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HomeMy WebLinkAbout0186 STONEY COVE LANE - Health 186 STONEY COVE LANE, BARNSTABLE r _ a jF z r 1 \ a a r1 `1� }�.� f/�`v, J� • " .. �' , u :. ' » .. .. .x � � � „• .,{�a a .. f J t d M w k • a n tr e n J o ._a a. C : - • ' y ... " ., .. ,. _ is .a. • - I '- "' t.. � , _ ." - .. n c M .• s : f a , 4 .. w, 3 , r • e , ` Y w, w " r , U i Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stone Cove R oad Property Address -- John Evanko Owner Owner's Name _�---- inforrnation is required for every MA _02655 3/30/15 City/Town page. Cum maguld __ State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to,move your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain ,y Company Name -- 8 Johns path Company Address �r S Yarmouth MA 02664 _ City/Town State Zip Code 508-364-9587 S113522 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 roving Authority 3/30/15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the sys em will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form: ubsurface Sewage Disposal System•Page 1 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko _ Owner Owner's Name information is MA 02655 required for every 3/30/15 page. Cummaguld State Zip Code City/Town Date of Inspection 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: The system contains a 2,000 Gallon H2O septic tank as well as a concrete Distribution box and 6 H2O Concrete 500 gallon leaching chambers. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquld State Zip Code Date of Inspection City/Town 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, t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M •''� 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquid State Zip Code City/Town Date of Inspection 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 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 t5ins•3/13 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 186 Stoney Cove Road Property Address — John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. CCum ate aquid St Zip Code Y Date of Inspection ® 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 'h day flow B. Certification (cont.) Yes No ❑ ® Required (pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(sy. 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 t5ins•3/13 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 186 Stoney Cove Road �M Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30l'15 page. Cummaquld State Zip Code City/Town Date of Inspection ❑ ❑ 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. 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 twoweeks? ® ❑ 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)] t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquid State Zip Code Cityrrown Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 D. System Information Description: The system contains a 2,000 Gallon H2O septic tank as well as a concrete Distribution box and 6 H2O Concrete 500 gallon leaching chambers. Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2013 -95,000 2014-41,000 Detail: 186 God Sump pump? ® Yes ❑ No Last date of occupancy: Occupied. Date Commercial/Industrial Flow Conditions: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquid State Zip Code Cityrrown Date of Inspection 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: D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaguld State Zip Code City/Town Date of Inspection ❑ 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):. D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 13 years Were sewage odors detected when arriving at the site? ❑ Yes .❑ No Building Sewer(locate on site plan): Depth below grade: 18 "s 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.): System is vented throught the roof Septic Tank (locate on site plan): Depth below grade: 1 ft feet t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 186 Stoney Cove Road Property Address — -- John Evanko Owner Owner's Name information is required for every MA 02655 page. Cummaquid State Zip Code 3/30/15 City/Town Date of Inspection Material of construction: ® concrete ❑ metal ® fiberglass ❑ polyethylene El other(explain) 2,000 gallon H2'G If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gallon Sludge depth: 3"s D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24"s Scum thickness 3"s Distance from top of scum to top of outlet tee or baffle 42"s Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick 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 at this time. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M •'•V 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/3G/15 page. Cummaquid State Zip Code City/Town Date of Inspection Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 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.): Tees are in place and levels are normal 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 page. Cummaquid State Zip Code 3/30/15 City/Town Date of Inspection 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 D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Normal 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.): Dbox is level and levels are normal. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M •°V 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquld State Zip Code Date of Inspection City/Town Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps'or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Concrete chambers Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John-Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquid State Zip Code City/Town Date of Inspection No signs of carry over. no signs of h drualic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydrualic failure. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaguld State Zip Code City/Town Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 "Jg 5p Y ftl ► 9P � i : v � TOWN OF BARNSTABLE LOCATION. �,/�9,6 ;� r8 "'�%' €P�la� F�r.',17c? SEWAGE #r✓ J �O' �/4f VILLAGE �_ €► � _ASSESSOR'S MAP & LOT 114STALLER'S NAME& PHONE NO. /iit� SEPTIC TANK CAPACITY �(��� ►; �. / ��I -- LEACHING FACILITY: (type) t(, ( ;P, (size) NO. OF BEDROOMS a°,;: j BUILDER OR OWNER PERIviITDATE:& ';/4 °.l .COMPLIANCE DATE: — �:;w Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and LeachingFacility ry ('If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet. within 300 feet of leaching facility) Furnished by eet Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 page. Cummaquld State Zip Code 3/30/15 City/Town Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 page. Cummaquid state zip Code 3/30/15 City/Town Date of Inspection ® Obtained from system design plans on record If checked, date of design plan reviewed: 10/29/02 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: NGE at 10 + ft according to plan on file test hole data with Town of Barnstable Before filing this Inspection Report, please see Report Completeness Checklist on next page. 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 f Commonwealth of Massachusetts W Title 5 Official Ins cctionForm 9 p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road _ Property Address — ---- ---- John Eva © r Owner Owner's Name information is required for every MA__ _02655 3/30/15 page. Cummaquld State Zip Code City/TownDate of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain raa Company Name 8 Johns path Company Address — - �r S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 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 roving Authority r` 3/30/15 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a.shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP, The original should be.sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. c v l5ins-3/13 v� Title 5 Official Inspecti ,Form.Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts `H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is _MA 02655 required for every 3/30/15 page. Cummaguld State Zip Code Date of Inspection City/Town B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: Z I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 2,000 Gallon H2O septic tank as well as a concrete Distribution box and 6 H2O Concrete 500 gallon leaching chambers. 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): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquid State Zip Code Date of Inspection Cityrrown 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, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts _ Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/3C/15 page. Cummaquld State Zip Code City/Town Date of Inspection 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 B. Certification (coot.) 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 186 Stoney Cove Road Property Address --- -- John Evanko Owner Owner's Name information is required for every _MA _02655 3/30,115 page. Cummaquld State Zip Code City/Town Date of Inspection ❑ ® 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 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 l5ins•3/13 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 '186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquld State Zip Code City/Town Date of Inspection ❑ ❑ 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. 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)] t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M a 186 Stoney Cove Road Property Address — John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaguid State Zip Code City/Town Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 D. System Information Description: The system contains a 2,000 Gallon H2O septic tank as well as a concrete Distribution box and 6 H2O Concrete 500 gallon leaching chambers. Number of current residents: _. Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes E. No Laundry system inspected? E Yes ❑ Nc Seasonal use? ® Yes. ❑ No Water meter readings, if available (last 2 years usage (gpd)): 2013 -95,000 2014-41,000 Detail: 186 Gpd Sump pump? ® Yes ❑ No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquld State Zip Code City/Town Date of Inspection Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day rgpd> 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: D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 17 it Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 186 Stoney Cove Road _ Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaguid State Zip Code City/Town Date of Inspection ❑ 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): D. System Information cont. Y (cont.) Approximate age of all components, date installed (if known) and source of information: 13 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 "s 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.): System is vented throught the roof Septic Tank (locate on site plan): Depth below grade: 1 ft feet t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 �n Commonwealth of Massachusetts H W jitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road M Property Address ------ John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. C CitYUTTo agUld State Zip Code Date of Inspection Material of construction: ® concrete ❑ metal ® fiberglass ❑ polyethylene El other(explain) 2,000 gallon H2O If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 Gallon "s Sludge depth: 3 i D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24"s Scum thickness 3"s Distance from top of scum to top of outlet tee or baffle- 42"s Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick 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 at this time l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection F e p Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�.. 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA Q2655 page. Cummaquid state zip code 3/30/15 City/Town Date of Inspection Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 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.): Tees are in place and levels are normal 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 • Commonwealth of Massachusetts , Jit•le 5 official Inspection I=orm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquld State Zip Code CltylTown Date of Inspection 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 D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Normal 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.): Dbox is level and levels are normal. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* l5ins•3/13 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 186 Stone �M y Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaquld State Zip Code CityFrown Date of Inspection Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: = ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Concrete chambers Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t5ins-3/13 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 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 , page. Cummaquid State Zip Code City[Town Date of Inspection No signs of carry over. no si Ins of h drualic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool — Materials of construction Indication of groundwater inflow ❑ Yes ❑ No D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydrualic failure. Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 t Commonwealth of Massachusetts 1 N Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 3/30/15 page. Cummaguld State Zip Code Inspection Date of Ins City/Town P Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 � 1 Z- 4 it i TOWN OF BARNSTABLE r LOCATION �� G �J 2° y lle,n '� SEWAGE # VILLAGE � 4�dG�/6�1 � � ASSESSOR'S MAP & LOT, Z I 1. INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITYQ} -� �� <�G�•�.1�.. — LEACHING FACIL'TY:.(type) Zr� �`/ `r (size) NO. OF BEDROOMS BUILDER OR OWNER/ PERMITDATE: � —COMPLIANCE.DATE: Separation Distance Between the: Maximum Adjusted.GroundwaterTable to the Bottom of Leaching Facility —Feet Private Water Supply Well and Leaching Facility (If any wells exist' on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) ___ __ �•, Feet Furnished by_ • 'Commonwealth of Massachusetts 1 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address John Evanko Owner Owner's Name information is required for every MA 02655 page. Cummaquid State Zip Code 3/30/15 City/Town Date of Inspection- D. t System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I - commonwealth of Massachusetts -Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road Property Address — John Evanko Owner Owner's Name information is required for every MA 02655 page. Cummaquid State Zip Code 3/30/15 City/Town Date of Inspection ® Obtained from system design plans on record If checked, date of design plan reviewed: 10/29/02 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: NGE at 10 + ft according to plan on file test hole data with Town of Barnstable Before filing this Inspection Report, please see Report Completeness Checklist on next page. 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r \ { 11 \\ OR uatgfi E' ACaTU "we,, uI o N 12-lc-9 1OW ee- �et� DISl�t.F 5 GU LAIL 6 Iper � �� � � � -�i��� d►u-r��s�� raR- �� ' Rirl _ S 0 "joa Olye • �� a'v ' 5 CD ®y.� o C C ' IU n M TIP lip CU I+ya I`'r�i7ooeU6f R f ldfFii L I(o o �. ' RAJVo - Massachusetts Department of Environmental Protection Bureau of Resource Protection " Well Completion Reports ab. Well Driller Please specify work performed: Address at well location: (New Well Street Number: Street Name: ,186 STONEY COVE LANE Please specify well type: Building Lot#: Assessor's Map#: Irrigation 325 Assessor's Lot#: ZIP Code: , Number Of Wells: 025 02637 City/Town: Well Location •BARNSTABLE In public right-of-way: GPS ( Yes (7 No North: West: 41.70725 70.26772 Subdivision/Property/Description: Mailing Address: r click here if same as well location address -_..__.._............................._...............--- ._....._._..._._.._...._.._....__...._....................... Property Owner: Street Number: Street Name: GAYLE HANS 445 PO BOX City/Town: State: Engineering Firm: BARNSTABLE MASSACHUSETTS ZIP Code: 02637 Board of health permit obtained: f;Yes i`Not Required Permit Number: Date Issued: W2020 006 iO3/10/2020 .......................................................... I j Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program , Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD Overburden Bedrock uger Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY Drop in drill i Extra fast or slow Loss or addition !From(ft) To(ft) Code !Color Comment I,•.•��-..._- I stem i drill rate� of fluid ! 0 20 Silty Sand And G Brown j f"Fast�"Slow ! ---•- - --•- ; YES NO w_ Loss Addition il I ! r (� 1 20 !31 Medium Sand I(Brown Fast "Slow E I YES NO Loss Addition WELL LOG BEDROCK LITHOLOGY j Loss or Extra Drop in Extra fast or I Visible Rust From(ft) To(ft) Code 'Comment drill stem slow drill rate addition of !Staining Large I fluid Chips [..r esYES NO IFast Slow Loss Addition I . ._._._. _. .......... ..............._.__ ......... ADDITIONAL WELL INFORMATION Developed OZYes C No Disinfected f Yes f"No Total Well Depth 31 Depth to Bedrock Surface Seal Type lNone racture Enhancement `Yes f:No CASING rls Casing above ground?i From TO Type Thickness Diameter Driveshoe i ..................................._.._........................._.....................__......................__...._.........___.._..__................-.........._._........ .....___........._..................................................................._........................_...................................................._...................._................................. ......................_..� �0 21 Polyvinyl Chloride ;Schedule 40 ! r Yes SCREEN IF No Screen From To Type Slot Size 1 Diameter �21 l 31 Stainless Steel Well Point �;! 0.01� 4 l WATER-BEARING ZONES Ir DRY WELL' From To Yield(gpm) PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Horsepower Submersible ((1 _..._.-------.._.. _..._..._......_ L..._ Pump Intake Depth(ft) 20 Nominal Pump Capacity(gpm) 15 ANNULAR SEAL/FILTER PACK �(g ater i Batches Method Of From To Material 1 Weight Material 2 Weight i ! al) (count) Placement 7 Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) ( I? } Choose Material ( (Choose MaterialIF ( Choose One L _._..._..........__...._..........._.__.....__..._ C1 1............ ........ _.._..................._............._.. _.... .._. ........_..._, �� _......m............__....................._ WELL TEST DATA Time Pumped i Pumping Level(ft Time To Recover Recovery(ft --------------- ---------------- -------- ------- ----------Date Method Yield 04/16/2020 Constant Rate Pump 17 01:30 E2�1 j00:01 18 WATER LEVEL i I Date Static Depth BGS(ft) Flowing Rate(gpm) Measured 04/16 22020 18 - 17 COMMENTS c . WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete and accurate to the best of my knowledge. PATRICK Supervising Driller DESMOND, DrillerDESMOND Registration# 877 Monitoring[M] Signature PATRICK, DESMOND WELL „r Date Job Complete Firm DRILLING INC. Rig Permit# 0551 [05/08/2020 j NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. EATYtdlOTL!:i�X.��yLABV"H_f:��.TORIE, , INC, " NA •r ' 8 Jan Sebastian Dt i.ve Lnii 12 ,Surrtheiett.11 1 02563 (.;0$)88&646r1 1-800-339-6460 FAX(508)888-6446 Client Name.: Desmond PVe11,p1•i11irrg I,trC'ri!%nt1: ,add e1,g PO Box 2783 186 Stoney Cove Ln Orleans; MA Cummaquid,,MA 02653 Lah NiOnber DW-200034 Collected By DWD 13tMe ReC.'eJ1'eti: 04/17/20 Sample Type Irrigation 31718' id'ell Specs..: New Well Arrrri�sis ltertnesteil L'rrits Rec nrrnenilerd titnits- Analvsts Result ,Ve1N;i1 119ate Anitlizall Ano1f,ier1 By Total Coliform GFU/100mL 0 0 SM9222B 04/17/2020 KF @ 16:16 pH pH units 6 5=8.5 6.27 SM 4500-H-B 04/17/2020 KB Specific Conductances umhos/cm 500 342 EPA 120.1 04/17/2020 KF .._..._. . Nitrite-N mg/L 1.00 <0.006 EPA 300.0 04/17/2.020 KF" Nitrate=N mg/L. 10.0 10.9 EPA 300.0 04/17/2020 KF Sodium m /L 20.0 28 EPA200.7 04/2172020 KB Total Iron m9/L 0.3 '0.09 EPA,200:7 04/21/2020 KB Manganese MWIn 0.05 0.335 EPA 200.7 04/21/2020 KB C otr meats: PH is below recommended,limit and may have corrosive characteristics. Nitrate level exceeds maximum contaminant level. Sodium.level is not a health hazard. Over a lifetime,the EPA recommends that people drink water with manganese levels less than 0.3 mg1L and over the short term, EPA recommends that people limit their consumption of water with levels over I1 O mg/L All samples were analyzed within the established guidelines of US EPA approved.methods with all requirements'met, unless otherwise noted at the end of a given sample's analytical.results. We certify that the following results are true and accurate to the best of our knowledge. Wafer is not Suitable for drinking purposes for parameters tested. Dute 4/212/2020 Ronald J.,Suari Labtirtrtoiy Director BRL=Belotir Reportable Limits *See Attached Page 1 of 1 n erttfecation.is 1101 available for this andlyle.for potable crater samples.. No. W �`�% s Dllo Fee BOARD OF HEALTH TOWN OF BARNSTABLE 2pplicatiou lot Yell Cou5tructiou Permit Application is hereby made for a permit to Construct`, Alter( ), or Repair( ) an individual well at: -�e- e- 352-, d2,5 L ation-Address //-- Ass sors Map and Parcel /qw Owner U Address fu- 5lyhe4- Lane Dkbe&nf l� Installer-Driller G U Address Type of Building Dwelling&,-s lcled�&Z-- Other-Type of Building 'l No. of Persons = Type of Well l{^�J�U'N`� l 1ISC-j) G{Je4'0�P6`Capacity /U�/ 4"h",— Purpose of Well rl Q GLL77 0 r— t ], Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Cert' Cate of Compliance has been issued by the Board of Health. Signed f Date Application Approved Byio Date Application Disapproved for the following reasons: Date Permit No.