HomeMy WebLinkAbout0200 PALOMINO DRIVE - Health 2.�- Pa[ernino ®rive
Barnstable F/R
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a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
200 Palomino Drive
Property Address
R Edward &Jeanne Garrant
Owner Owner's Name
information is Barnstable MA 02630 March 10, 2010
required for
every page. City/Town State Zip Code Date of Inspection
—i
Inspection results must be submitted on this form. Inspection forms may not�be altered iA any
way. ". a^ _:: C
r
Important: k
When filling out A. General Information
forms on the
computer,use w.�
1. Inspector:
only the tab key
to move your Patrick M. O'Connell r�
cursor-do not
use the return Name of Inspector
key. Septic Inspection Services Co.
Company Name
189 Cammett Road
Company Address
Marstons Mills MA 02648
renm City/Town State Zip Code
508-428-1779 SI 12855
Telephone Number License Number
B. Certification
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.
1 �
March 10, 2010
InsF ctor's Sign tui 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.
t.
10-66 Garrant doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is Barnstable MA 02630 March 10, 2010
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Tank is not in need of pumping at this time, leaching chambers were found empty at time of
inspection.
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.
Answer yes, no or not determined(Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old'or the Septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with 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.
1
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
10-66 Garrant.doc-08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is Barnstable MA 02630 March 10, 2010
required for
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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
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.
10-66 Garrant.doc•08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 15
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
200 Palomino Drive _ _.—
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is Barnstable MA 02630 March 10, 2010
required for
State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
1
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 colif 0rm
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 town overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
10-66 Garrant.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is Barnstable MA 02630 March 10, 2010
required for
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
El ® 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.
10-66 Garrant.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is required for Barnstable MA 02630 March 10, 2010
every page. City/Town 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
® El 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)]
10-66 Garrant.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is Barnstable MA 02630 March 10, 2010
required for
every page. CitylTown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 6 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
0
Number of current residents.-
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ®x No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes Z No
Unknown
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd) -
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
10b6 Garrant.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 200 Palomino Drive
Property Address
Edward & Jeanne Garrant
Owner Owner's Name
information is Barnstable MA 02630 March 10, 2010
required for — -- --
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: --
Type of System:
® J Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
compliance date of leaching system: 1/7/04
Were sewage odors detected when arriving at the site? ❑ Yes ® No
10-66 Garrant.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
I information is required for Barnstable MA 02630 March 10, 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal list age:g years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 10.5' long x 5.8'wide- 1500 gal.
4"
Sludge depth: —
Distance from top of sludge to bottom of outlet tee or baffle 29
3"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 101,
How were dimensions determined? Measured
10-66 Garranl.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is required for Barnstable MA 02630 March 10, 2010
--
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was found at bottom of outlet invert, tees were intact and clear. Recommend pumping
tank isn 12-18 months.
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.):
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):
10-66 Garrant.doc-06106 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is required for Barnstable MA 02630 March 10, 2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow: - gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm.in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required).is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
011
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.):
No solids or high stains.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes , ❑ No
10-66 Garrant.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.' 200 Palomino Drive
Property Address
Edward & Jeanne Garrant
Owner Owner's Name
information is required for Barnstable _MA 02630 March 10, 2010
-.. - --.---
every page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
00 gal
5
® leaching chambers number: Four Fourdryw 5 s.
❑ Teaching 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.):
Interior of leaching chambers had no standing water or sidewall stains.
10-66 Garrant.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 200 Palomino Drive
Property Address
Edward &Jeanne Garrant
Owner Owner's Name
information is required for Barnstable MA 02630 March 10, 2010
_
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration r
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.):
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:):
10-66 Garrant.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
200 Palomino Drive
Property Address
Edward & Jeanne Garrant
Owner Owner's Name
information is Barnstable MA 02630 March 10, 2010
requiredfor --------.._—._._...---._.._..----------__ ------... __.....-------- -__........------__- -----------------------
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all.wells within 100 feet.
Locate where public water supply enters the building.
44
3
r f
68
4 `N
Driveway
Palomino Drive
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
200 Palomino Drive
Property Address
Edward & Jeanne Garrant _
Owner Owner's Name
information is required for Barnstable MA 02630 March 10, 2010
- --
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 30+
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 hole within 150 feet of SAS)
® ( 9
❑ 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:
Low areas of abutting properties with no surface water are considerably lower than bottom of SAS.
10-66 Garrant.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 15
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" FORM30 C&w HOBBS&WARREN TM THE COMMONWEALTH.OFMASSACHUSETTS
BOARD OF HEALTH
`_*4 C_1 A 5L_F_
CITY/TOWN
a
DEPARTMENT
2 0o M n.i�1 sZ VA-1 A to tj
ADDRESS �G�( � Z� Z& gq
G,1M Svey`ow ` 7s(p 'I
TELEPHONE
Address eZO6 PALOMINO ANS,(AgLf—Occupant
Floor Apartment No. No. of Occupants �)
No.of Habitable Rooms `_dj No.Sleeping Rooms_
No.dwelling or rooming units — No.Stories -- P
Name and address of owne &R-,O -,Aa 4a^% If f.Nb+1- 9- A,t q
ZOO 9AI,0 M i►J0 Da\V G �P[a.�g'Us p�c.� C3Z Remarks Reg. Vio.
YARD Out Bld s.: Fences:
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
I/ Stairs: NQ
Lighting:
STRUCTURE INT. Hall,Stairway:
Hall, Floor,Wall,Ceiling:
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents: t
PLUMBING: / Supply Line:
❑ MS ElST I� Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: / Gen.Cond. Distrib. Box:
V Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room .
Bedroom(1),
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect..-
Stacks, Flues,Vents,Safeties:
Kitchen Facilities V Sink
Stove -
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation V Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Buildin Posted tn>w G fR- 010Vail! Mc S4 S
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES F PERJUR "
INSPECTOR �- TITLE kfA`-'tK
DATE TIME � '* P.M.
A.M.
THE NEXT SCHEDULED REINSPECTION ,✓ P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is'not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of sudh violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
•.t
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation,or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns,shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
WV
6� Ic
stx
.
