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HomeMy WebLinkAbout0039 WESTCHESTER WAY - Health 39 Westchester Way, Barnstable A= 349 - 070 and r '1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 39 Westchester Way, Cummaquid M-349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is Cummaquid MA 02637 October 18 2011 required for every , page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in.any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, (\�, use only the tab 1. Inspector: �I key to move your I cursor-do not Troy Williams use the return key. Name of Inspector Troy Williams Septic Inspections Company Name 19 Hummel Drive Company Address - South Dennis MA 02660 City/Town State Zip Code (508)385- 1300 S1682 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: Ra ® Passes it❑ .Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority. �. `3 October 181 2011 Inspector's Signature Datern 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. � � ► 11 t5ins•11110 Title 5 Official Inspection Form:Subsurface go Disposal System•Page 1 of 17 • 1 T } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Westchester Way, Cummaquid M -349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaquid MA 02637 October 18, 2011 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System meets minimum standards set by Massachusetts DEP at the time of inspection only.This inspection is not a guarantee or warranty on the future working conditions of leaching, pipes, components or the future structural integrity of said components and only represents conditions found at the time of inspection only. 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): N/A J yk� 1 t5ins•11/10 Title 5 Official Inspection Form: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 39 Westchester Way, Cummaquid M-349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaquid MA 02637 October 18, 2011. page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static waterlevel 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): N/A ❑ 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): N/A 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-11/10 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 39 Westchester Way, Cummaquid M-349 P-71 L- 188 Property Address John Alderson Owner owner's Name information is required for every Cummaquid MA 02637 October 18, 2011 page. Citylrown 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: N/A D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•11/10 Tide 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 39 Westchester Way, Cummaquid M -349, P-71 L- 188 Property Address John Alderson Owner Owner's Name information is Cummaquid MA 02637 October 18 2011 required for every , page C't fr wn Stat e 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 I) of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 39 Westchester Way, Cummaquid M-349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaquid MA 02637 October 18, 2011 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•11/10 Tale 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Westchester Way, Cummaquid M 349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is Cummaquid MA 02637 October 18 2011 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 10=32,000 gals. 9 ( Y 9 (gPd)) 09=41,000 gals. Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): N/A 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: N/A t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-,Page 7 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Westchester Way, Cummaquid M -349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaquid MA 02637 October 18, 2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: N/A Date Other(describe below): General Information Pumping Records: Source of information: Last pumped on 10/2/07 per BOH. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Tide 5 Official Inspection Force 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 39 Westchester Way, Cummaquid M =349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is q required for every Cumma uid MA 02637 October 18, 2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank is original from 8/4/77. D-box installed in 1996. Leaching was installed on 10/2/07 per compliance. