HomeMy WebLinkAbout0035 VANDUZER ROAD - Health 35 VANDUZER RD.
- -„ BARNSTABLE
`�` A = 352 065
TOWN OF BARNSTABLE
LOCATION 33,E � ��e SEWAGE #
VILLAGE '&42 04-P ASSESSOR'S MAP & LOT 5'02 Da�
INSTALLER'S NAME&PHONE NO. • Cd Iry
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) (size)
NO.OF BEDROOMS
B1 [t OR OWNER
PERMTTDATE: 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C.System Information(cont.)
35 Vanduzer Road _
Property Adtlress
Cummaouid MA 02632
cltyrrown state ZIP code
Laura Blair October 5,2005 _
Owner's Name Date of Inspection
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.
LOCATIONS
A B
1 52 ft 40 ft
2 56.5 ft 41 ft
SEPTIC AM 3 59.5 ft 41.5 Ft
EACMna
HELD o x®
EXISrwG #35
DWELLING
I
VANDUZER ROAD NOT TO SCALE
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t5-220e.doo•11 r2'604 Title 5 Official Inspection Fonn:Sul—Irrace sewage Disposal system
Page 15 of 16
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-VA ZZ E r�
TOWN OF BARN TABLE
5 va �'� zer ,Road
L33GATION SEWAGE #
ASSESSOR'S MAP & LOT3 S 0�O
�'S-'NAME&PHONE NOk&Z
d 1
SEPTIC TANK CAPACITY CO -RCb
n A11j,. 64T ,cal'® 0
LEACHING FACILITY: (type) 5`�.t uG �! � (size) 49 &&TA4-
NO.OFBEDROOMS—
BUILDER OR/OWN�—gQ6�619' �Z�). �
PERMITDATE: COMPLIANCE DATE: r
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
'i
Furnished by
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LOT- NO. . ,;- ADDRESS:_ 5. , A,ey T
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OWNERS
OWNERS NAME: LAu YLA (j-W ft
SEWAGE PERMIT NO. Yy NEW: REPAIR:
DATE ISSUED:- Z3 DATE INSTALLED: s
a..
INSTALLERS NAME:
. r
INSTALLATION OF:
WATER TABLE: FINAL INSPECTION BY:
DRAWING OF INSTALLATION ON, REVERSE SIDE:
1 _
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BORTOLOTTI CONSTRUCTION, INC. ocr
45 INDUSTRY ROAD,MARSTONS MILLS,MA 02648 . o x 20�� '
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- 508-428-8926 FAX: 508-428-9 99 �'sr
508 771-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
PART A
CERTIFICATION
O
Property Address:,.
Date Of Inspection Inspector's Name: °
O ier's Name and Address: n.
CERTIFICATION STATEMENT:
I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa-
tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform-
ed based on my Training and Experience in.the Proper Function and.Maintenance of On-Site Sewage Dis-
posal Systems.Th system:
Passes
Condition sses
Needs F th Evalu o the Local Approving Authos.. 4)/
Fail e
Inspector's Signature Date:
The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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 the System Owner and copies
sent to the Buyer,if applicable.and the Approving Authority.
INSPECTION SUMMARY•
A) SYSTEM PASSES:
`,/ I have not found any Information which indicates.that the System violates any of the fail-
ure criteria as defined in 310 CM1115.303. Any Failure Criteria not evaluated are indi-
cated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more System Components need to be Replaced or Repaired. The System,upon
completion of the Replacement or Repair,Passes Inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not
determined",explain why not.
The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil-
tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank
is Replaced with a conforming Septic Tank as Approved by the Board Of Health.
Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is clue 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):
-1-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is leveled 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.
C)FURTH]ER 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 HE LATH DETERMINES 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 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a Septic Tank and Soil Absorption System and is within 100 Feet to a Surface
Water Supply or Tributary to a Surface Water Supply.
The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public
Water Supply Well.
The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private
Water Supply Well.
The System has a Septic Tank and Soil Absorption System and 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 from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the System violates one or more of the following Failure Criteria as defined
in 310 CAM 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.
Backup of sewage into facility or system component due to an overload 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
- 2 -
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
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 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.. 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) LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 ggd 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:
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..;
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner;occupant,Pnd Board of Health.
_None of the system components have been pumped for atleast 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 part of this inspection.
As-built plans have been obtained and examined. Note if they are not available with N/A.
_ZThe facility or dwelling was inspected for signs of sewage back-up.
�rlie system does not receive nou-sanitary or industrial waste flow.
J;,�The site was inspected for signs of breakout.
_ All system components,excluding the Soil Absorption System,have been located on site.
�rhe septic tank manholes were uncovered;opened,and the.interior of the septic tank was in
for condition of baffles or tees,material of construction,dimensions,depth of liquid,
depth of sludge,depth of scum.
he size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
- 3 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
t. The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RE_,SIDENTIAL:
Design Flow:13gallons Number of Bedrooms:- Number of Current Residents:
Garbage Grinder: /�.,R— Laundry Connected To System( Seasonal Use:-Iq�,; -
Water Meter Readings,if a ailable:
.Last Date of Occupancy: -
C'OMMFRCIAL/INDUSTRIAL•//,7(Z-
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: (Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS any source of information:
�0/i/�)lz)jj�,Yaiza,4 k2&ww_d457-
System Pumped as part of inspection: I yes,volume pumped: ga lons
Reason for Pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
eared System(If s,attach previous inspection records if any)
Other(explain): -�
APPROXIMATE AGE o all components,date installed i nown)and source of information:
Sewage odors detected when arriving at the site:
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grad e: Material of Construction: concrete metal FRP Other
(explain)
Dimensions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,couditioin of inlet and outlet tees or baffles,depth of liquid level
in relation to outlet invert,structural integrity,evidence of leakage,etc.)
GREASE TRAP: •
Depth Below Gra e: Material of Construction: concrete metal FRP: Other
(explain):
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Continents: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level
in relation to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain):
Dimensions: Capacity: gallons' Design Flow: gallons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: ` _
m 'r
Depth of liquid level abo7ve outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or
out of box,etc.)
PUMP CHAMBER�.�
Pump is in working order:
Comments:,(note condition of pump chamber,condition of pumps and appurtenances,etc.)
