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HomeMy WebLinkAbout0101 RUE MICHELE - Health 10 i Rue Michele Road Barnstable A= 335-029 a V1 �- d NIN bLh�.S v.. G8ZOt Odn r�u i i i I 1 i No. c/1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es appf ration for Misposal &pstem Construction i9Prm t Application for a Permit to Construct( ) Repair( ) JJpgrade;iOrAbandon( ) ❑Complete System ❑Individual Components Location Address or Lot Owner's ,A�ress��No�o -77a-7-7G' Assessor's Map/Parcel 3r35 InsY a 's bAddL � esigner's e A dre an %/� x Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date- © a Number of sheets Revision Date 0 Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when ap licable) Date last inspected: Agreement: The undersigned agrees to ensure the c s tion and maintenance he afore described on-site sewage disposal system in accordance with the provisions of Title 5 o he E ro a 'Code d t pace the system in operation until a Certificate of Compliance has been issued by this Board f th. / gned Date Application Approved by Date J� ] Application Disapproved by Date for the following reasons Permit No. ck)p Ica- 1 Date Issued I 9� w �, . - ._ ;.� --�.., - ,-n_._�.,; .' ;L,: ... - 't yrr', �'+r. r ..`..�A,�`rri'av:• .,r.� ,-- n s .-5=a. � y 13 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye «: ' PUBLIC HEALTH DIVISIGN ,TOWN,OF BARNSTABLE, MASSACHUSETTS 2ppfication for 3pErmit Application for a Permit to Construct( ) Repair(,) ..3gradec6 Abandon ❑Complete System ❑Individual Components Location Address or Lot No�O(jfd' /� "� Owner's flame,Address,and Tel.No. x 7e,2- i '�� Assessor's Map/Parcel 3,35, —Oa(? Ins ler.'s Name Ad es ,and 1. 0. �'�s esigner's Name,Address;and Tel No. AW Type of Building: Dwelling No.of Bedrooms Lot Size . / sq.ft. Garbage Grinder( ) Other Type of Buildingj / No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided / / ` gpd Plan Date /a, �,t� Number of sheets Revision Date U 1 Sr Y Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when a licablePAI Date last inspected, x Agreement: A The undersigned agrees to ensure the constrfttion and maintenance f the afore described on-site sewage disposal system in accordance with the provisions of Title 5 o the Enviro 'ental'Code°and not p ace the system in operation until a Certificate of Compliance has been issued by this Board f He th. Signed Date Application Approved by Date l Application Disapproved by f Date for the following reasons Permit No. Date Issued ►1�' P r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY),that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(1 Abandonedf( )by I)A04 � i °?�w �4-0 at Lai " / has been constructed in accordance with the provisions of Title 5 and the for Disposal,System Construction Permit No:—_�4-)/F-1 1 dated Installer le i� � Designer LAI #bedrooms Approved �d'esign flow gpd The issuance of this permit/shall not/b/e cnW poued as a guarantee that the systemtwill f metio esigned. Date / f� C�� Inspector ' - - ---- + ---- ---------------------- * No. �7�i .� W j Fee / t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposar 6pstem Construction permit ' Permission is hereby granted to Construct( ) Repair( ) Upgrade V Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pe'rmit. Date f�{ / t - Approved TOWN OF BARNSTABLE / LOCATION i n4t� SEWAGE# `' VILLAG ASS SOR'S MAP&PARtrzw L INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _ UCnsize) �3 r��(-J3 K2. NO. OF BEDROOMS OWNER e-- t& PERMIT DATE: 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) h Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) N Feet FURNISHED BY 1 In "0 e .. c10 (-� o ' d- VK) Lo e., 4 (� Cn -ci �lC9 'i l 3 Town of Barnstable �y�OpSHEtp, Inspectional Services Public Health Division. IAWRABM » Thomas McKean,Director 200 Main Street,Hyannis,MA 026.01 Office: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: 1 LZO Sewage Permit# Assessor's Map\Parcel 33 2 Designer: DOWN W6 ag4fNgjWAUI�. NC, Installer: EKM Address: a q ULM bh Address: On (� ' was issued a permit to install a (date) (in tal erl ) septic system at J01 E M{C eLF, 0, rXIMMANID based on a design drawn by (address M P1,5 dated JOI q-'19 (desi ner) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was. inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral.relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfa I erti that the 'ystem refer ced above was constructed i cara iance with the to rms of ers(if ap licable) jHOFkAssq�y DANIELA. OJALA CIVIL N (Installer's Signatu t no.46502 s o+vnLST ���� -�--�' (Designer's Signature) (Affix.Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. WoAdeptAHEALTM3EWERconnecQSEPTIaDesigner Certification Form Rev&14-13.DOC i I 335- oa 9 t.�ommonweann or massacnuseus W Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Rue Michele Property Address Denise Robbins Owner Owner's Name 4? C" information is Barnstable V/ MA 02630 2112/16 required for every page. City/Town State Zip Code Date of Inspection G!1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms s/ //,q J2/ on the computer, use only the tab 1. Inspector: key to move your cursor-do not Trevor Kellett use the return Name of Inspector key. Septic Inspections Co Company Name 38 Vacation Lane ,. l Company Address r't West Yarmouth MA 02673 J City/Town State Zip Code 508-579-5502 S113744 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems_-I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: :Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2/12/16 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..lf_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. `t"*'°This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 T ! t.ommonweaim or massacnusens Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments «� M 101 Rue Michele Property Address Denise Robbins Ow er Owners Name information is required for every Barnstable MA 02630 2/12/16 page. Cityrrown State Zip Code Date of Inspection z_ 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no'or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exMtration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 l.ommonweann OT maSSacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 101 Rue Michele Property Address Denise Robbins Owner Owners Name information is required for every Barnstable MA 02630 2/12116 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 t , 16 l.ommonweann oT massacnusens Title 5 Official: Inspection Form o Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments �,M 5 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal f 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 t ommonweann or massacnusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable - MA 02630 2/12/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ , ❑ the system is within 200 feet of a tributary to a.surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section.E the system is considered a significant threat, or answered,"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 lt,ommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments uM 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 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: s 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i \ tommonweann or massamusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable - MA 02630 2/12/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: This is a standard title v with a tank d box and 2 leach trenches ,Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date'of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 tommonweann or massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wb 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable . MA 02630 2/12/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use:LaDate Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 tommonweann W massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form 7 Not for Voluntary Assessments M 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2005 per boh Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.9 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): 1.1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g z Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 tommonweann oT massacnusens Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments G1y 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) , Septic7ank(cont.) •Distance from top of sludge to bottom of outlet tee or baffle 18,E Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? measured 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 is structurally sound and water tight with liquid at the outlet invert, both tees are fine,tank does not need to be pumped Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass El:polyethylene, _ ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle, Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 q.�ommonweann oT massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 O toommonweann or massacnusens Title 5 Official Inspection ,Form a Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments wM s 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. Cityrrown_ State Zip Code Date of Inspection D. System Information (cont.) , : i ,; ; " r Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above cutlet invert even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): d box is level and water tight with liquid evenly distributed,the box is down 19" Pump Chamber(locate or site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are rot in working order, system is a conditional pass. Soil Absorption System,(SAS) (locate on site plan, excavation not required): If SAS not located, explaip why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page,12 of 17 %,ommonweann or massacnusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M s 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 32' ❑ 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.): The leaching of this property consists of 2 leach trenches that are down 19"surrounded by 2 feet of stone Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 toommonweann or massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary_Assessments M 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. City/town State Zip Code Date of Inspection D. System Information (cont.) M1. 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.): a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I i �N ltommonweann or massacnusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Rue Michele Property Address Denise Robbins Owner Owners Name information is required for every Barnstable MA 02630 2/12/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately back of house B A 1 2 A1)20.5 A2)27 61)30 B2)34 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 \ toommonweann oT MassacnUSeus Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Maps show GW at 20+ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 16 of 17 i t,ommonweann oT massacnusens Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Rue Michele Property Address Denise Robbins Owner Owner's Name information is required for every Barnstable MA 02630 2/12/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable Departinent of Regulatory.Services .XVM Public Health Division Date /l AM �d 1-3 r ie99 200 Main Street,Hyanais MA 02601 , Date Scheduled -b ! t J Tuna � Fe'e Pd. .So Suitability .Assessment for ,fie is ® ` 1 � Performed By: Witnessed By: LOCATION& GENERAL INFORMATIO1eT Location Address `O I (�Lz M /-,,,Ae ie Owner's Name / _ , //r y - 4-G`mi/� u.l , — /, �l, Address Assessor's Map/Parcel: Enginoer's Name l` e U 0 k) NEW CONSTRUCTION REPAIR Telephone# Land Use: Slopes % G—� r/� P ( ) Surface Stones Distances from: Open Water Body �(/v/� ft Possible Wet Area �f fk Drinking Water Well Drainage Way ���v ft Property Line 'l(J ft Other ft SIM'TCH.1(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands-In proximity to holes) o�d . ' ,Jj WQtl•t'h 3G . 1.1 03 Parent material(geologic)( a luL 10 rT(A�LAIAR�6 Depth t0 BatJrgak Depth to Groundwater. StandingWater in Hole: �!fT . '/ /I` Weeping from Pit Pnee ,�/�l�T EstimatedS cas.-,na1 High Groundwater DETERM[WATION FOR SEASONAL HIGH WATER TABLE Method Used: IV G w Depth Observed standing in obs.hole: ILI, Depth to soil mottles: !tl Depth to weeping from side of obs,hole: In. Groundwater Adjustment Index Well# Reading Date: Index Well lcYoi____ Adj.factor Adj.Groundwater Levol— PERCOLATION T +'ST Date V,ti �Thue/0!0�' Observation Hole# _ Time at 9" Depth ofPerc 4 16 Time At6" Start Pre-soak Time @ Time(9"-611) End Pre-soak Rate Min./Inch Site Suitability Assessment. Site Passed SIM Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole,Data To Be Completed on Back--------- d ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(I)week prior to beginning. Q:\SEPTICIPL_RCFORM.DO C DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Shcl Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoneg;Boulders. ' o i to =y,�6'(iravel) 0_0 A L 5 (�YP —�� -13� G DE]CP 013SERVATIONN HOLE LOG Hole# � Depth from Soil Horizon Sail Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (structure,Stones,l3ouldets. • o sis en 3o G e DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other' Surface(in.) (USDA)" (Munsell) Mottling (Stricture,Stones,Boulders. 0- 5 � o itcc G e �- (oyA:�" I ---------------------- DEEP OBSERVATION HOLE LOG Hole# Ll Depth from Soil horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (structure,Stoats;Boulders. • G— � Consistency, . 10y R 3�z Flood Insurance Rate Map: Above 500 year flood boundary No—, Yes _ Within 500 year boundary No v, Yes Within 100 year flood boundary No. Depth of Naturally Occurring Pervious Material Does at least four feet of'nafurally occurring pervious material exist in all areas obstrved throughout the area proposed for the soil absorption system? -e If not,what is the depth of naturally occurring pervious material? Certification I certify that on s' �- (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in�10 CUR 15.017. Signature �f� "' �-' —'c'—'— Date !Ai4//9 • Q:1SEl'•1'lC�l'L�ItCPORM.DOC . S Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is — required for every Barnstable MA 02637 ,. . .�[ 12�e­citi-on page. City/Town State Zi Code Dat of P Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick McDowell use the return Name of Inspector. key. PKM Contractors, Inc. Q Company Name P.O. Box 775 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-5993 SI 13023 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority fp - Inspignature The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. . ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M •''� 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 page. City/Town State Zip Code Da1 If nspecL tion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 7 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 page. City/Town State Zip Code Datb of Irlspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):, ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA. 02637 l page. City/Town State Zip Code - Dalli of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,•''• 101 Rue Michele Road Property Address Elliot Owner Owner's Name required for is Barnstable required for every MA 02637 page. City/Town State Zip Code Daterof I pection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ E 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.] Ej ® 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. iE) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is Barnstable MA 02637 required for every _ _ 3 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1500 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 ' page. City/Town State Zip Code Datd of I spection D. System Information Description: 1500 Gallon Septic Tank Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage Private well 9 ( Y 9 (gPd))� Detail: No water records, private well on site 130'from septic Sump pump? ❑ Yes ❑ No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 Y � page. Cityrrown State Zip Code Date of l pection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No pumping records on file per BOH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system. ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract El Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 page. Cityrrown State Zip Code Date of In pection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Records on file indicate system has been in place since at least 2005-actual date unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ' Depth below grade: 1 feet Material of construction: ❑ cast iron Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 130' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard 1500 gallon Sludge depth: minimal (Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t. Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 page. City/Town State Zip Code Dat of 'nspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3'2' Scum thickness 1'6" 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 3" How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended -BOH.confirms that system has not been pumped Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 page. Cityrrown State Zip Code Dat'of lbspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is - - required for every Barnstable MA 02637 ,_ `:,', f► page. CitylTown State Zip Code Da t of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert equal and level 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.): Box i level no leakea a and no carryover noted or detected Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not.required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M W 101 Rue Michele Road Property Address Elliot Owner . Owner's Name information is required for every Barnstable MA 02637 3_page. City/Town State Zip Code 2tbspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 8x32 El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): All is in working order Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637i('[;I',l rj page. Citylrown State Zip Code Datb of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts n=� �I _ _ T'tfe = Official Ins o® ®gym Subsurface-Sewage Disposal System Form -Not for V-oluntary Assessments ^M 101 Rue Michele Road V Property Address Elliot - Owner Owner's Name information is required for every Barnstable '�� "' MA 02637 ''[[, 3.-_s page. `; _ City/Town '` s,�= -_ State Zip-Code Dat of I spection _ _ -- D. System Information (cone.) - t a vfc--. ;: .._ 4;Sketch Of Sewage=DisposaI.System-Provide a view of thefsewage disposal system, including ties to _-T E at,least two permanent reference-landmarks or benchmarks. Locate all wells within 100 feet. Locate ur,erlr r;i-e �T where public water supply enters the building. Check one7of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately z�� i Flo, i - t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syitem-Page 15 of 17 4 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 page. City/Town State Zip Code Dat of I pection D. System Information (cont,) . Site Exam: Check Slope [�Surface'water Z'Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water,elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 101 Rue Michele Road Property Address Elliot Owner Owner's Name information is required for every Barnstable MA 02637 page. Cltyfrown State Zip Code "Da of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 e 7�e�g i gg y f o m) - o aq 0 e ------------------------------------------' oo' ------------------------------------------------- �ts��7 # ���r E I �� �� i 1 1 m • '� 1 0 I i 1 i i O O �Ib y�6 tt4 i I� 8 . , u • o e 000 000 16 k § 4o y y a a b V t r e.a « oaRnh} CERTIFICATE OF ANALYSIS Page: I Barnstable County Health Laboratory , ``ys cfru Report Prepared For: Report Dated: 12/7/2007 Marcia Elliott Order No.: G0744250 P 0 Box 277 Cummaquid, MA 02637 Laboratory ID#: 0744250-01 Description: Water-Drinking Water u Sample#: Sampling Location 102 Rue Michele;Cummaquid,MA Collected: 11/26/2007 Collected by: M.Elliott Map 335 Parcel 029 Received: 11/26/2007 Test Parameters ITEM RESULT UNITS RL MCL Method# Tested Hardness 200 ing/L as CaCO 0.1 SM 2340B 12/7/2007 Routine ITEM RESULT: UNITS RL MCL Method# Tested Nitrate as Nitrogen 0.98 mg/L 0.10 10 EPA 300.0 11/26/2001 Copper l 0.24 mg/L - 0.10 1.3 SM 3111B 11/30/2001, Iron ND mg/L 0.10 0.3 SM3111B 11/30/2007, Sodium 12 mg/L 1.0 20 SM3111B 11/30/2007 Total Coliform Absent P/A 0 0 SM9223 11/26/2007 Conductance 160 umohs/cm 2.0 EPA 120.1 11/26/2007` pH 6.6 pH units 0 SM 4500 H-B ,11/26/200T Water sample meets the recommended limits for drinking, water of all the above tested parameters. Approved By-, (Lab erector) t { e 1 A.�,t, _, '.at, ..t. E �.o'U ......it r. 1xa; +. s4•: f s.i, k. ..1 :.S a ,fit ..r .�'ti: x.Zb., 7,. _... ... �� , ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Y Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Commonwealth of Massachusetts FH��:Al P$ � � � 1 CIEN -- . Title Official Inspection Form ?r Not for Voluntary Assessments Y 1 0 2005 Subsurface Sewage Disposal System Form OF BARNSTABLE TH fiFPT.Inspection results must be submitted on this farm or on the official Title 5 Insa 6/1512000.Inspection forms may not be altered in any way. A. Certsfscati®n Important: V When filling out 1. Property Information: forms on the _ /V z ye- �l . I, computer,use only the tab Rey Prop rty Address to move your /l,(, cursor-do not Ownels Name use the return ) r� g key. l 2— 4� d t f c t>.(tom. ! ^ Owners Address Ci /Town State Zip Code 65 Date of Inspection: `rrrx� Date 2. Inspector: - -1 E"O Name of Inspector - -Company Name Company A dress Cy City/Town State Zip Code Telephone Nufnber 4 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( R 15.000),The system: V Pa 0 Conditionally Passes ❑ Fails V ❑ Ne Further Evaluation b the l- al Approving Authority J akr,r Inspect r' gnature Date / � L/ � �.