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston,Massachusetts 02108-1904
(617)723-3800 Ma Only(800)392-6108.FAX(800)851-8424
12/13/2008
Form of Notice of Casualty Loss to Building
Under Mass.Gen.Laws,Ch.139,Sec.38
E
BARNSTABLE!HEALTH DEPT.
BARNSTABLE TOWN HALL
367 MAIN STREET
HYANNIS MA 02601
Re: Insured: JEANNE M&EDWARD M GARRANT
Property Address: 200 PALOMINO DRIVE MA 02630
Policy Number: 1039569 bi f .
Type Loss: Water Damage:All Other Damage Loss
Date of Loss: 12/12/2008
Claim Number: 257895
Claim has been made involving loss,damage or destruction of the above captioned propert,which may either
exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any
notice under Massachusetts General Laws,Chapter 139,Section 3B is appropriate,please direct it to the
attention of the writer and include a reference to the captioned insured,location,policy number,date of loss
and claim or file number.
MPIUA Claims Division
CMA00021
611 Mo YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367
Main Street, Hyannis, MA 02601 [Town Hall)
Ynkit� �A---W
DATE: � !3 0
Fill in please:
APPLICANT'S YOUR NAME: -;�r®rJA-MA11 SA-1 � " '
- x BUSINESS YOUR HOME ADDRESS: 20o PA(.oM1N� DIL e�eJhVk ��
CL- 66 2-4- fry o2G30
�,.
.. TELEPHONE # Home Telephone Number 3Ct- 522Z
NAME OF NEW-0USINESS NA-Ty/U� (AW S.. P �F ChDE Cofl TYPE OF BUSINESS LAi4DS�PE
IS THIS A HOME OCCUPATION? YESi NO
Have you been,given approvol from the building idivision7 ,YES NO
ADDRESS OF BUSINESS Sao (AL-M%N� 0.91 Nywf r MA oZG3o . MAP/PARCEL NUMBER 2��0 �
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COM TONER'S OFFICE
This indivi ual a ben-infor e of aLny.permit requirements that pertain to this type of business.
_ i
A h rize igna ur. _
COMMENTS•
2. BOARD OF QLTH
This individual has�binformed of the permit r irements that pertain to this type of business. '
Author
d Signature
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
Date: q- /)3. /of. .
TOWN OF BARNSTABLE r
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: NAB-024,- (AtyScAAcT F- CAPE Co,o
V' BUSINESS LOCATION: goo PAL-tn't' DO- INVENTORY
MAILING ADDRESS: A8-,,F--) TOTAL AMOUNT:
TELEPHONE NUMBER: 5-0$ '3(;z' dF02..4
CONTACT PERSON: -j:;^P�f4AH S�
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: LAr►JDScpAPE
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous.waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
o Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
D Automatic transmission fluid Disinfectants
o Engine and radiator flushes Road Salts (Halite)
21, Hydraulic fluid (including brake fluid) Refrigerants
q�. Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
35� Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers _ Misc. Combustible j
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
1 S� Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor&furniture strippers Other products not listed which you feel
^' Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers
(including bleach)
Spot removers &cleaning fluids � Spry
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TOWN OF BARNSTABLE
LOCATION !p [�i�0�(� SSWA-6E 97�:'n5P
VILLAGE CnSTR,4 bLe ASSESSOR'S MAP&PARCEL
D4ffAttER'S NAME&PHONE NO. 'C1iL��®r►vct�' e" �-i 7r1
6SCv i
SEPTIC TANK CAPACITY IBM GJ
LEACHING FACILITY:(type) LJ 6 Jqy,%A b&(-S (size) 500
NO.OF BEDROOMS C0
OWNER L51Gi�6'c
PERMIT DATE: C ATE U p 410110
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) 2 Feet
FURNISHED BY
r f f f
r' f f r f
f r r r f f
f f f r f f f
J f f f r
ffffff 44 .
.f\J\f1J4 f4 f\f\
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tf;' 2rra \ \f;f; 33
68
Driveway
000000
Palomino Drive
TOWN OF BARNSTABLE f
LOCATION PWONIV " 6 t,g-. SEWAGE #-�'�7—
VILLAGE ��� ASSESSOR'S MAP &LOT29�Z-
INSTALLER'S NAME&PHONE NO. -"�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) size) GYI/
-NO.OF BEDROOMS
BUILDER OR OWNER o ✓ �'T�1
PERMITDATE: 1 Q 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
�,���
r
.�,�� 33
a ���, ��i
�� � ��
��i ��
T �� `.�����o
FEE
Board of Health, 2m MA.
APPLICATION FOR DISPOSAL SYSK 'l[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair ) Upgrade( Abandon( - ❑Complete System Wdividual Components
Location Z00 Maj A M I60 inLQ . Owner's Name -b r
Map/Parcel# b�� AddressLAI
I
Lot# 6 Telephone# --
Installer's Name 4-jcl Designer's Name
Address o, a 55 i5 Address 1A 19
Telephone# 7 d — G Telephone# (
Type of Building Lot Size L ,3 sq.ft.
Dwelling-No.of Bedrooms 5, Garbage grinder ( )
Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (min. equired) gpd Calculated design flow 7 Design flow provided 3 gpd.
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) ��
Soil Evaluator Form No.r 1 Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS API, 0, aetlfl
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ee to not to place the a in operation until a Certificate/00?
Comp ance as been issued by the Board of HealthDate Q
0
Inspections
°'+''� .•,. •.;.�...r..J'�•f'f�..-...•.�+n�.+-...l�s.— �.�-•.+ ..•1�«;�`Lv.:.-�'., . r.- *+v..:-Y•.x"7,�=^-�.�+ !^'-„ r" !^ ,��F+,..._•�._._
_ No. i � " .�a ` •� FEE
Board of Health, &r a5 -"J — , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
T"
FApplication for a Permit to Construct( Repair`oO UpgradeOAbandonO - ❑Complete System UiIndividual Components
Location f.�O f iam r 4) —1)e(11.e iXhf _:t Owner's Name!`-b I Jean1'j
Map/Parcel# "� -� Address w
Lot# O � + Telephone# ---
Installer's Name Designer's Name
t+
�'y�•. fb tit r '1G AddressAddressi . 155 7, { Arn
16.6 liz `
Telephone# ( " ,-7S-.`t?cl9 Telephone#
Type of Building 1t"^ Lot Size 73 `FQ`/ sq.ft.