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18"+ Depth below grade: feet Material of construction: ❑ cast iron 040 PVC ❑ other(explain): Distance from private water supply well or suction line. N/A feet- Comments (on condition of joints, venting, evidence of leakage, etc.): Flushed lines and found clear at the time of inspection. Septic Tank(locate on site plan): Depth below grade: 18"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: 5'X9'X6' 1000 gallon Sludge depth:- 4" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Westchester Way, Cummaquid M-349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is Cumma uid MA 02637 October 18, 2011 required for every q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2'8° Scum thickness none Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? probe/measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Concrete inlet and outlet tees were found present and in working order. No evidence of leakage or damage was found. Tank was not in need of pumping at this time. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/ADate t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Westchester Way, Cummaquid M -349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaquid MA 02637 October 18, 2011 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N/A Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene. ❑ other(explain): N/A Dimensions: N/A Capacity: N/A gallons Design Flow: N/A 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.): N/A *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 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 39 Westchester Way, Cummaquid M-349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaquid MA 02637 October 18, 2011 page. Cityrrown 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 level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was found level and in working order. 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.): N/A Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Westchester Way, Cummaquid M -349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is Cummaguid MA - 02637 October 18 2011 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 10 infiltrators with stone 13" under ❑ leaching galleries number: 70.5'X10.8'X2' ❑ leaching trenches number, length: ❑ Teaching 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.): Checked stone and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth-top of liquid to inlet invert N/A Depth of solids layer N/A Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Westchester Way, q Cumma uid M-349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaguid MA 02637 October 18, 2011 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.): N/A Privy(locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t5ins-11/10 Title 5 Official Inspection Forth: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 39 Westchester Way, Cummaquid M -349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaquid MA 02637 October 18, 2011 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 I I u.`'wf �- I '� SIP` U Lip�t t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 . Commonwealth of Massachusetts lugTitle 5. Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 39 Westchester Way, Cummaguid M -349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is 4 required for every Cumma uid MA 02637 October 18, 2011 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0'+ 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. 9/4/07 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: AIW 247 Zone C 23.7' 3.0'adjustment You must describe how you established the high ground water elevation: USGS maps show groundwater to be approx. 73.5'. Test hole on plan showed no water found at 152". Groundwater adjustment at the time of inspection was 3.0'. Bottom of leaching at 5.9'was found not to be located in the high groundwater elevation at the time of inspection. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Tide 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 39 Westchester Way, Cummaquid M -349 P-71 L- 188 Property Address John Alderson Owner Owner's Name information is required for every Cummaquid MA 02637 October 18, 2011 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION ��� g'' SEWAGE # c�V CJ VILLAGE ASS SSO 'S MAP & LOT3 NSTALLER'S NAME&PHONE NO. �1,&S 1 SEPTIC TANK CAPACITY IO�C� LEACHING FACILITY: (ty ) E.i ' (size) NO.OF BEDROOMS BUILDER OR OWNER iw- = 0 PERMITDATE: 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_le_a.�facie ) Feet Furnished by IG�J'yh . ��r s � _ i L) alb Jh'V C 3'-�� 0 Ir f Town of Barnstable Regulatory Services Thomas F. Geiler,Director • BARNSPABM • Public Health Division iOrFn ram" Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: /0-42-1 Sewage Permit# Assessor's Map\Parcel 379'107o Designer: ,�D/LA9a� 69055am./ Installer: oA Irt_ �JCIUZC� Address: p0, Age 11 Address: On $� _ S�� __ was issued a permit to install a (date (installer) septic system at 3y���.�"T!