HomeMy WebLinkAbout0036 OLD JAIL LANE - Health 6 Ola Jail,
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Commonwealth of Massachusetts , ...660—000-
- ,rA Title 5 Official Inspection Form
? �ii Subsurface Sewage Disposal System Form - N a
9 P Y of for Voluntary Assessments
° ,• 36 Old Jail Lane _
Property Address —
Linda Leung
Owner Owner's Name /
information is Barnstable
required for every _MA 02630 6-25-20 _
page. City/Town State Zip Code Date,of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
. way. Please see completeness checklist at the end of the form.
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Important:When A. Inspector Information u `' '
filling out forms I P ��avt l�fCe� 1
on the computer, DAMES
use only the tab James D.Sears_ =�:
key to move your Name of Inspector - c��: _ —
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cursor-donot Robert B.OurCo.INC "k ' *'
use the return -- - .��.:.�'c�_ _.E�•'�
key. Company Name - �i
363 Whites Path
• r� Company Address
South Yarmouth MA 02664
City/Town
_ State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
i
4. ❑ Fails
;— P-e-coto
tJ a� 6-25-20r's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
s of Health or DEP) within 30 days of completing this inspection. lithe 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung________
Owner Owner's Name
information is Barnstable __
required for every _ _ _ _MA _02630 6-25-20 _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System Pass. The system is a 1500 Gal. H-20 Tank D Box and seven infiltrator's.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old` or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
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f
Commonwealth of Massachusetts
is Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Lane__
Property Address - --
Linda Leung
Owner Owner's Name
information is Barnstable MA 02630 6-25-20
required for every - _ ._ ___
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety�or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
lg Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung _
Owner Owner's Name
information is Barnstable
required for every MA 02630 _ 6-25-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
II
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Lane _
Property Address
Linda Leung
Owner Owner's Name
information i e
required for every Barnstable _ _ _ MA 02630 6-25-20 _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in aeoapsM is less than 6" below invert or available volume is less
than '/2 day flow /-£13 e1-11,1vC
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy'is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
I ❑ ❑ 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 snapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 5 of 18
l_
Commonwealth of Massachusetts
Ri Title 5 Official Inspection Form
iQ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 36 Old Jail Lane _
Property Address
Linda Leung_
Owner Owner's Name _—
information is
required for every
Barnstable
MA 02630 6-25-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information.was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage 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)]
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r—
Commonwealth of Massachusetts
IF Title 5 Official Inspection Form
M11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung
Owner Owner's Name _ -
information is required for every Barnstable MA _ 02630 6-25-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
4 4
Nu
mber of bedrooms (design). Number of bedrooms actual
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
1500 Gal. H-20 Tank D Box and seven chamber's.
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit?' ❑ Yes ® No
If yes, discharges to:Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gp ))�
Detail:
Sump pump? ® Yes ❑ No
Present
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,(t� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung _
Owner Owner's Name
information is required for every Barnstable_ _ _ MA _ 02630 _ _6-25-20_page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment: -
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: - - --
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: --
Last date of occupancy/use: date
Other(describe below):
3. Pumping Records:
Source of information: _2017 _
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined? —
Reason for pumping: ---
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
C
CVO 36 Old Jail Lane _
Property Address
Linda Leung _
Owner Owner's Name _
information is required for every Barnstable___ _ MA 02630 6-25-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
2001 Permit #2001 -219.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2 -
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.):
Pipeing is 4" PVC SCH -40.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
L Commonwealth of Massachusetts
Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
36 Old Jail Lane
Property Address
Linda Leung
Owner Owner's Name
information is Barnstable _ MA 02630 6-25-20
required for every _
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
_
Depth below grade: 14"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
1500 Gal. H-20 Precast
Dimensions:
2„
Sludge depth: -- - -- -
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness - Off
-
11
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
18"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
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. Tank at 14". In and outlet Tee's. No sign of leakage or over loading.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
i
Commonwealth of Massachusetts
J P Title 5 Official Inspection Form
��� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung
Owner Owner's Name
information is
required for every Barnstable_ _ MA_ 02630 6-25-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: -
Scum thickness —
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(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 per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung
Owner Owner's Name
information is Barnstable _ MA 02630 6-25-20
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: -~ ----- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date —
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is,copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert —-- -=— ---- --___
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.): ,
D Box is 40" below grade w/8" center cover. Box is clean and solid. No sign of over loading or solid
carry over. _ -____-_ _
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung
Owner Owner's Name
information is Barnstable _ MA _02630 _ 6-25-20
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
7
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: — -—�
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
...........` / 36 Old Jail Lane
Property Address
Linda Leung _
Owner Owner's Name
information is Barnstable MA 02630 6-25-20
required for every _ _. —__— ..
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is seven infilators (12'x52'). Ck D Box and camera out lines. No sign of over loading or
solid carry over. 2"water in chamber's.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer �- - —
Dimensions of cesspool
Materials of
construction -
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2015 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
ig Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung
Owner Owner's Name
information is Barnstable _ MA_ 02630 6-25-20
required for every B _._
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: ---- - ---- --
Dimensions — - — -
Depth of solids - - - --
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�. p Title 5 Official Inspection Fora
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung
Owner Owner's Name
information is Barnstable MA 02630 _6-25-20
required for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
cI� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4 36 Old Jail Lane
Property Address
Linda Leung
Owner Owner's Name
information is Barnstable MA_ 02630 6-25-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
JV 0
Estimated depth to igh ground water: 3 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:
Abutting area drops off 30'+
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Lane
Property Address
Linda Leung
Owner
Owner's Name
information is Barnstable MA 02630 6-25-20
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
S
Bcc, OA4 3 °
7T, 5-/
t5insp.doc-rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Commonwealth of Massachusetts a? 9" D�-DD
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
r
36 Old Jail Ln.
r.y
Property Address
William LaPointe �
Owner Owner's Name
information is Barnstable
required for every MA 02630 8/23/2017
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
A. General Information a S
filling out forms �/ ! 2 G
on the computer, /
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
use the return Name of Inspector
key.