Dwelling-No.of Bedrooms ll1 Garbagegrinder ( )
Other-Type of Building 1 No*of persons Showers ( ),Cafeteria ( )
Otlier.Fixtures
// .fir
Design Flow (min.required) . gpd Calculated design flow-to�� .� .3 Design flow provided kf !J''. � gpd
Plan: Date j-�/0? Number of sheets Y Revision Date
P 6
t
Title t-
Description of Soil(s) .A V9 llrj,-�;!'L.—
Soil Evaluator Form No.l Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS .11
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreesI to not to place the/system /�
m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signe� .L: Date -�s)o( } 7
Inspections
�.
No. �2 11 t)Lj ()d2. FEE ,-
Board of Health, , J-M MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Y Individual Component(s) ❑Complete System
The un((dffersiianed hereby certify that
t�h_at the Sewage Disposal System; Constructed ( ),Repaired`( Upgraded ( ),Abandoned
K.�'T�/ ( )
by: K-)ts(.'�iJ 1i .�(�', c�....
p �"
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. c u t I_W Z dated 1 1 1 U Approved Design Flow (gpd)
r
Installer r / )
t Designer: Inspector: _ O (A Date: I /716 t9
The issuance of this permit shall not be construed as a guaranteeAthat the system will function as designed.
No. ���� —CO 2�-- FEE
C'OMMONWEALT14 ®F MASSACHUS ETTS
' t
`1 Board of Health, f ! i lf' MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( tf)4! Upgrade( J,)� Abandon( ) an individual sewage disposal system
1 at r � o,,l 0 1n J) ( y a'n� j ft { as described in the application for
w -
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of-this permitt.~All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date d��®� Board of Health
r
I
TOWN OF BARNSTABLE
C
ii LOCATION CID 9Pi0 la ` M-0 �` = SEWAGE # J 7cL
VILLAGE ASSESSOR'S MAP & LOT ?-?
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Fe
LEACHING FACILITY: (type)
NO.OF BEDROOMS
BUILDER OR OWNER ✓T r^d`'r��
>PERMITDATE: L/ COMPLIANCE DATE: J-710V
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
�rA �v ,�o
CARMEN E. SHAY (508)-548-0796
• ENVIRONMENTAL SERVICES, INC. P.O.Box 627,East Falmouth,MA 02536
January 7, 2004
RE: Certification of Title V Septic System Installation:
Residential Property—200 Palomino Drive, Barnstable, MA
Dear Sir or Madam:
On January 2, 2003, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at 200
Palomino Drive, Barnstable, MA, based on a design drawn by Shay Environmental Services on
December 26, 2003.
XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan
I Certify That the Referenced Above Septic System Was Installed With Changes but in
Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow.
The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is
Required.
If you have any questions, please do not hesitate to call the undersigned at (508)-548-0796.
Sincerely,
CARMEN E. SHAY
ENVIRONMENTAL SERVICES,INC.
F kA 0� a
i esi/E,
E.
Carmen E. Shay, R.S., C.S. o. 1131
President ��e1ST101
SANI TAW
Se;.;,,_20",�01 1 3 : b2 BARNSTABLE HEALTH DEPT 5087906304 ~ ��
:NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
PF_RCOLATIO:v TEST AND SOIL EVALUATION EXEMPTION
FORM
Ca•QM12, ti'AY hereby certify that the engineered pian signed by me
urtec j,2 concerning the property located at
meets all of the
i I ow;(1 c0,(eria:
• This failed system is connected to a residential dwelling only. There are no
_ommercia! or business uses associated with the dwelling,
• TF.e soil is ciass:;:cd as CLASS 1 and (he percolation rate is less than or equal (o
-ri.nutes per inch. The applicant may use historical data (o conclude this fsc: or may
_onduct pre!Imlcar,' tests a( the sl;e without a health agent present.
• ;here :s no incre:,se In flow and/or change in use proposed
• There are no vanances requested or needed,
• The bottom of the proposed leachin; facility will not be located less than fourteen
aoove the maximum adjusted groundwater cable elevation. f A. iusc the
1.0unc!.vater (able using the Frimptor method when applicable)
Please complete the following:
�. op of Grounr Surface Elevation (using GIS informatlon) 9 `
g; r;.w' F:cva(:or •'' _ ad;us(ment for high G.W.
�rF1=T.REfvt F EETWEEN and $ 'tea ' •.
D A'T : o f
>"
33sec J,r>n t,;e move information, a reoair permit wil! be issued for ')edr^ems
^-a,,r* uT. �:� ,cd a anal bedrooms are authorized to t`t- future without en,lneerec
plans. _ --- —
z �7:111)'r:Ocf puccamp
f
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: c�T�j �.�Ui�l,�� :�G'�ti-7� ���� Ca-� Lot No,
Owner: Address: a x3�N;- ,2
Contractor: ��Z� �n'.�: Address:
Notes:
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date
month ay/y ar
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: A1u
OAppropriate index well....................................................
OWater-level range zone ................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well •............
•• month/-year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ...•...•...•.•......•.........•..........•....:..........•........•................,.. S
STEP 5 Estimate depth to high water
by subtracting the water.
level adjustment (STEP 4)
from measured depth to,water
level at site (STEP 1) J'S S
h
Figure U.--Reproducible computation form.