- 5 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1 { SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive
` � metl[ods) If not determined to be present,explain:
�, �
Type:
.0. Leaching pits,number: Leaching chambers,number: Leaching galleries,number:
Leacahing trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
nunents: (note dti n of soil,signs of hydraulic fail.re level of ring,condition ofgetation,etc.)_
CESSPOOLS:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: q/' -Depth of scum layer: / '� Dimensions of Cesspool:( , 9,0 (�d
Materials of construction:61'ytk";6 2. Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil,signs of hydraulic failure, 5vel of ponding,condition of vegetation,
etca- i
` fi is
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation,
etc.)
- 6 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references,landmarks or benchmarks.
Locate all wells within 100 Feet.
� I
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DEPTH TO GROUNDWATER: _
Depth to groundwater: /J Feet ,L
Method of Determination or Ap roxi ation:
- 7 -
No. " �, 0 Fee G ��
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for iquar *pztem Comaruction 3permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3 r Ow er's Name,Addres Tel.No. , ®C,01,s n4q
Assessor's Map/Parcel
Instal is Name,Address,and Tel.No. 36a- c g 4 Designer's Name,Address and Tel.No. J `
V MG.
Type of guilding: ,
Dwelling No.of Bedrooms `'t Lot Size sq.ft. Garbage Grinder(/ )
Other Type of Building 4r� No.of Persons Showers(,k Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gal ons.
Plan Date Number of sheets Revision Date �'— 3 ` 01
Title
Size of Septic Tank .50 Type of S.A.S. ZO )c y
Description of Soil P' T
r
Nature of Repairs or Alterations(Answer when applicable) i W01
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 issueq by this
Signed OSAAL6, Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 0 Date Issued Z J Q
jk
No. s4,;ty `; i Fee
THE COMMONWEALTH OF SSACHUSETTS Entered in computer:
PUBLIC-`HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes
Zipprication for i�Pogar *r6tem Con.5truction Permit
Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Addressor Lot No. 3 S" Own is Name,Addres Tel.No. 10 GD ,0,i4l-
Assessor's Map%Parceljo
� H
Install s Name,Add
jess,and Tel.No. ra,. r-19 Ll 'P. Designer's:Name,Address and Tel'.No.
l Type of Building: J Dwelling No.of Bedrooms `t Lot Size-- � - -sq.ft. Garbage Grinder(� )
Other Type of Building A#'VPdhe4M e No.of Persons �_Showers(004 Cafeteria( )
Other Fixtures
Design Flow "7 gallons per day. Calculated daily flow 141 gallons.
Plan Date o Number of sheets Revision Date $- 3-
Title
Size of Septic Tank
Q 0G0 Type of S.A.S. ?-'0 X 3 U 1 j
Description of Soil
tJ W01
Nature'of RepaG r Alterations(Answer when applicable) 4'� !D 1 C.
Date last inspected:
r /
Agreement: � ,11
The under-sign''ed 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 afnd,not too p aclacl a the system in operation until a Certifi-
cate of Compliance has been issued,by this Ord f
Signed off Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued 7- /S- o
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS Q°W__11/116 ' �F ,�-0 k
BARNSTABLE; MASSACHUSETTS � -�0 1
Certificati'of Compliance
THIS IS TO CER Y, tha the On- it Sewage Disposal S stem Constructed_( Repaired( )Upgraded( )
Abandoned bv /�t G ►� C�u lI
at CJ a & a-+'"j 6A. 6-has been.constructed in accordance
with the provisions of Title 5 and the for Disposal System onstruction Permit N0-/ 8Wdated ���r /
Installer Designer_ /
The issuance of this permit shall not be construed as a guarantee that the syste ill fu on desig eV
Date -� I OI Inspector
r — _ o �-
---------------------------------------
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS
MigpooaY *y5tem Con!6truction Permit _
Permission is hereby granted to Construct( )Repair( )Upgrade ) bandon( )
System located at 3 /" 1<C /A- jP_ d)�'j �-
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 must be completed within three years of the date of this permit.
Date:�5 I U/ Approved by Iwk- i f" 14 M
J f j
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LOT NO or, ADDRESS 35, C*A40/ ' Mc.J .
OWNERS NAME: °-r� �
SEWAGE PERMIT, NO. . ZOv/'757NEW: REPAIR:
j ,DATE ISSUED:_y T u DATE INSTALLED:
iNSTALLERS NAME
INSTALLATION OF 1,5no wiz �ILI ,
WATER TABLE:��I�.FINAL INSPECTION-'BY:+
DkAWING OF INSTALLATION ON REVERSE SIDE:
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TOWN OF BARNSTABLE BAR—w 2512
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager y LIVIVz
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Address of Offender MV/MB Reg.#
Village/State/Zip
Business Name r 0 Lo�I, IX,aUam/ m- on '4 � 206t
Business Address
Sig ature ot Enfop6ing Officer
Village/State/Zip j
Location of Offense 3S 1/ d+sZ k60r'rhS6a'6k �' 'rrT/
Enforcing Dept/Division
Offense G as CI 7 S-,5(J/f"
Facts /�y p1,v�f'it t�✓ ��i I P �� 2>0J.V'X < d�—
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This will serve only as a warning. At this time no legal action has been taken
It is the goal of Town agencies to achieve voluntary compliance of Town '
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
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Ordinance or Regulation
WARNING NOTICE
Name .of Offender/Manager J. y,Lwl 404i 0 � �rti
e
Address of Offender MV/MB Reg.#
Village/State/Zip
Business Name 1 01 ovg� iti. team/pm; on, z6lioe I,.
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...Business Address
Signature of Enforcing Officer
Village/State/Zip r
+' Location of Offense s L/G.,.4dV22t. I59WOf
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Offense G. ,ff.f/ )�F&/zf ti; A,Ee� /T Z,y�l
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t,a' ..SOi Irk commaeAACere 1� c77 -�fid�vhj&� act ' d / 17 _
This will serve only as a. warning. At this time no legal action.ha.s been taken.
