from TOB
Were sewage odors detected when arriving at the site? ❑ Yes ® No
I
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
f
Commonwealth of Massachusetts
11zy Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is umma uid MA 02637 June 18, 2007
required for C q _
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain);
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints ok, venting through house adequate, no evidence of leakage
Septic Tank(locate on site plan):
Depth below grade: 1
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: 1000 gallon
12"
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle
24"
8„
Scum thickness
411
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
6"
How were dimensions determined? sludge judge, tape measure
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
iL ,
I �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is q required for Cumma uid MA 02637 June 18, 2007
every 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'
( p p 9 9 Y,
liquid levels as related to outlet invert, evidence of leakage, etc.):
maintenance pumping and tank cleaning recommended at this time, inlet and outlet tees good, tank
seems structurally sound, liquid level appropriate, no evidence of leakage j
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 s um to top of outlet tee or.baffle
Distance from bot m of scum to bottom of outlet tee or baffle
Date of last pu ping: Date
Comments n pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid level as related to outlet invert, evidence of leakage, etc.):
Ti t or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
epth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is q
required for Cumma uid MA 02637 June 18, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level.' Alarm in working order: ❑ Yes ❑ No
Date of last pumpin b
Date
Comments (con Ition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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.):
dbox seems level, 3 outlets distributed equally, evidence of minor solids carryover, no evidence of
leakage
Pump /workingrder:
lan):.
Pumps ❑ Yes ❑ No
Alarms ❑ Yes ❑ No
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is q
required for Cumma uid MA 02637 June 18, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
.If SAS not located, explain why:
Type
Z leaching pits number: 3, 6'x 6' precast
w/stone.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
El 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.):
leach pits appear to be in good condition
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/0.6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
` Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information isequired or Cumma uid
MA 02637 June 18, 2007
every page. City/Town State Zip Code Date of Inspection
D. System Information cont.
Y (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, s' ns of hydraulic failure, level of ponding, condition of vegetation,
etc.):
PZsolids
a plan):
Mruction:
D
DCondition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is q
required for Cumma uid MA 02637 June 18, 2007
every page. CitylTown State Zip Code bate of Inspection
D. System Information (cont.)
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.
U rJ r i c
ap
Cc V JA
4Y
3i
)qz, 11 ,6
2� �
ql
t3 5
t5insp 1443 Mary Dunn Rd Cummaquid.doc•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1443 Mary Dunn Rd.
Property Address
Paul Sheehan
Owner Owner's Name
information is
required for Cummaguid MA 02637 June 18, 2007
every page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to groundwater: 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 to 11.5% no groundwater encountered
t5insp 1443 Mary Dunn Rd Cummaquid.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
TOWN OF BARNSTABLE 0_
LOCATION f�{ y3 /714�,Y D k V V eD_ SEWAGE #
VILLAGE 4694AIS721644, ASSESSOR'S MAP & LOT S OO
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY i o a 0•
LEACHING FACILITY:(type) j PD 0 LS, (size)
NO. OF BEDROOMS �, OR PUBLIC WATER_,
OR OWNER JA IV
DATE PERMIT ISSUED: '��
DATE COMPLIANCE ISSUED:.
VARIANCE GRANTED: Yes No
S
` G
�OCII1,17
� �� N
0
f
i
ASSESSORS MAP : TEST F�OLE LOGS -�O-
PARCEL : 1) The installation shall comi. , with Title V anal 'Town of�j ( ( 1 Board oI.
FLOOD ZONE: 'A I SOIL EVALUA70R : 1� C I Iealth Regulations.
� � .� 2) The installer shall verify the location of utilities, sewer inverts and septic
�y REFERENCE - WITNESS : (,fir Lt WICx2 1
-- __2) Ca-`� DATE: !7kJ -A 1q4 components prior to installation and setting base elevations.
�" - ) gravity p piping
lrl _ __.. PERCOLA 1011 RATE: C z. U�t l �.. 3 All iravit septicto be 4 inch Sch 40 PVC at 1/8" per foot. The first
L -- - ,
;� two feet out of the d-box to the leaching shall be level.
_— X � �N g` 4 4) This plan is not to be utilized for property line determination nor any other
TI TH-2 purpose other than the proposed system installation.
5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over 1110 septic components.
7) The property is bounded by property corners and property lines.
� ,� sn 8) The property owner shall review design considerations to approve of total
�
LOCATION MAP -
3a - design flow and number of bedrooms to be considered for design. Receipt
!o � � � � V� , of payment for the plan and installation based on the plan shall be deemed
approval of the design flow by the owner.
� � 9) The existing leaching or cesspools shall be pumped and filled with material
per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
Title V specs.
�' ► ���0
i ���" � 10)System components to be 10 feet from water line. Sewer lines crossing the
199-93' water line shall be sleeved with 4 inch SCII 40 PVC with ends grouted if
applicable. The proposed SAS is being installed below the water service
r2G i �39
line. The line is to be sleeved as aforementioned and maintained in place.
t 11) If a garbage grinder exists it is to be removed and is the responsibility of the
SEPTIC SYSTEM
AD
� � owner to ensure such.
- ! i 12)The installer is to take caution in excavation around the gas line if such
� � �' �` ti FLOW EST I MATE exists.
- ( 12A7 ) q - 13)The installer shall verify-the location, quantity and elevation of the sewer
15 _ BEDROOMS AT I�"GAL/DAY/BEDROOM GAL/DAY
lines exiting the dwelling prior to the installation.
o / i 14)This plan is representative only that a system can fit on a property meeting
ll — , / SEPTIC TANK Title V requirements.
a
GAL/DAY x 2 DAYS - �EQGAL
PCL. 10 93.3 J _ USE GALLON SEPT I C TANK
57
5 00 h _
LEACH PITS �" ° D XI N SOIL ABSORPTION SYSTEM -_-- ---- — tit
3t
SEPT. �, t� I 4'`�� 7
TANK t;���410F9�
13.
LOT AREA �J SIDE AREA: Z �J�lirj�I' IZ�� ✓ �SZ'?( '� � �� ; 4, MASON U)
No.1666
40,903 s.f. BOTTOM AREA: �Z v -1b � ��
( 0.94 ac.)
E-TIC SYSTEM SECTION
00& 200.00)
OF Ass I N
NOTE: EXISTING SEPTIC LOCATION (RAIL
# __— . —� r
R qn
OAD) Iti b Z I nt
ARE FROM SEPTIC INSP. BY ---►
ROBERT OUR CO. 9/18/96.
L.PITS LOCATIONS ARE APPRO IL:Y7.
! i
ism Y a2 ,r:,\- s3 �t
1
p I�_;�1L7►1�-figs � p-BO 71
GALMilo
r SEPT I C TANKLox-I�57�1-kx4)
53,5 17�
-�CT) TbVA
SITE AND SEWAGE PLAN
1 L OCAT ION :
C),_ --__
ZO
PREPARED FOR :
^1
CC)TU k7
1" 0
SCALE: I
DAV I D B . Y9ASON,R5 DATE: la ZcjL
DBC ENVIRONMENTAL DESIGNS
W ` ---- EAST SANDWICH . MA
W DATE I HEALTH AGENT ( 508 ) 833- 2 177
Z
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