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HomeMy WebLinkAbout0306 OLD JAIL LANE - Health A 306 OLD JAIL LN. ,BARNSTABLE ; A 277 019 i : r No.W�b[6— Vj D Fee 4 0 J BOARD OF HEALTH TOWN OF BARNSTABLE 01ppYcc I tion _for Yell Construction Permit -7 7 Application is hereby made for a ermit to Construct( ), Alter( ), or Repair( ) an individual well at: oc t'on-Address I Assessors Map and Parcel Owner Address Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons I _ Type of Well f Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate o Compliance has been issued by the Board of Health. Signed <51 Date' Application Approved By r . \�'��/�—� �� Dat Application Disapproved for the following reasons: Date Permit No. « c (2 ( �-�, `-- (/ �� Issued Date ---------------------------------------- ----------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the I dividual well Constructed(k4f-'/Altered( ), or Repaired( ) by . �1�� � -�-� _ A Installer at 3o Ce has been install e in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector N0.VV2 4— V'V Fee Ll 5 BOARD OF HEALTH TOWN OF: BARNSTABLE 2pplicartiou ,for Yell Cou.5tructton Permit -V -71 Application is hereby /maade for a ,ermit to Construct( ), Alter( ), o/r Repai/r O an Q lindiv/ � individual well at:/ �1:ocati'on-Address t Assessors Map and Parcel nOwner Address? `innstaller-Driller. ( Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has beenissued by the Board of Health. Signed t F Dafe ..I Application Approved By e tom' -� L"o ,4 � Dater Application Disapproved for the following reasons: Date Permit No. Issued T Date BOARD OF HEALTH TOWN OF BARNSTABLE - Certificate of Compliance - THIS IS TO CERTIFY, CE�RTIFY,that the i/ndividual well Constructed(t—)-/Altered( ), or Repaired( ) ,;by �QK i/t Installer at has been Installed inaccordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Well Cougtructtou Permit �� . m tv Fee Permission is hereby granted to Installer to C��onstruct,((cc4/Alter( ), or Repair( an individual well at: No. 3tJ�s✓ C/ �f� 1 ✓ D Street as shown on the application for a Well Construction Permit No. Dated Date. 1 Approved By y� Ey i w4. LOT 3 r LOT 5 •o•� 4 S CONCRETE FOUNDATION y I 1 TF = 107.47' D� �h LOT 4 gti 66,331. s.f. (1.52 ac.) � K t ��24.5p JOB .# 99-183 1 CER TIFIED PL 0 T PLAN LOCATION 306 OLD JAIL LANE. BARNSTABLE, MA :':ALE : 1" = 60' } DATE : SEPTEMBER 13, 1999 PREPARED FOR: I R_FERENCE LOT 4 PB 444 PG 34 __._` .— MICHAEL & KIM COTTO HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. `�H Of off 3o8-3ez-4341 0� ARNE cy� rax soe xz-oeeo o ^, down cape a meerir�g, iac. CA e�'� 1L �nlc7�p e CIVIL ENGINEERS ND J1N♦+�1 — — — -------�-- 9fC! T aE� ,``moo LA SURVEYORS DATE REG. LAND S K main sL yarmouth, ma .02675 . w k\, Commonwealth of Massachusetts D/ f I � W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �j �M 306 Old Jail Lane P,ri Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees 45 Owner ,?� Owner's Name '°_• information is Barnstable Village MA 02630 Jul required for every 9, y 12, 2017 �. page. City/Town I State Zip Code Date of Inspection �� Inspection results must be submitted on this form. Inspection forms may not be altered in any''') way. Please see(completeness checklist at the end of the form. Important:When A. General Information ^� filling out forms � 7 4q on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-833-2177 S1287 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 115.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7- /z Inspecto 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 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �o �s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul 12, 2017 required for every g y 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: The observations noted within this report represent the condition of the septic system on July 12, 2017 at noon and does not quarantee the continued operating condition of the system into the future. 