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HomeMy WebLinkAbout0064 SURREY LANE - Health 64 SURREY LANE, BARNSTABLE O tl r, - :. ..7• is p- ,. �.: „ 4. a� c< ra _ ... .. ry - .. yr_ .a -w r - � �, � • 4. _ '} y , k � o • • , Y. r 3 F a .r " Y} e + • i 'r Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 4 a 64 Surrey Ln. =A Property Address Stanley Smith Owner Owner's Name r-} information is9 required for every Barnstable MA 02630 1/9/2015 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 CO 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: v (J key to move your cursor-do not Paul Martin use the return Name of Inspector key. Neighborhood Waste Water rab Company Name 350 Main St, Company Address " W.Yarmouth MA "02673 Cityrrown State Zip Code 508-775-2820 S15016 Telephone Number License Number B. Certification o 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 ,1/12/2015 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. t5ins•3/13 Title 5 Official Inspectio !Subsurface Sewage Disposal System°Page 1 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection form 1 i Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 64Surre Ln. �..� y Property Address Stanley Smith Owner Owner's Name information is required for every Barnstable MA 02630 1/9/2015 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: System in working condition. 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 t , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e nM- /- 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is required for every Barnstable MA f 02630 1/9/2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced' ❑ Y ❑ N ;.°❑ ND (Explain below): ❑ The system required pumping more than 4 times year 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 EIN ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ` ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to,protect public health, safety or the environment. .1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool.orprivy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated,wetiand or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts �X Title 5 Official Inspection Form -Subsurface Sewage Disposal.System',Form - Not for Voluntary Assessments sy% 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is required for every Barnstable MA 02630 1/9/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply: ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within,50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**: ; Method used to determine distance:' **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. ; 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or)"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS-or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f , Commonwealth of Massachusetts a=� T Title 5 official Inspection, ,Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments _..._ 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is required for every, Barnstable MA 02630 1/9/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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 El ® 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 15,006 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 ❑ 11 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area'— IWPA)'or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, . or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth.& Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is required for every Barnstable MA i 02630 1/9/2015 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? El 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?- ® E Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms-(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1.10 gpd x#of bedrooms): 110x3= 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Surrey Ln. ' Property Address Stanley Smith Owner Owner's Name ' information is required for every Barnstable MA 02630 1/9/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2- Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013=307gpd 9 ( Y 9 (gP )) 2014=334gpd Detail Sump pump? ❑. Yes No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: . Design flow(based on 310'CMR'15.203): Gallons per day(gpd) Basis of design flow,(seats/persons/sq.ft., etc.): - Grease.trap present? '❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑' No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is required for every Barnstable MA 026W 1/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records 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: c> ® Septic tank, distribution box, soil absorption system " ❑ Single cesspool ❑ Overflow cesspool Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ ..Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ;,• 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is Barnstable MA 02630 1 kOl5 required for every - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 15 Years per compliance on file at boh. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ` ❑ cast iron 0 40 PVC ❑ other(explain): +10' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched.with no sign of root intrusion. Septic Tank(locate-on site plan): • 8; 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: 1500Gal H-10 Sludge depth: 6-8" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts r L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments __.. 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is required for every Barnstable MA 02630 1/9/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2" 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? Estimated t Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 150013al H-10 tank in good condition. PVC tees in place and clean. Covers 7" down. Tank at normal operating level. Grease Trap(locate on site plan): Depth below grade: , feet Material of construction: ❑ concrete* ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts _r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is Barnstable _MA 02630 1/9/2015 required for 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: 4 ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑' Yes' ❑ No FAlarm level: — Alarm in working,order.. ❑ Yes ❑ No Date of last pumping:. Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes . ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A, 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is required for every Barnstable MA 02630 1/9/2015 page. City/Town State . Zip Code ' Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): „ Depth of liquid level above outlet invert 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.): H-10 DB-3 with 1 line in and 1 line out in good condition. Box is clean and level with minimal signs of solids carryover. No sign of overloading or hydraulic failure. Cover 2' below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: w ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-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 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is Barnstable MA 02630 1/9/2015 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: + 6 ❑ leaching galleries number: r ❑ 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.): 6- High Cap Infiltrators with stone in a 10'x40'trench configuration., 1-2"of standing effluent in chambers at time of inspection. No sign of overloading or hydraulic failure. Cesspools (cesspool must be pumped'as partoof inspection) (locate.on site plan): Number and configuration Depth top of liquid to inlet invert . Depth of solids layer- Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow . ❑ Yes ❑ No t5ins•3/13 s Titfe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 - j Commonwealth of Massachusetts i r Title 5 Official Inspection Form =� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , - 64 Surrey Ln. Property Address " Stanley Smith Owner Owner's Name information is required for every Barnstable MA 02630 1/9/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding„condition,of vegetation, etc.): t5ins°3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is required for every Barnstable MA 02630 1/9/2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below t ® drawing attached separately a: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 P Y rY 64 Surrey Ln. , Property Address t r Stanley Smith Owner Owner's Name information is required for every Barnstable MA 02630: 1/9/2015 A page. Cityrrown y t, State Zip Code L - Date of Inspection s D. System Information (cont.)