15
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVE®
350 MAIN STREET
WEST YARMOUTH,MA
O 508-775-2800 JUN 1 4 2002
BARNSTABLE
TITLE 5 1HEAL DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEN
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 297 PAR 045
Property Address: 200 PALOMINO DRIVE
BARNSTABLE.MA 02630
Owner's Name: 200P ANT,PALOMINO
NE
DRIVE
h JLED INSPECTION
Owner's Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Date of Inspection JUNE 3,2002
Name of Inspector:(please print) JAMES D. SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310
CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
X ails ,
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 tot
he buyer, if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at
that time. This inspection does not address how the system will perform in the future under the same
or different conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: N/A
_ 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:
B. System Conditionally Passes: N/A
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
_ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
C. Further Evaluation is Required by the Board of Health: N/A
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
D. System Failure Criteria applicable to all systems: X
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool ,
X Liquid depth in leaching is less than 6"below invert or available volume is less than�/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone 11 of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
' Page 5 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 550
Number of current residents: 6
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 2000 469,000/2001 180,000
Sump pump(yes or no) NO
Last date of occupancy: PRESENT ,
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: .
MAIN SYSTEM UNKNOWN.NEWER PIT ADD IN NOVEMBER 1994
Were sewage odors detected when arriving at the site(yes or no): , NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
BUILDING SEWER(locate on site plan): X
Depth below grade: 8"
Materials of construction: Cast iron X 40 PVC other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 14"
Material of construction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,500 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: N/A
Scum thickness: F,
Distance from top of scum to top of outlet tee or baffle: OVER
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How were dimensions determined:
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 FULL OVER OUTLET LINE,UP INTO RISER. INLET COVER UNDER ROCK WALL.OUTLET COVER
14"BELOW GRADE.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other
(explain): s - -
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float.switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
DISTRIBUTION BOX IS T BELOW GRADE.FULL TO COVER. UNKNOWN SIZE OR CONDITION OF BOX.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000. 8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 2
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS TWO 1,000 GALLON PRE CAST PITS.EXISTING PIT 28"BELOW GRADE—FULL.NEWER
PIT 22"BELOW GRADE—FULL.BOTH PITS FULL,NOT LEACHING AND NEEDS REPLACEMENT.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.,
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Title 5 Inspection Form 6/15/2000 10
b
Page I 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 200 PALOMINO DRIVE
BARNSTABLE,MA 02630
Owner: GARRANT,JEANNE
Date of Inspection: JUNE 3,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 26.6 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA. WELL AIW 247 AT 26.6.'
Title 5 Inspection Form 6/15/2000 11
TOWN O BARNSTABLE
LOCATION�f90 ��� /y+itio 1�•2 SEWAGE
VILLAGE )9Afi i157.99 /5� ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY ,E.r %r wg
LEACHING FACILITY:(type) )�?E c-fS T' (size) 6 X
NO. OF BEDROOMS PRIVATE WELL OR,PUBLIC WATER
BUILDER OR OWNER CoAlwv.�'
.DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
31
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LOCATION SEWAGE PE12G71T p0.
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VILLAGE
INSTALLER'S NAME 6 ADDRESS
(3 U I L D E R OR OVU ER
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DATE PERMIT ISSUED Z3 gZ
DATE COMPLIANCE ISSUED_��j ��Z
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L0•.CAT10N SEWAGI PERMLT N0.
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'fitSTA LLER'S NAME I ADDRESS
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�0IL0ER OR ' OWNER ..
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RATE PERMIT ISSUED
;DATE C0MPl1ANCrE , ISSUED
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Divi-pniittl Workii Tomitrurtivia run it
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
goo------------------------ -.
... ----------....... ------. -/----•-•-•--••---••. -••-•------------
rLocation-Address '------_-or Lot No.
................ii�- - .._^_....-----.•.--•-------- ._.__._._..............._....._
Owner !Addre
Installer Address U Type.of Building �. Size Lot............................5 q. feet
Dwelling—No. of Bedrooms............................................E xpansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons------------------------- Showers ( ) — Cafeteria ( )
0.' Other fixtures ------------------------------
d - --------
- ---------------------------------------- ---------•----------••---------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow-...................._................._.___gallons.
WSeptic Tank—Liquid capacity............gallons Length---------•...... Width---------------- Diameter..-------------- Depth........._......
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1 ' Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I--_---_----__-minutes per inch Depth of Test Pit-------------------- Depth to ground water-.--_-._--_.---.--_..---
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------- ------------------------------------------------------------------------------------------.........................................................
0 Description of Soil........................................................................................................................................................................
x
U
w
---- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U N,a re of Repairs or Alterations—Answer when applicable.-._-_-ATl�--------10GO......V�Iffa_',ll__....� 9.c'�l� .........
= ` l .....�� ---------------------------------------------------------------------------------------------------•-------._---.--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance been issue b th Bard of health.
Signed .. ............ --- --- ---------- --- -------- -------- - _
Application Approved By ............. ...t ..... . .......... .. ... .....e
L.1 v Date
Application Disapproved for the following reasons: ..... . ................... ........................................... ....
....... . .....................................qc Z--......................... ........ ........ ........................ .. -- . -- -- ........................................
PermitNo. ---------'? - .. .. ,-------------- Issued .........................- .....................................ae
Dare-
Fi
THE COMMONWEALTH OP—MASSACHUSETTS
BOARD OF HEALTH "'
TOWN OF BARNSTABLE
, pphration for Diinpwiai Workii (Somitrnrtinn 1rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ✓) an Individual Sewage Disposal
System at:
..............•- --/-----------.-.----.-
Location-Address, or Lot No.
w /o .7l ....G.�� •--------•------------------•••• �----------"-------C--"-------------------------.------
......................__-
Owner Address
_.._ .. - � ----
Type16. .r. �- 1 ..
F Installer Address
weBl Building
in No. of Bedrooms............................................(� Expansion Attic ( ) Size Lot--Garbage Grinder ( )
dg q. feet
aOther—Type
of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )�
P4Other fixtures ---------------------------------------------"---------------••••..._.._..------------. ---------•------•----•••-•.....-••...........----.......-•-•-
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width....._-_-____._. Diameter---------------- Depth...............-
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..-_____-_--_-_-_---Diameter-------------------- Depth below inlet.................... Total leaching area....._............sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by ----=:�" ="----"- Date.