It is the goal --of Town agencies. to achieve voluntary compliance. of Town `"
Ordinances, Rules and Regulations. Education,.efforts: and warning notices are
attempts to gain voluntary compliance.. Subsequent violations will result .in:
appropriate le al. action b the Town /0v,`
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TOWN OF BARNSTABLE B]*W
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Managed L0t/1 0 t a") It-
Address of Offender MV/MB Reg.#
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Village/State/Zip
,Business Name °" O l Ciy'i� am/ "m on '-tIZ4 f204
Business Address ... �t't
Signature of Enforcing .Officer
Village/State/Zip
Location of Offense 26-51'"f.",j t4 .�4/42 r
Enforcing Dept/Division
_Offense � � f "/. 5-t'ly A _ M 1�
Facts G� t✓-1� #.rtl -fin1f? r� F "� /lrtJ? R r d'tst �t r ,. + : fva�'i:J 1�"
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f� re, �tr 07�;py :.f��,;R •r1_f.al , s++� �r' I�It'+p� �jpjl
This will serve only as a warning. At this time no legal action has been taken.//,
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances_, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will, result in
appropriate legal action by the Town. P— / � /, ,tP4filtr+
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the
computer,use 35 Vanduzer Road- Cummaquid
only the tab key Property Address
to move your Laura Blair
cursor-do not -
use the return Owner's Name
key. 15 Indian Trail
Owner's Address
^� Cummaquid MA 02632
City/Town State Zip Code
Date of Inspection: October 5, 2005Date
2. Inspector:
David D. Coughanowr, R.S.
Name of Inspector
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364 0894
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 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
!Z)MA �. October 5, 2005 _
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.
t5-2208.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
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 ❑'forthe 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:
t5-2208.doc 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'GSM
A. Certification (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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
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Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'GSM
A. Certification (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached
to this form.
3. Other:
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Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
GSM
A. Certification (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
D)System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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
❑ ® 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
Yes No
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
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Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
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.
t5-2208.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
B. Checklist
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
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 available
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, including the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]
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Page 7of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
C. System Information
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
I
Number of current residents: 3 -
Does residence have a garbage grinder? Removal of grinder is recommended ® 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 years usage (gpd)): 710 gpd
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: -
Last date of occupancy/use: Date
Other (describe): -
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Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
C. System Information (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: owner -
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:
Age: 4+ years. Certificate of Compliance issued 5/14/01 (Board of Health Files)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-2208.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 9of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
iG^M
Subsurface Sewage Disposal System Form
C. System Information (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 2 -
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain): -
Distance from private water supply well or suction line: 20+feet -
Comments (on condition of joints, venting, evidence of leakage, etc.):
Sewers appear structurally sound with no evidence of backup or leakage into dwelling
Septic Tank (locate on site plan):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years -
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions:
10.5 ft x 5 ft x 5 ft(1500 gallon)
-
Sludge depth: 4 inches
Distance from top of sludge to bottom of outlet tee or baffle 30 inches
Scum thickness 1 inch
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined? Probe to top of tank -
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Page 10 of 16
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
4�M
C. System Information (cont.)
35 Vanduzer Road
Property Address
Cummaquid Ma 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended every two years. Tank
and tees appears structurally sound and functioning as intended. No evidence of leakage in or out
was observed.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: -
Scum thickness -
Distance from top of scum to top of outlet tee or baffle -
Distance from bottom of scum to bottom of outlet tee or baffle -
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: -
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
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Page 11 of 16
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
C. System Information (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
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.):
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert At outlet inverts
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-2208.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number: -
❑ leaching chambers number: -
❑ leaching galleries number: -
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 —40ftx20ft -
❑ 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.):
Soils above leaching field appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching field stone and no effluent contact staining or standing effluent was observed.
t5-2208.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o
Not for Voluntary Assessments
;M Subsurface Sewage Disposal System Form
C. System Information (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
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.):
t5-2208.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
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.
LOCATIONS
A B
1 52 It 40 It
2 56.5 ft 41 It
SEPTIC A 3 59.5 f t 41.5 f t
TANK
LEACHING 30 2F .1
FIELD
�D-BOX
B EXISTING
DWELLING # 3 5
W .
Z
J
W
N
Q
3
VANDUZER ROAD NOT TO SCALE
t5-2208.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
35 Vanduzer Road
Property Address
Cummaquid MA 02632
City/Town State Zip Code
Laura Blair October 5, 2005
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water: 4.67 ft
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 1
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:
Approved design plan on file with the Board of Health shows bottom of system to be 4 feet above
groundwater level observed in witnessed test pit. Applying a groundwater adjustment of 1.1 feet
(Index well SDW-252 Zone A, 4125101 reading=47.0)demonstrates that the bottom of the leaching
field is above adjusted high groundwater.
t5-2208.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System-
Page 16 of 16
Town of Barnstable Barnstable.
Regulatory Services Department Ml-A1tledcacfty
+ sexivSTABLE,
b 9. Public Health Division m
ArFD""a� 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2848 2206
August 1, 2016
Laura Egan Blair
15 Indian Trail
Centerville, MA 02632
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 35 Van Duzer Road, Barnstable,MA was last inspected on
07/07/2016, by Chad Hathaway, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally.Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Rotted distribution box.
You are ordered to repair or replace the septic_ system within one'(1)year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
KR"ORDER OF THE BOARD OF HEALTH
�om a McKe, , R.S., CHO
Agent of the Board of Health
CC: Barnstable Department of Health and Environment
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\35 Van Duzer Road Barnstable.doc
E
Town of Barnstable
• swRxsTnaLe,
Regulatory Services Department
RFD Ml��
1 Public Health Division
200 Main Street, Hyannis MA 02601 .
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO. REPAIR FAILED SYSTEMS .
(Town Code §360-44 and Title V: 310 CMR 15,000)
An"x",marked in the ❑ is the failure criteria and associated repair deadline
Y
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution.box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system.passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching pit or cesspool with high liquid level, <12" below-inlet(per Town Code
§360-9.1)
❑ Leaching facility with standing liquid level at or,above the invert pipe (per Town
-Code §360-20 h)
OTHER )
/. x
Repair deadline le A✓
Q:\SEPTIC\DEADLINES TO REPAIF FAILED SYSTEMS.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Van Duzer Rd C
r—
Property Address
Blair, Laura Egan r
Owner Owner's Name �7
information is
required for every Barnstable Ma V Ma 7/7/2016
page. Cityrrown State Zip Code Date of Inspection co
m '
Uq
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information i
on the computer, 'I j
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Hathaway
use the return Name of Inspector
key.