Cape Cod Septic Services
Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
City/Town State Zip Code
508-775-2825 S15016
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 the Local Approving Authority
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP, The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
••`• 36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
required for
is every
Barnstable
required for eve MA 02630 8/23/2017
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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System in working condition.:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑,N ❑ ND(Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not f
w p Y or Voluntary Assessments
,
r< 36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information isequired for every Barnstable MA 02630 8/23/2017
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
'safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•`� 36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is
required for every Barnstable MA 02630 8/23/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 1 00 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must Indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ® Liquid depth in cesspool is less than 6 below invert or available voltame is less
than day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 4 of 17
Commonwealth of Massachusetts
G Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
isrequired for every
very Barnstable MA 02630 8/23/2017
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No'
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
" ® tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water-supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving.a facility with a design flow of 2000gpd-
10,000gpd.
® The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes . No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of.a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is
required for every Barnstable MA 02630 8/23/2017
page. City/Town State Zip Code Date of Inspection
i
C. Checklist
Check if the following have been done. You.must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® Were as built plans of the system obtained and examined?(If they were not
available note as N/A) -
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ -Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,opened, and the interior of*the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at.issue
approximation of distance is unacceptable) [310'CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x4=
440gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
L W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is
required for every Barnstable MA 02630 8/23/2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder?
❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): 2015=252gpd
,
2016=244gpd
Detail:
Sump pump?
Yes El ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: _
Design flow(based on 310 CMR 15.203): w Gallons per day tgpal
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
. ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
l5ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
commonwealth of Massachusetts
951 Title 5 Official Inspection
n Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Ln.'
Property Address
William LaPointe
Owner Owner's Name
information is
required for every Barnstable MA 02630 8/23/2017
page. Cityfrown 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: 6/16/2017
Was system pumped as part of the inspection? ❑.-Yes Z 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
El Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
El Tight tank. Attach a copy of the DEP approval
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
F
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is required for every Barnstable MA 02630 8/23/2017
page. Cityrrown State Zip Code Date of Inspection
D. ,System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2001 Per BOH records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain);
Distance from private water supply well or suction line: +10'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Line checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
Depth below grade: 1611feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ . No
Dimensions: 1500Ga1
Sludge depth: 1-211
t5ins•3H 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•'� 36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is
required for every
very Barnstable MA 02630 8/23/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
0„
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
How were dimensions determined? Estimated
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural_integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500Gal H-20 tank in good condition. PVC tees in place and clean. Tank at normal operating level.
Covers 16" below grade.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official
cial Inspection _Form .
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is required for every Barnstable MA 02630 8/23/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet 4tee or baffle condition;structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or.Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:.
Material of construct• ion: •
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: .: gallons per day
Alarm present: ❑ Yes 0 No
Alarm.leveL'K;• Alarm in working order: El Yes ElNo
Date of last pumping: Date r
Comments(condition of alarm and float switches, etc.):
e •
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3i13 Title Official Inspection Form:Subsurface Sewage Disposal Systems•Page 11 of 17
Commonwealth of Massachusetts
u: m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
Y
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information
equir for
is every
Barnstable
required for eve MA 02630 8/23/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
DB-6 with 1 line in and 5 lines out in good condition. Box is`clean and level with minimal solids
carryover. No sign of overloading or hydraulic failure
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan,.excavation not required):
if SAS not located, explain why:
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
a W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M •'4 36 Old Jail Ln.
Property Address -
William LaPointe
Owner Owner's Name
information is
required for every Barnstable MA 02630 8/23/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 7-Infiltrators
❑ 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.):
7-Infiltrators with stone in a 12'x52'x10"Trench. 1"of effluent in chambers at time of inspection. No
sign of overloading or hydraulic failure.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
f.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is
required for every Barnstable MA 02630 8/23/2017
page. City/Town State Zip Code Date of Inspection
M.System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System a Page 14 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is
re uired for every Barnstable MA 02630 8/23/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,:including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
drawing attached separately
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
I -
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is
required for every Barnstable MA 02630 8/23/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar,
® Shallow wells
Estimated depth to high ground water' +10'
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: 2000
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:
Test hole data per plan on file at BOH.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