�EfE,�r�sL �Gf�Y based on a design drawn by - // (address) - Al,0RM4,/ dated SEpi 8 2D07 j 1/. j-27-a7 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF nstaller's Signature) NORMAN o GROSSMAN —+ No- 12705 y CIVIL Sl ERti� � (Designer's'-Signature) (Affix D Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUII.T CARD ARE ` RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. II . Q:Health/Septic/Designer Certification Form 3-26-04.doc No. '. i °B Fee 160 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for ;h6p al *pgtem Con0tructiun Permit Application for a Permit to Construct( ) Repair(4upgrade( ) Abandon( ) ❑Complete System)Ondividual Components Location Address or Lot No.yj W4;S4 GA t -S fcl Owner's Name,Address;and Tel.No Asse ssor's Map/Parcel 3� `7 y{ Installer's Name,Address,and Tel.No. V � a` � Designer's Name,Address and Tel.No. &v4-/AU-- Z'V_e'� Type of Building: Dwelling No.of Bedrooms 3 Lot Size 9j�25� sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided gpd Plan Date 9�/ (1 7— Number of sheets Revision Date Title Size of Septic Tank 00a 44110 ek,-Jb,Y4Type of S.A.S. Description of Soil e. i Nature of Repairs or Alterations(Answer when applicable) LGJ �C-atX,41l 74, rw A),?1 k 2 � k1l /D H 20 111-rA 6 ,P. //�1 -0. 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 alth. Sign Date 1 .,) �d Application Approved by M, j4p Date 07 Application Disapproved by: Date for the following reasons Permit No. '7W7?—Y3k Date Issued q `7 d7 dl # r� 0* eNo q 3 b `*i "It4- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC,.HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS. Yes Zipp--fication for" i 5poga[ pgtem Con0truction Permit ` Application for a Permit to Construct O Repair( pgrade O Abandon O O.Complete System Individual Components R Location Address or Lot Noll Al c S4 C t-S f Cr P/V,/ Owner's Name,Address,and Tel.No> (���A4L Assessor's Map/Parcel 31�9 — -7o tcA Pyll�'k� Installer's Name,Address,and Tel.No. v A-S0T1 SQL"' Designer's Name,Address and Tel.No. Type of Building: c Dwelling No.of Bedrooms Lot Size �7,.Zs0 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ?3v gpd Design flow provided gpd Y "t\Plan Date T�� �— Number of sheets Z Revision Date Title Size of Septic Tank touA .ef,f c- -Q,I -AY4 Type of S.A.S. Description of Soil &C ip-f:�e G► L4 Si 1 ` x/C6✓Nature of Repairs or Alterations(Answer when applicable) C.,,_, Au% 7d, 6-W/d i 17 2 Date last inspected: {{{III 4� F Agreement: ,, - The undersigned agrees'to ensure the construcgion 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 alth. �k. Sign e Date 7/d �-- Application Approved by 4., �� Date l`� 6, G7 Application Disapproved by: i Date I for the following reasons Permit No. �tk) -: ' Date Issued -1 7 -7 ' THE COMMONWEALTH OF MASSACHUSETTS r' BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (�pgraded ( ) Abandoned( )by !.t5 �!N , at has been constructed in accordance with rovisions of ' e 5 and the for Dispos I System Construction Permit No. 1W-7 `Ll 38' dated ght Installer Designer #bedrooms �j t Approved design flow 6 gpd The issuance of this permit hall not`U cons>ued as a guarantee that the system 11 unction as designe 0 Date Inspectorj, r r v I ———————————————— ——————————————I--—= No. to-7- 3a : Fee - THE-COMMONWEALTH OF 1V A ACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Oigpogal 6pgtem Co ruc"ion Permit Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) System located at f f �✓�j-fC�,-..�-F-�.� 6(/.�-�J .o-._ 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: Con truct' n must be completed within three years of the date of thi pe�0,, Date U Approved by f�f L0; lIT10N (a?'9rA9 SEWAGE PERMIT NO. XLUX 4-t- 3 2 �z Is-- VILLAGE 3�(9 -67 INSTA LLER'S NAME & ADDRESS B URDE R OR OWNER > f DATE ERIMIT ISS D DATE COMPLIANCE ISSUED �d vS� '' G3� �� S'" - 0 No..-------•--.2 G2 FizE ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ........OF......... .....* Apphratinn -for 4%ipoiial Hlorkii Tonstrnrtinn Prrniit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: p ^-�Ijocation•Address W T 2e o No. ._ . ............................................ e Addr / zo, nalr V!S` • -✓ Installer Address UType of Building/ Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder kVI? aOther—Type of Building ____________________________ No. of persons.....................:------ Showers ( ) — Cafeteria ( ) P4 Other jxtures ------------------------ - - W Design Flow........JL*2..........................gallons per person per day. Total daily flow........2.�®..................gallons. WSeptic Tank L Liquid capacity/ gallons Length................ Width................ Diameter____...._.._____ Depth._..____.----... x Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No------/......... Diameter....la.X.10 Depth below inlet.................... Total leaching area...._.__._.-_____-sq. ft. z Other Distribution box ( ) Dosing tank ( A,6� G — b - 7 7 '- Percolation Test Results Performed b ._=_.._ .