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust Jacqueline e Crowley and Monique Cro wley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul required for every g y 12, 2017 page. City/Town 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 l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is � required for every Barnstable Village MA 02630 July 12, 2017 page. CityrFown 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 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. 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is y 12, 2017 Barnstable Village MA 02630 Jul required for every g ! 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: ❑ ® 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. ❑ [A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 t. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owners Name information is Barnstable Village MA 02630 Jul required for every 9 y 12, 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: 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul required for every 9 y 12, 2017 page. City/Town State Zip Code Date of Inspection- D. System Information Description: Number of current residents: 3 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 Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 years usage d Yes Detail: 2016; 125,000 gallons and 2017; 174,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title.5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul required for every 9 y 12, 2017 page. Cityrrown 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: Board of Health Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Truck gauge Reason for pumping: Maintenance 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): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is required for every Barnstable Village MA 02630 July 12, 2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date issued 05/26/2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments (on condition of joints, venting, evidence of leakage, etc.): No observable indication of problems Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, Mist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Typical Sludge depth: 4„ t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul required for every 9 y 12, 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 29" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 7" How were dimensions determined? Scour Stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): All PVC tees in place. Effluent level with outlet invert. Risers to within 6 inches of grade on inlet and outlet manhole. 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 l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 306 Old Jail Lane Property Address 306 Old Jail Lane(Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village required for every 9 MA 02630 July 12, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as, related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping. Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul required for every 9 y 12, 2017 page. Cityrrown 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 Effluent level with 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.): New distribution box installed due to severe corrosion and inspected by the Town of Barnstable Health Department. Effluent level with outlet invert. Dbox is 37" below grade with a riser to with in 6 inches of grade. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owners Name information is Barnstable Village MA 02630 Jul required for every 9 y 12, 2017 page. City/Town State Zip Code Date of Inspection D. System Information coat. Y (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-500's with 4'stone around ❑ 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.): Utilized camera to observe leaching. There is evidence of 6 inches of effluent staining in the leaching chamber leaving 18 inches of effective leaching area not used. There is no excessive vegetation growth due to failure over the chambers. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM a' 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul 12, 2017 required for every g Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts i W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments ,M 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul required for every 9 y 12, 2017 page. Citylrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 306 Old Jail Lane Property Address 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul required for every g y 12, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 25 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: 1/9/1998 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain.- Groundwater contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized groundwater contour map with Health Department and abutting information in the area on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 306 Old Jail Lane Property Address ' 306 Old Jail Lane Realty Trust, Jacqueline Crowley and Monique Crowley Trustees Owner Owner's Name information is Barnstable Village MA 02630 Jul required for every 9 y 12, 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 _ :/ r l V TOWN OF BARNSTABLE LOCATION 47 :�Z Q1/7 a.lL I 4A/- SEWAGE M VILLAGEUU, AM-W SI'AFLE ASSESSOR'S MAP&LOT.Qj?/9 INSTALLER'S NAME&PHONE NO.(I-I—I MA, fj �VV//, SEPTIC TANK CAPACITY LEACHING FACILITY:(type)L. Cz�i4il,LIgge--S_(size) NO.OF BEDROOMS _ BUILDER OR OWNER — 't 0 PERMITDATE: COMPLIANCE DATE: DJ� Separation Distance Between the: / Maximum Adjusted Groundwater Table to the Bottom of Teaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 260 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � .z a91 I I r ate, http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=277019&seq=1 7/14/2017 No. Fee e7c/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplitatton for aispoBal *pstrm Construction vrrmit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot NOT 7k; Qe�6 V50 .�'/✓ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel "1 Installer's Name,Address,an Tel.No. Designer's Name,Address,and Tel.No. 1 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) 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 Boa -y Sign V0Date / Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 'C-2 Date Issued • -a.. .� .��, � ..y � � x,�, ..... x.r �'• •F r. r.l.,,, f :�-. +, .� .,.,... * c-, p- �.!M fir`;..'ti � +i,t�,y.,�'+r a R �is•.�, Y.F,a:�-4}�c,�� 11)01 No. �f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 2,+•^'"'""� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Disposal 6pstem, Construction permit -ter Application for a Permit to Construct( ) Repair$ Upgrade( ) Abandon( ) ❑Complete System /ES Individual Components w Location Address or Lot No + 'ta ®.46 V54! ++' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ,, ' ; '���' ��� '� J - Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building . -+ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title * Size of Septic Tank Type of S.A.S. t Description of Soil e• Nature of Repairs or Alterations(Answer when applicable) +G� � ,(� --�,�s►,�i' , ., 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 ea t a Sign d Date ""' /w ""!> Application Approved by Date Application Disapproved by Date for the following reasons ! i i Permit No. + s !1 °" "7 Date Issued / 7 r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired ) Upgraded( ) Abandoned( )by�.+7`,j .G'4_46po ez-'1ot- 4C4P;1--r at . 0 .6- O Z,6 .rl r/ ,,+� has been constructed in accordance - ---- - with the provisions of Title 5 and the for Disposal System Construction Permit N&17.0I LI dated Installers o .de � "' Designer .