� Site Exam: _ R ® Check Slope" y ® Surface water ® Check cellar ® Shallow wells - s� Estimated depth to high'ground water ;° +12' n feet Please indicate all methods used'to determine the high ground water elevation` ry Obtained from system design plans on record = f If checked, date of design plan reviewed: 5/25/1999 _ ,Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain El Checked with local excavators,,installers attach documentation) t El Accessed USGS database—exIplain- You must describe how you established the high ground water'elevation' Test hole data'per plan on file at BOH dated 5/25/1999. Test hole to 12'with no groundwat&r° encountered. Bottom'of leaching at 4'6'. Minimum of 7'6" Separation. iBefore filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 ` ` 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 la 64 Surrey Ln. Property Address Stanley Smith Owner Owner's Name information is Barnstable MA 02630 1/9/2015 .. required for every , page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked' ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ,.; 4 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE Aeir', S%���' ASSESSOR'S MAP & LOT' —(', INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 50,E y LEACHING FACILITY: (type) IlA,roe s (size) :OY `a? NO.OF BEDROOMS z' / BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 C - b �Lj l��ci -j ----------- --------- TOWN OF BARNSTABLE LOCATION 6' t L-l �EWAGE # VILLAGE ���'� ��u � ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 5-OJ19 LEACHING FACILITY: (type) (size) /'✓�w��0 L'� `a NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: I—%'�!`I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist sn 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 c;Z o ' 3 7' No. / � '� FeeP� THE COMMONWEALTH OF MASSACHUSETTS^ Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for�30i!6pozal *p$tem Construction Permit Application for a Pemut to Construct(, )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Cp A 4�LA NJ:-- Owner's Name,Address and Tel.No. Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. STEPHEN J. DOYLE & ASSOC. 42 Canterbury Lane East Falmouth MA 02536 Type of Building: Telephone: 5 0 8/54 0-2 5 3 4 Dwelling No.of Bedrooms _ Lot Size i sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ArA O gallons per day. Calculated daily flow gallons. Plan Date Co—1,4—!q Q Number of sheets ` Revision Date Title S-Mc— of= ibk_ .eta. ��A.i3l.►�. �-0�2. � �"�'j� �xc�, Size of Septic Tank i!j�jb 1:) Type of S.A.S. Description of Soil R:6 SiTt� Xt�4 Soj L l_thstS. Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate.of.Compliance has been issued by th' of Hpafth Signed Date - 7 Application Approved by Date &—/7-.O!P Application Disapproved for the ollow g reasons Permit No. Date Issued No. / �` f Fee C P THE COMMONWEALTH OF MASSACHUSETTSA0 Entere3 in computer:- _ r es - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppficatio„n for Wgpoar *paem Cowaruction Ver?ntit Application for a Permit to Construct(V)Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components } Location Address or Lot No. Ce A Isla�L��e.>�' LA NL Owner's Name,Address and Tel.No. -Assessor's Map/Parcel Za`00 �Aao�n ic.d@.r�►c Installer's Name,Address,and Tel.No. Designer's Name,Addr io �uI�IEN& J. DOYLE & ASSOC. 42 Canterbury Lane East Falmouth, MA 02536 .. Type of Building: Dwelling's No.of Bedrooms Lot Size rj sq.ft. Garbage Grinder( ) R Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow O gallons per day. Calculated daily flow 4d4- gallons. Plan Date G- k 4 -qq umber of sheets Revision Date Title S-me Ol~ L.f�'N3> kbk "5nm"ccaTu r=. Fo�L S't!Na1A Size of Septic-Tank 1!n)o Type of S.A.S. "SNA,T= Description of Soil -=�_ E�,VT-y 1R.A.i 50$k LO Nature of Repair or Alterations(A{lswer when applicable) ``Date last inspected: { Agreement: The undersigned agrees to ensure the cons on qd intenance of the afore described on-site seA�age disposal system in accordance with the provisions of Title 5 h En ir!Wn I yCode and not to place the system in operation until a Certifi- yl -Cate of Compliance has been issued by thK' B d _ Cl_ 919 Signed Date 7 e -� Application Approved by e Date /' - /7- 0f, Application Disapproved for the follo ' g reasons - z 4 Permit No. ��- �uw3 Date Issued .iI\ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(fir)Repaired( )`<Upgraded( ) Abandoned( )by 11A Ao�A 7-d at 4 's,C-grtA � ��,�Q,,�t i has been constructed in accordance with the provisions of Title and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this em 1 t be construed as a guarantee that the syste ille--untti n as-designed. f� Date % Inspector �/ --L -------------------------------------� No. ✓�` b-3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligofsar *p5tem Com5tructiou Vertu Permission is hereby granted to Construct(t<Repair( )Upgrade( )Abandon( ) System located at l0 9 5y v Y t a w-e /'jGt-r 6/,t 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:Constructioon�must be completed within three years of the date of th' it. � Date: / / — / Approved by - �� / TOWN OF BARNSTABLE LOCATION Smarr-,- Z SEWAGE # VILLAGEr ASSESSOR'S MAP & LOT' ) �n(�' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER ; PERMITDATE: �-L f COMPLIANCE DATE: `. .� Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 T �L r, 91, 6 (� 17 d: j i Town of Barnstable P# Department of Health,Safety,and Environmental Services _ 1m>� � Public Health Division Date — qq 367 Main Street,Hyannis MA 02601 � HARN9TA MAM BM °lfvMxt� Date Sclieduled lqqvTime Fee Pd. Soil Suitability Assessment for Sewage Disposat. Performed By: S 7��j\ t%, Witnessed By: LOCATION &GENERAL INFORMATION Location Address j j�)h�`l �l� _ Owner's Name Address STEPHEN J. .DOYLE & ASSOC. Assessor's Map/Parcel: Engineer's Name 42 Canterbury Lane East Falmouth, MA 2536 NEW CONSTRUCTION REPAIR Telephone# Telephone: 508/540 2534 Land Use Slopes p Surface Stones �� Distances from: Open Water Body 1 �i J R Possible Wet Area 1 O R Drinking Water Well AV/V R Drainage Way R Property Line R Other —`T —R SKETCH: (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) N �A, t v L r 160 A1. Parent material(geologic) Depth to Bedrock�`t a�j� Depth to Groundwater: Standing Water in Hole: Weeping from Pit Pace Estimated Seasonal High Groundwater bTERMNATIOl1- ORS EASONAGIt VVA'1`ER'I'At Method Used —ate `�— `a--� �©l '. _. Depth Observed standing to obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment R. w- Index Well# Reading Date:— Index Well level...--— Adj.factor Adj.Groundwater Level YERC. A.TION''rVST Date t me Observation ' r *' Hole# { ZT. Time at 9" Depth of Pere itI( P 3� 3� Time at 6" Start Pre-soak Time @ f (i���—o Time(9"-6") End Pre-soak Z' c)j 2� GI'A.11.c�kl.S Rate Min./Inch L "Z L Z l.1NaT3L -f-� fs U Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) '-�1 Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant Town of Barnstable P# Department of Health,Safety,and Environmental Services �Ila� Public Health Division Date /\'�'367 Main Street,Hyannis MA 02601 • BARNETABLE, MASS. i63q. �0 'rfn nw+" Date Scheduled Time Fee Pd. Soil Suitability-Assess»zent for Sewage Disposal Performed By: L,� Witnessed By:-ZH� LOCATION & GENERAL INFORMATION Location Address __...::._.. Owner's Name Address Assessor's Map/Parcel: rn Engineer's Name NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well �R Drainage Way ft Property Line ft Other R SKETCH:(street name,dimensions of lot,exact locations of test holes&pert tests,locale wetlands in proximity to holes) r. Parent material(geologic) /Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater bmElttNA`TIO1rI O1Z SEASONAL,HtOA ER`I'ABL Method Used: _.. Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. �- Index Well# _ .Rending Date:— _ Index Well level __ _ Adj.factor_ Adj.Groundwater Level_ T'EI2CQLATLON TEST tiate Ttme Observation Hole# Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant i i zN A - T 260142 TOP FOUND. EL 3'9,``i _ . . ,,— 3e, - MA-wl: �..��o'�1v G�w�-a1.:. -��{s`��`�� Grammer--e��y,;��.•r' S -; ZZ rmu WATER TIGHT COVER • b L r l� r ,L INV. El. 3 g•O 7 LEVEL 2 \ R � . . . FLOW LINE 2' TIN. 1/8" TO 1/2" WASHED STONE 10` YIN. .i � 4,? INV. EL. —� `t1'✓ -3LS 3,�h, ��' u34" Y 10 MIN. uoulo oEPTH MIN. e' 1 o INFILTRATOR Locus SUMP f �. �,,t / tJo Y r w tV 't l •>r rf * 1 3 4' =� 1 1 2" WASHED STONE EFF. DEPTH \ :I• •as• •`�' ;` ! w� "P INV. EL 3` I E 3� `d / / INV. L INV. EL -s.�, �. 1 o L.3 \ \ 7�r � , 24 ,�. .. S.A.S. 40 LONG x tO WIDE x.