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HomeMy WebLinkAbout0096 SCUDDER'S LANE - Health 96 SCUDDER LANI BARNSTABLE A 158 018 , - w L. , , F I 0 t .r a . y. ,1 • ' � � .. a .. 4 - '' ... - . , 1 ,.:. '.. ` �y •. ! •tip^~ 4 n i 4 .. � • � .. ,c. � � Y .. � • - r. f _ f`� r ' n Commonwealth of Massachusetts p Title 5 Official Inspection Form �i� Subsurface Sewage Disposal System Form -Not for Voluntary AssessmentsTj t 96 CSCNCclQrc L.C.?ki-e <-.r `J Property Address Al 4e- �owhS Owner Owner's Name / ✓ g a: information is G�h s.�A 61 Q Q�6 36 / G 8 r required for every -- — page. City/Town State Zip Code Date of In pecti 3�r 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. Inspector Infor ation filling out forms on the computer, o use only the tab G+'r� &e,Ili key to move your Name of Inspector cursor-do not use the return Company Name key.. Company Address — �Cjs��Q WI /� 0a6 9�j- CitylTown 06 �&O— •/^^-/�/n O State YO fd Zip Code rem [�✓� Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the sys 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Al, 916 J� Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �^ p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` % 9G Se w c)rkn1 L G&1e Property Address �ow�s Owner Owner's Name information is �{ -To required for every �`��Gi�� page. City/Town State Zip Code Date of Inspe on C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System sses: 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): f t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l c ScAldtL,s /— •r/ u Property Address U0ow4 s Owner Owner's Name information is required for every - gcvol rj 4 9 4 page. CityfTown State Zip Code Date of insActiorif C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 '\ Commonwealth of Massachusetts ,z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A 96 Property Address Ot„/h f Owner Owner's Name information is / p required for every ohs 4C le ��-�.TV I p v page. City/Town State Zip Code Date of In pect' n C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El due or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9(0 Property Address ©wvt s Owner Owner's Name // / VA Dj.4 3O 6 information is RIHs. j(,� f FT required for every page.e. City/Town State Zip Code Date of nspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ �( Static liquid level in the distribution box above outlet invert due to an overloaded u / or clogged SAS or cesspool ❑ ,�,/ Liquid depth in cesspool is less than 6" below invert or available volume is less U than 1/day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ eeloo," Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ;/0" Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ny portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- /10,000 gpd. ❑ ,_f�i_,/ 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following,,in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ 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 I I of a public water supply well t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for /Voluntary Assessments , / G CSC u C G*2rS L!1/ Property Address UD oohs Owner Owner's Name A information is &r04-41t /(�/e o /3o ? / i Qrequired for every _ / //�" P b V V v page. City/Town State Zip Code Date of In pec' n C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" 9 P for each of the followin for a//inspections: Y Yes o ❑ 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? XHave as the system received normal flows in the previous two week period? large volumes of water been introduced to the system recently or as part of is inspection? ere 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. El approximation 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts z Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 SC 44 clel'oes L. ot/ Property Address oG✓ivt s Owner Owner's Name information is Q eos.�`14 d v 6 SO p required for every /] o`l page. C4TTown State Zip Code Date of Ins ctio D. System Information 1. 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): Description: 0 /SOO 6-C.MOP? G `Ta S. Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes No Last date of occupancy: DaGte ur��� t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form l� Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments Property Address o wvf,.0 Owner Owner's Name 0 information is /1G(� / // required for every .S L page. City/Town State Zip Code Date of I pecq on D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: aC) owe Source of information: Was system pumped as part of the inspection? ❑ Yes If yes, volume pumped: gallons i How was quantity pumped determined? Reason for pumping: I t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Property Address J-90 WVI f Owner Owner's Name information is G rh S.�„ �� �� W 6 3o 6 required for every page. City/Town State Zip Code Date of I pec on D. System Information (cost.) 4. Type of Sy 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): , t sus-,�, /6�✓ don 3 Approximate age of all components, date installed (if k own)and source of information: A00d, oe�?/'oflf ®fin 53 Yh[ Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: _ feet Material of construction: El 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.): t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c� Commonwealth of Massachusetts ,p Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �Sc y dC140*'SkL........U-0 L Property Address Owner Owner's Name 1� information is Gi�`�S/ �I•G /�f¢ Qd`3o W/f required for every page. City/Town State Zip Code Date of Ins ecti D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material onstruction: concrete ❑ metal El fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No . Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle �Cli 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 0 e c%Q�IC j How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tj AN� GNC 4e" tV . t5insp.doc•rev.7/26/2018 Title 5 Offical Inspection Form:Subsurface Sewage Disposal System•Page to of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 ScW �4r5 L.,r/ j�)oProperty Address Owner Owner's Name /�information is 6a�•��( j¢ (/pl- required for every page. City/Town State Zip Code Date of Ins6ectioK D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page v of 18 t5insp.doc•rev.7/26/2018 Commonwealth of Massachusetts a Title 5 Official Inspection Form 14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 26 SC (4 C��4e;; Owner Owner's Name information is R .d/� 47J`J o 11np required for every /�page. CitylTown State Zip Code Date n D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): s li c/s oe 44 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection'Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ICU 96 Property Address Owner Owner's Name information is dwn S-�I/t required for every page. City/Town State Zip Code Date of I spec on D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No; Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: e: t 19 �l' ►7 J �l'S {. rod- `Ix x /o T YP / ❑ 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: --- ---- t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Fcrm:Subsurface Sewage Disposal System-Page 13 of 18 r Commonwealth of Massachusetts lqlip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '�-Ww ` 96 sC c.+dC r-$ Property Address whs Owner Owner's Name information is arKs b j.� /l T 0,-6 30 6 �� required for every page. City/Town State Zip Code Date of rnspeCtion D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): k?e. C.-N j �1�D// C(?C.vt QNc Opt- Jl V11 p c�/�.N/ C. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater.inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments <'e a C'c Jc Lit/ Property Address OL.-/K Owner Owner's Name I information is �� LC 30 6 required for every TTTwww page. Cityrrown State Zip Code Date of ln4ectiWf D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level.of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name O wn f information is s required for every 1) page. City/Town State Zip Code Date of In ecti n D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of sewage disposal system, including ties to at least two permanent reference landmarks or nchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buil ' Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately A a Ga ll�n Tpn� Cqr4 f �( A- l -30 al ` / � ac " j 0 � ,•.fin y i!y-��o�s �^'lS�o�e s(, t5insp.doc•rev.7/26/2018 // C� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 