" �L\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
36 Old Jail Ln.
Property Address
William LaPointe
Owner Owner's Name
information is
required for every Barnstable MA 02630 8/23/2017
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable.to All Systems)completed
® System Information Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or.attached in separate file
k
t5ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I�wk W TOWN OF BARNSTABLE
LOCATION _ CID T-Alt- LIV SEWAGE #,._0_0
VILLAGE L!a• ASSESSOR'S MAP & LOT�C -Sb
INSTALLER'S NAME&PHONE NO.GUIL/- -W Qro Clz I� � / Q
SEPTIC TANK CAPACITY 600 G-A-!- P •-9 O
LEACHING FACILITY: (type) IV EI1- r62- (size
NO. OF BEDROOMS
BUILDER OR OWNER RA420 a'Ti � l2 OR_ OUI Lbil—
PERMITDATE:_�IIlI�OI 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
a
t
F^
I �
-53 1 t� "
14- W 13--2-- I
3 - �3�
�Z r3-�� �� � � r
s 5
TOWN OF BARNSTAB�LE
LOCATION (���� �aL��_ LC�� ..1- SEWAGE # �'
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
TNT G S
LEACHING FACILITY: (type (size) �a' �
NO. OF BEDROOMS LI
BUILDER OR OWNER
PERMITDATE: t COMPLIANCE DATE: 2 "L
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
r, T
Furnished by �
Fee
No. 4 ✓,
42
THE COMMONWEALTH OF MASShCF's'iISFETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF-BARNSTABLE., MASSACHUSETTS
ZippYication for Migool *pztem Con.5truction i3ermit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Kcomplete System O Individual Components
Location Address or Lot No. 36 6 �A f L /_D / Owner's Name,Address and Tel.No. SOY'36 2-810�j(a 5
79 ] 8� �v>v A999�'4L49
Assessor's Map/Parcel 0 00-2 too 40 c COS-
Gv ++t w M/4 02fo 3
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
YUV4 v Co Ns;p'.. G0 . jfdLAVs-41nC6jM7H 5 N4 , rAof,,
Zoc,mAiN ST. FiQLmavtN mA 02SQ0
08eS -356
Type of Building:
Dwelling No.of Bedrooms _ Lot Size / OZo sq. ft. Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 440 gallons per day. Calculated daily flow 457 gallons.
Plan Date 3-O/-o f Number of sheets Z Revision Date
Title APO PDS Q Sg WA 0 �l /�IQ3e4,�4 L _5V T9M
Size of Septic Tank g-20 Type of S.A.S.
Description of Soil "AM. , Sal�L.dAm Q1_7- 44M ` F/N.E- SA^�0
I
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
i
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 ' ed by thi Boa4d all
Signed P,57, Date 03 6
Application Approved by Date
Application Disapproved for the following reasone.,Z
Permit No. Date Issued
~,
N,o.. �V' Fee
�` ! 1
HE COMMONWEALTH OF MASSA}CHUSgTTS-NI
p
Entered in com uter: t f
j �.
"•: � y , s
UBADVISOI TOW�100ARNSABLEi � MASSACHUSETTS r �{
Zlppt cation fo00tgpo!5at *pztem Construction Permit
Application for a Permit to Constt�t�ict( )Repair( )Upgrade( )Abandon( ) .Complete System ❑Individual'Components.
„
r Location Add ess or Lot No. —?(C`61,W
IL fk p`� / Owner's Name,Address and Tel.No. � s"OP—.36 2405(c
Assessor's Map/Parcel /"�O - 00-2 R6 ASOX COS
Cu r"IslAQVID MA 02(0 3
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. y
49V4 AXE Co Ns 7: CO . /�d uvvs4 mc60.1A7H c n/4
20041AiN5T. TpLM6V7r) y"A 02540
'roe-s 8-3s6
Type of Building:
Dwelling No.of Bedrooms 4 tLot Size rode 02.0 sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( ) t
.,,.
Other Fixtures
Design Flow 440 R gallons per day. Calculated daily flow 4517 gallons.
Plan Date 3-OI—o 1 Number of sheets Z Revision Date
Title APO POS ED SEWAGE. tb- i 5 6WA L S)/S7-F—/N
" Size of Septic Tank S'DO A/-26 Type of S.A.S.
Description of:Soil L-,QA ryi
Nature of Repairs or Alterations(Answer when applicable)
-Date last inspected:
-.Agreement: i {
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system it
in accordance with the provisions of Title 5 of the Environmental ode and not to place the system in operation until a Certifi-
cate of Compliance has been�isjd by thi oard alth
Signed117, Date 1110316,f
Application Approved by _ O Date" r
Application Disapproved for the following reason /
Permit No. v Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
/ BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERT FY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded ( )
Abandoned( )by r'. GC.
at h 1 t /o has. en constructed in accordance
with the provisions of itle 5 and the for Disposal System Construction Permit No — dated 9/1//(1 l
Installer Designer t
The issuance oV411
his permit shall not be construed as a guarantee that the syste will,fu ction as de ign d.
Date C2 )00- Inspector
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
li5pozar *pgtem Construction Vermit
Permission is hereby granted to Construct()()Repair( )Upgrade( )Abandon( )
System located 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 this permit.
Date: �'1 f o / 1�1 Approved by
1,
f
TOWN OF BARNSTABLE
LOCATION SEWAGE #eta — )
VILLAGE ASSESSOR'S MAP & LOT -5b;2
I
INSTALLER'S NAME&PHONE NO.WILD/VW D f kl(,r-
SEPTIC TANK CAPACITY ��00 1,-A-1- Ll — 4
LEACHING FACILITY: (type) T (size)
NO. OF BEDROOMS
BUILDER OR OWNER Q
PERMITDATE-—qkLk—COMPLIANCE DATE: 1,4
Separation Distance Between the:
I
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 fee_t of leaching facility) Feet
Furnished by
a
(V)
` f
1 umi ul Damsl.ame P#
Department of Health Safety,and Environmental p , y, Services
�Yt Public Health Division Date /0/6b
367 Main Street,Hyannis MA 02601
� + EARNSTABLE• • ..
y MASS.