-a;� 10 '�✓11 Issued / �Q Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS I TO CERTIFY,that the individual well CoTruec- Installer ted W, Altered( ), or Repaired( by -els IYIC' l? p at � ��P h . � has been installed in a ordance with the provisions of the Town of tamstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector _t Fee No. d � C� N BOARD OF HEALTH TOWN OF BARNSTABLE 01 pplication f or lVell Construction permit Application is hereby made for a permit to Construct, Alter( ), or Repair( ) an individual well at: Location-Address Assessors Map and Parcel (� Owner U Address Installer-Driller ({ Address Type of Building Dwelling Re's lc� A ra L- Other-Type of Building No. of Persons Type of Well r Y f 1(�(t l ii!`- �t�-SZ G�11 �� EJ NV-Capacity /0-,."/ iu JYL- U 1/ �✓ Purpose of Well J y Y 1 q cc U '�( 7� Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the +Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. r Signed j U Date Application Approved By ��W�"Z►d(r 1`'� lot Date Application Disapproved for the following reasons: t i i //��w t, Date Permit No. ,V (7-6 U/ Issued 3 1 Q Date 444BLLLOARD OF HEALTH - ;K 7 TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed , Altered( ), or Repaired( ) by � .S fYl G k 4 h i") .c / h L Installer r at (iJ1��.- LGI 61 YV1tiYra R�L1 (,I has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector e '' BOARD OF HEALTH F TOWN OF BARNSTAB1LE - n, Yell Construction Permit No. W a V t —60 Fee �`j, .•—. Permission is hereby granted to �-eJ 10,081 t MAGj/' 1101 q lit d.-- Installer u to Construct(�&\), Alter( ), or Repair( an individual well at: No. .J� ( J7 1Vr)-e-a t/ )y-ei A /)e, Street as shown on the application for a Well Construction Permit No. 1,1ob)4 /�Dated Q tao J � Date �j ( � ��� Approved By rltir 1 gtA.Vu. _ . - D i ! i EDGE OF f 49.65 52.f WETLAND FLAGS 7.50' 1 .29, 41 .69 21.53' 1 a — •�_ _� 1 25ru -- - cv 2g o / I 26—• a- NCE --, CEDAR cv n ICK r BRICK ST 1 UTILITY PO \ �� PATIO `�\ W � POLE > 7' ; O Z O D 2 o �. N u IL. EXISTM.7. DWELLING O BENtAMIG TOPRIGz . 2� RIGA r ELE33. L DEN 5' REMOVAL OF UNSUITABLE F` ;SOIL REQUIRED a� /•,ti4'�,� J \�It • crow �ee GAR 2 AROUND PERIMETER OF LEACHING FACILITY, ' / •-: DOWN TO SUITABLE SOIL LAYER, (F-M SAND). REPLACE WITH CLEAN MED. SAND. ENGINEER TO INSPECT AND CERTIFY REMOVAL 11.9i a;// /J/ \\ \ S EXIST �' .. PROP. NK G { GARAGE E�FENC {fJ �pC %. a o` 1 / '�• � AC UNITS LIGHT B 1 �� " jPOSTB2 '' ' N 4 B3 eel TOWN OF BARNSTABLE LOCATION 18(0 �j�1O (/�O✓� 1GGr' _ S t�4sE#��5 P ,\VILLAGE ASSESSOR'S MAP&PARCEL IN*T,�'S NAME&PHONE NO, LIB (2jCa fflpW 1-1,3 e;1')11 SEPTIC TANK CAPACITY (50 0 7 .1000 LEACHING FACILITY:(type) �_ S.��1 f�w rS (size) NO.OF BEDROOMS 0 OVINER�U PERMIT DATE: TEh SR la I1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet FURNISHED BY f ' fv1 f f f fvf f f f f i f f f f f i r f i f f f f f f f f f i 1 f f f I f 1 f f f f f f J f J f f 5 13 13 10 ' 22 26 TOWN OF BARNSTABLE 1 LOCATION J K 5_V0r1,0-4&✓_ 'CC) 946E VILLAGE O JM►til�tJJ ASSESSOR'S MAP&PARCEL �'S NAME&PHONE NO. ,c. n Co"a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ku.wn 6d'S (size) NO.OF BEDROOMS CD OWNER�TU t v-N b)k\ PERMIT DATE: IP414--05 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching f Feet FURNISHED BY M� � a CA) o W f f f F F f J f J f J ! f f J f ! ? f f f f f f f f f f ? f r f r ? ? F F f ? f r f F r ? f F f f r F F f ! J f f f ? f F F f ! f ? f l + - \ : A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments w„ 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull Owner Owner's Name information is required for Cummaquid MA 02637- December 1, 2009 _ every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information - When filling out I i forms on the computer,use 1. Inspector. (� only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name - VQ 189 Cammett Road Company Address Marstons Mills MA 02648 CityRbwn State Zip Code 508-428-1779 SI12855 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 f=do sited sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of M..•.,. 3 Title 5(310 CMR 15.000). The system: 3 ® Passes El Conditionally Passes El Fails ❑ Needs Further Eval:.13t?on by the Local Approving Authority k` ) December 1, 2009 _ In ctor's S gnature Date The system inspector sys "itopy 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. p ' 1 1 � 09-254 Turnbull PH.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,., 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull — Owner Owner's Name information is Cummaquid MA 02637 December 1, 2009 _ required for State Zip Code Date of Inspection every page. Cityrrown 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: Tanks are not in need of pumping at this time leaching system shows no signs of hydraulic failure. — B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board cf 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 09-254 Turnbull PH.doc•08106 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 186 Stoney Cove Road -Pool House- _ Property Address Jean Turnbull _ Owner Owner's Name information is required for q Cumma uid MA 02637 December 1, 2009 - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to,determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 09.254 Turnbull PH.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Pool House- _ Property Address Jean Turnbull Owner Owner's Name information is Cumma uid MA 02637 December 1, 2009 required for q — every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 ❑ ® 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. 09-254 Turnbull PH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 186 Stoney Cove Road -Pool House- _ Property Address Jean Turnbull _ Owner Owner's Name information is Cumma uid MA 02637 December 1, 2009 required for q — every page. Cityrrown State Zip Code Date of Inspection i B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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. 09-254 Turnbull PH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull _ Owner Owner's Name information is umma uid MA 02637 December 1, 2009 required for C q — every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been donee. 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? I 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)] 09-254 Turnbull PH.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 r — Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every page. CitylTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Unknown Number of bedrooms (actual): (Pool House)_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): — Number of current residents: 0 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 usa e d N/A — 9 ( years. 9 (gp ))� Sump pump? ® Yes ❑ No Summer 2009 Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ !No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 09-254 Turnbull PH.cloc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 cf 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Pool House- _ Property Address Jean Turnbull _ Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 5/12/03 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-254 Turnbull PH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 cf 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull — Owner Owner's Name information is Cumma uid MA 02637 December 1, 2009 required for q — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth g f th below grade: f — eet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 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: 1500 gal & 1000 gal. 01, Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 0.. Scum thickness Distance from top of scum to top of outlet tee or baffle r Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured 09-254 Turnbull PH.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull Owner Owner's Name required for is Cumma uld required for q MA 02637 December 1, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both tanks have liquid only, no solids. Liquid levels are at bottom of outlet inverts. All tees are intact and clear. 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,,in!et 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): 09-254 Turnbull PH.doc-08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull _ Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: — Capacity: — gallons . Design Flow: gallons per day — Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): 01. Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-254 Turnbull PH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull - Owner Owner's Name information is Cumma Uld required for q MA 02637 December 1, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: — Three infiltrators. ® leaching chambers number. — ❑ leaching galleries number: — ❑ leaching trenches number, length: — ❑ leaching fields number, dimensions: — El 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.): SAS shows no evidence of saturation or surcharge. _ 09-254 Turnbull PH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 or 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull Owner Owner's Name information is Cumma Uld required for q MA 02637 December 1, 2009 every page. City/Town State. Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert — Depth of solids layer — Depth of scum layer r Dimensions of cesspool — Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, ' etc.): Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 09-254 Turnbull PH.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Pool House- Property Address - -------..._..--------------..__._..-..--------------------- -- ---- Jean Turnbull Owner Owner's Name ------------------------------------------- information is required for Cummaq uid MA 02637 December 1, 2009 ----- ------------------ - - -- -- ---- every page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) 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. h \ \ \ \ \77,777 \?\/♦rat' tY\�'!��!`r\/ 1 5 13 10 22 26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Pool House- Property Address Jean Turnbull Owner Owner's Name information is required for Cummaquid MA 02637 December 1, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells m Estimated depth to ground water: 10 feet Please indicate all methods used to determine the high ground water elevation.