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HomeMy WebLinkAbout0116 OAKMONT ROAD - Health (2) 11 fi Oakmont Road Barnstable. P A =.349 .057 J . o d f ' O f TOWN OF BARNSTABLE y �, LOCATION 116 R- SEWAGE VILI:kGB .0 V/m M,4,2v)2 ASSESSOR'S MAP & LOT .INSTALLER'S NAME & PHONE NO. -775--6264 SEPTIC TANK CAPACITY /90V 9/1L �i9�lf 7J LEACHING FACILITY:(type) 00,, NO. OF BEDROOMS .PRIVATE WELT,OR PUBLIC WATER BUILDER OR(OWNER �'/�/P � ,P 0�- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I . 0 73: 1 119a p I 379-aY� Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rill 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address l Rita A Pedersen Owner Owners Name information is II// a required for every CummagtK -Yarmouth Port MA 02675 11/29/2017 t page. City/Town State Zip Code Date of Inspection I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form: Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your N. cursor-do not REIDC: ELLIS use the return key. Name of Inspector ELLIS BROTHERS CONSTRUCTION Company Name 23 ENTERPRISE ROAD Company Address YARMOUTH PORT MA 02675 City/Town State Zip Code 508-362-6237 S121891 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: L"J Passes ❑ Conditionally Passes ElFails ❑ Needs Further Evaluation by the Local Approving Authority inspe ors i nature Date ' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owners Name information is 4 required for every Cumma uid-Yarmouth Port MA 02675 11/29/2017 page: City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: J ] I have not found Vnyinformation which indicates that any of the failure criteria described I" in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes:'/ ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upor completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not detem ined" (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): t t i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information is i Cumma uid-Yarmouth Port MA 02675 11/29/2017 required for every q page. Citylrown State . Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operati al. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break ot tor high static water level in the distribution box due to broken or obstructed pipe(s)or due to a bi oken, settled or uneven distribution box. System will pass inspection if(with approval of Board of ealth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): i ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): s E ' ❑ 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): ; i C) Further Evaluation is Required by the Boa d of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information Is Cumma uid-Yarmouth Port . MA 02675 11/29/2017 required for every q page. Cityfrown State Zip Code Date of Inspection & Certification (cont.) 2. System will fail unless the Board of ealth (and Public Water Supplier, if any) determines that the system is functions g 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 cf a surface water supply or tribut 3ry to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a.Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysi , performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the pres nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other Inure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: t D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 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 Y2 day-flow t5ins.doc-rev.6116 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owners Name information is q required for every Cumma uid -Yarmouth Port MA ' 02675 11/29/2017 page. City/Town State Zip Code . Date of Inspection B. Certification (cont.) Yes No ` ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ tributary to a surface water supply. ❑ �� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ d 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.] ❑ E, The system is a cesspool serving a facility with a design flow of 2000gpd- 101000gpd. ❑ 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 failur E stems:Large Sy stems:y To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feE t of a surface drinking water supply ❑ ❑ the system is within 200 feE t of a tributary to a surface drinking water supply ❑ ❑ the system is located in a n trogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered-"yes"to any question in Se tion E the system is considered a significant threat, or answered"yes" in Section D above the large s fstem has failed. The owner or operator of any large system considered a significant threat under Sec ion E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. Th system owner should contact the appropriate, regional office of the Department. i t5ins.doc-rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form e a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information is q required for every Cumma uid-Yarmouth Port MA 02675 11/29/2017 page. Cityrrown 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.