A6g9• ♦� r�
OTEpMpIA Date Scheduled DFC9MA.69 7, Z000 Time /® /y Fee Pd. /i00'
Soil Suitability Assessment for Sewage Disposal
Performed By: Simi 6 Witnessed By:
.�
LO;�ATION ,& GENERAL INFQRMATION
Location Address�f� P� � � Owner's Name Sv or
fd��k ! +pG�� tvf4t Address
Assessor's Map/Parcel: Engineer's Name//O/Mrs
v
NEW CONSTRUCTION /� REPAIR Telephone#: sy —as
Land Use V6(AqJ4_01 " K160d f
! Slopes(%) .�'�� Surface Stones
Distances from: Open Water Body ;;00 ft Possible Wet Area - SOD ft Drinking Water Well It
Drainage Way A- ft Property Line �(����ft Other R
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
L-oT 1
lC,
p(��� 1 /
Parent material(geologic) �o� ,e, ) pfGpi�, lie � AM)Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face [
/ A
Estimated Seasonal High Groundwater >
............... :::....,......,:.:....:..............:. ....: : :::,.:,.,.:<:.:::::::.: .;.,........;....: ......,.;...::..:...:.;;:.;;
E Y'EI�AT (�l�T Cott SASONA�,HIGH'VVAli TAPL
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 R.
Index Well# ___. ._.-. Reading Date:,__,-,___ Index Well level. Adl.factor Adj.Groundwater Level
ix'�C�ir� [ O°r T] T UAtex l irtte
Observation .
Hole# Time at 9"
Depth of Pere Time at 6"
Start Pre-soak Time @ ln: g� Time(9"-6")
p
End Pre-soak Z a1 s t!1 i#'` hq.A �I '
Rate Min./Inch �t
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YM)
Original: Public Health Division Observation Hole Data To Be Completed on p Back
j
Copy: Applicant licant
DEEP bBERVTIOIV HILE LCJG Holtz#< x
Depth from Soil Horizon Soil Texture Soil Color Soil Other R
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
n i tent % ravel
0-0
AkN
36"p 1 2d C j 6 Aa� J►�
MY
I�EEI� OBSERVATION HOIjE LO,G
dole# .
SuDepth from Sol,Hofizon Soil Texture I Soil Color Soil Other
rface(in.) Soil
(Munsell) Mottling (Structure,Stones,Boulderes.
C i tent °° ravel
yes t
Ing Si
—itt 2M SAVE-
DEEP.CIBSERA'TI01�1I(�I,E I:OC Dole# .... "
Su
epth from Soil Horizon Soil Texture Soil Color Soil
rface(in.) USDA Other
(USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
( C nsi tent %Gravel
l 2 ro
q0� Z Ain 7/q
R Ala
J EE ' OB ER��4 Y€ —H�3I,lE Lt�G Hobe #
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling
g (Structure,Stones,Boulderes.
—CQnsistency.%Gravel
Flood Insurance Irate Man• Z570 ; 00C3 FJ
Above 500 year flood boundary No_ Yes X
Within 500 year boundary No X Yes
Within.100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? �,�
If not,what is the depth of naturally occurring pervious material?
Certification
ova
I certify that
$V Q@+ bfr. (date)I have passed the soil evaluator examination approved by the
Department of Environmenial Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017.
µ Signature � Date
. k ::...3 � Fizz.. 0
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............ ..................OF...., 7Z//5 �� ..................................
_.
App iratiun for Biapuutt1 Works Tonstrnrtiun rrmif
All S(.0Application is hereby made for a Permit to Construct (&/�or Repair ( ) an Individual Sewage Disposal
System at:
1� � �.... --�'•v-••--- 4�c/ T.f#'�3G ..... ................................... l...........................................
Location-Address or Lot No.
... .. ,?'.�!.v-........................................ /t7�/�r�i /l5 f� :ss
Owner Address-_----..•----------------••---••
Installer Address �� y
Type of Building Size Lot._ i? , ._.-Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q, Other fixtures ------------------------------------•------•----•.........-----
W Design Flow.......... ......................gallons per person per day. Total daily flow......... .......................gallons.
WSeptic Tank—Liquid capacity_Q.eia.gallons Length..8°6"... Width'!IK"... Diameter................ Depth..4:" '¢_-.
M---
x Disposal Trench—No. .................... Width.................... Total Length............J......... Total leaching area....................sq. ft.
Seepage Pit No....../............ Diameter....../d........ Depth below inlet....6............ Total leaching area_Z2�7.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by_gPh! ._—'-�2..DatC_�P f eTi!rc Date...6�K_23__f9 'o.._..
Test Pit No. 1 __minutes per inch Depth of Test Pit.... ....... Depth to ground water..................
Test Pit No. 2!�--. ...minutes per inch Depth of Test Pit---- "... Depth to ground water..........................
----•.............................................................. ...............•-----....... .........................................................
O Description of Soil--O"-Z4'...._ bv®GuA _,S� rSe�sG� 7� � '•c/ ?..._..
x
V
----------------------------------------------------------------------------------------------------------------------------------=-------------------------•----------------------------......-••••-•--
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'�ITIu: 5 of the State Sanitar Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en sued b the boar f lth.
ign ---;.. .... . ........... .._...... .................... ...... ..... .................
Application Approved B 'L�rLrr:` -
����' Date
Application Disapprov fo t ie following reasons:--------••-•-------------------•------------------------------•----------------•----------. •--------•._....._.