� 0. 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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•11/2004 Title 5 Official!nsYectien Form:Subsurface Sewage Disposa!System Page 1 of 16 j Commonwealth of Massachusetts Title 5 Official Inspection For Not for Voluntary Assessments ' Subsurface Sewage Disposal System Form A. Certification (cunt.) Property Address City/Town State Zip Code Owners Flame /indices f I pection Inspection Summary:Check A,g,C,Q cornete ail of Section Q A) System Passes: ❑ I have not found any information wny of the failure criteria described in310CMR15.303orIn310CMRilure criteria not evaluated are indicated below. Comments: , B) System Conditionally P ses; ❑ One or more system c mponents as described in the"Conditional Pass„section need to be replaced or repaired. he system, upon completion of the replacement or repair, as approved by the Board of Healt ,will pass. Answer yes,no or n determined(Y, f'ti;ND)in the❑for the following statements. if"not determined;"plea explain. ❑ The septic t k is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or extiiltration or tank failure is imminent. System Ill pass inspection if the existing tank is replaced with a complying septic tank as approv, d by the Board of Health. *A etal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of ompliance indicating that the tank is less than 20 years old is available. ND xplain: t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16, Commonwealth of Massachusetts Title 5 Official Inspection For Not for Voluntary Assessments z Subsurface Sewage Disposal System Form a A. ("#"erl tification (cost.) Property Address— ���'—--- City/Tovm State Zip Code Owner's Name Date of Insp lion B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high s tic water level in the distribution box due to broken or Obstructed pipe(s)or due to a broken, tiled or uneven distribution box. System will pass inspection if(with approve!of Board of Neal }: ❑ broken pipe(s)are replaced obstruction is removed ❑ distribution box is leveled or re aced ND Explain: ❑ The system required punt ' g more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspects if(with approval of the Board of Health): ❑ broken pipes) re replaced ❑ obstruction s removed ND Explain: /Furthva4uati®n is Required by the B®ard of Flealtho exist which require further evaluation by the Board of Health in order to determine if is faiisng to protect public health,safety or the environment. will pass unless Board of Health determines in accordance with 310 CMR b)that the system is not functioning in a manner which will protect public health, the environment: sspool 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 t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cone.) Property Address Y-� — • —_----- --- Cityfrown state Zip Code Owner's Name Date of Inspection G) Further Evaluation is Required by the Board of Health(c rat.): 2. System will fail unless the Board of Health(a Public Water Supplier, if any) determines that the system is functioning in a anner that protects the public health, safety and environment: [j The system has a septic tank and soi bsorption system(SAS)and the SAS is within 100 feet of a surface water supply tributary to a surface water supply. �} The system has a septic tank nd SAS and the SAS is within a Zone I of a public water supply. The system has a sep• tank and SAS and the SAS is within 50 feet of a private water supply well. The system ha a septic tank and SAS and the SAS is less than 100 feel but 50 feet or more from a ate water supply well''*. Method us d to determine distance **This system asses if the well water analysis, performed at a DEP certified laboratory, for coliform baet is and volatile organic compounds indicates that the well is free frorn pollution from that facility d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, prow' ed that no otherfailure criteria are triggered.A copy of the analysis must be attached to this fo m. 3. the... t5insp.doc•1112004 title 5 Official Inspection Form Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 OfficialInspection _^ Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.)' / / Property Address / City/Towrr 'r State ZipCode ?I(CLAP 51910 sr Ownir's Nagle Date of inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ElBackup 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 clue to an overloaded or clogged SAS or cesspool ElLiquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: Q Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. Q Any portion of a cesspool or privy is within 50 feet of a private water supply well. Q 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 to or less than 5 pprn, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No Q The systm fells. l have determined that one or more of the above failure criteria exist as described in 310 GMR 15.303,therefore the system fails.The system owner should contact the Board of Hearth to determine what will be necessary to correct the failure. t5insp.doc•11/2004 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts �_- .— Title 5 Official Inspection For _- Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cant.) Property Address-���i Y -- -- City/Town State- Zip Code Owner's Name Date of I ection E) Large Systems: To be considered a large stem 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" es"or"no"to each of the fallowing, in addition to the questions in Section D. YES NO [� the syst is within 400 feet of a surface drinking water supply th ystem is within 2t)0 feet of a.tribufary to a surface drinking water supply EJ ® he 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 swered "yes"to any question in Section E the system is considered a significant threat, or answer d"`yes"in Section D above the large system has failed. The owner or operator of any large syste nsidered a significant threat under Section E or failed under Section D shall upgrade the sys m in accordance with 310 CMR 15.3104. The system owner should contact the appropriate regional office of the Department. i t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 10 Commonwealth of Massachusetts - Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist _ P0z Rue- 141e fLe- Pro erty Address z City/Town / State Zip Code (`�►c( tC� III[0`l<1� og;7 . Owner's Name Date of Insoection 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? 2 ❑ 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 NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components,excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® Existing information.For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form r Not for Voluntary Assessments - g Subsurface Sewage Disposal System Form C. System Information Pro erty Address j — riisfahL City/Town State Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms -(design): Number of bedrooms{actual}: DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 3 Does residence have a garbage grinder? � Yes [] No Is laundry on a separate sewage system? [if yes separate inspection required] C Yes KNo Laundry system inspected? - 0 Yes 0 No Seasonal use? Yeso Water meter readings, if available(last 2 years usage(gpd)): NO Sump pump? 0 Yes ETNo Last date of occupancy: �� Date Cornmercialllndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203):, Gallons r day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): --- Grease trap present? 