- 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? r ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) LI ❑ 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, oKcluding 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, J dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ®/ ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): a' Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): `w t5ins.doc-rev.6/16 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information is q required for every Cumma uid-Yarmouth Port MA 02675 11/29/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 24 Number of current residents: Does residence have a garbage grinder? ❑ Yes 'M No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes [ No information in'this report.) Laundry system inspected? ❑ Yes E/No Seasonal use? ❑ Yes M�/No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? • ❑.Yes No Last date of occupancy: ' Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): ' Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No t _ Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information is q required for every Cumma uid-Yarmouth Port MA 02675 11/29/2017 page. Cityr town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? LI Yes ❑ No If yes, volume pumped: �L� Off gallons How was quantity pumped determined? SUS Reason for pumping: �! �' '�-�( �'OCY: � ✓ Type of System: . i L�1 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy i ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information is required for every Cummaquid -Yarmouth Port MA 02675 11/29/2017 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) vim=-- dt1*JrAd- � Approxima$e age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes EB No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron V40PVC El other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.)-. ti Septic Tank(locate on site plan): Depth below grade: �/4/ ,� �G-` � L, �• .�—t1i�y�l�- - feet ,Material of construction: , M concrete ❑ metal ❑fiberglass ❑ ❑other polyethylene er(explain) If tank is metal, list/age: yea /r Is age conf ed by Certificate of Compliance?(attach a cop certificate) ) �❑ Yes ❑ ><lO rr� �J Dimensions: Sludge depth: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information is q required for every Cumma uid-Yarmouth Port MA 02675 11/29/2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness V y Distance from top of scum.to top of outlet tee or baffle U Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? J Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet Invert, evidence of leakage, etc.): 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 led or baffle I Distance from bottom of scum to bottom.of cutlet tee or baffle Date of last pumping: date t5ins.doc•rev.6/16 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA rys Property Address Rita A Pedersen Owner Owner's Name information is required for every Cummaquid -Yarmouth Port MA 02675 11/29/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I Comments (on pumping recommendations, inl and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I i Tight or Holding Tank(tank must be pumpeJ at time of inspection) (locate on site plan): Depth below grade: Materia l of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): I Dimensions: Capacity: gallons Design Flow: i gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i *Attach copy of current pumping contract re i 'P p 9 uired . Is co(. q ) attached. PY ❑ Yes ❑ No II t5ins.doc•rev.6/16 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner owner's Name information is q required for every Cumma uid-Yarmouth Port MA 02675 11/29/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate site plan): Depth of liquid level above outlet invert i` j Comments(note if box is level and distribution to outlets equal, any evidence f solids carryover, any evidence of leakage into or out of box, etc.).- "tea Pump Chamber(locate on site plan): / Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ 'No* Comments(note condition of pump chamber, co edition of pumps and appurtenances, etc.): z t I * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 or 17 Commonwealth of Massachusetts _. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information is q required for every Cumma uid-Yarmouth Port MA -02675 11/29/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: r leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,,signs of hydraulic failure,.level of ponding, damp soil, condition of vegetation, etc.): , - - .��l/1/ // `-a- ' , �L,��� i--�✓e�°t� ...ems �.;�� Lr�� ��1d Cesspools (cesspool must be pumped P ( as rt f'p p p o inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer • . E Y Depth of scum layer Dimensions of cesspool Materials of construction . i Indication of groundwater inflow ElYes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Officinal Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments *•. 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address . Rita A Pedersen Owner Owner's Name information is required for every. Cummaquid-Yarmouth Port MA' 02675 11/29/2017 page. City/Town State Zip Code Date f Inspection D. System Information (cont.) Comments(mote condition of soil, sins+ of h draullc�� g y allure, level of ponding, condition of vegetation, etc.): 3 Privy(locate on'site plan): Materials of.construction: 4 Dimensions j Depth of solids i Comments(note condition of soil, signs of hydra ilic failure, level of ponding, condition of vegetation, etc.): { I _ ) FI { t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property Address Rita A Pedersen Owner Owner's Name information is required Cumma uid-Yarmouth Port ed for every Q q e MA ry 02675 11/29/2617 page. Cityrrown State Zip Code Date of nsspedion D. System Information (cont.) Sketch Of-Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all.wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below � El drawing attached separately V l[457 I ,i P � l 10 c,0 _. it�� d�S e .s r A a,- t5ins.doc•rev:6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .. 