............................•---------••--•-------•---------=----•-------------------------•--.......---...--•-------•-••---------•------------------------- ..........................................
Date
PermitNo......................................................... Issued-.......................................................
Date
m
J
Alp,
Fimic i.....................r/
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7a I Al^ —le)
...............................
Appliration for Uhiposal Vorkg Tomitrartion Vamit, .. '
Application is hereby made for a Permit to Construct V5 or Repair an Individual Sewage Disposal
System at:
Zo
............. ...................................................!�..............................................
Location-Address or Lot No.
Owner ...................................
Address 7
... ... ENO_,................................................................... ...........................
pq
Installer Address
79 Type of Building Size Lot------711,11-1... l----Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons....____..__.._______.____.. Showers Cafeteria
44 44 Other fixtures
Design Flow......... . . ....:.................gallons per person per day. Total daily flow....................S-70
..........................gallons.
9 Septic Tank—Liquid capacitv.6PGQ_gallons Length_.F�.'_.r(....... Width:!?.G....... Diameter................ Depth.A..�'
Disposal Trench—No..................... Width.....`.......__..._ Total Length............._......* ........ Total leaching area....................sq. ft.
Seepage Pit No.-.--/............. Diameter.._... ........ Depth below inlet_._�. .......... Total leaching area.:.'ez......sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed Z4f!5; Date...
Test Pit No. 1G_.Z!N ?_._minutes per inch Depth of Test Pit... ....... Depth to ground water...................
PLI Test Pit No. 2*-.!e e�...minutesper inch - Depth of Test Pit... ' .... Depth to ground water___._.."!_........_..
..................................
I.... *-----"---------------*......
........... ..................
0 Description of Soil---52 V,10e.> 4—
�4 ............................................................................. ............................................I........................
U ..............................................................................................................................................I..........................................................
.......................... .............................................................................................................................................................................
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 TIT M 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en ued by the board"'Offylo�Olth
4
e
0 �0
ign 1
......... ..... ----"-- ';O
-------------------------- .........
Application Approved B ........... et.......................•--•--••••••••-••-----..........----...
.....- ........
......Date---------------
Application Disapprov '.for'vh�" following reasons:.............................................................................................................
......................................................................................................................................................................................................
Date
PermitNo.......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7'e-)V
.........................................0 F...�. ..........
ntifiratr of Toutplianre
-S'THE .- (I
TIFY, That t4e Indivi constructed oual Sewage Disposal System constru or Repaired
by....... .. .... --------------------------------------------------------------------------------------------------------
Installer
at............... .......... ........ -----
......................................................... ........ .... ....................
e---
li the provisions of T 17 f The State Sanitary in the
has been installed in accorda e ary )�e
application for Disposal W onstruction Permit No._�j dated-........ ........I..............................
...................................
THE ISSY ANC POF TINS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE
SYSTEM L CTION SATISFACTORY.
..........
DATE.__(__... ............................................................... Inspector....._..__..... ................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........70'AIAI OF............................. .. ....... ...............................................
No .... FEE----....................
di n �_Totwtrndiott "Wrinit
Permission is hereby granted................ezl..'
........... ..........I...............................................................................................
to Construct Re air 'W
R
strucl�', wgrsposal System
atNo..... ........................
1114............................... .1......... ................... .. ..................
............... ...... .... ........ .
Street
as shown on the application for P,ispos 7orks Construction Permit-, --- Dated....''.................................
................. .....e............. .............................................................
DATE................. .......... Board of Health
................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
a tOWN OF BARNSTABL8` — UNDERGROUND FUEL AND CHEMICAL STORAGE WREGISTRATION
OWNER AND INSTALLER INFORMATION
ADDRESS: I ` 0, Q MAP NO. / ! PARCEL NO. te/
OWNER NAME: A4 )I- t Q=.5E'Tjr ) VILLAGE:
INSTALLATION DATE: BY:
ADDRESS: CERT. NO.
TANK INFORMATION
LOCATION OF TANK:
CAPACITY TYPE ": AGE � r Y FUEL/CHEMICAL ,- FVcL oa,
TESTING CERTIFICATION C J PASS C J FAIL DATE
LEAK DETECTION C1 CHECK IF N/A TYPE/BRAND s\ 1f
ZONE OF CONTRIBUTION C J YES. CJ NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C J YES C NO DATE
CUNSERVATION I CHECK IF N/A DATE
BOARD OF'HEALTH TAG NO.
�� JC JC JC J DATE
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
J IMIEN 19 '91 09:49 BARNSTABLE FIRE DEPT
BARNSTABLE FIRE DEPARTMENT
FIRE PREVENTION INSPECTION REPORT ✓ t"
BUSINESS NAME UST REMOVAL BRESSETTE
--- - . --------------- ---_--__--,+_-_- - -_-- -------------------------- -----
INS ECTION DATE 06/10/91 ADDRESS 19 OLD JAIL LANE
INSPECTION TIME 09 :46 :00 CITY BARNSTABLE STATE MA ZIP 02630
QUARTERLY DATE 00/00/00
--------y-------------„_--_----,. --- -------------------------------------- --
PROPERTY REP OL MRS. BRESETTE
VIOLATION BUILD VIOLATION ELECT
VIOLATION HEALTH VIOLATION GAS
HAZARDS WITNESSED THE REMOVAL OF ONE ( 1 ) 50D GALLON UNDERGROUND FUEL STORAGE
TANK FROM THE ABOVE NOTED RESIDENCE. THE EXCAVATION HOLE WAS CLEAN
AND THERE WAS NO EVIDENCE THAT THE TANK HAD LEAkED ANY PRODUCT. I
ORDERED THE EXCAVATION BACKFILLED AND THE TANK REMOVED TO THE TANK
YARD AS INDICATEDON THE REMOVAL PERMIT .