.a Test Pit No. 1-___----_____--minutes per inch Depth of Test Pit.__'--:?_____--- Depth to ground water________________________
fX Test Pit No. 2................minutes per inch Depth of Test Pit................._._ Depth to ground water........................
a ...............................................•-..........
0 Description of Soil.............................................................................------------------------""----"--"-'
x .
U ......•••---.......•-••.....---
w
U Nature of Repairs or Alterations—Answer when applicable -----APf�._.____._1,dYW0-.....C " .........
-"•"-"""""---"----"'-------------------
Agreement: '
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance been issue b th iird of health.
Signed ... . % - -,)�'� --------- .....
Application Approved By ..............% �t.�.e - -�._....`......................... =4'-�-- . e..--...
CJ " _... .........................
Application Disapproved for the following reasons: ....._.........
......... . ...................... . ............................... .............................................................. ...................................
Permit No. ---------q 7---- t.......... ...► c/� .............. Issued ........................................................
Date.....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate, of Complianve
THIS TO CERTI Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ................. /i✓I 4. G .-lf> ---------------Installer
-------------------------------------
s? � ? /
at ------ ------ p,,e........... ...... ..........................................................._..............---------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. --------7..1�.......I/..���.. dated ..........................................._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......./�0--""• - ....... ----------------- --- Inspector....... -:------- ----------........................... ------
--------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No....�... .... .....// FEE......lf?/^/.....
i rnstt nrk� n itrurtion rrntit
Permission is hereby granted........ ....../ %.___.. ... _...._._
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No....:-�n n.......�!�r, •• yr�.c.�a 7,t-1, / •_/�r� � ?f `,'-~ -It�'�= -------------"•--"..............""
Stre
P r� p Permit
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as shown on the application for Disposal Works Construction Permit No./__ __�. __.ly_.__ Dated_.=__��.�.... ...._.�.
, ifs �' -.--...-•--•-"---"•--------------------==-�'=-----,�.....---------__�.�.�-� ../.....
DATE. i� ------------------------- II vatrd of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
No... -.`l.' .. sY F�s...: .'�. .......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF WEALTH
- 1..�..Nt... .........OF.....� FP4.E...........................
Appliration for Dhgvviia1 Works Tomtrur#ion rainif"
Applica is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
/V_.,1 _ •------------------------- -------------------�- 7
.. - E_ ..r... Loca--• ............. .........
,_. Location-Addr ss or Lot No.
U.
Owner Address-
a 11_i e..... EYSOA- ----••-•---------- -----------•-----•- ------
•---------------
-----------
....----•----------•-----------------4-------•----•--•------
Installer Address
Type of Building `""" Size Lot. !.. ....Sq. feet
U
Dwelling—No. of Bedrooms.. ................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ............................
W Design Flow..........................P.�...T.........gallons per person per da . Total daily flow..........._.5.5..(>........._....gallons.
WSeptic Tank—Liquid capacity.1_54 .Qgallons Length._ 6 .4—._. Width---I._....... Diameter................ Depth.G
x Disposal Trench—No. .................... Width.............•...... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.___k--74..... Diameter........15------- Depth below inlet....�.�........... Total leaching area.g 14.sq. ft.
Z Other Distribution box (v l Dosing tank ( )
PercolationTest Results Performed by.......................................................................... Date........................................
Test Pit No. L-_Z.--__minutes per inch Depth of Test Pit....A Aes..____. Depth to ground water---- ----___.
Test Pit No. 2................minutes per inch Depth of Test Pit.......Xv...... Depth to ground water______"..............
P4 -------------------------•••-------------------•-----•-------------•-----•---..................-----.........................................................
O Description of Soil----...... v,...... ---------3 "-- 65 ''
W ----------- ---------------- -----•-----•--•-----••--------------•---••-------•-------••----------•--•--•--•--•--------------------------
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i?:I y g g p y .,
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the oard of health.
Signed...... ... �.. _...----•---------------------------------- -----------------------•-------
,c�f Date
Application Approved BY-------- ,: .• . . . .... ....................:. .... D......
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------•.
..-•---------------------------•----------------------------...--•----------------------•---------------------•----•--------•-•---------------------•-----•-------•-•----•--••--•------•-•--•-•---------
Date
PermitNo......................................................... Issued-.......................................................
Date
tom- � .. .+�'"• .— �'�
3.5
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H AL:TH
I.. ..+';`►..`hf "--.....OF..... .............................
, pphrFatiun for Diipniial Workii (famtrnrtion ami#
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
L c>�t: ..
............. ,.............................. .................... •=• ---- -......................................................
VoRt i ess or Lot No.
........_ _.._ • ner---•---._._•----•-------•------•----._..._ f 4_r� C`�?„1.1_ tt� k I....... >.:.......
�/�c; j�/ �i �,..
~fAddress
---------- ---
� Installer Address
Type of Building _ Size Lot. `.'.. `!.=-.___..Sq. feet
Dwelling—No. of Bedrooms......�?..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) = Cafeteria ( )
aOther fixtures ...................................................... . ---•--•------•---•-----------••---•-•----•--......------....
W Design .Flow............ ......... . .........gallons per person per day. Total daily flow............. __ ..............gallons.
WSeptic"Tank—Liquid capacity.!.a 0Ogallons Length._!- '+ Width..5.1....... Diameter................ Depth_*....'."
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._..__-_--.7-._-_-_ Diameter------- ....... Depth below inlet___........... Total leaching area..:-QAA_6.sq. ft.
Z Other Distribution box ( V) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
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.......:................
---------------------------------------------------•---------------------------..........------..._..........-----•----•----•----------•-------•-`----..-----
DDescription of Soil s` - .......`'. .......--`-:.......------7.....-------.......--�-�.......
U ................................................. 11 �............._.......__ ..� • a_...�..........
...... .................................................................................................
W ............._- --------------------------------------------------------•------------•------------------------------------•-•--•------•-•--------------•---•---------•-_-----------------••---•------
UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------
----------------------------•---------------------------------------......-----------..........-•------------------------------------------------•-----------------------------------------........---•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of f•)T[ry=E S of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been lssu?Z d of health.