SC U CIC�e�X J_4/ Property Address .,� /� Owner Do�✓r� Owner's Name information is / required for every C1 h 5-4 /" page. City/Town State Zip Code Date of Inspe 'on D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells M Estimated depth to high ground water: feet tc;2 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 ❑ served site (abutting property/observation hole within 150 feet of SAS) Checked with local oard of Health -explain: _ ��► ( ESQ �0%1 ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must de 'be how you stablished the high ground water elevation: 4A11 C'R a A- 7�70 !d Aeev - Ke. .2 ,9 low C4 4e 0/10 Y?I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official inspection Forth:Subsurface Sewage Disposal System-Page 17 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not f r Voluntary Assessments 94 Property Address Owner Owner's Name. q information is X N-6�O / �'l required for every page. City/Town State Zip Code Date of 16spe6tion E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 ilure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7t2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i• r DEPARTMENT OF ENVIRONMENTAL PROTECTION: DEC 1 3 �.. 2040 TITLE 5 , �r OFFICIAL INSPECTION FORM-NOT FOR YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM �k p.'►��' PART A CERTIFICATION Property Address: © �? � Owner's Name: Owner's Address: o J ' 4, d,&&, /� 4 CS 0 Date of Inspection: Name of Inspect r: please print Company Name Mailing Address: Telephone Number.: _/—99 ; CERTIFICATION STATEMENT I certify that Phave 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 pursuanXsses ction 15.340 of-Title 5(310 CMR 15.000). The system: Conditionally Passes.. r Needs Further Evaluation by the Local Approving Authority . ails Inspector's Signature: / � ^ ~ Datc: � . 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 1'0,000 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. Notes and Comments ****This report only describes conditions at the time of inspection.a,nd.under the conditions of use.at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS.: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:W Owner: Date of Inspection: Inspection Summary: Check A;B,C,D or E/ALWAYS complete all of Section D A. ystem Passes: I`have not-found any`information which indicates that any ofthe.failure-criteria described uin 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, p y m,upon completion of the replacement or repair,as approved b the Board of Health w'P PP Y ill pass. Answer yes,no or not determined(Y;N,ND)in the for the following statements. If"not determined",P lease explain. The septic tank is metal and over 2.0 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval.of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of-the Board of Health broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION7FORM PART.A CERTIFICATION(continued) Property Address: 96 126UA�A%A�� ' Owner: Date of Inspection: 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 witi_protect public:healthl safety and the e...=rcnm�rt: :� S _ Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a-bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines.that the system is functioning in a manner that protects the public health,safety and environment: The.system.has a septic tank and soil absorption system(SAS)and.the SAS is within 100 feet of,a su_rface water supplYor tributary to surface water.supply. The system has a septic tank and SAS and the SAS is within a Zone I 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 6.DEP certified laboratory,for colifonn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and rrin-ate nit ogee is equal:o or less than 5 ppm,nrovided.that no,other failure criteria are triggered.A copy of the analysis must be attached to.this form. 3. Other: 3 i Page 4 of 11 OFFICIAL INSPECTION FORM=NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: 6Q- , Owner: .