�1�-4�: •2- 7 Y - � ---------- - ------ -- ------------- --- ---- Date._.�✓---'-....-..----------------.... a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water... d__--f.----. 44 Test Pit No. 2-___-__-_-_____minutes per inch Depth of Test Pit____________________ Depth to ground water........................ ----------------..-------------- . ----------- ........................------ - - - G Description of oil = -1 __ ti / -.fir'_ e_j. - . ------------ x l�. e i V '� --------------------------------------------- W ------- ---------------:---------------------- f.. ..:--: •-- s-. .._._.. _ _ V Nature of Repairs or Alterations—Answer when applicable_____________________ ................-------------------------------------------------- ------------------------- .. Agreement: The undersigned agrees to install the aforedescribed Individu Se e.Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The and s gn further agrees not to place the system in operation until a Certificate of Compliance has een ssued by the o rd health. t Date Application Approved BY -- 'f -------------- ---_10 ,1-r.-7-7------- Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------------ -------------------- Date PermitNo......................................................... Issued.-----:�- --------R- -..--------------- Date r r x4.L / No..-.................. FEa......l.:V�.. s THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH YOF....... ....... ..-: � a. ... ................. Appliratiuu -fur 13iiivow'i Morku Touwtrurtiuu Vanift Applicatiori'is hereby made for a Permit to Construct ( 40�or Repair .,( ) an Individual Sewage Disposal Sys at , or L No. i canon ss•.................................. •- r--- ... ............. ...................... tr/ W OW Addre.. �V� ..• P ......................... Installer Address' Q Type of Building,,, Size Lot----- --------------------Sq. feet U Dwelling'.. I�o, oil vBedrooms:»-._. tiff� _-.._..___- Expansion Attic {ti �,') � Garbage Grinder p, Otlier—Type of Building ._.... ................ No. of peI sons_._.... .. Showers (' ) — Cafeteria ( ) dOther tares ---- ----------•------ -- ,--------------- --- -`- ----------------------------- Design W Flo . « la........................gallons per person'per day'. `Total daily flow ....._.......f..gallons. WSeptic T.Ink Liquid.cap tcity/gallons Length---------------- Width - ... .. ... Diameter............:..- Depth.. .......... Disposal Trench Flo _.- Width- _------- Total Length--------------------- Total leaching area....................sq. ft. Seepage Pit No ... Diameter _-,6.:ie-_/j0Depth below.- --.--_ --_-. Total leaching area... - ----------sq. it. z Other Distribution box ( .;) Dosing-- tan "" *r y Percolation Test Results Performed by..._ , .... .. ....... ............... Date;,----- Test Pit No L.';::.'..........mmutes per inch Depth of "lest Pit ---------- DepthaU bround watP_r ;�a......�------ (Z4 Test Pit No. 2................minuies per inch Depth of Test Pit-------------------- Depth Ito ground`water........................ a+ --------? - r ---------------- G '`�''`--`--- -- . ` `-""-'--� x Descri ti9n $oil - _ .� ----- -------- ....__ .:.._..._.--•-----.--- VNature of Repairs or Alterations—Answer when applicable...............,..w.:..................:._.._.... _.._..-....-............-.. Agreement The undersigned agrees to'install the aforedescribed Individu Se e Disposal System in accordance with the provisions of Article XI:of the State Sanitary'Code The, and s'gft further agrees not to place the system in operation until a Certificate of Compliance ha een ssued by.the o, _d health. N gne - --- ----- ----,P ` = Dat Application Approved BY- `� •-- ..AA. ......... --•-. - �'"°.i�.—7------- Date Application Disapproved for the following reasons:.--:: .........:.....`._........----------•------------•=----------•-•---. .............................. Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS.: - BOARD OF HEALTH . .... .......O F..V�, - ...:.....r::.:........................................... Ir %Untifirate of fU'omphaurr THIS T ERTIF That the Individual Sewage Disposal System constructed ) or Repaired ( ) ---.........................-....................................................................... tall _ f has been installed in accordance with the provisions of Arjj<jp XI of The SttCte Sanitary Code as described in the application for Disposal Works Construction Permit No.- Z._:.... ...... dated---......6;.' _.'..?.7.-----..-•-•------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM, WILL FUNCTION SATISFACTORY. DATE------------•--------------------------------------------- - --............. Inspector....--------------------------------------------...------------------....----....... 