0 lies No Industrial waste holding tank present?. Q Yes No Non-sanitary waste discharged to t itle 5 system? 171 Yes Q No Water meter readings, if a able: -- Last date of occ ncy/use: Date Other{ scribe): t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection _ Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) roperty Address City/Town State Zip Code Owner's Name Date of inspection General Information . Pumping records: h� 9wt ,,-t when to s4 Pw-pl tt)"r Source of information: - --- — Was system pumped as part of the inspection? ❑ Yes If yes, volume pumped: gallons - Y How was quantity pumped determined? ---- ------- Reason for pumping: "type of System: Septic tank,distribution box, soil absorption system 01 Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Attemative 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: M3 e J 2- yr-; Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc•1112004 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page S of 16 l i Commonwealth of Massachusetts ra Title 5 OfficialIn's ec ion orm _— Not for Voluntary Assessments - y Subsurface Sewage Disposal System Form C. System Information (cunt.) perry Address CityfTor L Ul l®4 Stag/,7' Zip CodeZIA , . Owner's Name Date of inspection Building Sewer(locate on site plan): Depth below grade: f j feet Material of construction: E]cast iron 40 PVC E]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: feet Material of construction: concrete 0 metal 0 fiberglass Q polyethylene ®other(explain) If tank is metal, list age: ----- years Is age confirmed by a Certificate of Compliance?(attach a copy of Yes No certificate) Dimensions: -- -- i/ Sludge depth: -- — Distance from top of sludge to bottom of outlet tee or baffle �r, Scum thickness -- Distance from top of scum to top of outlet tee orba.ffle - c� Distance from bottom of scum to'bottom of outlet tee or baffle — — ---- -- How were dimensions determined? r t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 1E f Commonwealth of Massachusetts 4 Title 5 Official Inspection - Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt,) Mi F j t�2 ?ute. r k& Property Address � r j City/Town q State Zip Code °clllrat �A F/�� Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, a pdence of leakage,etc} e -146+ Ri lej - : No Gv rLeiae_P_ dl to-akl"Iti a Grease Trap(locate on site plan): Depth below grade: feat --------'----- - Material of construction: []concrete ❑metat ❑fiberglass pol thylene ®other(explain): Dimensions: — Scum thickness Distance from top of scum to top of outlet tee or ffle Distance from bottom of scum to bottom of utlet tee or baffle Date of last pumping: Date Comments(on pumping recomm dations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outle 'nvert, evidence of leakage, etc.)., /belograde: k(tank must be pumped at time of inspection) (locate on site plan): n: metal C fiberglass ®polyethylene 0 other(explain): t5insp.doc•11/2004 Title 5Official inspection Prim:Subsurface Sewage Disposal System 'age 11 of 16 'e Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Property Address rr 7 rn ab(e L9yuwft)Ui� �/ City/Towrt rState Zip Code N1i ck& ill,o f- 'q-t7LD a: Owner's flame Date?fin p tion Tight or Holding Tank(coat.) Dimensions: Capacity: g allons --- Design Flow: gallons per day Alarm present: Q Yes No Alarm level: Alarm in working order: Q Yes❑ No Date of last pumpi — Date ". Comments ndition of alarm and float switches,etc.): Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert - — -------—- Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): .` _ � 1,✓2c. L'6acl .. _ �9 kLe� _ UDC r sto4�,n tot Pump Chamber(locate on site plan): Pumps in working order: ] Yes No Alarms in working order: 0 Yes No t5insp.doc•1112004 Title 5 Official inspection Form:Subsurface Sewage Disposal System• F • Page 12of16 . Commonwealth of Massachusetts Title 5 Official Inspection r Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (coat.) Property Addrress g Cityn,own State Zip Code AldrL owners Name Date of inspection 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: ❑ 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 ofhydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): o k 5 C� �farrM a 1 �a A" f�,{o �yf 4('-A c.e 'r) �_.. B`�u1t C ct Ua r ta(fJVecd t aAe,.. arctekd betc 1� t5insp.doc•1112004 Title Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form _ - Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cone.) Property Address----- ----------------- ------- —_-- -- City/Town State /Z--ipode Owners Name Date of inspection Cesspools(cesspool must be pumped as part of.inspection)(locate 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 0 Yes [3 No Comments(note condition of soil,Sig of hydraulic failure, level of ponding, condition of vegetation, etc.): Priv (locate n site n y( eo e ) Materials of const coon: _--- ---- Dimensions -- - Depth of lids Comm nts(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.)- t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts r Title ���a� seio For Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) k off_, tie !` L --- Property Address n ) {fig �fPl, Clf`r1 uEd ! 1�1 02G39 City/Town State Zip Code Mt'�it�t� r� � !% lam Owners Name Date of Inspection Site Exam: t Slope Surface water Check cellar Shallow wells „ Estimated depth to ground water: �f Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local,excavators. installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 1-4 aln Not" Pad Al ow If us. i,,%- 15-D _. (94 t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 16 of 16 l Commonwealth of Massachusetts �- - Title 5 Official Inspection r Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cons.) 1`3pperly Address ! r� CitylTown -� State Zip Code M= 1l r �#- Owners Name Date of InspOiction 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. , l r � X x �zo le�6 101 0 z- 34' l TD, jc/I L 100 75 WTP1(- Wov*reA t5insp.doc•11120044 _ Title 5 Official inspection Form:.Subsurface Sewage Disposal System- Page 15 of 16 i Permit Number: Gate: . Completed 6Y: ri3ru t<too HIGH GROUND-WATER LEVEL-COMPUTATION p ! c fC1 " Lot No. Site Location: �V� v • --_ -- Owner: Ado l e Address: /02- 'Ru,,­ /I-; j(e Contractor: (ik� �:jd)n J XnS Chi' Address: `'' 6 CiX �L�) ��S¢&��; 1�(4 � Notes: STEP 1 Measure depth to water table r t0nearest ii 10 ft. •........................--....-....--.........................--.._-... month/daY/Year �--� STEP 2 Using Water-Level Range cone aril Index Well Map locate site and determine: Ali, GAppropriate index well.....--.............................. 8, ... -itVater-level range zone.-.. _...-_:................................. t i STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well............................ STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), j i and water-level zone (STEP 2B) f 11 dT� determine water-level adfustment .................. ....................................................................... Ie STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP4i) from measured depth to water level at site(STEP 1) ....................................................•..........._._•,•...................... .::.