++ `, yr� #bedrooms Approved design flow gpd The issuance of this permit shall/hot be construed as a guarantee that the systekn will ct as designed. Date Inspecto( ------------------------------------- --------------------------- --- ---------------------------------------- No. CDC/_2 0 N Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS r3isposal -M&Pstem Construction i3efmit Permission is hereby granted to Construct( )! Repair( ) Upgrade( ) Abandon( ) System located at'"Y�od" 49-ee-s V" •�'a�' . °�''"°` '.+ � and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction musybe co ileted 'thin three years of the date of this permit. it Date '° 7, Approved by _ } . k r 1 *£. LL- Fo maw so ! - 1 t i I R^'�':a+�;,,'-m,+c'i^ ^'-�+^r.��^ca-^.�.-s��x-rr�^=��„+�'. ,,w+.,.:..• ,-.*.�,�pm.,....,rc;�.?e�� .r ra.:.. c. .... ., .,. _ .-rka^ .�;w.�A:'a'sr�y nra_:;;ax - ... �Y.... - .. ".:• mar,.-� ...�.,, -. t w r� Mot 58'1 iJ2' ��� � Y BlQawed�iw� - t O .a� F ,ads J ftk mate 2 BadnM R 3 ' mama Balk 3 10 if R '! 7oi►R - owe. 17J11/18 r salty 4 - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION MAP PARCEL V _ APPLICATION# �^ C Oct HEALTH DIVISION DATE ISSUED CONSERVATION DIVISION APPLICATION FEE PLANNING DEPT. PERMIT.FEE DATE DEFINITIVE PLAN APPROVED BY PLANNING BOARD - T HISTORIC-OKH PRESERVATIONIHYANNIS In �,A PROJECT STREET ANA VILLAGE E�RR� l W�i j7l� � ;�,, ,` -�,. . n OWNER t�k-�I�i�ll_G'1 l YVl G 1 LtLCNA1 y ADDRESS 'Ri�X OI C�.`J Ll tLyv1JL TELEPHONE ',7-D • Z U PERMIT REQUEST: brAil'V16"u1!41 SQUARE FEET: 15T FLOOR: EXISTING PROPOSED 2ND FLOOR: EXISTING PROPOSED TOTAL NEW ZONING DISTRICT FLOOD PLAIN GROUNDWATER OVERLAY PROJECT VALUATION 0,000• v CONSTRUCTION TYPE LOT SIZE GRANDFATHERED:❑YES .0 NO IF YES,ATTACH SUPPORTING DOCUMENTATION. DWELLING TYPE: SINGLE FAMILY 3/.TWO FAMILY O MULTI FAMILY(#UNITS) AGE OF EXISTING STRUCTURE HISTORIC HOUSE: l(YES ❑NO ON OLD KINGS HIGHWAY: U YES ❑NO BASEMENT TYPE: IZ FULL ❑CRAWL ❑WALKOUT ❑OTHER BASEMENT FINISHED AREA(SQ,.FT.) BASEMENT UNFINISHED AREA(SQ.FT.) NUMBER OF BATHS: FULL: EXISTING '� NEW HALF: EXISTING NEW 0 NUMBER OF BEDROOMS: EXISTING NEW 0 TOTAL ROOM COUNT(NOT(INCLUDING BATHS): EXISTING NEW (% FIRST FLOOR ROOM COUNT HEAT TYPE AND FUEL: lid GAS ❑OIL ❑ELECTRIC ❑OTHER —! CENTRAL AIR: L/YES ❑NO FIREPLACES:EXISTING�_ NEW (G EXISTING WOOD/COAL STOVE: ❑YES @d O DETACHED GARAGE: ❑EXISTING ❑NEW SIZE POOL: ❑EXISTING ❑NEW SIZE BARN:❑EXISTING ❑NEW SIZE ATTACHED GARAGE:CYEXISTING ❑NEW SIZE SHED: ❑EXISTING 13'NEWtSIZE OTHER: ZONING BOARD OF APPEALS AUTHORIZATION ❑APPEAL# RECORDED❑ COMMERCIAL: ❑YES ❑NO IF YES,SITE PLAN REVIEW# CURRENT USE PROPOSED USE APPLICANT INFORMATION (BUILDER OR HOMEOWNER) NAME: PABLO C.MARTINEZ TELEPHONE NUMBER: (508)274.3983 ADDRESS: 49 SMITH STREET LICENSE#: f4=jM 'C HYANNIS,MA 02601 HOME IMPROVEMENT CONTRACTOR t 142802 EMAIL: CLIMB512S(a)YAHOO.COM WORKER'S COMPENSATION#:VWC10060160852018 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO:TOWN OF YARMOUTH LANDFILL LOT 3 r / LOT 5 I' o 0) `381 0 1 • W 4_ I h hh" CONCRETE FOUNDATION TF = 107.47' -I- Cb- h ti LOT 4 4 66,331 s.f. (1.52 oc.) (< t JOB # 99-183 CER TIFIED PL 0 T PLAN LOCATION : 306 OLD JAIL LANE BARNSTABLE, MA ::':ALE : 1" = 60' DATE : SEPTEMBER 13, 1999 PREPARED FOR: R_FERENCE LOT 4 PB 444 PG 34 - MICHAEL & KIM COTTO I HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON .THE GROUND AS SHOWN HEREON. �tN Of ofr sos-aas-�sa ARNE tax soe x2-seeo o l ti N dotira cape engineering, iac. Q 1 o CIVIL ENGINEERS L� �� � 9fCl T RED ,tea LAND SURVEYORS — — --------- p S imain st. yarmouth, ma .02675 DATE REG. LAND S 1 TOWN OF BARNSTABLE ! LOCATIO Zi5Z�� 0V/2 � I SEWAGE # VI LLAGE (J sTA Rl ASSESSOR'S MAP & LOT — INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)1 ( /WAA13tZlCS (size) 00 ^ Po O NO.OF BEDR OMS' v ' BUILDER OR OWNER 't o PERMITDATE: r ' COMPLIANCE DATE: OJT Separation Distance Between the: / Maximum:Adjusted Groundwater Table to the Bottom of Leaching Facility y Feet Private Water Supply.Well and Leaching Facility (If any wells exist i 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 b;R j- -3 33 . 13 4 5 z13 ` T / / ` MAY-26-00 02 :09 PM DOWN CAPE ENGINEERING 508 362 9980 P.02 939 main Street rt 6a tel.