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD F 'HEALTH 2..........OF...-. ,. No.......... G 2---- FEE.- -�--•----•-•-- �,d {" �i���,� • � rk,� ���trurtiuu rrutit Permission is hereby granted....... -- -------------- --- ------------------------------------------- -------------•-----------------------•--••- 'fi, Constru ( �) or Rep r ( ) an In ' 1 Sewa e jDispf a�S s m at No.. = 4 -d/_[Cl.f! ... 2<-_•-'------ •-------- t. St reet reef as shown on the application for Disposal Works Construction Per No.... Dated_-.. ." '.7:• _.._._._._. ' ;;. . --- ---- i Board o�k DATE ! .............., -------- --------- . s _ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS � - '` ��' '. - r.#s t »�a }s°X r i t} �,y.n,'� 1 ' -' - ..Z "'$'-r rf .,1,t's -!tip} ., .x 4 r t - t.; •t_ _ It lki, -i *'Y L 'tl` F .•1 `�rl;!' 1. a K/4 '6 i i.i = 4 f s , r F i� t rtd; �. ..e 'b t .e. f 4f, ,".";t ,t1.4 1'I f yy� � rt- Lt ,\ i t t y t M�'"F te� r'Z - A r - r y{ 1J t � 777 r 1 rl a"� t-„t \\ �t t � '�d..` 4 'wr' itp`x F r t 5 [ r( . - 2 f r��' r r, + t y r t i s[ f f r 4U. r. i r:. 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C"� �.- t T L, w } "t +�.,. ,NJF'p� '.J�`✓ G JF27'/G Y.* 7'f-IFiT TL✓E f3u/LD/«V� art 11 ', *," k,�a � a js=.'I' ' Y'�' x CfiR'!0.! a, 7'F//S PL a�1,/ / OC ATE D O.V.TLIE 1 ", , "r, ? t ", r v s�p u - 44F"C►yt/.V ��eJ9oJti/ A:?"O 77NJs7 T i T �A' �� j"IJt ,= 1.'�- },��GQ f, co4CO",4Cr �.ti.� To TNT- zo«vi/vG pfr T,�. t� -� r�[ �i ± iFfN/:5�'`O THE 7�/A//t./ QF ,lgf1J'A.'ci'rQ,f3,'- - � `� ! ro_11e t i �r '. rr�vareuc rJE ra. w f «x 4 is h �} �, 11 ARPfE t «a T'; ill Cs� er�9Jnrir�9 c�3a8 i t S - .l A ~�. L t - retr.,.1, +tv', C'/�/'L E,t/G/.VE@"5� , / - c ip 2 s1-i a- . . .;�Z- v ,�z 1."1, �...ti;_; 3 ► f I ,;�erq"- .E'MOUTN� MA5°S. tSFiTJ�- .eE?r:a +f�WA . 3 , t ". , iw . a _ ., R� ', Town of Barnstable P# Department of Regulatory Services Public Health Division ' �"�"�� • Date •a39 200 Main Street,Hyannis MA 02601 Date Schedule _ Jo Time Fee Pd. -_/ Soil Su iability Assessment,for Sewa a D osal a Performed By: Witnessed By: ©� ZaI] � LOCATION& GENERAL INFORMATION Location Address Owner's Name ✓��JEU�f� L 1�1eSTGtE657 wA`( .3�4iEs.c,yr Gww R llfl,6 J )Y Address Assessoes MM�ap/J/Parceh r/JL f�(3� Engineer's Name�v,2va�,� C/ZoSS.15__Vt � NEW CONSTRUCTION REPAIR Telephone# SU8-S D Land Use Slopes(%) Surface Stones Distances from: Open Water Body /2 sy ft Possible Wet Area ZOv ft Drinking Water Well ' Drainage Way � (bO ft Property Line 2 ft Other ft SKETCH:(Street name;dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) - l07- F Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: 90W16 Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: QAIA Depth Observed standing in obs.hole: in. Depth to soil mottic5: jn. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# _heading Date: Index Well level Adj,factor Adj.Orsundwater Level, e Observation PERCOLATION TEST bate, , Time.. Hole# Time at 4" Depth of Perc Time at V Start Pre-soak Time @ Time(9"-6") End Pre-soak f69�A177 0Y162-� O Rate MinJlnch 5'16719 AL /s Site Suitability Assessment: Site Passed I Z Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# / Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. on istenc ravel /0 '1/ G� , ,try rr G Z fYl .e /l> � .vo • DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cons: ten %Gravel) q (a S Me> II •z '�Q•if G,-1 p AGt9 2 (v fi am s /o y/Z 6 u t ' DEEP OBSERVATION HOLE LOG Hole# f Depth'from. Soil Horizon Soil Texture Soil Color Soil Other Surface-(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) I' c e 6 f{ DEEP OBSER., TION HOLE LOG Bole;# Depth from Soil Horizon � �oal'-Texture Soil Color Soil Other Surface(in.) r _(USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. r. Flood Insurance Rate Man m._. Above 500 year flood boundary Yes _ y':` Within--$00 year boundary_ ,• -,.hl' Yes Within t00 year flood boundary No Yes Depth of Naturally Occurring Pervious Material .Does at least four feet of naturally occurring pervio s material exist in all areas observed throughout the area proposed for the soil absorption system? � If not,what is the deptkof naturally occurring pervious material? Certification I certify that on `` ' '` (date)I have passed the soil evaluator examination approved by the Department of EnvironmentitTrotection and that the above analysis was performed by me consistent with . _ the required training.expertise'and experience described in 310 CMR 15.017. 