� Date ofPnsp' cation: D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following foc all inspections: Yes No// _ O acxup.of sewage,into facility. or system component due to overloaded or clogged SAS`or cesspoolischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ctat ic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or esspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z.day flow _ Required pumping more than 4 times din 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. J Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary,to a surface lwater supply. ., . ...;. v l Any portion of a cesspool or privy is within a Zone 1 of a public well. . f//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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Ila {Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of.10,000'gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a.surface drinking water supply the'system is within 200 feet of a tributaryto 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 Is 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 CMRl 15.304.The system owner shouldcontact the appropriate regional office of the.Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE-DISPOSAL`SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: k Owner �! 05� � %J�.� Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumpingnformation was provided by the owner,occupant,or Board of Health l" — Were any of the system components pumped out in the previous two weeks? V1 — 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? V — Were as built plans of the system obtained and examined?(If they were not available note as N/A) 4 — 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? ' 4 The size and location of the.Soil Absorption System(SAS)on the site has been determined basedon:. Yes no _jZ_ 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)] 5 it Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR,VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:C SYSTEM INFORMATION Property Address:- ". Owner: (� Date of Inspection: OCR FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203.(for example: 1.1 0 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no) j-f if yes separate,inspection required] - Laundry system inspected(yes or no): Seasonal use:(yes or no):,Z!X&— Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: p`� 1 ��✓� COMMERCIAL/INDUSTRIAL, Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title.5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records � a Source of information: U Was system pumped as part of the inspection(yes or no):" 1p If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: } TYPE,OF SYSTEM septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be .obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): proximate age qf 1111 com one ts,date installed if known)and source of information: i Were sewage odors detected when arriving at the site(yes or no):—7 b— 6 Page 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM` PART C _ SYSTEM INFORMATION:(continued) Property Address* CP %�L Owner: Date of Inspection: /gD mil- p0 BUILDING SEWER(locate on site plan)z4KO� Depth below grade: Materials of c.onstruction:,_cast iron._40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,yewhig,evidence of leakage;-ef.): Y ` SEPTIC TANK:L(locate on site plan) Depth below grade: Material of construction:�/concrete_metal_fiberglass.___)olyethylene _other(explain). If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: �;.s ��' 5(s- Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:'e✓. Y4 Scum thickness: / �- Distance from top of scum to top of outlet tee or baffle: " Distance from bottom of scum to bottom of outlet tee or baffle: How.were dimensions determined:, � ,� Ct� .ad.i Comments(on pumping recommendatons,inlet and outlet tee or baffle condition;structural integrity, liquid levels related to outlet invert, evi ence of leakage etc.): /r GREASE TRAP-,Tecate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): ; Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping:T Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):. 