(SM)362.4541 yarmouth port fax(508)362-OM mass02675 down cape engineering . struttural design civil engineers&land surveyors Arne H.0jala P.E.,P.L.S. Timothy H.Covell,P.L.S. lard wun Daniel A.Ojala,P.L.S. surveys October 29, 1999 site planning Thomas McKean, RS, CEO sewage system Barnstable Health Dept. ins 367 Main Street Hyannis, MA 02601 inspections Re: 306 Old Jail Lane, Barnstable permits Dear Tom: On October 22 and 25, 1999, Down Cape Engineering, Inc. performed a soils inspection as required on the approved plan at the above-referenced location. This is to certify that the soils removal was performed satisfactorily. If you have any questions, please do not hesitate to call mie. Yours truly, Arne H. Ojala, BE, PLS Down Cape Engiaaerinq, Inc. cc: Michaei and Rim Cotto TOWN OF.BARNSTABLE ��- �01> LOCATION �� O.L�� ��t I L.LAA/OEWAGE # J VILLAGE'W, /31J&LSTAFLF, ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. G'y1441A,4A- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) t���AAA e.S (size) NO.OF BEDROOMS BUILDER OR OWNER t C� PERMITDATE: COMPLIANCE DATE: 0J Separation Distance Between the: / Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility y 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 �rN. M 'ry) ;• �.. } V QU A TOWN OF BARNSTABLE Dp '6131160 LOCATION Z0 7" � QC.2 OAkl aZ ' SEWAGE # VILLAGE ,�� �^ L�ASSESSOR'S MAP A LOT INSTALLER'S NAME&PHONE NO.�i✓�,C,G/s1/L�l / � ,� BLS_- `��//� SEPTIC TANK CAPACITY / Cr 0 LEACHING FACILITY: (type) ,Z �/�.4�lt/?/�'i@�' (size) Y NO. OF BEDROOMS EUILDER OR OWNER PERMTTDATE: � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility '� Feet Pnvate 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) Lam. Feet Furnished by a � 9s 4 4 s i r - No. " —F - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Dtgozar 6potem Cou!5tructiou Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Fy('.omplete System O Individual Components Location Address or Lot No. �G� O� r/,pr/ "9,ve Owner's Name,Address and Tel..No. Assessor's Map/Parcel �' ! � 7 G/f i�a .��,�.�E7 7C7 Installer's Name,Address,and Tel.No, Designer's Name,Address and Tel.No. Type of Building: / Dwelling No.of Bedrooms Lot Size G ea6 sq.ft. Garbage Grinder( ) Other Type of Building Gi600( .rTic'wr�r No.of Persons S! _Showers Cafeteria( ) Other Fixtures Design Flow M U gallons per day. Calculated daily flow gallons. Plan Date ✓,aw �. ,/T Number of sheets / Revision Date Title Size of Septic Tank /._60 f 651-,r Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) DESIGNING ENGINEER MUST SUPERVISE Date last inspected: INSTALLATION AND CERTIFY IN WRITING Agreement: THE SYSTEM WAS INSTALLED IN STRICT ACCORDANCE TO PLAN. 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 issued b s Board of Health. Signed Date a Application Approved b Date`, 'a � Application Disapproved for the following reasons Permit No. ,- 4;e�_67 Date Issued Fee THE COMMONWEALTH%OF MASSACHUSETTS' Entered in computer: t PUBLIC HEALTH^DIVISION - TOWNJOF BARNSTABLE, MASSACHUSETTS 01porication for -Mtopogar *pkem Congtruction•Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) �mplete System El Individual Components Location Address or Lot No. r%9A1r Owner's Na/me,Address and Tel.No. Assessor's Map/Parcel / / { �� �/�d 27 V/ P �/o JGiavhf.1 r w Installe[r'''1s,Name,Address,and Tel.No, Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size L 01'6 sq.ft. Garbage Grinder( ) Other Type of Building .`.Aawd ,l&tfT. No. of Persons Showers(3) Cafeteria( ) Other Fixtures Design Flow f%rl:U gallons per day. Calculated daily flow . gallons. Plan Date Number of sheets / Revision Date Title Size of Septic Tank f_ (3 IrO I Type of S.A.S'. Description of Soil t. Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: ma 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 issued bylhis Board of Health. Signed Date Application Approved b Date,% Application Disapproved for the following reasons Permit No. Date Issued T --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certifirate of (Compliance THIS IS TO CERTIFY; that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by Akaz f atl�� has`' been constructed in accordance F with the provisions of Title 5 and the for Disposal System Construction Permit No. dated '' /�- i Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date ,�- Z (An Inspector_ \ ­.-\n V w"" --------------------------------------- No. " Fee nJ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mizpoar *pgtem Conotrurtion Permit Permission is hereby granted to Construct( Repair )U gra e( )Abandon System located at 1 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: Approved by Town ul' Bai-astable r a fo S 7 Department or Health,Safety,and Environmental Services Public Health Division Date 1 - R 2�2 367 Main Street,Hyannis MA 02601 MARMABM NAM Date Scheduled 1 .. $ �� 63�_ Time_J0- Fee Pd. / a Soil Suitability Assessment for Sewage Disposal Performed By: 'D' 4`11F1_' 63A LP, 6rsr%1JtfrL1 TA cmWitnessed By: �GiNR -Z>\►NN 1nJ6-"(1 o t-t) LOCATION & GENERAL:INFORMATION Location Address 1 5oc- pt.b Jprt` L.C�-,NE Owner's Name 1 �PF3 GNA-IPWe- 3t{1•N S"�-'p,t..F , NSA Address Assessor's Map/Parcel: T.77-7/t°l Engineer's Name 1>0w rJ U F�•I�''� NEW CONSTRUCTION REPAIR Telephone N 3C Z - 4 Sry } Land Use V A-e,hnJT" Slopes(°/,) 1 't-b Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft La— Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands In proximity to holes) car O< Lo-r `A n Y 51.S(7 Parent material(geologic) Depth to Bedrock T-Zoco Depth to Groundwater: Standing Water in Hole: N e w NTFTL Fib Weeping from Pit Face N�a Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL MGH WATER TABLE' Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: In. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well N_ -Reading Dale:_ Index Well level...--- Adj.factor Adj.Groundwater Level N/� PERCOLATION TEST Date ,;laA7T1me U ►''''` Observation TH 2 Time at 9" P- dS Hole N .Depth of Perc TaP , Time at 6" Start Pre-soak Time© o Time(9"-6") 2 ds End Pre-soak Rate Min./inch Site Suitability Assessment: Site Passed t/ Site Failed: Additional Testing Needed(Y/N) Al Original: Public Health Division Observation Hole Data To Be Completed on Back-� Copy: Applicant DEEP oBSERVATION ROLE LOG Ilolc# �— Soil Texlure Soil Color Soil Ulhcr Depth from Soil I lorizon (USDA) (Munsell) Molding (Structure,Stones,t)ouldercs. Surface(in.) j>evL�tr-1� J nry f oc-\Lk 2 - 6-A L-v a&P, -7.e, Ytz 1/'r- 11 is - 30 3 t--oAn" 1°YY'�S/G G 1 S�LlTO hM °YID GAL �- V N Sv it Ab C- l0lmT 1Z0 PJ G2 A a �'SY 6/G DEEP OBSERVATION HOLE LOG Hole# 2 Dcpih from Soil I lorizon Soil Texture Soil Color Soil Usher (USDA) (Munsell) Mottling (Stmclure,Stones,Boul ercs. Surface(In.) O " L$ Ito.y . (1- 5/6 tica. 26 - 11H �� y-7�6 2 ��o cobb�5 �ctt�-r•-, or— e tNy ,. L op,rv. 7. 5 j 7/-L Le Am% G-L 6F,E i OBSERVATION HOLE LOG Ilole# Soil Usher I)cpllr from Soil I lorizon Soil Texture Soil Color Mottling (Structure,Stones,Uoulderes. Surface(in.) (USDA) (Munsell) DEEP OBSEIVATION HOLE LOG IIole# ` " Dcplh fromP Soil Ilorizon Soil•fexlure Soil Soil Mottling (Slntclurc`IStones,Doolderes. Surface(in.) (USDA) (Munsell) raved i Flood ]n��rrance Rate Man: / Above 500 year flood boundary No_ Yes ✓ Within 500 year boundary No_ Yes Within 100 year flood boundary No— Yes 'Death 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? rZA_ S'ertilication � M 1 certify that on /IOV 1�(date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required(raining,expertise and experience described in 310 CMR 15.017. — - 0/ 115113 Z3 Relocated Window ga aE3.-E = , , s 3 1/2"x7 Versa-Lam 1.7 K11 KW= ° 17' 5 3/4" n L - --- - - -- - - - - - - - - - -- - -- -- -- a 7 3 1 2n x7++ Versa-Lam 1.7 *3 ® 35 Wwd pog up mad down Post up Rw. IUV. WaM and itmS to be rMoved o I sd. fors I V1 . ASIA • i i � s i I 3 j 3 i I 3 i =e i I r� • ' C5 t ((t I I C f N i I f z, n j •� 0 t n v m • I I . a r � O ti i i I i L w 4 M