1 Signature A Date QAS.EP nCffRCFORM.DOC Commonwealth of Massachusetts Executive Office of Environmental Affairs "EC'I � Department of AAN 1 0 1997 Environmental ProtectionAL .aP� TO! QF BARNSTABLE William F.Weld Gowmot -` Trudy Coxe S.ueury.EOEA David B. Struhs Comminlonau ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / MAP# 3 7 9 PART A PAR# 0 70 CERTIFICATION ' Property Address: '9 Y Address of Owner: Date of Inspection: C��1n1yqu�D (if different) Name of Inspector: Company Name, Address and Telephone Number: A & B Canco 350 Main Street West Yarmouth, MA 02673 (508) 775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: V Pasaes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails n inspector's Signature. c- Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: Ljt�__ I have not found any information which indicates that the system violates any of the failure criteria"as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or-repai -,passes inspection Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) _ The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or enfiltmtion,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston,Masuchusetts 02108 • FAX(617)5W1049 • Telephone(617)292-5500 A i:.Printed on RetyW P,per i • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner. Date of Inspection: B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box ' due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspect' if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to brok 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 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF H TH: Conditions exist which require further evaluation by the Bo 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 HEAL DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLI HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a ace water Cesspool or privy is within 50 feet of bordering vegetated wetland or a salt marsh. 3) SYSTEM WILL FAIL UNLESS THE BO D OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM I FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT " The system has a septic 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 Sept' tank and soil absorption system and is within a Zone I of a public water supply well. The system has a se is tank and soil absorption system and is within 50 feet of a private water supply well. The system has a ptic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unl a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution m that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER /(rev'sed03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria efined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to de a what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloa or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or ace waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet inve due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or vailable volume is less than 1/2 day flow. Required pumping more than 4 times in the last y ar NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, spool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is wit 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is 'thin a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or p vy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality is. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile c compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply large systems in addition to the criteria above: The system serves a ' ty with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and environment because one or more of the following conditions exist: _ the is within 400 feet of a surface drinking water supply 3 the in is within 200 feet of a tributary to a surface drinking water supply e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) p' The owner o operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requireme of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for further information., (re ised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addreex Owner. . Date of Inspection: Check if the following have been done: !�lumping information was requested of the owner,occupant, and Board of Health. V None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into-the system recently or as part of this inspection. /As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. 21The system does not receive non-sanitary or industrial waste flow /The site was inspected for signs of breakout. All system components,I►(cluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. ZThs size and location of the Soil Absorption System on the site has been determined based on existing information or Z roxunated by non-intrusive methods. e facility owner(and occupants,if different from owner) were provided with— p information on the proper maintenance of Sub- Surface Disposal System. 