H.P.S.
� Company Name
P.O.Box 151
Company Address
Forestdale Ma 02644
City/Town State Zip Code
774-274-2581 12866
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
7/7/2016
Inspector's S nature Date
The system inspector sh I 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 Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
V'.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 35 Van Duzer Rd
Property Address
Blair,Laura Egan
Owner Owner's Name
information is Barnstable Ma Ma 7/7/2016
required for every
page. CityrFown 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:
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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. Cityrrown 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):
Dbox ha wrotted tthrough at the water level. Sand and rocks are starting to flow into box. box is a H10
Db5 with 1 inlet and 3 outlets being used.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ ,Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool:or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 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
35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
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.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-,
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply.
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen,sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance.with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•.Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no as to each of the following:
Yes 'No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r -•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: seasonal
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings', if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available:
t5ins-3/13 Title 5 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
35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
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: pumped at time of inspection
Was system pumped as part of the inspection? ® Yes ❑ .No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? tank size
Reason for pumping: maintenance was due
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2001
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gal
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
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
Scum thickness 8
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? tape and sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
pump every 2-3 years as maint. to protect leaching.. tank was pumped at time of inspection. needed
as maintenance to preserve leaching field.
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 Farm:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 35 Van Duzer Rd
Property Address
P
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: :
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 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
35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
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.):
Dbox is wrotted out at water line and needs replacement dirt is starting to was in to box
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
field has no inspection port. probed area of field stone is clean and dry no signs of hydraulic failure
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
41M 35 Van Duzer Rd -
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ Teaching trenches number, length:
® 1)20'x40'
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.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113 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
35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
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
M 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
3
oo 3
1 2
"2O X y o
V0
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
M 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4.5
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: 2001
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:
drip field was designed 4'above adjusted ground water per title 5 regulations in 2001. System was
installed and signed offf by town health dept in 2001
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
,M 35 Van Duzer Rd
Property Address
Blair, Laura Egan
Owner Owner's Name
information is required for every Barnstable Ma Ma 7/7/2016
page. City/town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No.
L � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftphLation for Mispo8al �6pstpm Construction 3permit
Application for a Permit to Construct( ) Repair(,X Upgrade( ) Abandon( ) ❑Complete System k Individual Components
Location Address or Lot No. 5 VAt{DiyZ E ���➢ Owner's N e Address,and Tel.No.
,,, "'. �04 1 `r-
Assessors Map/Parcel 3 57 oG,5 ( -z#j; A i, �v !..�—
Installer's Name,Address,and Tel.No. SOR°-` 1-1- 211 Designer's Name,Address,and Tel.No.
<114PW,v& 60racm,569 LLC-
tcc� I 5' r4S pe
Type of Building:
Dwelling No.of Bedrooms Lot Size - sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) RGPI CG D IMY _
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 Certificate of
Compliance has been issued by this Board of Hea
Signed Date
Application Approved by Date t 6 ' I&
Application Disapproved by Date
for.the following reasons
Permit No. Date Issued
- �, --------------------------- •------------------------ -----1.---- --------------------------------------=--
r �
J 1�
. - No. A 1�.. Fee...
-' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN,OF BARNSTABLE, MASSACHUSETTS
01ppliLatlon for Disposal *pstrm Construction 3permit
Application for a Permit to Construct( ) Repair(\ Upgrade( ) Abandon( ) ❑Complete System k Individual Components
Location Address or Lot No.35 VQO DuzER. P--b Owner's N el.,Ad ess and Tel.No.
I_At1P.
Assessor's Map/Parcel 3 S--2. Q(.5 (5 w L A- /(, dWrEZ) (,4-(=—
Installer's Name,,Address,and Tel.No. 568-4+71- 271 Designer's Name,Address,and Tel.No.
��t14+eJ�U� 'c�`'�G3t.I�15E�' �•G- w 1 / A
Type of Building:
Dwelling No.of Bedrooms N Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
_ l
Design Flow(min.required) v gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil l
ti Nature of Repairs or Alterations(Answer when applicable) KpOC6 D- G0 4 _
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 Certificate of
Compliance has been issued by this Board of Hea t .
Signed Date f V"(�-.?0 to
Application Approved by t Date
Application Disapproved by Date
for the following reasons
Permit No. 0 P3(01 Date Issued 0-���k2
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded
CEn ( )
Abandoned( )by l.;A P6 W f D& &j4E Zkiszs (..�..e,
at .3 5 VAA11)U7_67P: D k q"N -has been constructed in accordance
I
with the provisions of Title 5 and the for Disposal System Construction Permit No.,2 -�Gj dated [G - 0 -^ ( 6
Installer t EW(bF, � PRJS Lw. Designer Nj/
#bedrooms Approved des' flM
Jt/I - gpd
The issuance of his p it shall not be construed as a guarantee that the system w fun1 as desi e .
Date 0 I Inspector
------------------------ ------------------------------------------------4 ------------------------------
No. :2o � J G f Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( X Upgrade( ) Abandon( )„
System located at 3 15 VA�J[)U 2—Cli... DR.
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date �b— �2— Approved by
r
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION -�� -u- SEWAGE# r
SrII,LAGE r ASSESSOR'S MAP LOT Sa oaf
INSTALLER'S NAME&PHONE NO. Q* C2.