Signed--•-------------------------•--•---------•-•-•----------------•---------------•--•-- ...... ..................
Date
Application Approved BY -::----4 � .
Application Disapproved for the following reasons-........... --..............................................................................................._
........................................................-................................................................................................................................................
Date
PermitNo......--------•--•........------......--------••--••-- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
w.
."...... ............OF.. ...........t
(9rdifiratr laf not �t a rr
THIS Is TO CERTIFY, That the Individual Sewage Disposal System constructed (�or.Repaired ( )
,,,;,.
-- -•--- ------------>--• ;
..-•...............••--
` Installer
has been installed in accordance with the provisions of TITL, j of The tate- ariitary Code as described in the
application for Disposal Works Construction Permit No._*t_ . .................. dated_ .._..-_.-...__--___-_.--.-__:................
THE ISSUANCE OF THISXER-YIFIZATE'SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN
,CTFON SATISFACTORY.
DATE..............--...----•-•-•--........ ° 'fz ............. Inspector.....................................ILA........ .......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF-HEALTH
OF...-.��,
w ................. fir FEE.....
Disposal Worbi T-5undrudivit Viamit .
Permission is hereby granted--------- , .... - ---------------------------------------•---•-------------.--•--------------•--- ►�
to Construct or Repair ( ) an Individual ewage Disposal ystem
at No...------ ;+ --••------•---
x ....................................................
Street
as shown on the application for Disposal Works Construction Permit No.�__.....e.�.. Dated.___._..�:.__v��.�,,et....•.r_.
--- -•---
_ -�� -�✓ ealth
DATE...........
` . FORM 1255 HOBBS & WARREN. INC., PUBLISHERS y� J
r t
-_
-
SECTION - SEWAGEci
Its
1 , ` h •,t Q �+ :trilTC' 1r tn P ci ; • �
TOP(le 4{M
y 41
"2 Ft i T( -J
r '....
• 1!
_ ��� I.{ Z;,�cy Y� WIM,Star&�J_�i. T".:Jt.��i,� � i" r r� �.t ` !' f-^ � r ✓ "'� � •/ ?
zo
• CaG7 IN
. .
OUT \ty} IN- 1'�+., OUT
1 N
Ll'{` r l�r7L�. G g
l.,.r' 1 / �•� 1._ J �;. / .r / µ
� .J PTIC
TA
Et.4V NK �Z3,7S � � 2= Pf !{{ �' / �'�,` •0 f44}Cl �+� j' / /
'. ELEV ELEV. Ea sT'�^ 1 `
�•` �Z'3.3�_ I Z3,1,8 LE 1
r ELEV. ELEV. ► �+� t� C r r ! l f f �CF AQ �. N
v
OF Vi"
WASHED STONF �
1�
`LEST HOLE LOG
r WITNESS d2 S 1 s'
Tcsri7 TE. 1of13�81 �'"190 � BEDROOM HOUSE
DESIGN r�
T.H. 1 T.H. # 2
1
pp" ELEV.. .� ELEV. NO
F/ /7
DISPOSERDISPOSERSSua�Ssi� PE
RC RATE �— _MIN/IN.
FLOW RATE t
(GAL:/DAY ) 55c 7 r --
1t2 ..L , #
• '. . SEPTIC TANK S St> {),�w �_ '2-'->_._.., }-- - f . •'�' +; �3�
REO'D SEPTIC TANK SIZE
LEACH FACILITY v-
SIDE WALL X'3�t r Z 301.(,{ 2'5) = _75�L G D
CAZAN{MF_tk, S^t.ID CA-• N t4a.)r Slav t Q� I1 x Z 30 Q
BOTTOM __._. . G r D ( �� �
TOTAL - .F S 4 --Z' ' f `` n t ��, • ` 44-C-)a Z SC_� T . C
USE: LEACHING
4 C�'� ._.. � ---•i 1c5:'7 fs' l Co�s .._. .�. 11�-,3$ ---t, ..._.._
_WATER ENCOUNTERED
NOTES: (UNLESS OTHERWISE NOTED) �' riitr*+. .ZC
1. DATUM (MSL)+TAKEN FROM.-..,.G'yl?!.^ t�,E.:2_.......QUADRANGLE MAP ( , FA (9_ti c
2.MUNICIPAL WATER- 1-3.. .r.__.--...AVAILABLE ItiCI. (t 'lt j
3,PIPE PITCH: IA"PER FOOT
4.DESIGN LOADING FOR ALL PRE-CAST UNITS: AASHO- 3 1' C'7 -44 C, �`�• j
S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES.(1) FT. Q- ' DISTANCE AS CERTIFIED
G.PIPE JOINT$SHALL Be MADE WATER TIGHT -` "/•z ' Y
M
7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. � SITE P4AN
t HEREBY CERTIFY THAT THE BUILDING
STATE ENVIRONMENTAL CODE TITLE 5 SHOWN ON THIS PLAN IS LOCATED ON THE
GROUND AS SHOWN HEREON & THAT IT_ LOCUS: --
✓ / CONFORM TO THE ZONING BY LAWS OF THE G
1ti- TOWN OF
---
REG.PROFESSIONAL ENGINE E H 04HE N CONSTRUCTED. DATE
{ REF:
WOWI! CG'�De enfineering PREPARED FOR:
CIVIL ENGINEERS '
BOARD OF HEALTH I LAND SURVEYORS REG. -
LAND SURVEYOR
CONTOURS (ExrSTiNG)---- Yarmouth&Orleans,MA
•------ } SCALE _
(PROP¢SED)-O--O-O�-•O- APPROVEDDATE � �_. MA
DATE
- x
.. 3-24 O,A.M. ACCESS MANHOLES
. , „ tall) ♦ Y.F
' VENT PIPE (® least 24 inches ,
4 U 4 P.V 'In r A PIPES ARE TO BE SCHEDULE 0 .G ,. .. ..10 m from NOTE. ALL P ES . ,. .... ,,.. ,• ..•
Schedule 40 PVC w Charcoal Odor
septic •-•t ..
t Foundation nk Exls In - house to to � ..