COMMENTS
, Q FIL NG CAPT COFFIN
ON -.— � .... ._.....,_
,ON-1 J:N rN: SAC
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LOT 4
z 66,3"-1 S.F.Q Q h WOODED
APPROXIMATE
LOCATION OF
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SYSTEM
LEGEND
I WOODED EXIS77NG 2' CONTOUR
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u, x 101.5 EXISTING SPOT ELEVATION
E� �p�Y
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CB/DH o CONCRETE BOUND WITH DRILL HOLE
EDGE �'i OF I NE/Y FOUND
46 1 8 p PATIO
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106.73
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\ LAWN GENERAL NO TES.--
LAWN \' �rk h ' �`1c�`T
1. HOUSE NUMBER.• 306
0•
2. ASSESSOR'S INFORMA TION.• MAP 277, PARCEL 019, LOT 4
PAVED, DRIVEWAY 10 9 d 3. FLOOD ZONE.• X (FEMA PANELS 250001 0554 J & 250001 0558 J, DA IED JUL Y 16, 2014)
�. PLAY GYM 4. ZONING DISTRICT RG
5. LOT COVERAGE BY-
A. EXISTING STRUCTURES- 2,904 S F./ 66,329 S.F. = 4.4.E
VB. EXISTING & PROPOSED STRUCTURES• 3,738 S.F./ 66,329 S.F. = 5.6X
� OF
6. TOPOGRAPHIC INFORMA TION COMPILED FROM AN ON THE GROUND SURVEY
��s 7. ELEVATIONS SHOWN ARE BASED ON NORTH AMERICAN VERTICAL DATUM 1988.
& SI TF IS WI THIN WELLHEAD PROTEC77ON OVERLAY DISTRICT
BENCHMARK: =ry ry
TR. NAIL do CAP 1
EL 94.00 ! WOODED
o �
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SITE PLAN
PP
Q FOR
46-19 GILMAR & KELL Y BORSA TTO
#J06 OLD JAIL LANE
BARNSTABLE, MA
Scale: 1 "=20' Date: SEPTEMBER 10, 2018
OF Mq SS
q�
cd tiG
CB/DH , ( 1 GARY S.LABRIE IYarwick dPc Associates Inc.
FOUND I " No.40039
DRAWN BY L.M., R.J.W. DA TE.• 9110118
� G 63 County Road Box 801
c qr " cl,
CHECKED BY GSL SHEET 1 Of 1
R=24.50' 20 0 10 20 40 NOTt/l 1f'Ql�7ZOZ6t1ly AQ.S'S O.Z556
L�1.85 .L
CA
�508� 563 - 7777
�.
P.• Land Projects 2004 r SS78074�dwg�SS18074SP.dwg SC,4LE.- 1 INCH = 20 FEET
O
1500 GALLON
4
SEPTIC TANK
H-20 LOADING
P� O O 32' O
�O
6 HOLE pro
DISTRIBUTION BOX
t
3•2
77- 1
PROPOSED BUILDING DINGVN
'23
0
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►
:.• ''"�'"`'• 7 HIGH CAPACITY IN L
: ..: ••: ::..., ... ,.. : -.. . .•. . . .,.•..• ' 6 '• •:► . • •' : ....;•:.';r WITH 4 OF STONE ALL AROUND EDMUND M. CANNON
.17
AND SUSAN G. CANNON
N F
.: •.•.: . . . ..:.r.-'.- •,:..': :., ' •:.. :. .:'.." . . . . . ..:'.. ::'....... . . ..... . .... .. . . .. . : . , .. R. WALLACE McCLENAHAN -AND
156
�. . . , ... :�.-. . ... ... .�• ,�,�, .. ...�.. . . ^,�,.. SALLIE PHiLLIPS McCLENAHAN156-
RESERVE AREA I ?.
1't S•
,k
THE CONTRACTOR SHALL EXCAVATE 5 ALL AROUND
THE LEACHING FACILITY AND DOWN TO THE FINE SAND LAYER (11►f). 1 E
MATERIAL AND REPLACE WITH CLEAN GRANULAR SAND 77 56 3
REMOVE ALL UNSUITABLE TE F, N . 46 �2
CONFORMING TO THE SPECIFICATIONS SET FORTH IN 310 CMR 15.255 (3).
UP TO THE SIDE WALL OF THE LEACHING SYSTEM 144.
FoJ
» E o
g 35 �+
SEPTIC COMPONENT DETAIL N
77•5 �• �
— 19.30
1 - 10 ti
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LOT 1
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1 .83 ACRE
u' PE FACTOR = 16.6
ON 69197 S.F.
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J AND JUDITH COLLINS N � •O I
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N
NOTICE
8 u (/ ` : .f.,a•,'.= . :,: Off:•:. , •
p LIT $ , " r O Unless and until such time as the original (red) stomp of the
66 Y E --_.0 �``.•, responsible Professional Engineer, or Professional Land Surveyor
SF qSE 44 r P 9 yo
105. ::.,.�-Fa:, :' O . ,:;:. LOT 8 appears on this plan:
NT 18 :,. Q�, .