SEPTIC•TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
B OR OWNER
PERNfITDATE: 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
fj bn site or within 200 feet of leaching facility) Feet
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within 300 feet of leaching facility) Feet
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• _ Subsurraee Sewage Disposal System Form
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Oct 18 2016 22:16 Jim The Inspector Mani 5085349919 page 18
b(P�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
tv
35 Vanduzer Road
Property Address a+
Laura Blair
Owner Owner's Name
information is
required for every Cump6quid 6g",3*7_616 MA 02673 10-18-16
page: City/Town State Zip Code Date of Inspection 401
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 �e P
filling out forms CS/ '�9 JGJ ����N�Ufnlffrr4p�
on the computer, `�����`P�ZH OF u4
use only the tab 1. InSpeCtOr: �`` �� IC,
key to move your 0=•' yG
cursor-do not JAMES N
use the return James D.Sears
key. Name of Inspector
Capewide Enterprises, LLC
ref Company Name
153 Commercial Street
Company Address
Mashpee MA 02649
CityfTown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
.1 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
10-18-16
spector'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 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.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
4ove,011 Vs
Oct 18 2016 22:16 Jim The Inspector Man 5085349919 page 19
Commonwealth of Massachusetts
ANN= Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is required for every Cummaguid MA 02673 10-18-16
page. CityTTown State Zlp 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:
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 is a 1500 Gal. Tank D Box and three pipe field.
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):
15ins.doc•rev.6116 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 0917
T
Oct 18 2016 22:16 Jim The Inspector Man 5085349919 page 20
Common Mssachusewealth of a tts
J Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
"< 35 Vanduzer Road
Property Address
Laura Blair
Owner owner's Name
information is required for every Cummaquid MA 02673 10-18-16
page.. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Oct 18 2016 22:16 Jim The Inspector Man 5085349919 page 21
I
Commonwealth of Massachusetts
I
Title 5 Official Inspection Fortin
A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is required for every Cummaguid MA 02673 10-18-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of,a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well`*.
Method used to determine distance:
+�This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 porn, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
i
D) System Failure Criteria Applicable to All Systems:
I
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
0 ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
EJ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
1-1 ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
s ❑ ® Liquid depth in MIMRW is less than 6" below invert or available volume is less
than 'Y da flow E C
y NG
t5ins.doc•rev.8116 Title 6 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Oct 18 2016 22:17 Jim The Inspector Man 5085349919 page 22
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is Cumma uid MA 02673 10-18-16
required for every q
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
El ® 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"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 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in.Section D above the large system 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Oct 18 2016 22:17 Jim The Inspector Man 5085349919 page 23
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is Cummaquid MA 02673 1.0-18-16
required forevery
page_ City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following.
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks.
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of.
this inspection?
® ElWere 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?
i
❑ ® Was the facility owner (and occupants if different from owner) provided with I
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins.doc-rev.6/16 Title 5 Official hspecilon Form:Subsurface Sewage Disposal Syslem Page 6 of 17
i
i
Oct 18 2016 22:17 Jim The Inspector Man 5085349919 page 24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 VanduzerRoad
Property Addiess
Laura Blair
Owner Owner's Name
information 's required for every Cummaquid MA 02673 10-18-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal. Tank- D Box and three pipe field.
Number of current residents: 0
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
2014-149,000Gal
Water meter readings, if available (last 2 years usage(gpd)): 2015-176,000GaI's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy. NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15,203): Gallons per d
Pe y(9P )
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
i
Non:sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Oct 18 2016 22:17 Jim The Inspector Man 5085349919 page 25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
r 35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is required for every Cummaquld MA 02673 10-18-16
page. Citylrown 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: 2014 -2016
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins.doc•rev.6/16 Title 5 Ofticlal Inspection Form:Subsurface Sewage Disposal System-Page 8 or 17
Oct 18 2016 22:17 Jim The Inspector Man 5085349919 page 26
Commonwealth of Massachusetts
Title 5 Official Inspection Forums
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is required for every Cummaguld MA 02673 10-18-16
page. _ City/town State' Zip Code Date of inspection
i
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2601 Permit #, 2001 -088 10-2016 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"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.):
Pipeing is 4" PVC SCH-40.
i
I
Septic Tank(locate on site plan): I
Depth below grade: 101,
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. Precast H-10
OilSludge depth:
-tsins.doc•rev,6/16 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Oct 18 2016 22:17 Jim The Inspector Man 5085349919 page 27
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is required for every Cummaquid MA i 02673 10-18-16
page. Citylrown state; Zip Code Date of Inspection
D."System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 30"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 8
Distance from bottom of scum to bottom.of outlet tee or baffle 17
AsbuHow were dimensions determined? Slud - Plan Tape
Sludge Judge
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 at working level. Tank at 10"below grade. In and outlet tee's. No sign of leak age or over
loading.
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
i
Date of last pumping: Date
l5ins.doc•rev.6/16 Title 5 Official Irspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Oct 18 2016 22:18 -Jim .The Inspector Man 5085349919 page 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dlsposal System Form -Not for Voluntary Assessments
4 35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is required for every Cummaquid MA 02673 10-18-16
page. Citylrown State Zip Code Date of Inspection
Do System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
i
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
15ins.doc-rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Oct 18 2016 22:18 Jim The Inspector Man 5085349919 page 29
Commonwealth of Massachusetts
ui
Title5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
informations CummB uid MA 02673 10-18-16
requlrediorevery q
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
i
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 16"-16" below grade. Box is new 10-2016. Box has three line's out w/cover at 6".
Pump Chamber(locate on site plan):
w
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6116 _ - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i
Oct 18 2016 22:18 Jim The Inspector Man 5085349919 page 30
Commonwealth of Massachusetts
: ..Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is required for every Cummaguld MA 02673 10-18-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
20'x40'
k
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,etc.):
Leaching is a 20'x40' 3 pipe field ck 0 Box and camera out line's. No sign of over loading or
solid carry over. No sign of holding water.
i
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 4
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
15ins.doc•rev.6/16 Title 5 Dfficial Inspeclion Form Subsurface Sewage Disposal System•Page 13 of 17
Oct 18 2016 22:18 Jim The Inspector Man 5085349919 page 31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is MA;Uld
required for every CUmma 4 02673 10-18-16
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
4
,t
Privy(locate on site plan):
Materials of construction: x
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
• .t
tl
i {
K
f
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systam-Page 14 of 17
S
Oct 18 2016 22:18 Jim The Inspector Man 5085349919 page 32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Vanduzer Road
Property Address
Laura Blair
Owner Owners Name
information is Cummaquid MAC 02673 10-18-16
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cost.)