7 Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (969 OwnerI'1i �/)'I1�7r Date of Inspection: TIGHT or HOLDING TANK: a.O(fank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constriction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Zofresent must be opened)(]ocate on�site Qplan) 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 Az4age into or out of box,e c.) _ As t PUMP CHAMBEI+��ocate on site plan) Pumps.in working order(yes or no): Alarms in working order(yes or no):..,_'. r Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 ragcyui I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. � Owner , Date of Inspection: 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 of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc. ' p 0 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 or no): Comments(note condition of soil,signs of hydraulic failure,level:of ponding,condition of vegetation,etc.): PRIVY tlocate 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.): s 9 f Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9,/, Owner. Date of Inspection: 1W 6C' 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 b ilding. poIa \� qo, 7 I L 10 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of -14 Inspection: �/�--�®p SITE EXAM Slope Surface water , Check cellar Shallow wells Estimated depth to ground water 4 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: on 11 FROM FAX NO. Oct. 23 1999 02:50PM P1 A & M Lund Services, Inc 1.5 Sunset I)rive South Yarmouth, MA 02664 (508)394-2723 December 4, 2000 Barnstable Health Dept. Donna Miorandi South Street Hyannis,MA 02601 RE:96 Scudder Lane wS Dear Donna, We have calculated the daily flow under present Title V requirements for an area of 12'x 36 x 2'deep as shown on sewage permit#95-53.In this calculation a percolation rate of less than 2 min per inch is assumed. Please find the following calculations referring to Sewage permit number 95-53_ Sidewall 2 x 2 x 36= 144 Endwall 2 x 2 x 12= 48 Bottom 12 x 36 = 432 Total Area = 624 Sq.Ft. 624 x 0.74 — 461 Existung Septic Flow Design=461 G.P.D. This calculation does not confirm or deny that the existing septic system located at 96 Scudder.Lazne is actually 36'x.12'x 2'.It is to show the calculated area for a leach area that is 36'x 12'x 2'with an assumed perc rate of less than 2 minute per inch. If you have any questions please feel free to call. omm of WIUtSfAMf . Winslow Spofford RLS,PE. cc:Kinlin Grover Norton Real Estate ofIMET � Town of Barnstable * STAB Department of Health, Safety, and Environmental Services BARN9 MASS. �a Public Health Division TFp MAY A 367 Main Street, Hyannis MA 02601 FAX Date: Number of pa/es to follow: To: � � From:CZAMA g 0 Phone: Phone: 508-862-4644 Fax phone: . , �� -- � Fax phone: 508-790-6304 CC: REMARKS: C1 Urgent For your review Reply ASAP ❑ Please comment 9 � vL� TOWN OF BARNSTABLE 'LOCATION �'� �' y ppetc L;4 SEWAGE # '7�- �3 VILLAGE I-Q, ASSESSOR'S MAP & LOTo79'8 - j INSTALLER'S NAME & PHONE NO.--1/7 0SX0 SEPTIC TANK CAPACITY lC LEACHING FACILITY:(type) (size) / Z x3 G NO. OF BEDROOMS 3. PRIVATE WELL OR PUBLIC WATER , BUILDER OR OWNER /l7 ig DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: / � VARIANCE GRANTED: Yes No t/� c� t7 cD cz, c7 > c� n% T% . � I f/ I Q � 4 No.._ .:_ Fss..�.3d....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........-1..UWy.\...........OF..'1Ja fvri�0 —.................................I.... Appliration for Disposal .darks Tanitrnrtion Permit Application is hereby made for a Permit .to Construct (k/�or Repair ( } an Individual Sewage Disposal System at: ................. .... (_)±..� ..-- •---•............. ^p p�! Locati n- ddress or Lot No. y/a .- ...... G � /... adressO p //4��. ............................................ ._ J . __ •---.......-•-•............................. Installer Adress- Type of Building Size Lot. Z} $ ....Sq. feet Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building . No.'of persons .................. Showers — YP g -------------•-•----•------ P - ( ) Cafeteria ( ) QOther fixtures -----•------------------------ ---------•---------- ; W Design Flow.............. ��.....................gallons per person per day? Total daily flow.3 .---------.---- _-.---.._.- I lons. Ri Septic Tank—Liquid.� acity`�°grallons _ Length. `..60�.. WMdth.. ..Y ... Diameter---------------- Depth_ 7..". Disposal Trench—No... .............. Width_..12 U"-- Total Length.--3 l...... Total leaching area-.�Z.%�_. sq. ft. 3 Seepage Pit No--------------------- iameter..............._... Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( V Dosing tank `" Percolation Test Results Performed b1U_.. G� ................................... Date1. .