�EFF. DEPTH 30 ♦\ \ '� t 1, #, y, ;' � � �.:" PRECAST REINFORCED CONCRETE WITH __ HIGH CAPACITY INFILTRATOR CHAMBERS \ 28 \ r `� 32 ♦ 26 MAa�.jyyy 1500 GALLON PRECAST REINFORCED CONCRETE SEPTIC TANK DISTRIBUTION BOX ♦ �\ \, ' ';. ' ar ,y' 34 ♦ \ \ \ \ Panted Ih m TOKiel WildtbweL P,od.teoro(aw,.tope aom) MINIMUM CONSTRUCTION MATERIALS PER 310CMR 15.226(2) INSTALL ON A LEVEL BASE 36 �o6�Dt ♦\ \\ \\ `\ �` US C S LU C T- S MAP MINIMUM WALL THICKNESS - 2" ♦ \ \ \ TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND 38 ♦ \ \ a SHALL EXTEND A MINIMUM OF 6' ABOVE THE FLOW LINE MINIMUM INSIDE DIMENSION 12' ` ♦ ♦ \ \ \ \ �m OF THE SEPTIC TANK AND BE ON THE CENTERLINE OF THE 40 ♦ \ ` `\ \ \ \ `, j SEPTIC TANK LOCATED DIRECTLY UNDER THE CLEAN-OUT I MANHOLE OUTLET INVERTS SHALL 8E EQUAL TO EACH ' ` ♦ ♦ \ \ \ OTHER AND AT 2' MINIMUM' 42 BELOW INLET INVERT. ` 4 � ♦ \ \ \ \\ ��� 44 THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2- NOR +o ` \ \ \ 1 r MORE THAN 3' ABOVE THE INVERT ELEVATION OF THE THE DISTRIBUTION ONES. FROM THE DISTRIBUTION BOX OUTLET PIPE SHALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING ♦ �\ ♦ ♦ \ \ \ \ \ \ THE.OISTRIBUTION BOX TO THE HEIGHT OF THE DISTRiBU110N ♦ ` ♦ \ \ \ \ \ \ �� •� `\ ♦` \ \ \ \ \ I �� LINE INVERT AFTER ALL LINES HAVE BEEN SEALED 'IN PLACE. ` SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRAD INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE ♦ ♦ ` ♦ \ ` \ \ \ \ �.'a ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY E ♦ \ ♦ \ \ AND NON-DEFORMABLE MATERIAL PERMANENTLY FASTEND TO THE / `♦ `� ♦♦ `♦ \ \\ \ \ I \ ° COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE LINE OR RECONSTRUCTING THE LINES UNTIL ALL INVERTS ARE OF ♦ ♦ \ \ \ \ \ 1 \ N. :` 48 ELEVATION.. AS BEEN PLACED TO ENSURE STABILITY AND TO PREVENT EQUAL / / i \ ♦� \ \ I \ a SETTLING. 00 SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9'. / I I �• ! ! 1 ! ♦ -`' THREE 20 MANHOLES WITH READILY REMOVABLE IMPERMEABLE I / I I ♦ ��� COVERS OF DURABLE MATERIAL SHALL•13E PROVIDED WITH ACCESS PORTS BEING PLACED AT THE CENTER AND OVER THE INLET AND ! I / • J ,i. / / \' OUTLET TEES. 26 - THE OUTLET TEE SHALL BE EQUIPPED WITH GAS BAFFLE. GENERAL CONSTRUCTION NOTES � 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN OF =G�.rraas�r� RULES AND REGULATIONS FOR / / / .. ♦ `♦ � THE SUBSURFACE DISPOSAL OF SEWAGE. ' / ,� \ � may\ ' . .. . ` . ♦ � ♦ °� 2. AT LEAST ONE ACCESS PORT OVER TANK TEES SHALL BE ACCESSIBLE / A° \♦ ` ` ` ` 3 WHITHIN SIX INCHES OF FINISH GRADE WITH ANY REMAINING ACCESS / ` ♦ ♦ ` �'�' PORTS BROUGHT TO WITHIN TWELVE INCHES OF FINISH GRADE. �/ ` ` \ \ j \ ♦ \ 3 ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' / :```. A `° r5� �. ` � `� `� 30 OF \` OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR WITHIN �♦ ;;moo �`. oA ` CZZ, °.po 10' OF DRIVES OR PARKING UNLESS NOTED. 32 S ono m� \ \ \28 4. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF ALL SITE UTILITIES PRIOR TO ANY EXCAVATION. °� ' q `� \ 34 5. SEWER PIPES SHALL BE 4 SCHEDULE 40 PVC LAID AT 0.02 SLOPE. 00. � •''••••�' `, 0 / t \ 36 6. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE ;, DEC MORTARED IN PLACE. 48 \ i � PROPOSED 7. FINISH GRADE-SHALL HAVE A MINIMUM SLOPE OF 0.02 FEET PER FOOT. 500 GALLON — • � ♦ TANK ♦♦ - ; i / 1 ZONING DISTRICT- RF2 �, ♦ \ / o,• 1A-R� /I �}� BUILDING SETBACKS: ` ♦♦ \ / >h lr" l� (� FRONT 30' \ t Of Alp RIEAR DE 1 5' REFERENCE MAP: 38 , z��� '�c OVERLAY DISTRICT: AP \ SOIL OBSERVATION DATA: WILLIAM � \\ / / / � UEBERMAN �� CAPE COD DESIGN DATA: \ ♦ / / / // A°j �E `� EB RM t ASSESSORS MAP: 298/63 WATER TABLE CONTOURS \ A4 // // / I�0 375 $.11 N a�'o�`♦ STREET ADDRESS: 64 SURREY LANE AND TEST DATE 5- z 5-°1`\ PUBLIC WATER SUPPLY STRUCTURE _ ♦` t / 14rt`�,�p4, a,�Es IS aG�a FEMA DATA: WELLHEAD PROTECTION AREAS TYPE�S � ,� LOT 2-8 \\ i\ // / l��D suwq `- s��At E LOCUS DOES NOT LIE IN A SOIL EVALUATOR -_. S '��ey .r SEPTEMBER 1995 N0. BEDROOMS GARBAGE DISPOSAL ♦ ♦ \ \ \ / FLOOD HAZARD ZONE WATER RESOURCES OFFICE DESIGN FLOW A)( lko AAo l�r-n���nr. •-�--- 35,151 sq.ft. B.O.H. AGENT \ \ f`n►'�5f~�'yLF CAPE COD COMMISSION RECORD PLAN: 260/42 GRAPHIC SCALE EXCAVATOR _ �.v�...'r•o Ge-pus;. �� � \PERCATE \ \ 21? o 10 20 40 so ` \Z +��ly � �\v�t� 40 `ssr- � \ , . - SEPTIC TANK `i. .art . tr5�,s p y �L. 4L.0 �It \ \ \ ( IN FEET ) Sl. a tb ytz -s Z „ s�. � LEACHING FACILITY - �tn i. .o }go ���� K Z = Zoo \ \ ----- ke l 3�Zgii \\� \\ \ \ 42 P Z..A�N"� 20V�C� W L S "� Lo 2 s LS � _ 3 if 3�'" ♦ 44 7'�'y Tz s/c� d , x •-1� _ �a�t c,�;� s��,�t n \\ �\ I-,A.N O 17 T A l_�'T ID Icki \ IN 46 DEPICTING THE PROPOSED Sa�•ap t Z•o� t`L tt7 i ' 48 l\/-E I '�' N" Scale: As Shown Date- June 14, 1999 Prepared By. NOTE. SHOULD SOILS ENCOUNTERED DURING EXCAVATION THAT DIFFER Stephen J. Doyle and Associates FROM :SOIL LOGS, CONTACT DESIGNER AND/OR BOARD OF HEALTH BEFORE 42 Canterbury Lane, East Falmouth, Massachusetts 02536 PROCEEDING WITH SYSTEM INSTALLATION. Telephone: 508/540-2534