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:
1
® hand-sketch in the area below
❑ drawing attached separately
i
3
t5ins.doc•rev.6116 Title 5 OTfltlal Inspection Form:Subsurface sewage Disposal System-Page 15 of 17
i
I
Oct 18 2016 22:18 Jim The Inspector Man 5085349919 page 33
13
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a
y
3
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1
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3
Oct 18 .2016 22:18 Jim The Inspector Man 5085349919 page 34
Commonwealth of Massachusetts
. Title, 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is Cummaguid MA 02673 10-18-16
• required for every ,
page. Cityrrown Stale Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
5
Estimated depth toihigh ground water: 70
feet
Please indicate all methods used to determine th i e high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 1-19-01
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain: a
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Field designed 4' above ADJ. G.W. per title 5 Reg. 2001. System was signed off by B.O.H..
T.H.per design plan 1-19-01 70" G.W..
Y
4
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15ins.doo•rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page iS of 17 e
Oct 18 2016 22:19 Jim The Inspector Man 5085349919 page 35
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35.Vanduzer Road
Property Address
Laura Blair
Owner Owner's Name
information is required for every'. Cummaquid MA 02673 10-18-16
page. Cityrrown 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-
;T
15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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NOTES A b I. TYPICAL ROOF CONSTRUCTION: -
Arehileebaal ane,puG on.Is Dpednp+en on APA r.lad Grwau:np ' - }
span ralmp 2E',sap 1 on rod tremin0.I6•Aldo I..6 wafer Weld
cor1L al roof a0pe,valleys.0 roo0w.2 i,IwseaiarW. I I a-baalel:1 l'bl bo«sown. ------------ I \\\
..., - c.iwp:In'ow.bowel I _
2. TYPICAL WAIL CONSTRUCTION: - -
0,cooler wAh as Nd,r.lbn b nw. y' .
GENERAL NOTES: YuuWnn.R.l l Matt. I - - \. 's.•E .
A.1.Belo,.final Drawvp6 and SPe.A�bo wG 4aa.0 I« h wipr.In•aw bowd
aMaY, jo.,I 1 I.W Ili.b as 0ovw uv a,dd g J.TYPICAL FLOOR CONSTRUCTION(FRAMEI:
age is b 4 6 the,carpfierKe Willi all appi oaa bcal and "60«on APA rased Neau+inp J/E'T&G on TA Soar puts. -
naborul codes.d c00e daa.pancna e,Dr.wvgs enala SEE PLAN FOR SIZE AND SPACING - - .
Spacifi U« appear,Ilw D.slprw Wall W mWUA a such C.;pnp:In'aw board - - • -
d eaepantW.Y,-w1mg by Bwldw o1 ou4d.Q."6.l,urd E.TYPICAL F:AOR CONSTRUCTION:
eEH Aewc
tlbweo b e1W Drawin0s and Sp.l hz"w w Y I.Amply (SLAB ON GRADE):
w4h OAwMV eod.Data.co'revu Lion WO'ns. J-Cant.Pleb m 6 COmp.Clad Oraratw N. 1. .
2.upon w.v�n r.c.ia a.paws:Yam th.q-+ i3O McW. (Gould.6a6 I,0 W WF r..nladrg.
appA.c Intl Aew'v,pa and Spec4icadww slree W aWmitled Provide 414 poly V.S.under Bleb.
b Te Bw'der by b Deuprw. (BASEMENT CONCRETE SLAB)
J ll.dedaaap+na es we OrccAwed d.lrtrq,ne wruYutn m' -
0'corK.stab on 6'Nmpae d pranaw N`
,=.D.wprw=W mW".nd Wb .d a ome W Y ..
r.m...id daoeI—i. (GARAG E rSY poly V.B.rab.i tlab. ... .� - .
(GARAGE SLAB t I e
E.Au wart per,ormb shau carnply INN.,apD K.ae bce',:use 1 - r 3 CAR GARAGE
and mfnna!GWd n0 mdea.«dal n "1.9u grc.WIC N c«K.sub on 6'WF,.w.d V. wee.
as.T aWw,W61uvu,p urisdicepn.Fdlowirp c.partial Provide fu6llO WWF rNngxonp.
4a1 a apu&K i cod in brce',. NOTE:All cans-b'W 30000v B 2e A M , Z
a.Massatnuseda Suu BuAd V Cooe.760CMR,61h Wdlo:t, S.,Glor bobs T W 12'Yam L 2XI and 6 o.c. Qt,
1r,19
e S. INDICATES OVE2XGR
0MRIOR POST INLE66 NOTED t '
6.ALL HEADERS OVER EXTERIOR OPENINGS TO BE
B.N oon.adore sr6ran>actas,wp{Jiws,and labrictlas,tl 4 W 2.2X10 UNLES6 NOTED OTHERWISE. T;
rGEDawiWe,a d,.,xnlwn of Orarvgt and 6D.r+IKa,gna aM IOG - I` - (/) '
m.wpp.y am d.aipn a ap«oprul.� -W.ar,d w«t U WINDOWS BUILDER
AND SPECATIOIFIES
DOORS SHALL BE'ANOERSEM
UNLESS BUILDER 6PECIFIES OIFFEREMLY.(APPRO)aIMTE ROUGH _ ¢ Z.C.All mNNaGea.a.rddes.rtWwWaampWprtrwnaFllbe app Rel. OPENINGS MUST STILL BE MAINTAINED AND TYPE OF DOOR OR Frew wau Wl:a,RlltrgM-�1� •�Q Q
e
Y,eMlbd.erected uGW,c,aanad and oorrdba,ed n aaYA
S.5,r YET atcordw,c.wM manuf 1vMs r.cortvnendY�onc S. UNTS COO BLUE BOARD ON ALL UVIN AND i Walexiwwa. -� " v Q.
0.AL alumtles w.tl U,e option d tn.-Sakes"Nall W W.. CEIl1NGS COMMON TO GARAGE AND LMNO SPACE.