A no person or persons, including anymunicipal or other
W ,, •:.�' .: ', ;•;`. N/F public officials, may rely upon the information contained herein; and
S " • B this plan remains the property of Holmes & McGrath Inc.
�"`� j•, 42.7 SUBON CO. O P P P Y c
-' -
42.9
LOT 2 N 4 x
N/F 03.
42.4
N CO. � PROPOSED SEPTIC SYSTEM '
SUBO . GATE (SEE DETAIL)
�
POST
,00 42. DATE DESCRIPTION Drawn Checked
1i 100
LEG
END
D
PLOT PLAN
BENCHMARK.
UTILITY POLE OF PROPOSED SEWAGE DISPOSAL SYSTEM
NOTES NAIL IN PAVEMENT
PREPARED FOR
BOUND � _
ELEV. 42.51
A
TP
1. HOUSE NUMBER: 3s B RNSTABLE HARBOR BUILDERS
.TEST PIT � FOR LOT 1 OLD JAIL LANE
2. ASSESSOR'S NUMBER: 279 50-2
WATER SERVICE � � `
wV 3. ZONING DISTRICT: ' RF-2 1N
WATER VALVE D4 7 BA MA
—G
4. FLOOD HAZARD ZONES: C RNSTABLE,
GAS LINE
5. BENCHMARK. AS SHOWN EL.-42.51)
GRAPHIC SCALE
FENCE 6. TOPOGRAPHIC. INFORMATION BASED ON AN SCALE. 1 20 --TDATE. MARCH 1, 2001 ,•:,. - ,.., t,
ON THE GROUND INSTRUMENT SURVEY
HYDRANT 0 60
20 10 0 2
mes and meC�rath inc.
GAS VALVE
7. ELEVATIONS SHOWN ARE .BASED ' ON THE NATIONAL
D4 civil engineers -and `land surveyors
VERTICAL' DATUM. 9 Y
GEODETIC
PROPOSED SPOT GRADE 44.OX > FEET 200 main street �508 -548-3564(PHONE)
8. REFERENCE: PLAN BOOK 502, PAGE 11 ( N >
EXISTING SPOT GRADE 44.ox
1 inch = 20 '- ft. falmouth, ma. 02540 508 548-9672 FAX
PROPOSED GRADE 38 DRAWN, -MAH, GAB CHECKED: (,�
—38
EXISTING GRADE 78 1 16
BHBLDRS 201051PP.DWG
JOB N 0. , 201051 DWG. N 0.. SHEET 1 of 2
Finish grade above and adjacent to system shall slope away at a min. of 2%.
4" diam. cast iron or Schedule 40 PVC pipe (tight joints). DEEP OBSERVATION HOLE LOG NO. 1
20' min. distance (building to edge of leaching system) SOIL TEST
( g g g SOIL SOIL TEXTURE SOIL COLOR SOIL (STRUCTURES,
DEPTH ELEV. HORIZON USDA Munsell MOTTLING STONES, BOULDERS,
10' min. distance Date of soil test: 12�7�00 (USDA) (Munsell) CONSISTENCY, % GRAVEL)
First floor Test taken by: TIM SANTOS
Elev. = 46.00 3-Removable covers within y'Results witnessed b DONNA MIORANDI 41. 7
_
6" of finished grade Dist. box Percolation rate: <5 min./inch 0=10" 40.9 O/A LOAM 10 YR 3/3
Access Holes in Tank to Ground water NONE ENCOUNTERED SANDY LOAM 10 YR 5
be 20 in Diameter 10 -36 38.7 B /4 NO
Inv. elev.= 40.83
36"120" 31.7 Cl S/L T LOAM 2.5 Y 6/4 NO
120"-144" 31.7 C2 FINE SAND 2.5 Y 7/2 NO
w
2' s= VARIES
s=0.02 s=0.01 level 0.01 MIN. Clean Backfill 3' 144"-156" 28.7 C3 /4 NO
S/L T LOAM 2.5 Y 6
aiiQuiid leve MAX. 2" layer of 1/8" to
1/2 washed stone
`4 � '-SEPTIC TANK-'�� 4 ft. of 3/4" to 1 1/2" washed
N N stone all around infiltrator.
Foundation �+ d- 1500 GAL. r? o o .. .......•
II ELEV.- 39.50
,. .. .design
by others IA. . . . II II II . ::.:.:.:.:.:.:.. . . . DEEP OBSERVATION HOLE LOG NO. 2
a> > > > . .. . . . . . .. . . .. . . .. . .'.'.'.'. .. .'.'.'. . . .. . . 12t
H-20 >
SOIL SOIL TEXTURE SOIL COLOR SOIL (STRUCTURES,
C \-- BOTTOM OF TEST PIT DEPTH ELEV. HORIZON (USDA) (Munsell) MOTTLING STONES, BOULDERS,
6 LAYER OF CRUSHED COMPACTED STONE - ELEv.= 27.2 CONSISTENCY, X GRAVEL
PROFILE 6" LAYER OF CRUSHED COMPACTED STONE 0" 41.3
THE CONTRACTOR SHALL EXCAVATE 5 ALL AROUND
Not to Scale THE LEACHING FACILITY AND DOWN TO THE SAND LAYER. (11 'f) O'=10" 40.5 O/A LOAM 10 YR 3/3
REMOVE ALL UNSUITABLE MATERIAL AND REPLACE WITH 10"-36" 38.3 B SANDY LOAM 10 YR 5/4 NO
GENERAL NOTES CLEAN GRANULAR SAND CONFORMING TO THE SPECIFICATIONS
SET FORTH IN 310 CMR 15.255 (3). UP TO THE SIDEWALL 36"132" 30.3 C1 SILT LOAM 2.5 Y 6/4 NO
1) No change to this system shall be made unless OF LEACHING SYSTEM. FINE SAND 2.5 Y 7 2 NO GRAI/EL
approved in writing by holmes and mcgrath, inc. 132 -192 25.3 C2 /
2) Subject to inspection during construction by the
Board of Health and holmes and mcgrath, inc. INSPECTION HOLE
3) Heavy construction equipment shall not travel
over disposal system during or after construction.