9
.4 A
nk ve must t e
,
1 .00 (Assumed)
S e tic to co r5
H e, i:"
00 FOUNDATION ELEV OF TOP �* � .,
C S M f r h PRO. ILE YIEPY OF LEy1CHIN S}'' TL' 4 .
within B In. n f1n s ed rode � I
9 I y {
Grade over Septic Tank - 96.00 Grade over D Box 94.50 Ce over SA.. I Varies from ele. 96.00 to Elev. 91.00
l r
o-
3 of 1 9 - 7 . Washed Peastone _.__
/ / INLET
- ', 3J4 to 1 1/2 M,ae!*ed Cr,raned Stone .r l � OU 7
i. INLET •, `:J .. �
S - , ;
0.02 6 HOLE Fk-10` THE ACCESS COVERS FOR THE SEPTIC TANK ,
DtST. 80X ,. r
TOP OF SAS 8C.00 -, COMPONENT
S 0.01 3 Moxtrnum Cover ti,
DISTRIBUTION BOX AND LEACHING COM- CNEN.
EXIST. or r
,. .. JS G enter �
. •' SHALL BE RAISED TO WITHIN 6. OF
a� a 1 500 GAL. a .�-� . .,
,_ 5 0.01 per foot
NEY FSIPE P .t.•.� v.a,, .+ •.
/ x n u� 25 FINISHED GRADE.
FROM EXIST: FOUNDATION Li SEPTIC TANK N
ijris,w. �
/ 30 /� ," o r=a c7 STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TiTE GAS BAFFLES OR EQUALS
H 10 PVC TEE C] ;, / ;•i'.,,.. EO
os O
as eaau ...,;. � C.J G7 -C] Ca
C7 O _ m _
/ REQUIRED a a w ON ALL OUTLET LEE ENDS
> it ..:=•.,'. Ct C7 M ...- .>,..:.
CONCRETE FULL FOUNDATION- TO REDUCE W cv xr< PLAN VIEW
N y > WATER VELOCITY 07 r � 4 Units @ $,5' w/3'.Stone In 1wPtwaeL22
' \
u & ea3-24" REMOVABLE COVERS
a) " - IN O-Box 1 4 4' r. 46
a_ o I > 2.2 B tn:ot 3/ 1 1J2 �!{ r
F' m II -.�.I - / r6 2a.r•5�
SYSTEM PROFILE � compacted atone � a'� � `�
I
Not to Scale _ m 5
Effective Width 50 5 T
c EFfeCtTve Length .• 3 min, clearance '
c c u &' mina-. 2• min. Inlet to outlet I
GENERAL NOTES
..INLET •'
6 In.of 3/4 -1 f/2 SOIL ABSORPTION SYSTEM (SAS) --_�-- L ievdT e mh. OUTLET
:,tone INS `, ,o•min. „• 1 1. Contractor is responsible for Digsafe notification
compacted a i. I
m l 500 C H-20 LEACHING UNITS / WIGGINS PRECAST s' -r ' --� !__ ,'s' -7• and protection of all underground utilities and pipes.
E I t' 4-0• min. 2. The septic„tank-and distribution box shall be set
Not to Scale b Liquid depth level on 6 of 3/4 -1 1/2 stone.
,f ,I 3. Backfill should be clean sand or gravel with no
r stones over 3„ in size.
1 . ..,, ;. ,. ., ........ 1 .
4. This.system Is subject to Inspection during installation
to.-o" 5' _e^ by,Carmen E. Shay Environmental Services, Inc.
„ 5. The contractor shall install this system in accordance
NOTE: ALL•COMPONENTS MUST HAVE RISERS TO WITHIN 6 BELOW GRADE CROSS SECTION END-SECTION
with Title V of.the Massachusetts state code; the approved plan
and Local Regulations,
6. If, during installation the contractor encounters any
TYPICAL 500 G/d'�-�-QN SEPTIC TANK soil conditions or site conditions that are different
NOT TO SCALE from those shown on the soil log or in our design
installation must halt & immediate notification be
(H- 1 0 LOADING) made to Carmen E. Shay - Environmental Services, Inc.
7. No vehicle or heavy machinery shall drive over the
septic system unless noted as H-20 septic components.,
S. install Tuf-Tite as baffles orequals on aH outlet tee ends
9. All Distribution Lines shag be 4' diameter Sch, 40 NSF PVC pipes.
"'. 10. All solid piping, tees & fittings shall be 4" diameter
` h ul 4 NSF PVC pipes with water tightjoints.
. / PERCOLATION TEST Schedule� o S PP g
44 ', . 11. MUNICIPAL WATER'AVAILABLE AT SITE and Surrounding Properties.
O� d 18 Date of Percolation Test: DECEMBER 24, 2003
\ N �� Test Performed B CARMEN E. SHAY- R.S. C.S.E.
\� Results Witnessed B WAIVER (per Barnstable BOH
\ Y (P )
\\ Excavator: SHAY ENVIRONMENTAL SERVICES, INC.
Percolation Rater Less Than 5 min./inch
19 \\`\ -- _------ THE PROPERTY LINES ARE APPROXIMATE AND I
LOT 93 _ __J 04 Test Hale COMPILED FROM THE SURVEY PLAN GENERATED BY
Q� �� �� / , # - �_ -- -- No. 1 YANKEE 'SURVEY CONSULTANTS OF MARSTON MILLS, MA, DATED 8/19/85�
r 1 1 43,929 Square Feet + '----_-_ DEPTH SOILS ELEV.
� � ENTITLED �� .PLAN OF LAND IN BARNSTABLE, `MA of LOT # 93 PALOMINO
0 91.00': DRIVE", AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
/ r 1
Loamy Sand I IT SHOULD BE USED FOR N0 PURPOSE OTHER THAN
toYR 3/2 THE SEPTIC SYSTEM INSTALLATION.
1
0"-6, Ar 90.50!
Loamy San
to YR 5/8 THERE ARE NO WETLANDS LOCATED WITHIN A 200' RADIUS OF THE SAS.