Buddw a r.cwtl,raxuar.p.o.,aediYan b«in f.a a tW CLAPBOARD SIDING(MAX S'E)(POSURE)ON APA RATED - .
lyplu'eMav 1pL at YgKalaO m Gawiye. SHEATHING SPN:RATING IV.EXP.1 ON 2X4 STUDS AT I6 - -
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REVISIONS: law+
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I I n I WING ROnM
0 I. KITCHEN } `
SCALE: 1/4'=1 r-0•
UNLESS NOTED
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- Ida MASTER SUITE
PLAN DATE: itmoi
iz sA _.. �- _ 17 tP_... ...------ ---.. ......- -- tra .. .-....._ _......._ REVISIONS:
BEDROOM#3
i z_su
I BEDROOM#2
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SCALE: 1/4._1.-0.
UNLESS NOTED
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7iN' T•B�A' � T•1 K' T•fIti'
f-0' 7-0M 11-11' 3'A' 1{'S SS
SECOND FLOOR PLAN A2
2,206 SQ.FT.LIVING AREA
- - ---- r- -- - - r - - --- --- -- - - - - - --__-._._ �.------ --- --- -
PROVIDE PRECAST CONCRETE EXTENSION 5" DIA. OUTLET(S) ° FINISH GRADE OVER LEACHING FIELD= 33.60' - 33.20'
4" SCHEDULE 40 PVC MIN. SLOPE 1 /° - s. N Re , NOTES
TOF RISER WITH CONCRETE COVER TO WITHIN °
REMOVABLE COVER SLOPE @ 2/° MIN. OVER SYSTEM
ELEV.= 34.21' FINISH GRADE WHEN NECESSARY. C 3/4" TO 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE
FINISH GRADE OVER D-BOX= 3 3.4 0 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION
FINISH GRADE @ FND. EL.= 33.50' FINISH GRADE OVER TANK EL.= 33.40' 2" OF 1/8" TO 1/2" DOUBLE WASHED STONE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE
ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES.
20" MIN. ACCESS COVER
4" PVC PERFORATED PIPE
(TYPICAL FOR 3) 36"MAX. SLOPE AT .5°I° TOP OF S.A.S. - 32.15' 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
- 9" MIN. OF HEALTH AND THE DESIGN ENGINEER.
PROPOSED 4" 36" MAX.
SCHEDULE 40 PVC __ _-_„_.__ _ 31.50'
- ` I 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL
7
PROVIDE WATERTIGHT END CAPS + BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED.
MiN s�oPE@ i 6"+ 3" 3" DROP MIN. 3" g„ JOINTS TYP.
( )
4" PVC IN FROM
r 14" SEPTIC TANK 4" PVC OUT TO 4. TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE LESS
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
32.80' LEACHING FACILITY ?" r ` .� u` ^- THAN ELEVATION = 32.15' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS.
5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
r
31.92 31.75'
EFFECTIVE
OUTLET TEE
48 MIN. a" . y ---- w Y -- I---------- ----------I DEPTH
1
o 0 6" CRUSHED STONE 31.70' BOTTOM OF TRENCH TO BE LEVEL EL. - 31.00' 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
60.0' 22"ZABEL FILTER �� ��OVER MECHANICALLY 4' 6' 6' 4' _ 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED
MODEL #A1$01 HIP (GAS COMPACTED BASE ; 40' - PRIOR TO BACK FILLING WHEN SYSTEM IS NEARLY COMPLETE AND
BAFFLE ON BOTTOM)
5 OUTLET DISTRIBUTION BOX 20 READY FOR INSPECTION. SYSTEM IS NOT TO BE BACK FILLED
6" CRUSHED STONE TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV.- 26.96' WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
�� OVER MECHANICALLY BASE. FIRST TWO FEET OF OUTLET AND DESIGN ENGINEER.
COMPACTED BASE 4' MIN.
PIPES TO BE LAID LEVEL.
8. ELEVATIONS BASED ASSUMED DATUM OF 30.00' MSL OBTAINED FROM NAIL IN OAK TREE
- - PROPOSED 1500 GALLON CONCRETE SEPTIC TANK CROSS SECTION VIEW TYPICAL FIELD PROFILE FIELD END VIEW AS SHOWN ON PLAN. SURVEY PERFORMED BY JOHN FARREN, PLs, PLYMOUTH, MASS.
FOUNDATION DESIGN LENGTH 10.5' WIDTH 5.6 ' DEPTH 5.58 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
(BY OTHERS)
DISIFt-� T X DETAIL 8€ DETAILS THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE
S ..s A P � I ION �� "" D DISCREPANCIES SFTO THD ANY OTHER E DESIGN ENGINEER.ABLE AGENCIES. REPORT ANY
NOT TO SCALE NOT TO SCALE NOT TO SCALE
-- ---------- -- --------------- 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE
u TEST mrA
y STRUCTURES SHALL BE MADE WATERTIGHT.
11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR
m ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN
INSPECTOR: Donna Miorandi (BOH)
SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
w * SOIL EVALUATOR: John L. Churchill Jr.
January 19, 2001 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
DATE: rY
aoay v � +' �� TEST PIT#: 1 (P_9928) LOCATED UNDER PAVEMENT, DRIVES OR TRAVELLED WAYS IN WHICH
a.t, .. � µ CASE THEY SHALL BE WITHSTAND H-20 LOADING.
c0- � `.,. ,�� � .� ELEV TOP 29.2'
t '' 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND
�98 � , . I D, ' ELEV WATER = 4.66' BGS (24.54') FINES.
Ysr
PROPOSED DECK 4 "" !° �" ° PERC RATE = MIN/IN
#35 �. PROPOSED 1500 `a s
TOF - 34.21' 7q \ �s. b#' " 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND
Sg3oo647 GALLON SEPTIC TANK +R DEPTH OF PERC = UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES
2 EXISTING FOUNDATION33s„ '�° , � ,r OF LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN
TEXTURAL CLASS: 1 COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN
N. ` 4 d y
EXISTING IItCs DRIVE -- ACCORDANCE WITH 310 CMR 15.2
�.
` 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES
A Sandy Loam
„ 10YR 312 FOUND IN SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
6 28.7'
EXISTING CESSPOOL TO BE -'```" PROPOSED - %� r"
0, �� + . B Sandy Loam 16. PROPOSED PROJECT IS LOCATED IN THE RF-1 ZONING DISTRICT.