4) Disposal system to be constructed in accordance
with Title 5 of the State Environmental Code.
5) A copy of these plans must be kept on the site
during the time of construction. 16"
6) A copy of these plans must be furnished to the
contractor constructing the disposal system. 11" DEEP OBSERVATION HOLE LOG NO. 3
7) Before backfilling, the contractor shall notify
holmes and mcgrath, inc., and the Board of Health OTHER
Agent to inspect the system as constructed. SOIL SOIL TEXTURE SOIL COLOR SOIL (STRUCTURES,
8) If the contractor encounters an variation between DEPTH ELEV. HORIZON (USDA) (Munsell) MOTTLING STONES, BOULDERS,
Y ,► ,f CONSISTENCY, r GRAVEL
the existing conditions shown on the plan and the 34 6 -3
conditions encountered on the site, or any soil 0" 42.2
condition different than shown on the soil log, or
any adverse soil, the contractor shall immediately
O'-12" 41.2 0/A LOAM 10 YR 3/3
contact holmes and mcgrath, inc. Holmes and TYPICAL NIGH CAPACITY INFILTRATOR PAIR H 20 LOADING) 12"-40" 38.9
B SANDY LOAM 10 YR 5/4 NO
mcgrath, inc. will examine the soil condition
and report to the owner any .suggested revisions. -
NOT TO SCALE 40'=132" 31.2 C1 SILT LOAM 2.5 Y 7/4 NO
132"-180 of 272 C2 FINE SAND 2.5 Y 7/2 NO GRA VEL
3-20" Diameter Access Holes� • •. N
\ C° ALL ACCESS MANHOLE COVERS FOR
INLET 1 OUTLET SEPTIC TANK, DISTRIBUTION BOX,
AND LEACHING STRUCTURE SET MORE DESIGN CRITERIA
• THAN 6" BELOW FINISHED GRADE,
SHALL BE RAISED TO WITHIN 6" OF
FINISHED GRADE WITH RISERS. , INSTALL TUFTITE SPEED LEVELERS Number of doctors: 4 Equivalent to 440 gal. s/day
ALL OUTLET PI ES FROM THE ON ALL OUTLET PIPES Garbage disposal unit: NO
•.. :♦ .. • . DISTRIBUTION EOX SHALL BE 16.5 Leaching area - capacity required: 440 gal.'s/day
FRAME„ & ,COVER SET LEVEL FOF AT LEAST 2 FT. CONCRETE COVER Side area proposed: 115 sq. ft,
STEEL REINFORCED PRECAST CONCRETE OVER T S WHERE REQUIRED. Bottom area proposed: 560 sq. ft.
PLAN VIEW, - 5 - 5" OUTLET Total area proposed: 675 sq. ft.
PRECAST CONCRETEKNOCKOUTS Proposed leaching capacity: 499 gal. s/day
% \�� Water Supply:
•� REMOVA LE COVERS 6" TANK RISER WHERE �' `� ,_ „ pP y: TOWN
6 �- REQUIRED , 15.5 INLET 19.5 Precast Concrete units: H-10 + H-20 loading design
OUTLET
• 9 to
:, -�-- 3" min. clearance required •- '' INLET "T" 11 .25
INLET 2" min. inlet to outlet
OUTLET 20"
1.75
DATE DESCRIPTION JDrawnlCheclked
6,_01f a Liquid level „
6 -° PLAN SECTION CROSS- SECTION R E V I S I o N s
;o TU F-TI TE
DETAILS
Cr GAS BAFFLE :..;. J OF PROPOSED SEWAGE DISPOSAL SYSTEM
�- 6 H OLE' DISTRIBUTION BOX PREPARED FOR
BARNSTABLE HARBOR BUILDERS
• FOR LOT 1 , OLD JAIL LANE
: .. . NOT TO SCALE IN
10" 6,_2f, BARNSTABLE, MASS.
CROSS- SECTION END - SECTION N-s- „
Unless and until such time as the original (red) stamp of the SCALE: 1 = 20 DATE: MARCH 1, 2001 � ry
responsible Professional Engineer, or Professional Land Surveyor _Y
1 (A) no person or persons, including any municipal or other holmes and m ed rath, inc.
TYPICAL 1500 GALLON SEPTIC TANK engineers an survey public officials, may rely upon the information contained herein; and civil en id land ors
(B) this plan remains the property of Holmes & McGrath, Inc. g
NOT TO SCALE 200 main street :,:. 4
1 �F
falmouth, ma. 02540 <4sr�a�° f
(H-20)
DRAWN: MAH, GAB CHECKED: o �
BHBLDRS 201051DET.DWG JOB NO: 201051 DWG. NO.: 78-1 -16 SHEET 2 of 2
V