116 Oakmont Road, Cummaquid-Yarmouth Port,-MA Property Address Rita A Pedersen Owner Owner's Name information is Cumma required for every quid-Yarmouth Port MA 02675 11/29/2017 page. CiWrown State .Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water /'V vA-l-- - ❑ Check Cella, 9 ❑ Shallow wells Estimated depth to high ground water: • f�et 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: f Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: 42 You must describe how you established the high ground water.elevation: D 7� / Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official In`s pection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Oakmont Road, Cummaquid-Yarmouth Port, MA Property AddFess Rita A Pedersen Owner Owner's Name information is required for every Cummaquid-Yarmouth Port MA 02675 11/29/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness"Checklist L 1 spection Summary:A, B,•C, D, or E checked 10 pection Summary D(System Failure Criteria Applicable to All Systems)completed stem Information—Estimated depth to high groundwater e Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file f > t5ins.doc-rev.6H6 Title 5 Official Inspection Fomi:Subsurface Sewage Disposal System-Page 17 of 17 { 1 FROM :down cape engineering inc FAX NO. :15083629880 Jan. 04 2006 02:04PM P4 Town of Barnstable _ Regulatory Services 3Y�' Thomas F. Geiler,Director NAM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-962-4644 - Fax: 508-790-6304 Installer&Designer Certification Form Date: I�Jb Sewage Permit# J—y b©(� Assessor's Map\Parcel \ v Designer: VJUWrt e, h neC� Installer: Address: �31 f-tsar h ✓ L Address: l� D . s®0 x D /l J , Zl-lD On �4/��O�OlT�(�Jl�lSj`�"_was issued a permit to install a (date) ,(installer.) �� p septic system at 116 Oa.k Ma K`(•' Q.Q. Mm ,4, based on aaddetsign drawn by / (address) ✓� a�.GGt dated. / L-o J ( signer) 1 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. T 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 designer to follow. _ t p�tYY OF�4�, ARNE H , YS (lnst• er's Signature) Q�IALfi '' ClVllu ' No... 7 3Q 92oa I SS/ONAI (Designers Sig ture) (Affix a er's Stamp Here)� � PLEASE RETURN TO BARNSTABLE PUBLTC HEALTH DMSION CERTIFICATE OF COMPLIANCE WILL NO'r BE ISSUED UNTIL BOTH THTS FORM AND AS-BUILT CART) ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTI4 DIVISION THANK YOU Q:Hcalth/Septic/nosigncr Certification Dorm 3-26-04,doc _ - TOWN OF BARNSTABLE LOCATION SEWAGE #'VILLAGE ASSESSOR'S MAP & LOT , 4 �✓ INSTALLER'S NAME&PHONE NO. /"AV, �w>�r��.ea-� S/d Tr- 5��•�� SEPTIC TANK CAPACITY i-Ova CcC LEACHING FACILITY: (type) faf .L Ckt;*4-9 "(size) /3 �X�f"it.� NO. OF BEDROOMS 3 BUILDER OR OWNERec✓E�J�ks PERMITDATE: /,2-.2-6S- 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� u Cie E.� �fi+tr.s7 .�i/d 1 f"r0��T .gyoG� �� e � �r' ��' yd' _ �4, Q / / ` \ 1 S �I ft�lfd�l G ; �.'�9 1 �p y��il Lim✓ No. f�- � (�l" Fee ©� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes O Otpphrotton' for Mt.5poga1 *pgtem Cow6trUCtion Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. /�6 /� � ,. Owner's Name Address,and Tel.No. Assessor's Map/parcel C Q u�� Installer's Name,Addres ,and Tel o. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms p Lot Size Y7z Sr3Z-- sq.ft. Garbage Grinder (,,410 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requt ed) 33 gpd Design flow provided L� / gpd Plan Date `®It!® Number of sheets Revision Date Title , / / Size of Septic Tank /�D�9P/ .�XfSLA'�Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. ncci 5 o f Date Issued - No.. q5l Fee �OG v : i THE COMMONWEALTH OF MASS"ACHUS�ETTS Entered in computer: �. _ ... Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for bi.5po!5aY 6p,5tem Con.5truction Permit App'1'ication for a Permit to Construct O Repair(Vl Upgrade O Abandon O ❑ Complete System U Individual Components Location Address or Lot No. �f0 Q�Q % kd Owner's Name Address,and Tel.No. 3�9-os7 =��� vvvlh "'Assessor's Map/Parcel C Q(��� on ' eAj Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size y/~/ �.�Z. sq.ft. Garbage Grinder Other Type of Building ��C e No.of Persons Showers( ) -Cafeteria( ) Other Fixtures ' Design Flow(min.required) 3J t) gpd Design flow provided -F-�- gpd Plan Date /D/s/Q Number of sheets / Revision Date 5� Title ! Ir Z/ OQZk- ,0W4*V7 z;/ Size of Septic Tank /&IQ/9,01 ,��J'/S�lA9 Type of S.A.S. z - O® 4yv G 4 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. / Signed r Date /?- "/�S Application Approved by Date Application Disapproved by: Date . for the following reasons Permit No. Coco 5 "r o Date Issued - --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site y (_..