- Obtained from system design plans on record If checked, date of design plan reviewed: 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: Bottom of SAS is 10-12 feet higher than marsh at rear of property. 09-254 Turnbull PH.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is 4 required for Cumma uid MA 02637 December 1, 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector. only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 S1 12855 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 1 December 1, 2009 In pector's Sign lure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 09-254 Turnbull MH.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 f� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 'December 1, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching system shows no signs of hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the❑ for the following.statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 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 09-254 Turnbull MH.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. 09-254 Turnbull MH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is Cumma uid MA 02637 December 1, 2009 required for q every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is.less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: A You must indicate "Yes" or"No"to sach.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 E ® 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. 09-254 Turnbull MH.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts „ = Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 186 Stoney Cove Road -Main House Property Address Jean Turnbull Owner Owner's Name information is Cumma uid MA 02637 December 1, 2009 required for q every page. Cityrrown State Zip Code Date of Inspection i B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont,): Yes No ❑ ® Any portion of a cesspool or privy'is within a Zone 1 of a public well ❑ ® -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 2060gpd- ° 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. 09-254 Turnbull MH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every 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)] 09-254 Turnbull MH.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 L Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every page. Cityr town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 6 Number of bedrooms (actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d N/A Irrigation g ( y g (gpd)): system Sump pump? ® Yes ❑ No Last date of occupancy: Currently Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ 'Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): L09-254 Turnbull MH.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is required for Cummaq uid MA 02637 December 1, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 5/31/05 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-254 Turnbull MH.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40'PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gal. 0" Sludge depth: Distance from top of sludge tc bottom of outlet tee or baffle 011 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? Measured 09-254 Turnbull MH.doc-06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every page. Cityrrown 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.).- Tank is not in need of pumping at this time, tees are intact and clear. Liquid elvel was found at bottom of outlet invert. Tank had liquid only, no solids. 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 :f Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 09-254 Turnbull MH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is Cumma uid required for q MA 02637 December 1, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(coat.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes t ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-254 Turnbull MH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: Six 500 gal ® leaching chambers number: drywells ❑ 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.): SAS shows no evidence of saturation or surcharge. 09-254 Turnbull MH.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is Cumma uid required for q MA 02637 December 1, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 09-254 Turnbull MH.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is required for Cummaa uid MA— 02637 December 1, 2009 -- _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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. 40 \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ it \ ♦ \ \ \ \ ♦ \ + \'\ - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 186 Stoney Cove Road -Main House- Property Address Jean Turnbull Owner Owner's Name information is q required for Cumma uid MA 02637 December 1, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells _ Estimated depth to ground water: 18feet 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: Bottom of SAS is 18-20 feet higher than marsh at rear of property. 09.254 Turnbull MHdoc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 No.4?Qp7 '' 1 Y Fee -THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes A PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES-MASSACHUSETTS r� 2pprication for �Digpooar 6pgtem Conotruction Permit Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) Complete System El Individual Components Location Address or Lot No. j � �j�'®(�1 � Owner's Name,Address and Tel.No., Assessor's Map/Parcel 2 �� �6� �`� 1 Installer's Name,Address,and Tel.No. '7 7/ T 3 9 O Designer's Name,Address and Tel.No. `� I;b t-i C-Ave ti 61 oml;�ic- Type of Building: 57 41 Dwelling No.of Bedrooms Lot Size �' ��� - sq.ft. Garbage Grinder( ) Other Type of Building IU A No. of Persons Showers( ) Cafeteria( ) Other Fixtures /J 4 r� Design Flow �8�� "0 �'� ja�llon_soper'day. alculated daily flow ffJ'® gallon . / _ Plan Date 8 umber of sheets / Revision Date-A 0 4�2- S/ /oS Title A,-J te 9.6 srp,a, 0.o c- Size of Septic Tank 240®0 6eAL Type of S.A.S. Description of Soil C4 A y `Ta OA,y Pit' Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the co c on and mai trance of the afore described on-site sewage disposal system in accordance with the provisions of Till t nvironme ode and not to place the system in operation until a Certifi- cate of Compliance has been issued b B f Hea Signed Date 1® ,4 Application Approved by Date Application Disapproved for the following reasons Permit No. -.--00Y -7 1 Date Issued �� G• ' -'ti.. YTS+f•0 _r.1 47 1 r /No. Fee / Tzar '•�'is t f - t Entered in computer: es THE COMMONWEALTH OF'MASSACHUSETTS p - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEi.MA$tACHUSETTS �3pprication for 'Mi4po!�ar,,*pgtem 'con!5truction Permit + Application for a Permit to Construct(X)Repair( )Upgrade )Abandon( ) Complete System El Individual Components t g Location Address or Lot No. j C�' �„>t'd(�! 1 1 Owner's Name,Address and Tel.No. pS Assessor's Ma p/Parcel 3�J G Z S 2X0 5TD0 CDC r,A .5 v2. ��9 ; Installer's 1 w4 ne,Address,and Tel.No. 7 7/ J 3 9 9 Designer's Name,Address and Tel.No. �N46CO--r1- OAR5TD s, Mli,65 39 MA,4J sT , .M 44 Sag,%Z s'+-1 Type of Buildingy. Dwelling No of Bedrooms Lot Size '��� ' sq.ft. Garbage Grinder( ) Other Type of Building N q No.of Persons Showers( ) Cafeteria( ) Other Fixtures = /J A Design Flow .5•Bk �C 1 gallons.p er day. , alculated daily flow .r✓5-0 gallon . Plan Date /Q9102 Number of sheets / Revision Date q /D �OZ S vS Title / .4Ai m S job cove G A'nl E Size of Septic Tank 2.040 GA L Type of S.A.S. Description of Soil Cl-AY 'Td ,5A AJ.P y Nature of Repairs or Alterations(Answer when applicable) Date last inspected: -. Agreement: k•>-.. The undersigned agrees to ensure the con tr"uction and mai nance of the afore described on-site sewage disposal system g g � g P Y in accordance with the provisions of Title 5 the nviron e al Code'and not to place the system in operation until a Certifi- Cate of Compliance has been issued b}��s Bd f Heal . ' Signed '` Date Sb Application Approved by Date Application Disapproved for the following reasons `ti Permit No. r.P©OY "' S-7 1 Date Issued ^'.:.. /011 0l1 THE COMMONWEALTH OF MASSACHUSETT — A1.) I���G,�el .t.�- ��, 0,1414431,/BARNSTABLE, MASSACHUSETTS = /�QLIr+`+ VQ✓��f ✓`�"X n�➢�' Certificate of (Compliance THIS IS TO CERTIFY t a t�e On-site Sewage Disposal System Constructed(YO Repaired ( ) Upgraded( ) Abandoned( )by .,� U 1 at k�?-ILAP L4 (nir0 4,_Q has been constructed in accordance with the provis ons of Tit©N d the for Disposal System Construction Permit No. a2 UQ t/ — S7l dated /D -)6u (- Installer Ir71r ' Designer r 1,A /A The issuance of this permit shall not be construed as a guarantee teat the syste _ nction as desig ne . Date !/�.� Inspe�ctoorr a No. �� �( � � ------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mig0-Sal 6p! tem Construction Permit Permission is hereby granted to Cogstr cp t(K)Repair( )U gr de System located at P `.�1i•� v rvl mkt and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must be ompleted within three years of the dattb ( p'~'t. Date: l[� Approved JUN-09-2005 02 :02 PM DOWN CAPE ENGINEERING 508 362 9880 P. 03 v� ' 'own of Barnstable Regulatory Services s i Thomas F. Geiler,Director eJim tAM Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-962-4644 Fax: 508-790.6304 Installer& Designer Certification Form Date: �l +� Sewage Permit# Assessor's Map\Parcel SZ Designer: e `//k°C n Installer: r Address: Address: y✓� 19G�"Gl� r On &y'�D�Ol�� CD<125� was issued a permit to install a (date) (installer) septic system at At) gLVe IP40n based on a design drawn by address) dated /3 OS ( signer) — 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. 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. "o,OP/Ags. ARNI_ H cy�, OJALA (Ins er sSignature) CIVIL No 3079a a• ST E��0�1�� FsSrpN41 E��'\ (Designer's Sign re 9/a5 (Af ix Designer's Stamp ere) PLEASE RETURN TQ BARNSTABLL PUBLIC HEALTH DIVISION, RTIFICATE OF COMPLIANCE WILL NOT BE ISSIj]ED UNTIL BO'I'H THIS FORM_AND A&BUILT CARD ARE RECEIVED BY THE BARN§IABLE PUBLIC HEALTH DIVISION. THANK YOU, Q:Health/Septic/Designer Certification Form 3-26-04.doe r 00 No.- �od -bd Fee BOARD OF HEALTH TOWN OF BARNSTABLE Application,forlVell Con5truttionPermit Application is hereby made for a permit to Construct (Alter ( ), or Repair ( )an individual Well at: � I--.-Location — Address j\e Assessors Map and Par Ice 4iyoUCL /�(o Ce_vc-_-_,C,u �M 274 &,e' —_ Owner `— — — Address —— 7;7 Installer — Driller — Address Type of Building Dwelling --- -- —------------ Other - Typed oaf �Building-- - --- No. of Persons-- --- - —_ Type of Well If/pFPCE/��`''fii Capacity—__—� _: � Purpose of Well 67 Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation.- The undersigned further agrees not to place the well in operation until a ertificate of Co phance has been issued by the Board of Health. Signed ZdeApplication Approved By Gate Application Disapproved for the following reasons: --------- — -- date Permit No.—2 603 ^0 d Issued 6 A 3 -- -- ----- _ —date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (t-1, Altered ( ), or Repaired ( ) d C�,ne / Installer _ < at! �C� J . UE L /Cl (;�rr7 1 -ihas been installed in accordance with the provisions of the Tog of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. W- Zed 3-gVDated �a ----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector----------- --_ —_____ No.-''�?o d 3-d f `�` Fee--L- ------- BOARD OF HEALTH " TOWN OF BARNSTABLE 0pptication,-*rVeri Cootruct ion Permit Application is hereby made for a permit to Construct ( Alter ( ), or Repair ( )an individual Well at: 1<INE" - �/,��i/r�r u�,� yS)- 02 5' _ - ocation — Address — S 'e Assessors Map and ParrVI — /_V 64G G 1t?6 C e��i .�.0 Cam/ /77 1ri 4? ----- - � Owner—`� -- -- ------------Address — — — E•5/x d jr-d GU�=7� c �c' %_d_'2 e�qGCh,it/1- Installer — Driller Address Type of Building Dwelling - Other - Type of Building--= - ------- No. of Persons--------------- Type of Well �/� - �Ef�G ?CEff7�-rS/T Capacity Purpose of Well.-.� �' q7-10AtJ — � — — -1�! 1 ; IL Agreement: ; The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The. undersigned further agrees not to place the well in operation until a ertificate of Co pliance has been issued by the Board of Health. Signed -- da e Application Approved By -- ==--- k 2 ---- date Application Disapproved for the following reasons: ------- --- -- -- date — 2 6113 -0 L.p __ Issued� �6/0 7 Permit No. -�! --- -- ------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certifirate ®f Compliante THIS IS TO CERTIFY, That the Individual Well Constructed (v), Altered ( ), or Repaired ( ) by—��/ 0,-7,4— LC/ '�Z)R /LLi/v Trr -- — - -- 5�'rp Installe at/o L V 6 G iV �U ih/Yi :i --- has been installed in accordance with the provisions of the Tog of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. 1--)00 3-Qy-Dated � - PP �l THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY-. DATE--- - Inspector-------------- - --- BOARD OF HEALTH TOWN OF BARNSTABLE loerr Con5truct ion Permit No. -�2 0e - OYO Fee Permission is hereby granted —�— ---------- to Construct G.,Y' A,,ltt ( ), or Repair ( ) an Individual Well at: No. 1IF6 Street as shown on the application for a Well Construction Permit No.- W;)oU 3- 0%U Dated - j --- ---------------- - - s---------- _... Board of Health 7 6. DATE �0 __ F1Vl'IROTL,C.'HI.A1 ORA70IUF.S,INC: AAA CF.R7: NO.:M-ALA 063 RECEIVED 8Jan Sebastian Drive-Unit#12 Sandisich MA 02563 � 508(888-6460) 1-800-3.39-64(,0 SEP '� 20� TAX(508)888-6446 TOWN OF BMNS7-ABL HEALTH DEPT E. CLIENT: Desmond Well Drilling LOCATION: 186 Stoney Cove Ln ADDRESS: (,Vurke/Turxnbull) Cummaquid MA ,t COLLECTED BY: Desmond Well Drilling SAMPLE DATE: 8/27/2003 SAMPLE TIME: 12:30 WATER SAMPLE TYPE: Irrigation Well DATE RECEIVED: 8/27/2003 LAB I.D.#: 0308633 WELL SPECS.: 4"x 30 f 19-6 RESULTS OF ANALYSIS: Parameters Units Recommended Results Method Date Analyzed Limits ' Coliform bacteria / 100ml 0 0 9222 B 8/27/2003 PH . pH units 6.5-8.5 5.85 ', 4500 H+ 8/27/2003 Conductance umhos/cm 500 172 ' 120.1 8/27/2003 Nitrate-N :,. .rs <<'" mg/L 10:0 ' "` r ` 6.25 300.0 8/27/2003 g .. k Nitrite-N �f�. m /L 1':OO R < 0:004�. .--- - ,• 300.05. ( 8/27/2003 Sodium mg/L u 20.0 ' 19.2 200.7 ' "`� 8/28/2003 Iron mg/L 0.3...,, , <0.1 200.7 8/28/2003 Manganese mg/L 0.05 0.028 200.7 8/28/2003 COMMENTS: Low pH indicates high corrosive characteristics: WATER MEETS EPA STANDARDS AND 1S SUITABLE FOR DRINKING PURPOSES FOR PARAMETERS TESTED. , I t <=less than Date- U t►t >,=greater than i onald J. Saar' °TNTC=too numerous to count s( Rotatory Di ctor , , , { t Massachusetts Department of Environmental Management 121942 Office of Water Resources TYPE OR PRINT ONLY Well Completion Report 1. WELL LOCATION GPS(OPTIONAL) LATITUDE LONGITUDE Address at Well Location: IS4 ;::M-,l pV 600 EEeCJProperty Owner: 'suLL AJ Subdivision Name` 27 C<- Mailing Address: �g� �� Uyy�, 1 City/Town: G 4/'/757A6e City/Town: ,0 a-",06 � Assessors Map Assessors Lot#: OtQ NOTE: Assessors Map an Lot# mandatory if/no street,address available Board of Health permit obtained: Yes WJ60r3 40 p 0''� Not Required ❑ Permit Number ate,IssueU' 2 WORK PERFORMED 3. PROPOSED USE t 4. DRILLING METHOD ❑ New Well ❑ Abandon ❑ Domestic rrigation ❑ Cable ,.N ',,Auger ❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer` Q Direct Push CUo'Re lace ❑ Other ❑ Industrial ❑ Other ❑ Mud'Rota ❑ Other 5 WELL LOG CL Unconsolidated Consolidated 6.SITE SKETCH(use permanent landmarks with distances) W Permeability . Q High Low .> m From (ft) To (ft) > `� m Other Rock Type U X - � rbN! 7.WELL CONSTRUCTION 8. CASING Total Depth Drilled From (ft) To (ft) Casing Type.and Material Size O.D. (in) Well Seal Type Date Drilling Co plete 0 - / la IDV I 9. SCR EN From (ft) To (ft) Slot Size Screen-Tape and Material Screen Diameter 10. FILTER„PACK/GROUT/ABANDONMENT MATERIAL 11. ADDITIONAL WELL INFORMATION" Developed? EV es ❑ No From"(ft) To (ft) Material Descriptio Purpose Fracture n a" Enhancement? ❑ Yes ER Flo Method Disinfected? C2111Yes ❑ No - 12. WELL'TEST DATA(PRODUCTION WELLS) 13. STATIC WATER LEVEL(ALL WELLS) Yield ""Time Pumped Drawdown to Time Recovery to Depth Below Date Method (GF'M)`' (li'-& min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) 24� _ 9 114. PERMANENT PUMP(IF AVAILABLE) 15.NAMElADDRESS OF PUMP INSTALLATION COMPANY Pump Description AQa �Sl Horsepower �. �3/yI[2f/� !JE✓c ,2jC /r Pump Intake Depth -- (ft) Nominal Pump Capacity _(gpm) Pp,(3 16. COMMENTS It.WELLDRILLER'S;tTATEMENT_ This well was drilled and/or abandoned under my supervision, according to applicable rules � � and regulations, and this report is comp)fte and correct to the best of my knowledge. Driller"":� .r '1?i -� U/Z)Supervising Driller Signature: Ih -� mod. Registration #: yj y Firm:c+� htib Z-Az-- Date: - .0 - Rig Permit#: 1VOTE:. Well Compdetion,Reports must be_fled.by"the,•,registered well driller within 30_days..of=well completion. ,r .`BOARD OF HEALTH COPY. TOWN OF BARNSTABLE LOCATION � 34MV SEWAGE # l VILLAGE_OM i 4 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. BAl d 1O % d SEPTIC TANK CAPACITY nn. U gt LEACHING FACILITY: (type) _ C lJ> cmiV.,w-fi (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: di COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility .(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I pA �b1 � l 1� / TOWN OF BARNSTABLE L `� LOCATION /mil® .S�b�> P'' SEWAGE # 49o-' LI Z - VF LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 15?X LEACHING FACILITY: (type)7-elnc1WJ 6) (size) ;9j NO.OF BEDROOMS .UILDE OWNER G7/I i�J ¢ Somas PERMITDATE: z//7��7 COMPLIANCE DATE: ��1- I03 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ¢ Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist �60 within 300 feet of leaching facility) Feet Furnished by CC L- ( A)i9 f �' Scat / _ No. � � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE!, MASSACHUSETTS 01ppYication for �Di000al *Proem comaruction 3permit Application for a Permit to Construct( _ )Repair( )Upgrade( )Abandon( ) EJ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. _/ C�►m. ��,�������.`c����Lea �.cy . Assessor's MapMarcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,Ll 5 m ti,s t.t..s � t•e �,A. �-t o c;TT-4 e of B 'din ()ATyp g.wellin No.of Bedrooms �d LotSize 7S2b®Q sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow S gallons per day. Calculated daily flow gallons. Plan Date 2- tuber of sheets Revision Date Title - U� Size of Septic Tank /�S�t � -�<<. Type of S.A.S. 0 'to Poo U llu^ 4l� Description of Soil Nature of Repairs or Alterations( nswer when applicable) i9tiol O t� t'l0 t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this Bo4pof 1 Signe � Date Application Approved by ate Application Disapproved for the following reasoC/-'/ _1 Permit No. Date Issued 40 *J)-� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: V1 .1 Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE8 HUSETTS t ZippYication for Migogal 6pgtem Congtruction Permit 1 .Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components r Location Address or Lot No. 18 6 sTo��/ ���,�] Owner's Name,Address and Tel.No. Assessor's Map/Pazcel� 35 2 j Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. JA k(ZSTT6N S Type of Building: P I $`�jy OA wellin No.of Bedrooms G d Lot Size ySbO O sq.ft. Garbage Grinder( ) Other Type of Building , _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date o 2- V'. Number of sheets Revision Date Title E 1.A�-1 0,;.. Size�of Septic Tank /,V 0 of S.A.S. A/ to a Description of Soil � - Nature of Repairs or Alterations(Answer when applicable) v �O uje ty 'k c Date last inspected: Agreement: The undersigne&agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this Bo d f f Heal h. e f 1 /0 Signe � A-�, - Date _ m Application Approved by L/I� v d6 ate Application Disapproved for the following reaso Permit No. Date Issued ————-———————————————————— THE COMMONWEALTH OF MASSACHUSETTS :BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CEgPFY, that the On-site Se age Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by r at f Y C 4e,1W 1Y?1.':�P&VAW e n constructed in accordance with the provisions of Title 5 and&e for Disposal System Construction Permit No dated r Installer I Designer // The issuance of this permit shall not be construed as a guarantee that the syst � wil func n as designe� Date 1 L) Inspector r �v --' --- —�— -——————————————————— jr No. �.+ Fee— -- r / , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 30f6po5ar 6pgtem QCongtruction Permit Permission is hereby granted to Construct Repair( )Upgrade( )Abandon( ) System located at t 7-, h ev Y /�Olrr° r'® and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust be completed within three years of the date of ibis, emilt. Date:_ �l i G Approved by - i j TOWN OF BARNSTABLE L LOCATION SEWAGE # .?25Z, y/y/ VTLLAGE�„+��� � ASSESSOR'S MAP& LOT 35-d-o.?t— INSTALLER'S•NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO. OF BEDROOMS UE DjjD OWNER Gr /lbrr Jove• } PERMITDATE: COMPLIANCE DATE:_ ,11 J p 3 Separation Distance Between the: ` Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ¢ Private Water Supply Well and Leaching FacilityFeet on site or within 200 feet of leaching facility) any wells exist Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) /60 f Furnished by _ ' pay ,9 s cjt O ,x . ........ . s CO\ maxxkzALTH.OF MASSACHtiSETTS _ ExECL TIVE OFFICE OF EI VIROI ME\TAI.:AFF_A,IP.1 E' DEPARTMENT OF ENVIRONMENTAL PROTECTION G ONE R'INTER STREET. BOSTON bLA 0210c 1617) 292-550k, TRUDY COXE Secretan ARGEO PALL CELLI;CCI - DAVID B STRtuS Governor Comnuss:one7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ce. PART A CERTIFICATION' Property Address: 186 Stoney C ove Lane Name of owner Qr h ]r R rnS"te in C umma q id Address of owner: Date of Inspection:j� Name of Inspector: (Please Print)WM. E. Robinson Sr. I am a DEP approved systeM inspector rsuarrt to Section 15.340 of Title 5(310 CMR 15.000) +, CorripanyName: Wm. E . Robinson septic Service Mailing Address: PO Box 0 9. Centerville .—RA Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site age disposal systems. The system: _7se asses } Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: GN ' Date:' 1 -'!V°i f " The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to tfre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS s'"4 `+ TOWN Of BARNSTABLE si HEALTH DEPT. r ,+ , rev sce . Page 1 of 11�/ I y e M i� ✓,.r!ed o�Rec,16cd Pane, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f CERTIFICATION (continued) "rop"Address: 186 Stoney Cove Lane , Cummaquid. Jwner: Arthur Bpxn tein Date of Inspection: INSPECTION SUMMARY: Check A, Q C, of D: A. SYSTEM PASSES: 4 I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. ' Indicate es, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION(continued),_ n V 186 Stone Cove Lane. Cumma uid Property Address: r q owner: Arthur Bernstein Date of Inspection: i D. SYSTEM FAILS: ` Y You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310'CMR,15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility-or system component due to an overloaded orclogged'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 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach.,copy of well water analysis for- coliform bacteria, volatile organic compounds,,ammonia nitrogen:and nitrate nitrogen. E. LA GE SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: - The following criteria apply to large systems in addition to the criteria above: <.., The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is-a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply, the system is within 200 feet of a tributary to a�surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area•IWPA) or a mapped Zone 11 of a public water supply well) The wner or operator of any such system'shall Upgrade the system in accordance with 310 CMR 15.304(2).' Please consult the.local regional office of the Department for further information. ' revised 9/2/98 PaR.4of11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contimmd) Property Address: 186 Stoney Cove Lane , Cummaquid owner:Arthur Bernstein . Date of Inspection:/I/. Q 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zane I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER revised, 5/2/58 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 186 Stoney Cove 'Lane , C ummaquid Owner: Arthur Bernstein Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: . Yes No .. . Pumping information was provided by the owner, occupant, or Board of Health. L! _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. z As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. ✓/ _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. ✓ _ All system components, excluding the Soil Absorption System, have been located on the site. r _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: L1 Existing information. For example, Plan at B.O.N. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / 115.302(3)(b)l The facility.owner (and occupants,if differeru from owner) were provided with information on the proper maintanaorA-0f SubSurface Disposal Systems. r, revised 9/2/98 Page 5orll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C SYSTEM INFORMATION 4operty Address:186 Stoney Cove Lane , C ummaquid. Owner: Arthur Bernstein Date of Inspection:j//.:(,—p �J FLOW CONDITIONS RESIDENTIAL: Design flow:6/ O g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual) Total DESIGN flowG/,j o Number of current residents:-2-- Garbage grinder lyes or no):N b Laundry(separate system) (yes or no).,Ld; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):X O Water meter readings, if available (last two year's usage(gpd): 1998 62, 000 gal. Sump`Pump(yes or no):h ,0 Lest date of occupancy:2--1—fq p 1997 63 , 000 gal COMMERCIAL/INDUSTRIAL: Typ of establishment: Desi n flow: qpd ( Based on 15.203) Basis f design flow Greas trap present: (yes or no)_ Indus ial Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Wate meter readings, if available: Last ate of occupancy: O ER:(Describe) L e of occupancy: GENERAL INFORMATION PUMPING RECORDS and s urce of information: System pu ped as part of inspection: (yes or no If yes, volume pumped: gallons Reason for pumping: - TYPED 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed lif known)and source of information: _/ �/ •� 100, Sewage odors detected when arriving at the site: (yes or no)�i d revised 2 91 Page 6 rd 11 . E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION leontinued) bop"Address: 186 Stoney Cove Lane ,-' Cummaquid. Owner. Arthur Bernstein Date of Inspection: /e—/,j 9 ci ' BUI ING SEWER: (Local on site plan) w Depth b low grade:_ Material of construction: cast iron 40 PVC other(explain) Distanc from private water supply well or suction line Diame r Com ants: (condition of joints, venting, evidence of leakage,-etc..) *. SEPTIC TANK: (locate on site plan) ' Depth below grade: $ ." Material of construction: concrete—metal—Fiberglass:—Polyethylene—other(explain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth: 3�-c� Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: Distance from top of scum to top of outlet tee or baffler , _• Distance from bottom of scum to bottom of outlet tee or baffle: - How dimensions were determined:d 1P4. 'omments: (recommendation for pumping, condition of inlet and. utlet tees or baffles, depth of liquid vel in relation to outlet inve t, st u Ural integrity,+ evidence of leakage, etc.) /b es (2,,o� 'j>- �` o �t ��a_ a��/L` 'S I.I.— IW 'A C> Lsc G SE TRAP: (loca a on site plan) Depth below grade:_ 1 4 Materi I of construction:—concrete metal_Fiberglass _Polyethylene—other(explain) Dimen ions: Scum t ickness: s Distan a from top of scum to top of outlet teeor baffle: 'Distan a from bottom of scum to bottom of outlet tee or baffler Date o last pumping: Com ents: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to'outlet invert, structural integrity, evid nce of leakage, etc.) a.. i* revs se'd Page 7 of II .;. b,. I _ • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i ,ropertyAddress: 186 Stoney Cove Lane , Cummaquid. Owner: Arthur Bernstein Date of Inspection: TIGHT OR HOLDING,TANK: (Tank must be pumped prior to, or at time of, inspection) (loc a on site plan) Depth elow grade:_ Materi I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm pr sent Alarm le el: Alarm in working order: Yes_ No_ Date of revious pumping: Comme s: (conditi n of inlet tee, condition of alarm and float switches, etc.) DISTRIB TION BOX: (locate o site plan) Depth of iquid level above outlet invert: Comment : (note if le el and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP AMBER:_ (locate n site plan) Pump in working order: (Yes or No) Alan sin working order(Yes or No) Co ents: (not condition of pump chamber, condition of pumps and appurtenances,etc.) revise6 9/2/98 Pageorn I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM— PART PART C SYSTEM INFORMATION(continued) ' 'rop"Address: 186 Stoney Cove Lane , Cummaquid. t Owner: Arthur Bernstein Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) , If not located, explain: a Type leaching pits; number. leaching chambers, number._ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signg off hydraulic failure, level of pgnding, damp soil, condition of,vegetation, e c.l c5es C SPOOLS- (I _ ota a on site plan) Numb and configuration: Depth- p of liquid to inlet invert: -r Depth o solids layer. )epth o scum layer. Dimensio s of cesspool Materials f construction: Indication of groundwater. i flow (cesspool must be pumped as part of inspection) Comments (note cond ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.),A s .. PRIVY: (locate site plan) Materials of construction: Dimensions: Depth of olids: Commen s: .g - Inote co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revJLs';e 9/2/9c PdFc9orI I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 186 Stoner Cove Lane , Cumma uid. 'roperty Address: q. )Wrw: Arthur Bernstein Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at beast two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3 d V ,v -waylW__ revised 9/2/9R Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,, PART C J SYSTEM INFORMATION Icontinuedl rop"Address: 186 Stonev Cove Lane, Cummaquid. ow"ef Arthur Bernstein u Date of Inspection: NRCS Report name Soil Type Typical depth to groundwater - USGS Date website visited '- V Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater f J Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basemeAt sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps .3 , Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 06 IV revise. 9'/2/96 Page tlorlt LOCLI.TLON 3(o iStow SEWAC PERMIT Mo.VALLA -1WST LLE S--U&tAE --MITE-PE_RM1T - :, D ATE -COMPLI-/�.t`10E__ISSUE�_:_ a ., �. � •.- � � . �� ., f. ;,- ., �. j� �' _. _. ' I .. _ - _ �. No.*`....... 4. FRS. ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD QjF HEALTH 4. .-....-.OF.... _,... .. .... - Appliratioo -for Mapmal Works Tawitrurtioo Vrroiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: s"...... —......... 2 S' ..... 1oM �v11....... AA&S. vl�i.. .........d........�/ .........................� as L r._l..e ................ ............................... .. Lot .... W wner Address Installer Address UType of Buildings Size Lot.............................Sq. feet Dwelling+�No. of Bedrooms............... ....................Expansion Attic ( ) Garbage Grinder Other—Type of Building ---------------------------- No. of persons------------------_--------- Showers — Cafeteria a' Other fixtures ...................................................... .._.........gallons per person per day. Total daily flow..........Zn Q__________________gallons. W Design Flow....y____________ __�•-. g� P P P Y• Y WSeptic Tank o�Liquid capacity/PRP..gallons Length................ Width................ Diameter_-___-.._.-._-__ Depth-----_--__--.