-` 3.--....-._... a Test Pit No. 1.....1.Q....minutes per inch Depth.of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 _--• ---•--•• -. 0 Description of Soil..!; �. tz.1... —,....Cti ...........................g... ..� 71�' ;o fo `i .l, . ----- --- v ............................. ,5 Za. . Is.. ---------------------------3iR. '... �. 144e li U Nature of Repairs or Alterations"Answer when applicable--------------------02,o J'--------------------------------------- --------------------------•-----•---••----•-•-•-............-•-•--------•--...-•----••--•--------•--•----•------•-•----------•--•---------••--------•---------------•-••--•---------.........-•-........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been��Ss by the board of health. Signed ................6,1 ................................................. -- I ad'-y� ---------------------------------------- Date . ApplicationApproved By ....... , .. ................................................................................. Dtte Application Disapproved for the following reasons: ...... ..................................... .................................................................................... ------------------------------------------------- ..................................... .................................................................... ............... ^-` Dare Permit No. , .:-...�t,..� f.................... Issued .......................... Date d e No......................... FEs.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0F...�V.i , .a I— ...................................... Applutttion for Disposal.Works Tons#.rnrtiun Prrmit Application is hereby made for a Permit to Construct ( ,, or Repair ( ) an Individual Sewage Disposal System at: . ...:..:� ..... ' . �>�C aa C ...... ... ! . � . . . ...............•-----. ...J..�_ �._..............................................................." .........-----.. Location-Address or.Lot No. 1�t......•...................... ...._._.........._.._...................... Owner Address W Installer Address Type of Building Size Lot.. 11. R to....Sq. feet Dwelling—No. of Bedrooms......................Jam•-•---_--.-__--_-.-Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons....l .................. Showers ( ) — Cafeteria ( ) a' Other fixtures ----------------_-__--___--.... .< ----------------------------------------------------------------------•------------..... ------------ W Design Flow................``f..........•...........gallons per person per day. Total daily flow.:_. ...........................gallons. , u It 9 Septic Tank capacity..._°:!��allons Length..�._`.E�� Width__.':?_.: .. Diameter................ Depth. ._...... 14 Disposal Trench—No. ....�.............. Width____J.��.U"- Total Length___..,=a1�...... Total leaching area-_'� _Fi..._._.sq. ft. Seepage Pit No..__----..------_____. iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( y� Dosin tank ( ) 1Z 1 to Percolation Test Results Performed by 9' ', 'n r_ .•.................•....----•._..... Date.1__'-.:.1 :_f� p Test Pit No. I......1.10...minutes per inch Deptlhof=�st Pit ................. Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil VW Soi l.. Lls . �7l� L ftY�. � ,I.i � 1 ..... . ._ ...._ c: d a�� - ---- . 4Z .. ... .._._...__.. } .. _____________________ _____ UNature of Repairs or Alterations 'Answer when applicable_____________________ _____a. Y Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ..--.....---".................................................... ................................... -----'--............................... Date ApplicationApproved By ----'.................'--------.........---...-------'---...........................................---.........--. -----..........---........... ................15;re----"----"----" Date Application Disapproved for the following reasons: -- '-----' '.......................... '--....-----' ."--'-' .----"---- . '----"----------'-----"----'--- ................................................................................................................................................................................................................ ................Date .... PermitNo. ..