- Sewage Disposal System Constructed ( ) Repaired ( k/ Upgraded ( ) Abandoned( )by /, Ap D/Se ,/�r/ Q&j` r at /1b O/?,C 10411 1'7 y�%f �u�1�Ql�G1/G�' has been constructed in accordance L �9 (D dated with the provisions of Title 5 and t e for Disposal System Construction Permit No. �� S - � Installer �1"�r �d 1 Designer 0,m LA #bedrooms Approved design flow gpd The issuance of this permit shall not be coj�sstruuee"d as a guarantee that the system will nctio as' esigned. Date ` / 3P 1 `J Inspector No. Q 0 0 (Q Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS lwioponl,Q�pgtem Con5truction Permit Permission is hereby granted to Construct ( ) Repair ( � Upgrade ( ) Abandon ( ) System located at �/� i Cla l.,^w/1,` / t�1/4/1/1�'4V1 z and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date(fthis pe Date �' �'� Approved by ,I f� f COMMONWEALTH OF MASSACHUSETTS z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a a DEPARTMENT'OF ENVIRONMENTAL PROTECTION K Q '�qM cVOy 350 MAIN STREET WEST YARMOUTH,MA �C® 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 349—PARC 057 Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 t Owner's Name: PEDERFEN,RITA t e Owner's Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Date of Inspection DULY 19,2005 Name of hispector:(please print) RICHARD K. CANNON Company Name: _A&B Canco Mailing Address: 350 Main Street 'f West Yanuouth,MA 02673 _ Telephone Number: 508-775-2800 _ C:) ' ems., CERTIFICATION STATEMENT r7i I certify that I have personally inspected the sewage disposal system at this address and that the informat on 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 _ Needs Further Eval by the Local Approving Authority F #/ ails Inspector's Signature: . 4 Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments SEE PAGE 9—SOIL ABSORTION SYSTEM NOTATION OF LEACHING PIT. "This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Owner: PEDERFEN,RITA Date of Inspection: JULY 19,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes:.i I have not found any infonnation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair;as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N.ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or root)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imuninent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: _ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass.inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Owner: PEDERFEN,RITA Date of Inspection: DULY.19, 2005 C. Further Evaluation is Required by the Board of Health:N/A Conditions exist which require ftuther evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unlesss 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 public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/152000 3 r Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Owner: PEDERFEN.RITA Date of Inspection: JULY 1.9, 2005 D. System Failure Criteria applicable to all systems N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit is less than 6"below invert or available volume is less than''/�day flow *— Required puunping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tunes pumped ✓ Any portion of the SAS;cesspool or privy is below high ground water elevation N/A Any portion 4 cesspool or privy is within 100 feet of a surface crater supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 1.00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of.10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of 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 11 of a public water supply well. If you have answered"yes"to any question iu Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ` y Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Owner: PEDERFEN,RITA Date of Inspection: DULY 19, 2005 Check if the following have been done. You must indicate"yes''or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,including 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)has been determined based on: Yes No ✓ 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(3yb)] Title 5 Inspection Form 6/15/-2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Owner: PEDERFEN,RITA Date of Inspection: JULY 19, 2005 FLOW CONDITIONS RESIDENTIAL✓ Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: { 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2003—76,000 GAL/2004—75,000 GAL Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CUR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):'- Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancyhise: OTHER(describe): 1 GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): _ Approximate age of all components,date installed(if known)and source of information: 1982 PERMIT#82-799 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 _ Owner: PEDERFEN,RITA _ Date of Inspection: DULY 19,2005 BUILDING SEWER(locate on site plan): Depth below grade: 20" Materials of construction: Cast iron ✓ 40 PVC other(explain) Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 24" Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500-GALLON PRE CAST Sludge depth: 3 Distance from top of sludge to the bottom of outlet tee or baffle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 16" How were dimensions deternnined: ASBUILT&TAPE Commnents(on pumping reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage;etc.): TANK AT WORKING LEVEL,INLET TEE—OUTLET TEE. NO SIGN OF LEAKAGE OR OVERLOADING. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116`.OAKMONT ROAD CUMMAQUID,MA 02637 _ Owner: PEDERFEN,RITA Date of Inspection: JULY 19,2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarnn level: Ala,--,In in working order(yes or no): Date of last pumping Comments(condition of alann and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Continents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): D-BOX IS 9"X 15"—3'BELOW GRADE. ONE LINE IN—ONE LINE OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comiments(note condition of panp chamber,condition of pumps and appurtenances,etc.): } Title 5 Inspection Form 6/1 R'2000 8 e Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 OAKMONT ROAD CLJNLV1AQUID,MA 02637 Owner: PEDERFEN,RITA Date of Inspection: JULY 19, 2005 AI. SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits, number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE I 000-GALLONT PRE CAST PIT,PTr&COVER AT 30"BELOW GRADE. LEVEL IN PIT HIGH. CESSPOOLS: N/A '(cesspool must be pumped as part of inspectionX locate on site plan) Number and configuration: _ Depth—top of liquid to inlet invert: Depth of solids layer: _ Depth of sctun layer: _ Dimensions of cesspool: Materials of constriction: Indication of groundwater influ v(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Constriction: _ Dimensions: Depth of solids: Cormnents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15i2000 9 a_f ^y Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Owner: PEDERFEN,RITA Date of Inspection: JULY 19,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least.two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building, rr /I'ONr w 2p )3 t G� 3-4 0 0 Title 5 Inspection Form 6/15.'2000. 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Owner. PEDERFEN,RITA Date of Inspection: JULY 19,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 15. feet . Please indicate check all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _T Observation site(abutting pronertv/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:.. LOT&AREA HIGH,NO SIGN OF GROUND WATER PROBLEM. TEST HOLE 15'NO WATER. TEST HOLE 6'BELOW BOTTOM OF PIT. q; ,Boil Title 5 Inspection Form 6/15/2000 11 F r COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 �'� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 349 PAR 057 Property Address: 116 0AKMONT ROAD CUMMAQUID,MA 02637 Owner's Name: DOYLE,WILLIAM �px Owner's Address: 116 0AKMONT ROAD o :: o qq CUMMAQUID,MA 02637 � � � T9 Date of Inspection MAY 17,2002 O 91 Name of Inspector: (please print) JAMES D. SEARS PARCEL • __ Company Name: A&B Canco LOT Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT & I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Inspector's Signature: Date: The system inspector shall Obmit 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 116 OAKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X _ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: _ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 f Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 116 0AKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety,or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zoned of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 1 16 0AKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than'/s day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. 1 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t ' Title 5 Inspection Form 6/15/2000 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 116 0AKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,including the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 r Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION . Property Address: 116 0AKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: PRESENT COMM ERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy,/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: OCTOBER 2, 1998 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1982 PERMIT#82-799 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 16 0AKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 24" Material of construction: X concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,500 GALLON PRE CAST Sludge depth: 3" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.INLET TEE,OUTLET TEE,INLET COVER 4"BELOW GRADE.OUTLET COVER 24"BELOW GRADE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: v concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 0AKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): DISTRIBUTION BOX IS 9"X15",36"BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS CLEAN AND LEVEL. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title 5 Inspection Form 6/15/2000 8 Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 0AKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: I leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,.damp soil,condition of vegetation,etc.) ONE 1,000 GALLON PRE CAST.PIT AND COVER 30"BELOW GRADE3.ONE FOOT WATER IN PIT. NO HIGH WATERMARK,WALLS CLEAN. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 16 0AKMONT ROAD CUMMAQUID,MA 20637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 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. 