-. x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area-------.-----_.....sq. ft. Seepage Pit No--------/.......... Diameter....f4O.A..... Depth below, inlet__.._.___ Total leaching area..-____------._--sq. ft. z Other Distribution box ( ) Dosing ank ( d �G - "7— 2—-76 Percolation Test Results Performed b .... Date..... a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...__ ............ �iq Test Pit No. 2................minutes per inch Depth of Test Pit..__-_-_-.______-_-- Depth to ground water--.-..---_---.---------- --- ---,-� -- --- _ ' J� ' -- --- ---------- .O Description ofS --_--- ----- ........••- ____..._. W � 1 - 2'------------ - - _ -- x ----- .ate =------ -d-- ,�.--..... V Nature of Repairs or Alterations—Answer when applicable._......................................... .................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 ' s ed by t bo of a Signed -... --------• -------------------------------- Date Approved By.... .. - .-------6- Application = G _v Date Application Disapproved for the following reasons:................................................................................................-------- _.._.. ................•---.......•-•--•-•-_..._•--------------_--••-•--------•-•••••------_.........-•----•--•-•-••-----...•-••••----•••................-•----_------•----_---.._...---------••---..........-- Date PermitNo......................................................... Issued........................................................ Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , m / �C(�'J IL DATA i- ®r6' No..-, D F��..... fl.... v. THE COMMONWEALTH OF MASSACHUSETTS BOARD O/F HEALTH .......OF.......... .. ....42'. --- .............................. Applirtation -for Dispa5Fal Workfi Totwuurtion Vantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at 3 s^ -� s } # / Location-Address or Lot No. .........��..... .............€1......_`..7`••-•--...__........... .-................. ...................•-••-------•....._..... .....•-•---------------..................----..... W ` Owner Address -----------•-•-••-......f................... ....................................._........................................................... Installer Address Q Type of Building,,. Size Lot............................Sq. feet U Dwelling -"No. of Bedrooms__________________ ------___-__--_____.Expansion Attic ( ) Garbage Grinder aOther—Type of Building ------------------------_- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ----------------------------------- W Desi n Flow.....................P'.`____-_-.._-_--_ Mons per person per day. Total daily flow.__.__.___." '-.' �' gallons. g . g P P P Y Y -------- g� WSeptic "Dank Liquid capacity------------gallons Length---------------- Width................ Diameter--------- ...... Depth.._.----_-.--_. x Disposal Trench—No_ ____________________ Width-------------------- Total Length_-_______-__--_.__-- Total leaching area--------------......sq. ft. Seepage Pit No..........`----------- Diameter....._........!�---- Depth below/inlet__________ _______ Total leaching ar.ea------------------sq. ft. Z Other Distribution box ( ) Dosing ank ( ) O,r1 /�G - '7 - -2 a - -76 nA`- Percolation Test Results Performed by.__. Pt"_._.. _ ___ _.. Date-------------------------------- Test Pit No. 1----------------minutes per inch Depth.of Pest Pit_.................. Depth to ground water__�_rJ_______.... �Lq Test Pit No. 2________________minutes per inch Depth of Test Pit_................. Depth to ground water-_.-..---__-__--_._..--. P4 - --- - O Description of Soil = --- --------- ----- s. r uwl. W " � ----- Gl .�J V Nature of Repairs or Alterations—Answer when applicable.-.-__-..---_-._. --------------------------------------------------------------------. ----------------------------- -------------------------- --------------------------------------------------------------------------------------------------------------------------------------- ---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 th,e board of health. Signed__ n�, Date Application Approved BY- -- -�--- -- - ------. ;..... lyc.� 7 V �. --_---- Date Application Disapproved for the following reasons:.---------------------------------- - --- --_------•----•---- .............................................. -------------------------------------------------------------•••--------------•--•••••-••-----••-•--•----.. ------------------------------------------------- Date, PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH, Gr" -s/vJ.........O F..........Z./.4�LlYl/� i?�ir:............ Trrtifiratr of feontphatnrr Tjl S ZCTIFk, That the Individual Sewage Disposal Systein constructed ( or Repairedby---- - ; ------•-•------------------ taller �' -- -= ----------- dZc cJY�-P 11--�------JCS �''L`'� ---------•----------- at e ------. has been installed in accordance with the provisions of A XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No___ __________ U._` ------------- dated------ I ................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. , DATE.-------•--------------------------------------------------------------------•-. Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH / 3 5�? .........��J .�.........O F........ �.G!... .......... .......�........_ No................ FEE-`d............... ?i /�du k oat r#ioatrrntit Permission ' reb ranted_____-_ Y g �t � -------------------- to Constru ( or epair rr)�n .. I Sewage D(j saP5yst J at No.' 1�'i - .Z ---- .. ------ Stree as shown on the application for Disposal Works Construction Permi o.... .......U... ated------ ............ oa d of ealth DATE................ �...-7-----------.....-----------------------------• /` �d-_ �t�'y..-.."�-' --a FORM 1255 HOBBS & WARREN.. INC.. PUBLISHERS / i s ko � 6ITnlS6- AeGA � I N \ IN ���- Ii GSE PMpYe� Hem H�llC� '' �; �n�► Ki " � - Gum �� rautis 8o�r IL I r�1ll�;T/ Bfl2h'� - 1/e" - -I J&, S7oI,4b"Y CU\i6 W,CjMHAgtj1g --------------------------------—--------- ~' -- OLO 1 j x I ! . 1 I • orb ;bw,p . 1 BNy --- I ox D-7---- -------------------------------------- ------ 1 0 P o� I 1 am: >.�17 u 63 " OipR b�ioi3 I Zi 1 O ETei RIP ,O ------+ s - --� rn 1 ' ' s-o• 1 H'-a• m 1 o 1 PER CLIENT ; '. ; a cn , I ! A f i 1 A 1 O' ay 70 m ! j X' ; e 1 s O , 0 U I ; oo O 4 Ij �s i ! • cn I � / ; • i �Q.1f•11J1��� �o . i I I/` — ! n I 1 - !Hl 116 '1'.�T � 1 ! , L'-11' 1 ' 1 1 1 I _ ---- --------------------------- - i Z ,T4�A"LOCAL 4 , -pi - SCALE 1 P-,'-0' - MWAILY AG160 W ao1MR1Y. 019 To ' NORTHSIDE CDPIRIGHT DATE REVISIDNS A+IrA O*MOM 000MI07111 LIILe- 0 , >< a . S D OR PLAN „ ., �HEREBY ON ESLY ILAW .m � n DESIGN COPYRIGHT.THESES PLANS ARE MR MY M®71.OMAII7{OKLq lm NOT TO K REPRODUCED - SHEET ND. DATE:. I t'M �M.�� I✓400 RESIDENCE � L � ASSOCIATES CHANCED OR COPIED A ANY TAE DEW,p,MM•OEM AOWE! FORM OR MANNER WHATSOEVER. A.2 , 8�� ISL STONEY COVE LANE MIXPLTREOO.E11gw° "°� WITHOUT FIRST OBTAINING THE ,R�PIAM9 TA%ER TO VON LOCAL EesnNcnvE RESloanu#CDNMQtCIAL DESIGN EXPRESS WRITTEN PERMISSION YOIIIO OVM11OfI AlO�tl1 M�'IOI IA MAIN STREET YARMOLITHPORT•MA 0al70 CUMMAQUID, MA 02431, P`°o�LE�'°�E:�• "^ . c�T.3L:-2210 (ce),2!.jl .000NSEN T OF NORIH9DE 1W All S1 .255� Nc S cct� s VW F A 06 i 2'/,t4 SrR;Q VJNI7Z U$� l 5eeop WN11E GftVi / ' b /.`C3 to,p , to,O E _ Wjnow IIV e (l`� U Y or STf-IpvjuI /KS t�/v p7tF :t • - - N�, f r—� � CEO.• ,—► r 57f-1 WNt c Diic 8'ccc, �f low y LIS'/flrJfs f mac,s; �Vwu vM6 � . , �'� K� I-Owes_ voio ' — - i �. I � i � � i = j I I ` � 3�/y'��G. QEta w . � I j . _1— � � � i_� I _ . � cxcPosrTr� Ih 11 i �. � y � I IIIIII - _.__ _ w_. _ _ _ I fit. 1 ,� .j �` _ _ � _. _ _.. , �� ��rY cod I. ' 1 ' i I . i � �/� cuc- ExrsriN4 �Q%o4� t � � � { �05 �I p _ ��! 4 �.�{ o �gx3/ � ° _ �i . G � � .� � � - i� n �XY9l.G�c� . � i G—vxrrrKd—Grr�'E �o ��ooR . �ran� coin- c�✓•culth>9 ui �� - � � �. � � SCALE: //�� � ARPROVED ET: ORpWN BY�J/./� - DATE:/ /fGf D REVISED _ ' � s.o sT2�fGi�P.�/f� pv�,e,c.�j. " - . DRAWING NUMBER �kNes?- E.aov-rLGS �SdIJr fNG- 5?��qs�-rr6 c�0/ _ .. a n Y , • • 'vim r .£ i , J • _. ` .. A, • q gk31 SL I� AitiS WLDEp EY i . ton . P, "P �iDL� slrrra imp a� Lv/%Xy3 '���sr��/G;- �c�� ��'w�• _ = Zrio �{ i CT 0 • 5 e , a 14 SCALE: '�/ /I/I A3YIPPROVEO BY: - DRAWN BY V ~ ;. �•.. �.. DATE: I/• f�I D_I REVISED v =—EE j 5gcTIOA) , - - •. G X/.Sf .STL �T Jl�� .. � DRAWING NUMBER 3•L -- u H War( dll) N '— ----_ _ Ai O'-r�r �d(zIIDk) - SOU r 419 T -------------- FTT .01 r . Fa -__-- . Er�r4�'rro .PE.rv��i�e-G,9,e�9Gtr �i✓.D fr�i� 19'.6 _Sra"G (llV£ Cn/ H H �6 6CALE:S �/ r APPROVED BY: 'DRAWN BY(fII� DATE: 12raCj tog REVI..D PRo/'05�0 Ei.�'!/>/Tron/s - DRAWING NUMBER I I Der:•[R. f-0--t-.d/ /z�C:.-un Lrtr3c5 F7�E. C=/ST.�rs� O 1 ` � � of �uJ:= F, ; i locaFC. � /�� / F-M,- /ram -31 ! � � , I ) ! �I 11' I II I I T--'--1 9 L 1'� }—� II I I I —11 I � FI �QLMo;GS QoRMC.R AlootTlo 1 /1/Gi-T- �J-._:;�Y.-T✓ors. _ JSf�H-�f.E!� /� �' PPADVED BY. S Cf DATE: e� • _ DPRW-11ul-EP. e I L— r� Z yu./.. J 7111 11111w. A >A l/r. aT q S • ram'✓- L-PA .I,ca,W _" !i a . ------------------------ \i0.l.lp 1•MII•6 Or T1Y• • ~ ■ 4 E)S MG SECOND . °� ■ „•$T m•r - fe FLOOR MOPS HAFT TO �• 1 ,► - p ; Der• �W7/ i -__B. D________________ 101G FRbT FLOOR RENOVATED " * 1 V TOP ELATE SITTING NEW - tf0�1^-� wie1°aa Y RSIGSHAW NALI M'OL. TSG EXIEISOR S MASTER /� LOSET ..r./ --" ----- 2C1 WL t n C /each ail; s r G r � • Vr PLYNIM SIEAIMG ""R. ---� IMTING SECOND FL C OOR JW ar w+/ ar tr i ---------s --' __••---- - Mew R N04AT 6 pE aww°aea•m r+ >. aua wes°�la►arm DINING liE Y 6$$gppE aw i< rr J u/s eaEXISTING . ----{ - _ nQ -<;=;_eeatf;;e= �9_:_"' •e;i:�},o yc GREENHOUSE-- 1 --- - •-----c: DETAIL F PLYWOOD SHEATHING i en a•. as I am,... � �la� *� ,� •lMa INTERIOR KITCHEN WALL a �; an+ RENOVATED — °°a MASTER BEDROOM pG ■ �^ lem: Q + ea: i■®..i'Iano AREA ---•• ---•-- -'4 _ e "SCAM I V74-17 V �e S g -. _ _ ---- ------- -- - $� c7o " _ ___ __=__-_c_7�asn/.ne•i.1/a * Mar s - - - p V]CA a _ IMi1R�Ml/a ] G]yC/� 1eiI�ew�seers RENOVATED - KITCHEN • - Il�i[[ll t ---- - - - - � _ * ' r.a•� slam �S Ell• Q E NLUI iar�l w ■ /ea ev i�l. A EXROOMSe cola y; n : ; y ,aw ;� ;, - .,, ENTRY�M—l" __L_. , R aW .ra►,w ae i R ; �. : - ; y lrua,o c,Aao F" _ .r L,n NEW = w'q/. ~ FOYER _ - -I-- its a ae i OFFICE ST Iaa •• .iej - - - 2swm 1 r i jw Ae MTENR --ET J I�E`r r� 'S6nai - ow �91i0�/i;j,i,!1 6 im— p Im�irvr vwT �c er s r - vraea'm.o'e °.wiw r• /• ir-a• --- -- d w w. w ,s - ..� fck ldilty2�'kalE Q w w wm w�ia�i �• _ r•i W P-9 a!P f{ _ P-O V- rI ,-• r e •Ief/e110 P{ ® . _ ra WNW •' eR . s-0 p 1 aasonl�•rea k T aVAN I Ju u Ju of CONSTRUCTION NOTES: - ? T O OTC U= L oul"mat. oom=u.a MIA,am nisi/ O ffU. al �. minurna/"aore!°ro. R a erw F \O< 1111111111 IN -/yr .r eaa, -4 /e�/re ew,/e orewee•••/a f� i F _ wu 1 S w s we O//RII//. *I ¢ rr .