•....-.....__. 1 Figure 13.--Peproducible=Dutatbrl form. _ .. � i`,r-.� `� i,..�r- .., �55t0�-pRt t�- q'=:�{ j y ''-�,•-'.I i � � t a� .00 7 , rye a ' raQ en7j xa1N�Q3 mod � w - - - - ----- NONOHYY1oA o 2f LOCid aDNd— 'Of VN —. 1D _— -.o StJ I 'L / I b3tle� - /-, SSW zs• .1 I { --� J� I I 'Y t O i ROAD 393N01 30a ` > w! rfy 3 I t 181, ' _�8 7d Pl�' T � � 9RF.SitNO (� �� .....,.• h - awl 101; J '• < ` i Zb pvga NNnav o avr .' np yroc 1 ` NVIWY t- paw• 1 \ 1'. ;n/ ~ i — .. aaoa 31aavw w . �•ib 43?'Oj' 3AI80 pvoa >IDoa o ' Dtutao.ad LL � �� I I S i i aoo` b� ti. NCl ap, 'v wl HD`f j b _ op x u 'u 1SNr .- _A?YtrTs 3OV182N3 'Nl 135N§� 830ra0d 3Nv1 3 Q 1N 3Ptb'31 M .i OVOa IIH.3aDv 1 41213•Y. fyOPA oAD S�c♦'i�FR - AVM.' V.,t ! 't.. SQ' f .�'t•,try �LY,i j t t '.S aD ---- --._.............. .. ao iH OAO cj -3 1 bt -N) g N3 s "'r °• / �_ I •� ININd 10 _.._..34V1` NDONY rn S`? ff ` d,• g,� p�.d a(!\ � / �io. .. BEALE aN Nap 6' p Md LO G 4 1 t Md V �• — �.�.s � 1 .. ! 1 oAb� I y N�)) Sa0N83 of I > r z1 O a . __ sCW ER ' UAiS Ground water tar USA: Water Levels — 4 saes ' Data Category. Geographic Area: Water v �a9r� � Ground Water United Mates go round-waterlevels for the Nation Search Results -- 1 sites foam Search Criteria site no last� ® 414154070165001 Stine mile of selecte l ssL .s to local disk for future upload U SGS 4:141.54070.1650lf MA-AI ' 247 B YS '.� aE ' t� Available data for this site; Ground-water:Levels GO Barnstable County, Massachusetts €utput formats Hydrologic Unit Code 01090002 ---® Latitude 41°41'54",Longitude 70°16'50"NAD27 �abblele of data Gage datum 44.52 feet above sea level 1 GVD29 Tab-separated data The depth of the well is 510 feet below land surface. Graph of data The depth of the hole is 52.0 feet below land surface. This well is completed in®LMVt1SHDEPOSTTS (1120TSLi deselect pereod _ 24.6 q ``. 22.9 ft7 I y y 21 24.0 ja —�{(?,(�yd�,� �" '" a� .x -.6x t iBeYt 1y&�ds.•.�� a.a @ v .'26,0 Al ti v ,'xiw.jy 3 s _. ..... G.3 - ± f+' L-d 44. bl 2 8.9 1984 1979 1979 IM2 .�3a� 1994 29" Breaks in the plot represent a gap of at least one calendar year between two consecutive paints. http-.//nwis.waterdata.usas.gov/nwis/gwlevels/?site no=414154070165001 5/8/2005 April 2005 Departure q _ "te Ni Well Water Record Record frortAverage** Location No. Lever High* Low* Monthly (finks tz US(I s wa.fiowlal Overall m,:ater-level database) I Barnstable 23 W 21.8 20.5 26.6 0.8 1.8 4139;6.070164301 Barnstable 247W 22.3 20.5 28.6 1.4 2.2 4141540 70165€fit11 Brewster BMW 9.0 6.9 13.6 0.8 1.2 414518t1711112(�311a21 . 21.6 (Note: CGW Corrected Chatham. 20.9 • 26,6 1.5 2.4 4;4100I17013�1_1���_ 138 level for March 2005 ywas 21.8 i!1IW 919 Mashpee 29 6.4 5.6 10.0 1.2 2.1 413_5 . 70204 Sandwich SDW 46:2 45:9 48:2 0.7 1.1 4144180-70241601. 252 ID Sandwich Z W 49.4 4:5.8 55.1 0.2 0.8 414124>7 -)659 �1 Truro TSW 11.2 10.2 13.0 0.4 0.9` 42021 641-00451401 89 Welitleet r 17NW 9.4 7.3 12.8 0.3 1.1 415-5, 16 9 585401 Measurements are in feet below land surface. Y* Measurements are in feet above mean sea level. * Well inaccessable I I A USCkS national water-level database provides historic data, hydrographs, and site maps. The USGS compiles the above data and other water levels into a monthly, online Watekr l .esoaa -ees Current Conn' ions Report that covers all of Massachusetts. /1 �v '711 �t No.. �....... Fni&.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OP, i=---- - 7'. WAK.............OF..... .....Z? !""'` � -------------------------------- '�� Applirafilan for Roposal Worko Toes .rnrtinn Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at 160� � C" Y Q-. 1�1 rzS ......1: G.d»,Sss?`5 ...d ..✓� /.tP.: � .C. .Tf: - - .k6,. ,rr�!- ?,c�f ...... � -���.. ...4? --* ?:.0 0 f Location-Address or Lot No. :r......_ .!.�f .fr!h. .�I.�r.�Via. ........ r - •4--. .- ........................................... A er Address i w f �° .: ............. nsta ier Address �„ U Type of Building Size Lot_. _3'_.'? fX.Sq. feet Dwelling—No. of Bedrooms-•--- ...............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building 15219&I:O.__..... No. of persons ................ Showers — Cafeteria a YP g --------=--- P ( � ( ) Other fixtures'........_ Design Flow......... ______________��..gallons per person per day. Total daily flow....... ? ........................gallons. WSeptic Tank—Liquid capacitf� gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...... ............ Diameter._.... ...... Depth below inlet.......6........... Total leaching area. :�s" !:---sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0­4 Percolation Test Results Performed 4............ Date. .A.,+ !3........ aTest Pit No. 1..=..Z,..minutes per inch Depth of Test Pit-------a......._. Depth to ground water---M . ....... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' •------------------------------------------------------- ------- -------- -------------------- •......... . .+:0 Description of Soil-------I ... O►.�l..4?_�.Sz _ -•- :t-. `' 'g-`-`-A ? ..................................................... x V ---------------------------------------------------••---------------------------._......------•----------......------------------------------------•----•----...----•------------....----•----•-----_... VNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------•----------•-----------------------••-------•--•••••---••••--•------•....-•-•--•-----....-•-•----------••-••---•-------..._......••••-•••••------•---..........•-•------....--•--------•-••-- Agreement: 3 The undersigned agrees to. install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. i Signed.. ------�---- ------------ .���1� Date Application Approved By....' ./- ----�-- --- ----------- - ,...._ C� - -- 2 Date i Application Disapproved for the following reasons----------------------•-----•------------------....-------------•--------•--•---------...--•...............--•••- -----------•-------------•--.....----•-------•---------------•---•--•--•--•......•-----------••-•--•--._-----••--•--...................----••......••. ......------•----••-----••---•----._......_.._ Date Permit No......................................................... Issued...�- tea.......- -. !` 4 A Nos��Zl....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................ ..._•----..... .............OF_...........V4eeA.C.fM.. ...41vi.e...-----................................ Appliration for Disposal Works Tonstrur#ion runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �LrorT-------L'-km"A�?.t1.e4.....�-~.. .4....r . Qs.. Location.-Address or Lot No. i✓af ei..l:� la rr '� ... '. = - - �`'r Y. elf/5---114-cs......................................... �Address ♦ Jf/f{/ 4'� Address Type of Building Size Lot_. .e.2...:..:rtf�2"Sq. feet U Dwelling—No. of Bedrooms._...__ -...............................Expansion Attic ( ) Garbage Grinder, ( ) . Other—Type e of Build_n� yp g _% !? ------- No. of persons--------4................'Showers Cafeteria ( ) Otherfixtures .................--------•-----•---•--•..................----------------------•---......--------•-•--•--.....--•---------------......-•---•--..._.. W Design Flow.......... ..........................gallons per person per day. Total daily flow......�.e-.Od._......_......_..._..__gallons. WSeptic Tank—Liquid capacity_<®_00gallons Length................ Width................ Diameter-_________: --- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....../------------ Diameter......8........_. Depth below inlet.....6........... Total leaching area-�....sq. ft", Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed .._.P.E....._........ Date_.5: ? ....t. .7.3........ Test Pit No. 1..—.2..minutes per inch Depth of Test Pit.....:........... Depth to ground water...K hLF......... Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .............................................................................................l ........._......... €: :.v ........... O Description of Soil------- _.�- t+, .o �t'S- !CAV�mk-D----------r_xz� -1N x , - ------- , U --.. " � ONALD J, rn 1 Nature of Repairs or Alterations—Answer when applicable..................................................A M._.. U' P PP Ni Fl f7T"E"IV"" , Agreement: Ao�fiIsT ������/' The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys\, with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to"placethe`system in operation until a Certificate of Compliance has b issued by the board o , .:.... f...! _.:. � al : l ���)Signed: ... -,j 'Dat Application Approved BY Cl% : --------------------------------•----; --•--...-•---.........------.......---..�.----- ----- / .•r'=Date Application Disapproved for the following reasons------------------------------------------------•-----------------...._........-------------•-..._..._........... ...................•--•...--•--•••---•......•--•.--•-•-•----••-•--••-•-.._....--•••-•..............-••--•.......•---•-••----•-•••--•-•-•----••--•------•-•-•-•••-•-•---••--••-•-•---•-•-•-•--•-•.....-••- Date 5 PermitNo......................................................... Issued....................... Data THE COMMONWEALTH OF MASSACHUSETTS ��� t �H OF 1 BOARD OF HEALTH �� 9rsq Ln .............................. ..................--•c....-ate._r r M "RTEN ; T,HISIS wOrCE2TIFY, Thatathe �ndividuai _ice •,; i ram_�/ t �t x: .e -».�s._r��insta ler, t�- �° �e at.... ... -= -----------•-- ------..•..........-----------------.......... _ :.. a: . r r ..�--.....` has been installed in accordance with the provisions of Articl I e State Sanitary Cody,asuede ri /P the application for Disposal Works Construction Permit No.......... . :. ..__._.__._ dated-------_. ................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ' DATE................................................................................ Inspector.............................................---.................................... » �1.1. THE COMMONWEALTH OF MASSACHUSETTS p� �P1 o fi b'ys4s� P BOARD �,0 diFFALTH - 0 DO3Kd�A J rn ' No....... `".................... .........OF..........................._._.._................ ..................._............ .Ii- MARTEN .................. '� .T����G��� .� Permission ieke�reby granted-- ----------' ' .... r l . c..�` .........................................:...... to Construct (_ ) or e`pair_(�I� an-individual Sewage(Disposal Sys 6m t, at No... Z r .................•--...._.....--------•-----------•--•----••••••-�- .. ` -- -t . .. _... ...M . Stree f" 1 '` as shown on the application for Disposal Works Construction Permit'a..•.. ........... Dated_ ... _..• f .......... .......•.• . ....... F�: ............_ - Board of.Health ✓ DATE------� ......... FORM 1255 HOBBS.& WARREN, INC.. PUBLISHERS Q> w r 9ALN'•vsI.BAffiN aams 49'O 4 4 9'i 9'-T 4'9 - —.:::it,l_:- S i MARK j McDOWELL ❑❑ ❑❑ ❑❑ ❑❑ AIA' . . o - IF= er Below - EuaecoAiaccrc rt----------'--------- --- ---- ------ -------- ---- - ------------- -- --- - -Q --- --- O - —� - —O O - i traet P ® 017 s erteta s Bent ,/-DemEle-da-0zsss, —� — O O I/ ENTRY o O O 0 O O - Rm'rESI rba p � Denise LeClair Robbins] ;,y p- .� Fw .: ________1L__ ____ Dam __ _ CloaO BEDROOM a - mOARA6E ®C] I FAM6Y ❑--------------' - ----- - I - Lima I- >� O rEe ----------— r ------ Cloa - p, ---------------- ofQ I II I ' ; FIR®YrA'YJ We3Mn i ; I I I i Td' 3'6' 6'J' zo r Closet - I I I I I I ---I KIT�lfER _ FT__ wv�Lrixa 4 - O O , o I ' ` I I j, i 4 e o B BATH O - § p MASTER BEDROOM 101 Rue Michelle ❑ Barnstable,MA 0!!30 0 � FIRST T S'0' i, 9.5' 2 4 p FI T FL — PLAN p FIRST FLOOR PLAN 1 FLOOR PLAN NOTES '❑' wm a,t-LE�w g..BP6E..SA RL IRSER TO IT.w rABItETNffLF recta 3. sw-—1 AT IB•.la 3z: —I..9F AIR mmmB.Ile Pre a. z'IT I. Irle STAIR-eBmml.Rre Y STAIR IR GNP(REFER ro -Y6PE T6 2° Ya4R_R SaEE IPRWIOE REc—.Ic.Ix LKL FOR ]3. 3�In.PIPE__SO Risx ur nln.Iz EnBEO- a9. 22:6 ITIDRUPLL 6 2. 6?UUSsIjj[IU5OIRueI�vER u x> 6G IBFR6LR99 i1H Yt TI 9OUER OPIRAR�0IK3P�1 E 2 x 0 SiW YxL 3 UiILITv H!'I E RISER.IUERIFr LOEPI IOx uI IN sz.aaEx6nRlRIx Ra) ORPI 25.. II.E K ERIWSi UE.T I �' OAKS.PIS.—IRTIeI.—S. ' - •. 4x°r RYS&'E`L�°YR":i8x"sRS"Y�eG'{'n o1�LRIREFEx ro �`E$f3TF'nrRE�"LR4'� RL Tlm a 19 xICII nolsT 9Rot nla',FT u.ww 33 ',� s"ao F°E4'L'i$'F$�°'L x°io6RT :6: Ln�3F L.�oY �s nw snx om wrF - . [mc pP HtmGE 1iN wppp pBU a cI�*a Sl�6�96Y€6FLE ""dfia'iF�F`°kE sE6'rcR RT Si.E a of 5�9 i PPRpJ G♦FSLr 90pRi 3B. u.E 9F mFFI!React v'' EPIC LLEECCR��gIqUe ELEuol IW916"xcU�Rn1W'1CCE.OU.FSE.pF.11(REFpt LO 1 E i1�E 5 �p 1� i eRNE-SEE 6EiRil �R6PtD 96-F TBGREF�LosF➢`16RBI.E SPR¢• R 51. BRiuRLL 6NELF IT 36'RFF 6" ER6aJINc',Y IF.`isl"Rfldx°u644d IrtlLin ' �TT 0 4-4d 128PeM/E F10 I`PRWIOfiRaEEE65E0H KR R�pi�S� p 61� 1DN 61p 3 ] 30'nR%—xl.RRIL'xc 9EE 92. ORYWLL 91ELF ISEE PLR.EUR HEI 1 ]] EE T 506vbQ5. Y/x S11NiNiL BE STRdw9EJp'EFaat.E�dtER� T• O�TRIL.IHUn i 33. SELF nT' AFF . '. Po6�tEdS6RECEs5E06i�6ugLLR SPPEE Rx0 RNa FOR Icfi EOESTRL LS�tORrER[OR ELENtlIOV9 py�� qEL Ei U­pLI�EFI060u1510fi ,- CURRG3nil-BEE @T<IL SR. L Ri '.1 m P PRWEO N ' 39 LL MO D.RMRRIL R1 34'TO 39'R90UE HOSING SS. O[tFCHI05E 21zERERSpREEo IEo III RBi.el F y"flb"Y6RPf�f7e8P .xRe usnbe' P 6sd�€l91•.ER 333 OR AFAR——I SR. 21. NoEl ISEE.—I.ELEURT10.9 FOR BT2E RtN ��I,p,�p� T_ � O 6. 6PEc9.M0 NTERIOR ElEtMTIOF91 51 dEt R 41gS alRl. I15 MSO.ii FIRERR[E R'—TO OETRIL9 Si. LLI—I Ix1ERlat ELEURIIMSI RBLE.TI.S IREFEA i0 I.iERIM WR_AI RVJPI66RFEIi6f1R93E."OAIRE-FL.LT IEnPEREO - ;diE` REW I¢ED ' 0 nININN 12wti. SB. xELF RIO POIf IB ELEYfRiTlOiii"I ' ♦ fT BII IREPLRCE FLUE PER UR 39. 9.ELF o.p p01Bi.f POLE B£ET II: A7 6 ti n �I W �O ❑ qg ^ a _____________ -- _ . Q 0 � e d O m g K w a 0 O W N G m e J m tl Y: Jle - - '❑ - E tl 8 r 2!1 $ - u is d m S P"^ 4 k --- ---------- Q _ and 36b m O n p F 03 r R 4" SCH40 VENT WITH ALL SYSTEM PROFILE MAR ED WITHSYTECMAGNETICTTAPE OR SHALLBE SHOWN AL AN VIER WAS V NOTES \ COMPARABLE MEANS FOR FUTURE LOCATION. PITCH BACK TO SAS, 2' CAST IRON COVERS TO GRADE OR CONCRETE (NOT 70 SCALE) jv �� COVERS TO WITHIN 6" GRADE, COORDINATE W/ OWNER NO LOW POINTS. APPROX. NGVD29 � � � 2' CAST IRON COVERS TO GRADE OR CONCRETE 1. DATUM IS ?. 2" PEASTONE OR GEOTEXTILE n FILTER FABRIC OVER STONE COVERS TO WITHIN 6" GRADE, COORDINATE W/ OWNER C , 2. MUNICIPAL WATER IS PROPOSED o o_ q WALKOUT EL. 34f MINIMUM .75' OF COVER OVER PRECAS 2% SLOPE REQUIRED OVER SYSTEM /8" PER FOOT. 3. MINIMUM PIPE PITCH TO BE 1 ROUfe 6 �� PRECAST H-10 BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS r RISERS (TYP.) PRECAST H-10 PRECAST RISERS [ �J 2'0 RISERS (TYP.) 4"OSCH40 PVC MORTAR ALL H-20 TO BE AASHO H-2Q. (TANK TO BE H-10) J Q� 6• MIN. SUMP PIPES LEVEL 1ST 2' COMPONENTS * 12' MIN. INT. DIM. ENDS (TYP.) INV'S EL. 36.50 S DES 37.5' S. PIPE JOINTS TO BE MADE WATERTIGHT. °TIP •. ... .: .,. ._ •.. •. - ... .: .. .,� ° -l+i-FF++- v 10' 2000 GAL H-10 14' EE' o°� Q o o 0 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH o Locus 31.75 TEE ° ° ° ° OI�®0 E=MM MM�® _- MMM '°°°°°°°° SEPTIC TANK TEE *31 .5' 10" 1500 GAL H-10 / O�Oo TEE.4 J9PUMP CHAMBER °000000o0o0o WATERTEST D'BOX b >°°°°°°°° ®®�®�®®®®®® �® 3a 310 CMR 15.000 (TITLE 5.) GrOn! c °oo°o°o°• N °°°°°°o° =mmmm o°o°°°°° °�°. ° FOR LEVELNESS n°n°n°n° BOO®�Oo 000�® ®0��®®®®®®� °o°o°o°o / J ZABEL FILTER °o ° ° ° ° / �� �3, 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO a °°o°n°°O e,000000aoo '. 