-------'---"--"---'----"..................................... Issued .............---"---'----...---.....'--"----"----"---........... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Q HEALTH G ................ OF -- --.-.:..............:' .... ....---............................ Certificate of C1omplian.ce THIS IS T01 Y, That he Individual Sewage Disposal System constructed ( ) or Repaired by-------"..................... �....------.... --_-----------............---------_-------------_.......----------..........----.....---..............--------'------------..... ... /ems � �' Inualler �"�"" '-•�•• Zoe has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ... dated dated ., ................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOr BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... .---.---"----... -----" .... ....................... Inspecfo .... - ' ``or........ . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... No......................... FEE........................ Disposal Works Tonstrnrtion Prrntit Permissionis hereby granted---------------------------------------------------------------------------------------------------------------------------------------------- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... .........................................................------------•-•-----............-•--••--...... Board of Health DATE...........................••----.............................._------•---•--•-- Form 1255 H&W Homs&WARREN TM Publishers Y" I a a', , j {trr IP e �II O Z \ 00 4 a a' r Q �Pa�} i "- O 0 '04- v V I � •DD� � V j LU LU 2111 Lij Z D Q \ I �, •o. N Z ZL Z o: lU ct O I :61 Q1 U) -jN T Cr a p / I °I' Z5 c O n t4j ct O ty • CLWCr. 4- O �. Ir jp � � Wti o �CQ Lutlj t� c�, a. a � c A r .:J Q 5@ .362 90@i P. DEC-05-2000 09:24 KINLIN kOVER NORTOra r6R . ry L fam GROVE I R � a iftWA Estate P. O. BOX 156, 322I ROUTE 6A, BARNSTABLE, MA 02630 TELEPHONE (508) 362-2120 / 800-321-2120 FAX (508) 362-9001 WEB SITE: www.KinlinGrover.com E-MAIL: kgpbarnst@capecod.net TRANSMIT TO: Oj�1V1 ! COMPANY: FAX NUMBER: DATE-. TIME.- TOTAL PAGES: FROM: U t10QA Vo tI Ig REGARDrNG-. S4ee,-- [K &( �L Message: Ifyou do not receive all pagC.f at indicated above, or if there is a transmission error,please contacr sender itnmecliatcly at(SO8) 362-2120. Thank yox Office Loc:two))s: Baravlahle, lirewmer. Uhatham. rant Orleans. Last Swidwich, Lactham. ' DEG-05-2000 09:25 KINLIN 6ROVER NORTON 50,.;: 2 j 1 P;02 F" : FAX NO. Oct. 23 1999 02:51PM Pi A & M Land Services, Inc. 15 Sunset Drive South Yarmouth,MA 02664 (508)394-272 3 December 4,2000 Barnstable Health Dept. Doaoa Miorartdi South Street Hyannis,NIA 02601 RE: 96 Scudder bane Dear Donna, _ We have calculated the daily,flow under pre-sent Title V requiKments for an area of 17 x 36'x 2'deep as shown on sewage permit#95-33.In this calculation a percolation rate of less than.2 nit per inch is assumed. Please find the following cakulatians referring to Sewage permit number 95-53. Sidewall 2 x 2 x 36= 144 Endwail 2 x 2 x 12 = 48 Bottom 12 x 36 4222 Total Area = 624 Sq.Ft. 624 x 0.74 = 461 Existing Septic Flow Design=461 G.P.D. This calculation does not confirm or deny that aw existing septic system located at 96 Scudder Lane is actually 36'x 12'x 2%It is to show the calculated area for a leaeh area that is 36 x 12'x T with an assumed pore rate of less than 2 minute per inch.If you have any questions please feel ft+ee to call. s: e Winslow Spofftrd RLS,PE. cc:Kinlin Grover Norton Reap Estate TOTAL P.02 , T OWN.OF BARNSTABLE O LCATION( SEWAGE# 3. VILLAGE ASSESSOR'S MAP & LOT,578 INSTALLER'S NAME & PHONE NO. C� 'Z• Sao SEPTIC TANK CAPACITY L ( t1 '®i✓lC LEACHING FACILITY•(type) � r'-A s (sue) I k3 Z NO, OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER (�-P-PK Sec Al( 14,d II i j DATE PERMIT ISSUED: �^- --- "j DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f A N S3, - -- - - - (3-G q3 ' r3 - D 30, G- c .21 tel.