DK ` __
6"-24" Bw 89.00i
' I \` ``-------------------
i SILT LOAM THERE ARE NO FLOOD PLAINS OR VELOCITY ZONES LOCATED WITHIN
2s v z/e 200' RADIUS OF THE SITE.
\\ \ d
! \ 1 ( 24"-40" C, 87.75
Med- Fine
t r � Sand
1 EXISTING r � 2.5 Y 8/4 ASSESSORS MAP - 297 PARCEL - 045
IN--GROUND
nJ 48"-144" Cz 79.001 ..
r 1 POOL
, ZONING - RESIDENTIAL _
FLOOD ZONE C , ,
f
cp Perc eft {
i� •\ Depth to Perc: 48" THERE ARE NO FLOOD PLAINS OR VELOCITY ZONES LOCATED WITHIN
r 4 Per'c Ra1e=<2 min inch T, _
Groundwater Not Obsewed
BOTTOM OF TEST HOLE Elev. = 144"
THERE ARE NO WETLANDS LOCATED WTHIIN A 200 RADIUS
r' ADJUSTED H2O Elev.-= No Adjustment Required.
Q r' OF THE PROPOSED SAS,
ALL DISTRIBUTION
PIPES SHALL
THE
/ ON BOXALL 8 -12" CONCRETE COVER
LEGEND
- SET LEVEL FOR AT LEAST 2 FT,
I
y- - ,• 6 - 5 OUTLET „r..,,,. •.e.,r„ 2
KNOCKOUTS
, DENOTES PROPOSED
88xa
PROJECT BENCH MARK \
- ,ss• { 12• INLET SPOT GRADE
' rrrri v _, i OUTLET �.J � ,
TOP OF FOUNDATION -g -
/ DENOTES EXISTING
2 x
ELEV. 100.00 (Assumed) 104.46
� / t , ,ss• ! SPOT .GRADE I
PLAN SECTION CROSS SECTION
PROPERTY.. LINE
r / 6 HOLE DISTRIBUTION BOX
r \ 1 / r 97 I----- PROPOSED CONTOUR
� '�• f t f ! f � LOT #94 NOT TO SCALE _�
O 1 �` J / cbi
C11 �\ / / / 97- - - - - -97 EXISTING CONTOUR
co
i DEEP TEST HOLE &
\ / /� / -
LDT #92 \ GRAVEL Desl n Calculations
DECK / / - PERCOLATION TEST LOCATION
EXISTING �\ DRIVEWAY f ,r r1 /
\ y r Qj /
i / Number of Bedrooms: 5 Bedroom EXISTING - (6 Bedroom System Proposed)
5 BEDROOM `. �� � � �- FENCE
\ , r Garbage Grinder: No --
r9 HOUSE `� 1 �� Leaching Capacity Required: 660 Gal./Day (MIN. PER TITLE V)
Tor 1 / / Septic Tank . - 2 x 660 Gal./Day - 1,320 USE EXIST. 1,500 GAL. Septic Tank.
\ # \ , ,' / PRIVATE DRINKING WATER WELL
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch
Bottom Area: 0.74 gal/sq. ft. x ' 656.5 sq. ft. = 485.81 gallons
idew ll Area: 0.74gal./sq. ft. x 254 . ft. = 187.96 gallons\ \/ S a e sq. , g REVISIONS
Providing: r 673.77 gallons
Use: (4) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH NO. DATE: DEFINITION
`\ ____--__ 1 �r 94 TO BE USED WITH 4 OF WASHED STONE ON THE SIDES AND
y 2.25 OF WASHED STONE ON THE ENDS AND 3 STONE IN BETWEEN CHAMBERS.
Q EXIST. 1500 90l• 1 / ��
Septic Tank 1 \ �/
\ /
\ \ / �a3 1 '
\ 1 1 r
\ \ a f 1 hrY•. File 1 -
\ / 1 1 \ 4?a � _ a d
\ \ �. 1 ,v ,I 1 ,
\Le ch Pit
\ � I PROPOSED
\ \ /
FOR .
PREPARED _
e
1. r
� WA DISPOSAL T
,. 1t I
SUBSURFACE SEWAGE D S OS L SYSTEM
.,� 1 i r\ ASPHALT f
r ,
w
� \ 1
1 1
4 /
f
\ m \ 1.
RN DRI
VEWAY 50.
D \
t
1 _
t ,-
/
\ I .: 1
r
F Iled O
1
t r _
r r
r
\ . . h P,T L c t
1 , �a
\ . 1
1 a
\ i
EDWARD � J ANNE GARRANT
„t E
i
20 PALOMINO DRIVE
... 1
\ .,< TEST H LE 1 r
' k
x ES ,
_ \ T
1
\ EV. 91 A0 1
\ EL i
1
\ -�- MA
, ARKS ABLE
.\ ,-••_ -L to �
200 .PALOMINO DRIVE
8
\ { 1
\ r`
\
o \
PREPARED Y.
.. _ f•s _._. B
_ r _
t `
o
A N TA A 2630 .. ,
\ B R S B LE M � r n
1
t a
1 ,
1 I_ , .
20.25 __ o �r 1. �1AP1'i'l
I \ i_ t r- s
1
\ _
fi
__ , V R VICES, INC.
_ _ 1 .�' IRONM.E'N7AL - S.�' .L'S I
ra
N
\ ,
40_ 50 h
>2.9 0 ar
.- f 20
4 0 1�.
m PVC t /
O\ pp
,r / n P e tt P:�. DO 627 Vet I X
/ ( F:
F
d 32 59 E ,
N 13 c
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,
S T
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F T EAST A MOU H A 02536
0. \ ES L M
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e
F 8 54 079 TEL AX 50 8 6
88
V
A Y• ATE: DEC. 2003
SCALt._ 1 20 DRAWN B CES D 2&
WAY)
(
40 FOOT :RIGHT OF
A
- W SHEET 1 F 1
FILENAME: SD513PP. G S EE 0 T' D 5 LE E. _ D PR JEC S 13 0