4' LIQ. LEVEL (ACME OR EQUAL) •1 (A100) OUTLET SEE DETAIL BELOW 36.77 36.60 34.5 , >/ BE USED FOR LOT LINE STAKING OR ANY OTHER TEE W/EXTENSION / N °o' o 0 0 0 0 00 0'o 0 0 0•o o"00000a000000� NOTE: 2" MIN. WALL / O •�•••••• PURPOSE. o �,, o°o°o°o°o°o°o°o°°°00000000000 o°o 0 0 0 0 0 0 �* "'` •' -'' ' H-20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. / N .�,'.•.'. / „o°o°o°o°onononono0 0o0o0000� _°onono�00000. �°o 0 0 0 0 0 0 0•o 0 0 o o•o 0 0 0 0 0 0 o`4THICKNESS REQUIRED I o°o°o°o°000°o°o°o°o°0°00.0°0°0°0°0°00000000000 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. (8) UNITS REQUIRED / J I 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. a 0 0 0 0 0 0 0 0 0 0 ° ° o o ° o 0 0 0 0 0 0• zk o 0 0 0 �`_n_n_�.o o. ALL AROUND PRECAST STRUCTURES (J1 •�•'•'•' *THE INSTALLER SHALL VERIFY THE } 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 73.00' X 12.83' / N 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED LOCATIONS OF ALL UTILITIES AND ALL COMPACTION. (15.221 [21) �" " co O WITHOUT INSPECTION BY BOARD OF HEALTH AND BUILDING SEWER OUTLETS AND L6 / m l. . . N PERMISSION OBTAINED FROM BOARD OF HEALTH. ELEVATIONS PRIOR TO INSTALLING ANY ( 1 7. SLOPE) ( 1 % SLOPE) / 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING LOCUS MAP PORTION OF SEPTIC SYSTEM ( 2 y, SLOPE) H-20 DIGSAFE (1-888-344-7233) AND VERIFYING THE LEACHING / �' LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES NOT TO SCALE FOUNDATION- 15 SEPTIC TANK 1 SEPTIC TANK 143 D' BOX 12' 29.0' BOTTOM TH-1 / , '• •'• • • PRIOR TO COMMENCEMENT OF WORK. FACILITY NO GROUNDWATER FOUND ACCESS FOR ROUTINE MAINTENANCE / I. . . .' 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE ASSESSORS MAP 335 PARCEL 29 MUST BE PROVIDED FOR ZABEL FILTER. INSTALLER MUST FOLLOW ALL / '" REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. / L. . . MANUFACTURER'S SPECIFICATIONS FOR S 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND PROPER FILTER INSTALLATION PROP. WATERTIGHT COVER TO GRADE // �Uc. a I REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. ALARM AND CONTROL PANEL / 13. WETLAND FLAGGED BY DOWN CAPE ENGINEERING 2005 ZONING SUMMARY TO BE INSTALLED INSIDE PROVIDE QUICK DISCONNECT FOR PUMP i BUILDING. ALARM TO BE ON 37 � $ 14. DRYWELLS PROPOSED FOR ROOF RUNOFF SEPARATE CIRCUIT FROM PUMP / j 3 15. POOL FENCE SHALL HAVE SELF-CLOSING SELF-LATCHING / GATES, SIZE AND MATERIALS TO MEET LOCAL AND STATE ZONING DISTRICT: RF-2 RESIDENTIAL DISTRICT BUILDING CODE, ALL DWELLING DOORS OPENING TO POOL SHALL BE ALARMED TO CODE. MIN. LOT SIZE 43,560 S.F. !fir rr III MAP 335 PCL 29-3 TAI ELLIOTT i p MIN. LOT FRONTAGE 20' ?ri,:ri r , '� INV. IN 31.49' NO LOW POINTS 37 RUE MICHELE RD l (Q o, MIN. LOT WIDTH 150' 2" PRESSURE LINE / CUMMAQUID, MA 02637 38 A qj MIN. FRONT SETBACK 30' 1500 GAL. H-10 S/T / 880 GAL.+ SLOPE TO DRAIN BACK TO PC ,p j� N MIN. SIDE SETBACK 15' ALARM ON L - -- - - p MIN. REAR SETBACK 15' FLOAT SWITCH RESERVE - - - -- p SETTINGS: PUMP ON 0.25' WEEP HOLES MAX. BUILDING HEIGHT 30' CHECK VALVE �,^� % - , ` NOT MAPPED NHESP 4" WORKING RANGE 8 SITE IS LOCATED WITHIN THE AQUIFER MYERS SRM 4 EST.A ORITr - - - - PROTECTION OVERLAY DISTRICT 4„ NHESP SUBMERSIBLE 4/10 HP PUMP 39 �' ' _ PUMP OFF 8" SYSTEM (OR EQUAL) ° TEST HOLE L CV _ O LOGS OWNER OF RECORD PUMP MB CHAMBER .�'" DANIEL E. GONSALVES, SE #13587 ENGINEER: DENISE LECLAIR ROBBINS (NOT TO SCALE) Q 40 19750 BEACH ROAD #304 WATERPROOF/WATERTIGHT �" DONNA MIORANDI, RS r� . . . WITNESS: JUPITER, FL 33469 Q. 39 DATE: 1/16/14 < 2 MIN INCH m I o .. . .• • 38 PERC. RATE _ / REFERENCES SYSTEM DESIGN. I - - - '.' .' NOT MAPPED RIO,NHE P - -- - _ 8 .p�C p 37 NHESP EST./PRIORITY CLASS I SOILS P# 14238 0 - DEED BOOK L7284 PAGE 205 PROP. VENT WITH CHARCOAL FILTER ( / PLAN BOOK 276 PAGE 95 m AND BUGSCREEN (FINAL PLACEMENT • GARBAGE DISPOSER IS NOT ALLOWED lie CONTRACTOR WITH HOMEOWNER CONSULTATION) / 1 ELEV. 2 ELEV. 3 ELEV. ELEV. DESIGN FLOW: 8 BEDROOMS @ 110 GPD = 880 GPD S82.34'45"Y`I 4 •> 0„ 40.0' . .'.' '.'.. '. .'.'.'.'.'� 012 40.0 0 40.5 0 40.0 . . . . . . . . . . . . . - - - - USE A 880 GPD DESIGN FLOW a . . . . . . . . . .. .. . . . . . . . A A - A --- A . . . . . . . . . . . . . . y. LS LS LS LS . . . . . . . . . . .. . . . . . . ..'.'.'.'.'.'.'...'.'. ... . .. . . . . . . SEPTIC TANK: 880 GPD (2) = 1760 \ . . .:. ..... . ........... . . .LF7. 10YR 3/2 10YR 3/2 10YR 3/2 10YR 3/2 �� 6„ 6" 5„ 5„ USE A 2000 GAL. SEPTIC TANK & S �: � A 1500 GAL. PUMP CHAMBER s�3s, x I s o '. B B B B wF-2 w a . . . . . . . . . . . . . . . . SL SL SL SL LEACHING: " " " " " " " " ' ���8' 9F '`•L� 1 � I � • � � � � ' • . � 3 10YR 4/4 10YR 4/4 10YR 4 6 10YR 4 6 , �h� 36 37.0 36 37.5 30" 37.5 „ SIDES: 2 (73 + 11.83)2(.74) = 251 GPD ,� N I �2 H1 t 30 37.5 BOTTOM: 73 x 11.83 (.744) = 639 GPD / x oa EXISTING TH2 TOTAL. 1202 S.F. 890 GPD w � I Q DWELLING 0 1 �, C C C C FLAX w N ,� ��, I 33.7' PERC PERC USE (8) 500 GAL. H-20 LEACHING CHAMBERS ( - w -3 '� I p 1p , BENCHMARK: (ACME OR EQUAL) WITH 3.5 STONE SIDES 2.5 ENDS. ,� �i I `* / 41 9 I NAIL TO BE SET IN M/CS M/CS M/CS M/CS POND co ,� �� 01p I w a x TREE ELEVATION ;y i 20' OAK n a 9 =42.00 oo i ,\ 0 2, / 2.5Y 6/4 2.5Y 6/4 10YR 6/4 10YR 6/4 OBS. WATER ,� \\I 0 #101 / 1-14-2014 / I a E G E N D RUE ELEV. 26.7 0 / / I o MICHELE 0 I / 132" 29.0' 132" 29.5' 120" 29.5' 120" 29.5' - 99 - EXISTING CONTOUR .� /IO� ( 3 X 99.1 EXIST. SPOT ELEV. O� , ,/ O NO GROUNDWATER ENCOUNTERED NO GROUNDWATER ENCOUNTERED -[991-' PROPOSED CONTOUR � / f� �O W 4y 198.4 ] PROPOSED SPOT EL. TH1 `� WF-5 �� J �(v� � - � � z/i SITE PLAII�pJ TEST HOLE '� ^� I OCe (�`\`� I '� -J OOHS ` PROPOSED OF / ADDITION 2> SLOPE OF GROUND I C-Q� UTILITY POLE I 35, �• p ^ }- � PATIO co F_ O1 RUE MICHELE FIRE HYDRANT I \ LEI x �O Q C I D NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING h� I 0 Ix 1 1�, MAP 335 PCL 29-2 •�� '� L0 wI EXIST. JILL ELLIOTT ao� I �' I POOL 37 RUE MICHELE RD o PREPARED FOR Dc CUMMAQUID, MA 02637 O� - tx Q DENISE LECLAIR ROIBDINS Dc• �j WF-6 � 50 ^`NF-9 x / / � / DATE: SEPTEMBER 12, 2018 ram" w REV: OCTOBER 4, 2018 (TANK SIZES) 1� ~ ' O 2�291 wF-10 wF 4 STONE / �� 1 EXISTING POTABLE WELL r � EL. 38.5 TO BE CONVERT » �� !IRRIGATION WELL D TO Scale: 1 = 30 Zo SHED / (25' SEPTIC SET BACK) 0 15 30 45 60 75 FEET MAP 335 PCL 77 C,1 - `^�/ LOT3 �0Fh1tis COMMONWEALTH OF P 0 i v wF-11 / /0 / 89, TNIELA. ys ' � ';` DA,,,E`s�\ off 508-362-4541 677 SF f /f P wF-1 0' �,o OJALA MASSACHUSETTS F 2.06 ACRES �4E CIVIL - A. �� fax 508-362-9880 _ - / (80,337 SF f UPLAND) No.465020 �' kl" OJ LA P p downca e.com c Q, / 1 e� STER� No.4{)960P L=548.62 FS ,o1 down cape engineering, MC. R=5669.65 °SUPS' , civil engineers land surveyors RAILROAD ( 939 Main Street ( Rte 6A) DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 DCE # 13- 146 13-146 McDOWELL.DWG I