PUMPED AND FILLED WITH r' ADDITION / coo i +� _, "` a� M '°'a ' 10YR 4/3
/ cn /1 LOT 4 W E. , , + w e 1 36 26.2
CLEAN SAND GARAGE �� 74 g "q , MINIMUM SETBACKS PER ZONING: EXISTING SETBACKS:
3
3.,\, -, o /-"D"-BO 9 � ; ~ "" li +�k" � 1E i + FRONT SETBACK = 30 FT. SETBACK FROM TOKAMAHAMON ROAD = 74.9 FT.
+, Y ? *�+4 x ` d� Mottles 10YR 4/4
� FIELS� � r " t � t REAR SETBACK = 15 FT.
20' X 40' LEACHING -* t ,I ,° 3 r @ 56" 24.54' SETBACK FROM HARBOR POINT ROAD = 18.9 FT.
�� �v + l Y SIDE SETBACK = 15 FT.
o T ° `� E, m + - ° Groundwater SETBACK FROM VAN DUZER ROAD = T.
tl i + ff 6-L,
y
N K �, � ,. f Standing &Weeping 23.3T PROPOSED SETBACKS:
M' 0 29xz 37 3 Sit �r
h
� t4. A� - ,""- 70'
0 3 _ ....... - ' - _ C SETBACK FROM TOKAMAHAMON fiUAl�
�� Fine Loamy Sand SETBACK FROM HARBOR POINT ROAD = 19.8 FT.
33 l/ti SETBACK FROM VAN DUZER ROAD = 16.4 FT.
2.5 Y 6/1
LOCUS PLAN , f
` SCALE: 1" - 1000' 17. OWNER OF RECORD: ROBERT A. AND ELEANOR BELMONTE
ADDRESS: P.O. BOX 197
120" 19.2' CUMMAQUID, MA 02637
REMOVE AND S
Spike in 12' Oak / REPLACE SOIL DOWN
o TO C LAYER SEE - -- ----------- ----- ------ ------------------------- -- ----
Elev.-30.00 / o ��; ( TEST PIT DATA
Assumed o` cy, NOTE 14) �,,� A .�..
�ry ! DESIGN DAIS"
LOT 5 = I INSPECTOR: Glen Harrington (BOH) LEGEND
-o SOIL EVALUATOR: John L. Churchill Jr.
' � EXISTING CONTOURS
LOT 28 DATE: May 2, 2001
NUMBER OF BEDROOMS: 4 TEST PIT#: 2 (P-9928) 102 PROPOSED CONTOURS
NUMBER OF PERSONS: 4
DESIGN FLOW: 110 GAL/DAY/BEDROOM ELEV TOP = 31.6' EXISTING SPOT GRADE
TOTAL DESIGN FLOW: 440 GAL/DAY
\ ELEV WATER = 4.66' BGS (26.96')
PROPOSED GAS
SEPTIC TANK: PERC RATE = 15 MIN/IN
TENNIS COURT 440 GAL X 200% = 880 GALS. DESIGN CAPACITY PROPOSED WATERLINE
\ � DEPTH OF PERC= 42"-60"
USE 1500 GALLON SEPTIC TANK (Min. size per Title 5)
TEXTURAL CLASS: 2
TEST PIT LOCATION
(-- 20.0 X 40.0 LEACHING FIELD: 0" 31.6' U r7 PROPOSED 1500 SEPTIC TANK
'✓ o� A Sandy Loam
N �-
cv SIDEWALL CAPACITY 6„ 10YR 3/2 31.1' 4" SOLID SCHEDULE 40 PVC PIPE
Total Area= 54,599 S.F. NONE B Sandy Loam - - - - - - - - -- 4 PERFORATED SCHEDULE 40 PVC PIPE
co 10YR 4/3
® or 1 .253± Ac. 36" 28.6' ;-, DISTRIBUTION BOX
BOTTOM CAPACITY
�... 40.0' (LENGTH) X 20.0' (WIDTH) = 800 SQ. FT.
Mottles 10YR 4/4
@ 56" 26.96'
800 SQ. FT. X .56 GAL/SQ. FT. = 448 GAL.
LEACHING/DAY Groundwater
Locus is Map 352, Pcl. 65 Standing @ 56 1 5/03/01 JLC PTM TEST PIT 2, GARAGE, SEPTIC
Owners of Record: TOTALS: C
�3°�',�5� ( Robert A. and Eleanor Belmonte REV. ,- DATE - _ BY _ APP'D. DESCRIPTION
� `�° Lots 4&5 Cert. No. 7353 Fine Loamy Sand -
t`a. L.C. Plan 7353 D TOTAL NUBER OF DISTRIBUTION LINES: 3 2.5 Y 6/1 PROPOSED SITE PLAN
_ L.C.t8 7353 G TOTAL LEACHING AREA 800 SQ. FT. PREPARED FOR:
TOTAL LEACHING CAPACITY 448 GAL./DAY LAURA BLAIR
120" 21.6' FAR � LOCATED AT
35 TOKAMAHAMON ROAD
A REVIEW OF FLOOD INSURANCE RATE MAP COMMUNITY PANEL �^ ,, .`/��,
NUMBER 250001 0001C DATED 8/19/85 ___ . __..___... ____ .__._ __....._ _.__._..- ______.- __._.._____ _____- __ - ____.__ _.___-.- - A) ,,,, y,,, CUMMAQUID, MA 02637
HAS BEEN CONDUCTED AND TO THE BEST O�INTERPRETATION,THIS RESERVED FOR BOARD OF HEALTH USE '
DWELLING IS IN FLOOD ZONE C AND IS NOTLOCATED
WITHIN A SPECIAL FLOOD HAZARD ZONE. --- - --- ---- --- -
' ' SCALE: 1 INCH = 30 FT. DATE: JANUARY 29, 2001
0 15 30 60 120 FEET
Of Mp ff9�y -__PREPARED BY: --- -- - _ _-
T.
MEENTEE G� JOHN L. CHURCHILL JR.
5 UNDHILL BLVD.
No 35109
SITE PLAN A c�S EAST WAREHAM, MA 02538
508.273.0377
SCALE: 1" = 30' 1 Drawn By: JLC Designed By: JLC Checked By: PTM i Job No.: 87