(508)362-4541 939 main street rt 6a fax(508)362-9880 yarmouth port mass 02675 d6W/1 cape en fineering civil engineers& land surveyors structural design Arne H.Ojala P.E., P.L.S. Daniel A.Ojala, P.L.S. land court Timothy H.Covell, P.L.S. surveys May 22, 2003 site planning Thomas McKean, RS sewage system Director, Barnstable Health Department designs 200 Main Street Hyannis, MA 02601 inspections Re: 96 Scudder Lane, Barnstable permits Dear Tom: On May 20, 2003, Down Cape Engineering, Inc. performed a soils inspection as required on the approved plan at the above-referenced location. The installation was also inspected. This is to certify that the soils removal was completed satisfactorily and the system is installed in substantial accordance with the approved plan. If you have any questions, please do not hesitate to call me. Yours truly, Arne H. Ojala, PE; PLS Down Cape Engineering, Inc. cc: M. Downs w S-YS TE S �.. k FIL E _ NOT TO ;:'cFLE TOP FNDN. r"""INI:>.�' GRADE OVER FINISH GRADE EL • yO' FINISH GRADE 's'Q• FINISH GRADE OVER 91ST. i BOX OVER TRENCHES 8 0! O SEPTIC TANK '�'�, 12" MAX. b o;4q °o: „ :: �j: :oQi°Qp�:p4;:p•o'� 'a:ao!'P;b+.OpJ•c ! b. q+iQ r ; i .O' n a. .•.e'• '••s'. b.•A .a o o•. °� oQ. TOTAL L ENG ASH OF TRENCH -� OUTLET PIPE LEVEL ° 3 /: FOR 2 FT T. MIN. [ g "� d Di° . •w. o. .,o .Q,., ,A: .o •Qd, b.. .o . •e io• y'�,ep�� .p o.• ,0. 19 �'-� �.J" M' .J q '•D' 'o; •�'° '� .p p�po 0 39.IS ��,u,.,:: :. :r+:X:a.•: . . •. . .. . . CAP END 0 i :so.qo 0• 38,8..� o' �° 3c5',�ca '- "'M1� 3 8,3 3 \ � ••' � .C� � O � � ® 0 0EL 0 :da C. I. OR PVC TEES .5'v G: C G r! •S'O /i !+".n •ate a^•�' 14 o.o° 3- 1000 yf�yy/���/ BOX +$y �1aiv -C'I-.a � BSMT FL . o GALLON o, . ' : �` EL o o c 4d Ia `.5 TA�L ON LEVEL BASE � F+�.. 0 D.�"FFUSORS • PRECAST CONCRETE \ \ \ \ E/, 33.a 'r • w ob H- 0 REINFORCED o: O• bQ 1 •°7p:Q4.vi:bp'.arj'11:• ';6.':G1•q.:Ce•A'd>•<IY�' Vy�•D'O•,FsQ•0".-O.Qf�y•. i •s.is..o,o, -p.•,. .o••!D .D..p..e. .�yp,.••0�1. .a•a .p•4. r ,� � TRENCH SECTION SEPTIC TANK �a — \\ \ INSTALL ON LEVEL BASE i/6 a r },� EXCA VA TE TO ELEV. OR ;�'ER TO REMOVE ALL IMPERVIOUS MAMA I t2" N/IN. \ \ �\_ r :d=1.CAL BENEATH THE L EA CHING AREA 4 DIAM. F E ACE EXCA VA TED MATERIAL WITH �. � 3" OF 118 j �`\ \ \ -�`- i — ___ "•r �° LL N. CLAY FREE SAND ° a•'b:° r°g' #ASSED PEASTONE .7 � is .Q �'•"D" OQa• s , 314" _ 1-1/2„ WASHED � CRUSHED S TONE m° G NL": TES T c;ENCH WID TH 1. ALL EL EVA TIONS NO t,V ARC BASED ONNG VD NUMBER OF TRENCHES 2. ALL PIPES IN rr c ''S TEV MUST BE CAST IRON NUMBER OF DIFFUSORS f \ I OR SCHEDU.P E 46 OSSER TIC,Al PI 7s-'.•E' SrV PD ��� �1 - 4' ��/``7 - SE NOTIFIED _ u.., - ---`_' WHEN � JOHN JACOE3I P B1 •-_"_ +4 / I"'+ � _ _.._ _ �",Li•tv w.'i,.r, b." ' f. ti I tom. _. TO BA C FIL L eMI 4 3 s 4. ANY CHANGES 11 p �. �. ? AWST BE APPROVED ?0 +'�!IN.,fIN. BY THE BOARD 0, A::. :. 7 1 AAD CAPE 6 ISL ANDS ICI TNESSE 0 S Yy p SURVEYING CO., v'%$.`' GFRRY DUNNING' N a 5. MATERIALS AND +�/„° "� a ATION SHALL BE IN BARNS BRD. OF HEnALTH , � , ® T U COMPL LANCE NI7 r T4'E .TA TE SANITARY o CODE — TITLE V + +' '�:: LOCAL APPLICABLE DA TE: DEG. 10, 1993 _ RULES AND REGU A T?°Of S 6. NORTH ARROY IS, -W 314; PECORD PLANS AND 0 NUMBER OF BEDROOMS 3 IS NOT TO BE L�L':O !R SOLAR PURPOSES GARBAGE DISPOSAL NO 7. FLOOD HAZARD -� F' ' (NON—HAZARD) TOP - LOAM DA IL Y FL ON 330 GAL . 0 8. )VA TER SUPPL Y— %,,-- ,.—;,_T01�/'V 1�A TER /2 SEPTIC TANK PEG 'D. .?000 GAL . B" CLAY LENS SEPTIC TANK PROVIDED 1000 GAL . SUB/CONSOL IOA TED LEACHING REOUIFIED 330 GPD. �\•. p 'ALL IMPERVIOUS OR UNSU�''TAB1,: HA DIAL e�" �r� D $ , _ - r- \- WITHIN 10 FT. OF THE LEACH) ''v Fv'c-rLITY IS TO �.t (400 SF. REQ 'D. ) BE REMOVED AND REPLACED WI,'` Ci.f.AN SAND TILL W/COAF)SE _e^ c f' ' ~ 1_ _' �o! i .\p 'k FRAGMENTS TO CORBELL SIZE MEDIUM SILTY SIDEWALL AREA S.F. S PD 4 SAND W/LOW X CLA Y 96 S.F.X- . 0 G/ .Fo - 96 G ° N ONSOLIDATED FINE SAND BOTTOM AREA �32 S.F. r{,EGE ND I TH FINES 6 .1OX CLA Y 432 $,F, • 55 GIS.F. 237 GPD ° LEACHING PROVIDED 333 GPD _ _ o p .,jPpSED ELEVA TION -- Epp, �+TING CONTOUR SEPTIC S YS TEM ��./PGRA DE �'ON PIT D rs 7RIBUTION BOX ry rt L r , •I PROPOSED SE NA GE DISPOSAL S YS TEM _ t :.Jk' 0 rFFUSORS PREPARED FOR _ EMERSON MA RKHA M �e� c e/ — �` � —•— L t� l .��9 (HOUSE" 95) SCUDDER LANE N , 6,o , �� ,,, OF BA RNS TA DL E -- MASS. Al 72 DAbO 4° • s a .� .: .?NVERT EL EVA TION lr.HARLFS ' — yy SA�U cat DA TE.' ,�� , CAPE ter ISLANDS ENGINEERING 29UE35 a $ PLOT PLAN „.., �� .� ti� ,`+ �i�� w, :r-x .-_.,� � SCALE AS MOTED 133 FALMOUTH ROAD — � N SCALE: 1 " � o;' '�L Pr, S� r, �. ._ d � ✓� /� ��+ ',' ;' ?•c�. r NEo� t;, \ SUITE 2E MASHPEE, MASS. -n k �., t - � ; ' .. PLAN NO. s