•-/-vr •v LA11ND. x IV oe -•--- w NEW TYPICAL NOTES: MUDROOM/EN.TTi. FDIC wl•�'�',�tMO'rpp/"�°l.Ya0/aa.TRla.011 �� tea""' � MATCH LINEMENNEN ~ era rwla••w/ar/a/a cownua ' ��, � ■ laoelb/N M .�rww.eri..a rrne,R �M o{�-� �'�TEG�'-O�-i 5 '-�. • a °� 1,/rarrCT ALLp,r6 h rlOr0//D NPTE: . °r Am °a �' '^'Q'• 1'A� UTERI OF IE"5 TO A"ALL M81 Md'r K=SPACES V ExSTm - • w COAT-CTOR TO ALU NES FMATO MU S TO AC=KWTE - Fo� KIERT OF GTCNeJI DEWAI S POR LAYOUT TO 5E CDrt6tED ' ■ O �n n o//�,er ii'w w/•i A�° °*+r,a ON REAR DOWER V MR DOM OK I ROOD TTOSS. a tM aral rww:,w w DE VA TO FALL ON TENT Cf](iER UE • Q Lam 4 S� S` ` 7 - ylili�f OA.M. ' ■asp■W ids b i .gym.®■■w. rl WN URN So ,>F 1 op712 exsnw xar ro pgpg �■m�■raw�s .u4i ww.o I/ .. ,PR BE RBWM -----------------...._....................... TOP 4T Km = . " am 1 xa IV U No"NA6f 840E EXTERIOR n . amI ■ =4UL law .. . I Vr PLYWO 61EAT13lK. @E7mW,BECm FLOOR JDKT us yr yr i Bfill! I DETAIL OF PLYWOOD SHEATH w fa R r'" I ® INTERIOR KITCHEN WALL I '� mo `"vv�, . PRO 861JARD'8 RDOH ■�t I �E •• t■Cy WC■dam r ■1■! ■ 3��fx•�f �sc EpE��le���!f''i Y M101M rY :r_2 W - _ _ - •/- ®� � ran � Q �V J cl i■ UlO P Ul € a g o e _ w.y...� - ,. ul.13 , e Cl o �O< J 1-E V � D�TGT'ORs " x of w F MATCH LINE ■ E I`'�w�mMfe1tl1ma�i°"mws■:fono'c° sr W4& ' w1oMT a-" [ 'OYIW 710Y YNL e � w�M�rMw wuM to Is•itTiu i� I *10 ME If g -NEW PULL BASEMENT i Ham 3 GR XIISTSPACE a ... p S 4 _ - ' rex is Nrra MlPar EXISTING • - Mj z . . f` ' . L : m .■B�R�iI C\! ._ illi a� • w rn �Q I roe�T i x• EXIbTIH CL��/]C/� • NEW PULL BASEMENT �^'�°A'�-y*� LPL 0101'"D�T �. � PULL BEMENT eRIAfJ V TA V*Jt M' a rewx Mm Tl! CRAWNG A� _ 40 SPACE A® EXISTINGp 4 PULL A ai=[ M•r f 4 CRAW SSPACE asumw Hair 1m ire+yr�v�aearw aw +x ■ R 1LOI� GRTB�TONCE�4a AM RM OM TO V�W WE TM X If11 men.Y.e.Ts•s w� T-T&I&%wnm am1w.=Y COILING. •C lo6Cd� ee ,oM 1 FULL BASEMENT �7g lr a� 7p� it 9r�I .� - I I rws -- loam L W s P•s � - - �; � xMl rrar I . I arw I ---------------- BASEMENT NOTES: M„Y °r e°'Tw�e xwJPn:. _ - 41' - a � IIAM POIMItN MAI'Lw TO=b POWAD COW.V MMtM Tw M gI \ ]` ` ��pTTpn pA TYp is r =� � � - i� rear M.���0.��.c1c1^^1�1++,01�•a��111O9YO�riTfa!q�o�w .• ALL P ►in. ----- O � Z' tcrtr '6�°tSw+L v • - �irleYw=MML _ s ' NEW P_LL BASEMENT I =Pwm MACH my Pa'oii"i3 z�'"aa°"x•,YF°i�� i'czsv AI T� .9 eu�waw a -------� `-- 7. ~A s, waMMa rLear sn Ym wLL PAMALLB►wemnr I�l a ruse tar rio �° 1 a ouar w To r Pam aeec w Isl•Acrm ramiwD1® •- t I bW sP r MMLTMM aP IL. m cur Aaltn wrap MwLt!AMD wlAN Deus uea. •ii Oo�O R®�Cw�tpR�CO�1QW�y O�OY .�lJ��•~ b � _____ ____ T X e f-O'IOwfl11 ODVR xald THAT ALL FOUm IreM Mriw KN " - Of T PeevM»as MTPPMIMIO PUTT AT MMDM a MTTYIL MMANM.TTr xGmEMN�ERAp�LypNO�TTEpS_ MATCH LANE r A OU MrMM:TI•K DeA=ew PM LOCATYMe O�P�pwLLL Vj%CflxwL Cp�!l�gK �IeLLaIY oll�aeipM�AAAAU�OMTpAPLLpMPlJ KC "VON"V e 101. `CA�y�O}P�jxpe�POW�T�pMe�LL{i eP Tlx COIIOT �C�TORT MIA �x0�RUM rfJOIIRPaeO ONL xOADMR M - ' YW10rlACaP{apeN7V VrwWq NBC.a`a6�Yt 4 YyNM6rLx .*AMA R SAM "0.,M Pae "w uL To mMM1gVp AA YIOYI Aa OAYMO. • �'y 'N[f CByaeMemepe�lgl�LMPW'� RT OgOr°dali'llwepre,Tyr&AT=..naMe plft. arT MIIWOA7l1aIf. TD,�..OL cvmcrrOIY. • ..s sYen• • D•xa~OPMw Paarwr**CWrACT=POUAR I Me=reM art L .itMMAN POCa w44L INVM rrr"W MrM PLATE= x GROW MM0.M. . wlPls MuerMw MAm mMelMe _ O CaIM TN• colrolMt Tb awn i rs"urMTw�IA Tt�s i w�riTtl°"M , • I I i Z. wn wnaa. r •f� rn u Z..• -' ' S € � !•Ir�VaLAa01f i w 0c0c'°"wuri a e.�'••ti'3t I A� ------------------------------ Ev EMS TRG SECOND w V mtUK • I t=vs+LOFT TO � I _ - RENOVATED EW I r•o TOP MIEN FLOOR B'.�BitiCTAiES�w NEW �• r a• 3d NWI M LAU YOt MASTER LOSET m v r PIMP zw R s ; r ------- ----- DW ULL .c r r I VT PLTYOOO NEATNMfi Y - I L5 R708TNG 6EODIO ft00R �3�• €�4�� �n- ,` "mamma mar r •� wmm a mmf am R NODIN NG D •w ` +r MOWN vs. ------ � 1I ----------- --- - GRE ENHoO USE --- - m•°Um. A — _.... I}}S DETAIL OF PLYWOOD SHEATHING RENOVATED *� *-* •� r''w � `'•- - _' "�'m`' ® INTERIOR KITCHEN WALL pa A T E R DRCG -_ _ mre°•' � j W 3' mr onA amo w �� -------------------------------�a-�--'�__°° °{®`1Omw 'd SCALE-I V74-T a Cd- 1,=_ , aoo ----------------- --------------------- ------------------ afmaaia mUU •-•__�', 1 [ B �'4m�a mums ao�c R NO%) LN D m 1 ii6 Of � NEWm'waIsnu h EXERCISE &R _ RENOVATED ---- f6 3 ROOM �'; loll 7 vraim elan - ;• '• :'r, - ENTRY - -- - a •ar aei %`, a roam` mid y KNEW a�rsw�fw r".. FOYER- • ' s•a ..._E am�fmsa vaintr r•{{ - - arm• p ____ „OFFICE f __ --- - son �a r _ - - '+ _ -- •� CLOSET22 ___�._______..________________�_- �.•'am'ml e a R`i rrta vma�iw enif r; fines nr '` 'm r. yr • 'yrw�e".• w• >.a m _ aEys!idE M1•r MO• an �fw ,an a !a I . vs• m r war mr®• p � - � I. me mr ® � J�. avo i'• owws�•�mes 7C t IIIp ai�eaaV.—rww P m - +' �•+•m 0_5 - -- `, mli '` L oe oe CONSTRUCTION NOTES: I_ �,vr---- I .,.: _ of <_ }r�otma✓wi inrueeaf•aoi�•m - ¢ rs r arti -� y vs wm 0 � . fi�Sl6�° ��•. f. =Z v �o�•�•i w�e�°•iw•n� esa`a�01�°a r f yr ° F' _ of oR ,,.wriar7nr°.nm oaaym mO0°+mTA1°ue�+aa w° IIiow<°O°~ a y r r . ::I u m o TYPICAL NOTES: t S MUDRO ENTRY ��»+.,� °�• 0 "•��"°'°` MATCH LINE ~ r,r RS gap. 1D �iw""F'iwr- NTEMT OP OESW B TO AU M ALL kU PFBT FLOOR SPACES O/E)(STM ..•n,ric.^"n T•""O""'^ WWTRA67OR T'OLAL"RED FOUNDATION RMLB TO AC)OMMATE IM i rr _& manc=_ro• • I �a" m• � NTEMT OP mC1oL DE9K�I S POR LDO TO sE CE7fT£RED- Q ON REAR PAU N MES LaBM L100RS alMc I NDOD TRLRS DL'SION ro PALL ON THAT tEMTElt tNE ' Q , 4 t a` .- MATCH LINE . �•1•x•v is■r YID■on s ,A w „ n a d T t ',---- -.--------- 16 V] a .BATH I z: ss i •w ay _ _ �.__ __. �._.._.... _ of N �'§ oil K ; JU T BEDROOM a] • Y Q 2e L W�p S OC K>t OV w• p a40 3= 13 o< V J t E ot ms . �11'OG�110R6Y�iq � • � w ha w "A ,Mamw. '. a YT c a` CY J AZ "A fJ2 v,. .� :I t _ A—',a9'.je �yF. 7-A 0 4. 6 2 �iN t 4r .4 7-c jU e r s d g ,50/L 7''.d=� :�• •�:� + +wr f�. �Lip',? ,�f�,"� .. :.�: e.:s».a.kt }E� .�� � s�t � N t' � _ �'�. t» • �'�'.aa-f� °�... ,�.r !"� yam, ��•s. ,c,+ ,�' w�t+ � ,�, �i '{�..-.--{ E.. /A1 ('..+ter 's��'� ���"�i✓G ,� G.rf°..�7 7 .. ^/� a a 4 ° �as� '1� y� �+e ,�+, MO OF Z�4L it . �� " ...,/�" l'-�'7 ,yam :.4yr r •' it �i{ 5 NO LEGEND . TOP FNDN = 31 .3' SYST aM PROFILE TEST HOLE LOGS DWELLING ACCESS COVER TO GRADE (voT TO SCALE) NOT ALLOWED Locus SEPTIC DESIGN: (GARBAGE DISPOSER IS ) ACCESS COVER (WATERTIGHT) TO AH OJALA PE z 100.0 PROPOSED SPOT ELEVATION _ 550 ENGINEER: WIT"IN 6" OF FIN. GRADE DESIGN FLOW: 5_ BEDROOMS (1 10 GPD) - GPD MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM D. MIORANDI, RS 100x0 EXISTING SPOT ELEVATION USE A 550 GPD DESIGN FLOW 30.70 WITNESS: 550 = 1100 t \29.0' F;UN PIPE LEVEL 2" DOUBLE WASHED PEASTONE DATE: JULY 20, 2000 '- z 100 SEPTIC TANK: GPD ( 2 ) FOR FIRST 2' ASSUMED < 5 MIN IN F-M SANDS PROPOSED CONTOUR 2000 (PROP.) PROPOSED 2000 � OTTER LANE USE A ____ GALLON SEPTIC TANK PROVIDE MIN. 2 ACCESS 3 MAX. PERC. RATE _ 10O EXISTING CONTOUR GALLON SEPTIC 28 33' COVERS TO GRADE IF UNDER LEACHING: 28.58' TANK (H- 20 ) GAS DRIVEWAY 27.70 CLASS I SOILS (DESIGN) 2(58 + 10.83) 2 (.74) = 203 BAFFLE 27•(?3 SIDES: ' �� o � aa0 0 aQ00 o Z W 58 x 10.83 .74 = 464 2 26.84 O Cl O 3 ® SIDES BOTTOM: ( ( % SLOPE) �6" CRUSHED STONE OR MECHANICAL 0 [� Q Cl O a 0 N W COMPACTION. (15.221 [2]) �`o B ELEV. B ELEV. w TOTAL: 902 S.F. 667 GPD DEPTH OF FLOW = `I'� 1 s ���$ 2 � � � � � � � � � 0 24.84 Q Q Y ( % SLOPE) ( 1 SLOPE) Q" 32.6' O" 32.7' RrE sa USE (6) 500 GAL. LEACHING CHAMBERS WITH 3' TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE STONE AT SIDES AND 3.5' AT ENDS INLET DEPTH = 10„ OUTLET DEPTH = 19" LOCATION MAP NTS FOUNDATION- 21 ' SEPTIC TANK 69' D' BOX 21' LEACHINGFACILITY CLAY 13.14 SILTY MIX ASSESSORS MAP 352 PARCEL 25 BOARD OF HEALTH CLAY MIX ZONING DISTRICT: RF MA YARD SETBACKS: APPROVED DATE 17' 15.7' FRONT = 30' SIDE = 15' HIGHEST OBS. WATER EL. 11.7' COARSE - REAR = 15' MED COARSE SAND FLOOD ZONE: C & EL. 11 ' N 1 g, 13.6' 19, F-M SAND F-M SAND 25' 7.6' 21 ' OBS. WATER 1 1 .7' QELEV. Q ELEV. cQ, UTILITY O" 32.7' 0 31 .3' POLE NOTES: IL 46 3' 33 4' ' SILT LOAM NGVD , COBBLES 29,7' SANDY 1 . DATUM IS EDGE OF j 8.03 ---'-'- - I i LOAM W/ EXISTING WETLAND �l 49.65 52. 7 -gib o`F ,' 3 2. MUNICIPAL WATER IS FLAGS 1 .29' 41 .6gb � COBBLES & % 21.53' 17.50' _ f �`',, ti o� co ti�O �► STONES 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. . 25 ' _ SALT F-M-C 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 20 ti 2 N `, MARSH TR GRAV 5. PIPE JOINTS TO BE MADE WATERTIGHT. (MAIN HSE) N �' 2 E��R,f `'' ..•'. ° ("MEADOW") PLANK 12 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. ry *� I' 17 ENVIRONMENTAL CODE TITLE V. ENCE I `• < // " - - CLAY 7, THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE 11(�0' TIDAL F M C USED FOR LOT LINE STAKING. ;. . ,,•-----, CEDAR ••-�: .. •.. ., � 4;, (INN��Rl GRJVE . � , � +RtAn��-- .,/� �C SAND 7, •3� - TIC' Sf_ " «� (F RC M ECI 1 14 R. PIPE FOR Sf P SYSTEM TO H 4n 4 PVC. 19' BRICK ICK �� 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT of . I -s"1�r s? F-M SILTY F-M SAND INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED pool ,�r� `-��` ��� 21' SAND 1 g' FROM BOARD OF HEALTH. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE PO E k LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR UTILITY r PATIO `�\ D'Otl6LE :. :- ,,� �� 8 F-M SAND �► POLE > 7' G OAK < < '� i! ' M-C TO COMMENCEMENT OF WORK. OV D R. � �� -J �� � ,�'S a � SILTY SAND SAND JZ C cV U IL. EXISTING TH LAYER v SITE FLAN DWELLING FF�° 9.7' 21' OBS WATER 10.3' BEN HMARK ` GE C AWN PREP °Q 23 OBS WATER TOP BRICK W lL R W ! 2,�.!• RIG/ I G ELEV 33.37' 1 �P �- °tiF OF 18 6 STONEY COVE LANE ` /g6�° IN THE TOWN OF: % a, L (CUMMAQUID) BARNSTABLE T GCE sE ( CEDARS 22�� PREPARED FOR: JEAN TU R N B U LL \% G Noy PRISCILLA MYERS 5' REMOVAL OF UNSUITABLE SOIL REQUIRED w N G AROUND PERIMETER OF LEACHING FACILITY, VR.�%' �� ,% IN sro►r 'CURB GARDEN c^ y EXISTING POOL HOUSE SEPTIC DOWN TO SUITABLE SOIL LAYER (F-M SAND). r.• ��/ ' ?� OG F 62 �� SYSTEM 30 0 30 60 90 REPLACE WITH CLEAN MED. SAND. ENGINEER x TO INSPECT AND CERTIFY REMOVAL 11,9� ,cam y/ i EXIST SCALE: 1 ' = 30' DATE: APRIL 9, 2002 s � GARAGE NK "`FENC EXIST. LEACH PIT REV 6/24/02 /(• {` �pC�p% (PUMP & FILL) REV 7/12/02 0� , • A 0 2 REV 5/3/05 e� uwN°R �i'' 1� � AC UNITS LIGHTPOST B2 �H OF Mq �. � ,9 . •. `�ENE ��' .� 5'82 �, ssq� ��•cK of��tiss 0 0 �� OF �wN;-- ' 82 g� e4� A HNE B3 y1_61 ARNE H 9tiaN c� OJALA a OJALA WOOD POST /` -'~*/ '° � U No OIL V GATE PROVIDE VENT WITH CHARCOAL FILTER AND b).. SUGSCREEN (FINAL PLACEMENT WITH L AL �`` c a„ '\ . ( DATE HOMEOWNER CONSULTATION) rtr . / UTILITY t( POLE 1 I I off 508-362-4541 fox 508 362-9880 down cape ?engineering, inc. CIVIL ENGINEERS LAND SURVEYORS 939 main St. yarmouth, ma 02675 00- 144