1 Title 5 Inspection Form 6/15/2000 10 • a; Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 116 0AKMONT ROAD CUMMAQUID,MA 02637 Owner: DOYLE,WILLIAM Date of Inspection: MAY 17,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 15 feet Please indicate(check)all methods used to determine the high ground water elevation: x Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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 groundwater elevation: LOT HIGH NO WATER PROBLEM.TEST HOLE ON DESIGN PLAN. Title 5 Inspection Form 6/15/2000 11 r - oFtHE lw,. Town of Barnstable Regulatory Services BARNSTABM v N"ASS. g Thomas.F. Geiler,Director 1639• ♦0 Public. Health Division Thomas.McKean,Director 200 Main Street,Hyannis,MA 02601. Office: 508-862-4644 Fax: 508-790-6304 May 20,2002 RE: 116 Oakmount,Cummaquid,MA Dear Sir or Madam:. The Town of Barnstable Health Department Records show on the.As-Built card that a 1500 Gallon Septic Tank was installed at the above.property. Sincerely, LAA— David W. Stanton Health Inspector, Town of Barnstable P � onSz UN�h oW� w�I;q„� c L,)kV C •e0 f� -, '/-000 ���i►s. l� J� irn lP T Or U G 1� .I / / 71d by /��1 c c,_I cd IN,-,2 ,f 19 pot-/ ©CC utr Wei-c w t! cGl( f 770 ��,l��f 1 4 71 No. B y Fee `" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye_s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS l/ 2pplication for Oftq gof *p5tem Cow5truction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3ha�r,4%I Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building f S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) OOC Q�'£0 Cr00 r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss ed by this Board of lth. Signed Date l0 ' '!r Application Approved b Date A0 Z— Application Disapproved for the following reasons Permit No. Date Issued — No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Y s 2ppricatiou for nigpoal *p5tert Construction Permit. Application for a Permitto Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. it G ,dlr MU N Owner's Name,Address and Tel. C No Assessor's Map/Parcel ? /P 4 Installer's Name,Address,and Tel.No. ` Designer's Name,Address and Tel.No. w W Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building Gt' F S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. -�"Plan Date Number of sheets Revision Date +.. Title f Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) OA Rr o: a4 rAr,% Date last inspected: t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by this Board of H041th. Signed 2 — a Date --Application Approved b Date Application�Disapproved for the following reasons Permit No. "4f Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CE TIFY that the On-site Sewage Disposal System Constructed( " )Repaired( X)Upgraded( ) Abandoned( )by Q 04 yCG 3 S O w - �'wk at 6 ©Ali'M O A17 D C Q&//Z has been constructed in accordance with the pr ions of Title 5 and the Disposal System Construction Permit No dated Installer Designer The iss ce of this permit shall not be construed as a guarantee that the system will function as designed. Date ( e� '?i - Inspector No. �� ----------=---------------Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigozaf *p.5tem Construction Permit Permission is hereby granted/to Construct( )Repair( X Upgrade( )Abandon( ) System located at /I C, G�/1- AGR/T �J (' 0lelh14 aV/D 'f at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t it. A�Date: F "`'� R Approved by �� � O CATION �2f/".�j iri.��.% �f SEWAGE PERMIT N 0. V .LLAGE �. r A .� L- I N Sj A E 'S_ M E i A D//P R E S/S BUILDER OR OWNER DATE PERMIT ISSUED OAT E COMPLIANCE ISSUED /�� • '3®e e a 06 \ r V � 8 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................OF...... . Appliration for Uiipnsal Works Tnnitrnrtinn "pantit Application is hereby made for a Permit to Construct (X4 or Repair ( ) an Individual Sewage Disposal System at: ......... ------•..e2>..r.............. --•-•---•--•......................cs T_ ......-��--6-7.----------••-•---•----•-.....----- Location-Address or Lot No. W ....----•---••---•--•-. ..........-............................................ .......................................... a Owner Address _-----.---•-••----------•-----•. Installer Address Type of Building Size Lot..... __�_-- ._Sq. feet U Dwelling No. of Bedrooms______________I____________..___.._..___Ex Expansion Attic a g— p ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of:persons_______.__________.__.__.._. Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------•------•---------------..__.__....-------------------.._..-------------------------------------._.....-•------............___. W Design Flow.............. .....................gallons per person per day. Total daily flow________-____5� ................... Ions. WSeptic Tank—Liquid capacityA20.0gallons 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 area5 .�.tT._+ D Z Other Distribution box (X) Dosing tank ( ) a Percolation Test Results Performed by......... -0/,J._ �. 4 _ '-.../_./U�Date..............................._........ fes a Test Pit No. 1...., .......minutes per inch Depth oft Pit___/W______ Depth to ground water_Aa_T'___45�V" (%4 Test Pit No. 2....A!.......minutes per inch Depth of Test Pit..... Depth to ground water....................... P+ •••--••----••----------•-•--•-•-•••-••••--••--••----•••.............•-•......-•-•---.._......_------........................................................ Description of Soil T'1- ,K .�-�Q_-................................................................... x x •••••-•-••-•---...------••-•-------•--••-••••••••-•••- .--------•••-•-•••-•--•----•-•-•••---•-•••-•••--•••••••----••••-•=•---......_. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in,accordance with the provisions of TITi Uj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be e by the board of Sl — - _..._ _D. _..._ Application Approved Blore ••--••-•-----•--•--•••--•-••-----•--••._....•-------•---•------•--------------- �'� f Date Application Disapprovedllowing reasons:-----=-•------ ................................................................-----•------------- -•-•......................•--••••--•-----•----••••---••••---•......._....--•--••---••---•-----.....----_.._...••---•-•-•--•---••-----•••••---••----••••-•--------•-•--•-••-•••-•••---Date----------..._ PermitNo......................................................... Issued-....................................................... Date -No-----­------- 7­ ..1�................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �AJ..........OF....... .:... 21........................................? Appliraation for Disposal Works Tonotrnrtion Famit Application is hereby made for a Permit to Construct (>�4 or Repair ( ) an Individual Sewage Disposal System at: .............`..___. o.!U.T" ��—'�..!.............. ............................................................z .. --------------. Location-Address or Lot No. ` ` •----•-•--------------------------------------------------------------------- Owner Address Installer Address d Type of Building Size Lot_.`1'7_L3�..Sq. feet Dwelling—No. of Bedrooms.........................._.._.._...._..Expansion Attic ( ) Garbage Grinder04 ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures --------------------------------------•--•.----------.•-•••••••••-•---•--••••--------------•-•---•••----•-•-•.........-••..........-•-•-•----•-'•-••• d W Design Flow.............. 5........____..__---_-gallons per person per day. Total daily flow.............. �................_ Ions. WSeptic Tank—Liquid capacity��aG.gallons Length....._8 Width.....`1�..... Diameter________________ Depth_.`_...__. x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No------- ------------ Diameter-__w__----_ Depth below inlet..... ....... Total leaching area. _.!.sq:-€tG i- Z Other Distribution box (><) Dosing tank ( ) 04 Percolation Test Results Performed by........�0_Gli__- .•GcJ L-L__ ..•/sIJCDate....................................... aTest Pit No. -------minutes per inch Depth of Test Pit... Depth to ground water.L-=__r-HA�- (i Test Pit No. 2....%3........minutes per inch Depth of Test Pit----- Depth to ground waterC'S?!;/rA .E-Z .......... ................................................................................................................................................. 0 Description of Soil.......... ......(q.? _cs r ......./L,9AJ--.................................................................... x c., W -•-•-•----•----------------••---•---------•----•--•--•--•---•-•--•-••-----•----•..._......••---•••-----•-••-•-------•-••......------••............................................................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... -------•---------------------------•--------•-----•---------------------------------.....--..........----.......----------------------•-----_---------•-----------------------------•-•••..........•_•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.I, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be .issued by the board of health. ,;7 .//y Application Approved By •---•- .. ..f / l ......_.. r Date Application Disapproved or he following reasons----------------•--•-•--•---------•------•------------------------•-------------•---------------------....._..._ -•.................•------•-•----------•-•--••-----------------------------------------•--------•--••'-----...-•-----•'-•---••---••------•...••••••--••--------••••-----••----••----••--- .............. Date PermitNo-------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............................I..........OF.................................................I................................... f Tnrtif iraate of fwompliaanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (��) or Repaired ( ) ,Lf/X,j , a.............. ....;... --•---------•-------- �.. 7 � ` Installer at..................................... ------------ has been installed in accordance with the provisions of TITLE of The State Sanitary Cod ascribed in the application for Disposal Works Construction Permit No.c__`Z.......... . ................ datedw____1_l__... . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - 7/�y FEE G�....................... > / .....................OF................._.......................-••---••-••--•------........................ l> No......................... Disposal srko Twonotrnrtion Vprrmit Permissions-hereby granted = .....---------.......................................................................................................... to Construct'..(?:--) or Repair ( ) ban Indivfduah S .wage Disposal System ---......-•-.....•------..........................--..................................................................................................................... Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ............................... -------------------------------------------------------- Bgard of Health DATE....................................................................... FORM 1255 A. M. SULKIN, INC.. BOSTON j --- ---_ ExCF3 v' TE l'tAl P A/!o (J-!� _'_-$ - ta=- ._ _ _.. - 3 T , l f-? G, F c ./�'1 _ _W1 T1�f/ _ _ O.�_ LE F�C H P/,T x G f7 l!f.?T.� _ f32 k`' o T'/-1, 84,33 F 8� 1� a tf _ OO i , I 7 . 00 A-/0 TE- GG EXT&A-1D ALL AF'P4- /9BLE ------- e X�stinc� c�rounc� Pro¢� le HO,Q/Z. Sc/9LE V E Q 7' Sc /9LE- 1 = /p' rVHOC_ E COVE,25 TO !nJ/TH//V —a—o — P�-o/ooscd ground farofile ED G �F� L� E. . C HE D. 4 C] O e F 1 O ln/ ------�.- `� EQUAL Sc:f'TiC �r»in�rnurn per- f'oof� 2 Of c, mshe& s4orle 1 n ✓ \` D/ST SOX e Surnp s D J r co 5 I i �r rJ OOC7 GA[.. SEPTIC THAJK r • � e e D s s f -T`_-- C L Y� Z-, EDAT C- TEST B _ _- --- 44-1 10, OW ,q'7E "- t�ALS�DAY pL` " TEST HOLE / -TEST HOLE q0a 1 � uSE- . .�'_��' GAL. TA�v� J� L C'fIC H PIT; a1 ° .h ;;r� p r`r a5 � fU TvTAL = .J ' _..-!_ G tom. n PItT ��.r { �Z/ �f• armor-.. h .p7'3k.' �` },+... - 3-7 1 -77- 0:1V cq 7" e, 8U/4- D1AJG E) '��>' � PF2©GOSEL7 o.v 7-NE Grec>v^Jn ,vs $/-a O w ti On,/ -r E ,; -)t:>L ,c J�9 6•�� G01`-1F0,e1-7 T01 7-A-VE E3U/L D/A/G SET- TS o F T NE .k' ^f; 0 /�.�7- T U 4A//\l G) r (Y ` . _}, Pe� P� e � D Foy: � ,� . t''►'r' � > r� C:r Cfy '' OF Af !o `'`� R 0► ���aiNs'�y SC_f�LE : �9S SNOwti/ ZDRTC- / � EVEREFT c EVEREtT' H INCKLEY H No.;787 HINCKLE �Na 23230�� 7— coo - e xiS-tinr/ elevat-yon BL DG. S�TBF�c,� >< 42 /''10 L/ 7- , /V'714--75S_ 10001 = pr-oPoSed' ele vafion E'QU/A2E/"?E �1TS — -- -- — e X /S t/ c v n f c>u r•-S r- 0 r-n* _ 3o__- f. —�—o—c __ c-- �roPosea COn {OUrS c�r c B C7< ,� © - f- E AL 7-/-1 r-e —Lam �' r' ^-7 - - ------- :,t* rh,,*Uk4iw TOP FNDN. AT,EL. 98.4' PROVIDE IF NECESSARY PROFILE TEST HOLE LOGS SYSTEM ACCESS COVER TO WITHIN 6" OF FIN, GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN 6" OF FINISH GRADE Q.A. OJALA SE wuvcF W ACCESS COVER (WATERTIGHT) TO ENGINEER: , oor 5 MINIMUM ,75" OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM Z90-0. - SILO' WITNESS: D. DESMARAlS, RS z 2" DOUBLE WASHED PF.ASTONE DATE: 10/3/05 �- °. ELEV. 93.1" RUN PIPE LEVEL i o Locus FOR FIRST' 2' < 2 MIN/INCH MONr EXISTING 1000L11 PERC. RATE GAu.ON SEPTIC 91 .7't* I TEE 88.0' CLASS i SOILS P# TANK (H- 1„� ) GAS c,o [I 87.24' caocl �a0oocao RE-USE - SEE NOTE BAFFLE $7.41 � ' , c 87.17 . CI Cl CI C� © © L Cl 4 AROUND 6" CRUSHED STONE OR MECHANICAL $o , COMPACTION. (15,221 [2)) $ 2 1� 0 0 0 l� c 85.17 ( ELEV. 4„, " 87.5 0" 92.0' DEPTH OF FLOW = 4 ( 19 % SLOPE) ( 1 - 9 SLOPE) 3/4" TO 1 1/2 DOUBLE WASHED STONE � TEE SIZES: iA INSET'DEPTH a 10" FILL FILL OUTLET DEPTH 14 LOCATION MAP NTS 12"" 48"" LEACHING FOUNDATION--�-�- EXIST. SEPTIC TANK 23' D' BOX 9' A FACILITY A/B ASSESSORS MAP 349 PARCEL 57 11.6' LS SL *THE INSTALLER SHALL VERIFY THE THE INSTALLER SHALL CONhRM MINIMUM SEPTIC 16" 2.5Y 3/2 10YR 3 2 LOCATIONS OF ALL UTILITIES AND ALL TANK SIZE OF 1000 GALLONS, AND DETERMINE BUILDING SEWER OUTLETS AND ELEVATIONS TANI<BIF or SUITABLE FcP­lAusE I&ADD 0 GAL B / 2.5Y 7 $ PRIOR TO INSTALLING ANY PORTION OF REQUIRED TEES AND GAS E Fs., q SEPTIC SYSTEM 84" 85.0' LS M 73.5' 2.5Y 7/8 C 48" 83.5' LO rn L. M/F SAND co PERC C PERC BY INSP. EDGE OF LAWN L. M/F SAND 2.5Y 7/6 16" P. PINE` N 2.5Y 7/q � ,� 10% COBBLES » N 168 73.5' 144 80.0' 16" TREE ExIST.'UWELL. NGWE NOTES: NGWE : APPROX. NGVD TOP FNDN LOT 202 6PTIC DESIGN: (GARBAGE DISPOSER IS NOT Al I QWFr) ) 1. DATUM IS 98.4' 47,832t S.F. DESIGN FLOW: -3 BEDROOMS ( 110 GPD) 330 GPD 2. MUNICIPAL WATER IS EXISTING 14" OAK " USE A-330 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FC)OT. R.. 4" FLOWERING TREE '� 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 TH 1 o+ SEPTIC TANK: 330 GPD ( 2 ) = 660 `� 5. PIPE JOINTS TO BE MADE WATERTIGHT. s USE A Jnnn GALLON SEPTIC TANK (RE-USE EXISTING) , 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. 20" P.PINE � LEACHING: ENVIRONMENTAL CODE TITLE V. ` T 2(25 + 12.83) 2 (.74) = 11 7, THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT SIDES: TO BE USED FOR ANY OTHER PURPOSE. 25x1283 : BOTTOM: '74 = --�1- 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" . PVC. �c � 1 TOTAL: 472 S.F. 349�GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT ' USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. G VE EQUAL)„ WITH 4' STONE ALL AROUND 10, PUMP & REMOVE OR FILL W CLEAN SAND) FAILED LEACH PIT DRI 8 E q _ REQUIRED LO ' F UNSUITABLE`SOIL AROUND, PERIMETER OF LEGEND ' 8 �� LEACHING .FACILITY, DOWN TO TITLE 5 SITE PLAN SUITABLE SOIL LAYER. REPLACE =.. 2 .2T WITH CLEAN' MED. SAND. ENGINEER 1 OO.O PROPOSED SPOT ELEVATION OF I �' TO INSPECT AND CERTIFY 1 1 6 0 A K M 0 N T ROAD so REMOVAL. 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF: MA i N o--�-100 PROPOSED CONTOUR 00,(CUMMAQUID) BAR N STAB LE �; •.„� 1 100 EXISTING CONTOUR PREPARED FOR: 29, ; .; ,,. , . ., RITA PEDERSEN x Qy�. 20 0 20 40 60 -7-7-777771 .:. .� BOARD OF HEALTH ,,, �{ ,. 3.21' MA SCALE: 1 = 20' DATE: OCTOBER 5, 2005 s yYp APPROVED DATE I REV 10/28/05 (MOVE SAS) PROVIDE APPROX. 50 OF 40 MIL LINER IN AREA SHOWN, 5 OFF LEACHING FACILITY. TOP AT ELEV, 88.0', BOTTOM AT EL, 84.0' off 508-362-4541 .?: fox 508 362-9880 OF 1,14,9 �zH OF ass BENCH MARK - HYDRANT ON }'. ;. . a x G�OWI� CQ%?E' E'i�C�ll'1E'2/^ll�l� �� gcti 9y � 1r)cl o ARNE H ARNE TAG BOLT �179 'ELEV. - 89.9 OJALA H o }' CIVIL ENGINEERS CIVIL OJALA N No 30792 No.26348 •:s LAND SURVEYORSST 939 Main st. al^r�outh rIa 02675 �,A_ 05--•,2 > F y A.t I E . JALA, P. ., P.L.S. DATE