1 (revised 11/03/95) 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION Property Address Owner. Date of Inspection: FLOW CONDITIONS RESIDENTIA U Design flow:�gallons Number of bedrooms: Number of current residents: / Garbage grinder(yes or no): 4/0 Laundry connected to system(yes or no):—�/f S Seasonal use(yes or no): Na Water meter readings,if available: A-4 Last date of occupancy: �— COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: ......gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yea or no)_ Non-sanitary waste discharged to the Title 5 system: (yea or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 30 A/- System pumped as part of inspection: (yes or no) ND If yes,volume pumped: gallons Reason for pumping: TYPE Oy SYSTEM Septic tanVdistribution box/soil absorption system Single cesspool Overflow cesspool Privy ` Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: I L 1 d 4 Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: SEPTIC TANK V (Locate on site plan) �r Depth below grade: � � Material of construction: I/ooncrete_metal_FRP_other(explain) Dimensions: /06C S7_" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: 0 '' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:� Comments: (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.) ��1 N J�T- Gva/('/�/�� £//f L d rs T�F/— ,B,q1 FL £` O U£,,e—1 GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP 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: Comments: (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.) I (revised 11/03/95) g ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection TIGHT OR HOLDING TANK_ (locate on site plan) 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: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of)eakage into or out of box,etc.) PUMP CHAMBER.- (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): ' (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool, number: Comments: (note condition of soil,signs of hydraulic failure, level of pondin ,condition of vegetation,etc.) i 8" G�1.Le", FAQ CESSPOOLS: (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: Mow(cesspool must be pumped as part of inspection) 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 s4 signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 X SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. Date of Inspection SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Q 410 DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: -_ 40 e, '00^-,5L (revised 11/03/95) 9 PLAN REFERENCE:BARNSTABLE COUNTY REGISTRY OF DEEDS PLAN BOO 235,PAGE 149. 100 98 96 \ 1600 ESTCHESTER 96 /WAY J ' Bit.Cone.Driveway 100 / / 98 98 ��\ 9 �/ \ \ OOO� / �'100 Garage \ Vent with N (slab) Charcoal filter A B.M.=98.0 Exist J \�h 98 Dig Safe marked / 5 \ 3 Bedroom "No Gas" Dwelling Hse. #39 No wetlands or wells 96 within 200'of prop. Fx tin i \ S.A.S. Septi3 Tank 1 ain Pump-out& to r/ F ' remove exist. / Lot 189 leach.pit / Lot 184 I � N LOT 188 49,258+/- S.F. -Lot 201 " \ 98 96 \1 Cape& Vineyard Electric Company Easement '100 a � Lot202 LEGEND Exist. Spot Elev............. 35 3 Exist. Contour................ - 36 - - - - Prop. Spot Elev.............. 35.9 Prop. Contour................. 36 Setback Dimension........ 13' Perc. Test Location........ Water Service................ _ W Revise per written BOH comments 09127107 jth Revise S.AS,add ventljUter 09127107 jth REVISION DATE BY x ° SITE & SEWAGE DISPOSAL PLAN RORM�" �'nsfu � � GROS6AAAN � etot No. 12705 cn C"YPress Pt ch L 114 #39 WESTCHESTER WAY CrSJE4�� LOCUS a amont BARNSTABLE, MA. Of Barnstable APPLICANT: ENGINEER: 4 MAry Jaqueline Alderson Norman Grossman, PE, RLS ( cssnaaaa y J No. 12773 8005 Kerry Lane P.O.Box 97 Chevy Chase, NO 20815 East Falmouth, MA 02536 'tee . �`�tiTl LOCUS MAP 508-548-1920 ` � MAP SEC PAR LOT ZONE. FLOOD ZONE MAP SCALE DATE SHEET NO. PLAN NO. 349 070 188 RF-1 C 25001 0005 C 1"=30' Sept 18, 2007 C-39Westchester 1 OF 2 H-1007-1 i is • 1 i SEPTIC SYSTEM PROFILE VENT WITH FIRST FLOOR NOT To SCALE CHARCOAL FILTER ELEVATION 100.5+/- FIN. GRADE AT FIN.GRADEOVER FOUNDATION SEPTIC TANK FIN. GRADE OVER SOILFIN. GRADE OVER ABSORPTION SYSTEM TOP FOUNDATION 98.5 98.0 DISTRIBUTION BOX 97.1 ELEVATION 99.25 + / 97.7 INSPECTION PORTS + + 2 RE UIRED) INVERT AT + RISER SET TO WITHIN RISER SET TO WITHIN RISER SET TO WITHIN FOUNDATION ++ 6"OF FINISHED GRADE 6"OF FINISHED GRADE "OF FINISHED GRADE ELEVATION 96.50 ++ APPROVED GE01 EXTILE I LTER FABRIC (VERIFYINVERTIS 3" ! 92.10 INFIELD ++ o �2., PRIOR TO START + - 6° OFINSTALLATION) ++1 5 EXISTING 96.00 suw. 96.2 + � 1000 GALLON + S + SEPTIC TANK BASEMENT FLOOR ++ INSTALL EXISTING ELEVATION ++� GAS BAFFLE ON OUTLET TEE 3 HOLE DIST. BOX 4.00' 10 INFILTRATORS @ 6.25'=62.50' 4.00' 89 7 + +j I TOTAL EFFECTIVE LENGTH=70.50' / + + + TOTAL EFFECTIVE WIDTH= 10.83' (j4-�u + TOTAL EFFECTIVE DEPTH=2.00' l SOIL EVALUATION 34" SH DESIGN DATA HIGH CAPACITY INFILTRATOR CHAMBER DATE OF TEST: SEPT. 4, 2007 6.25'X 2.83'X 0.92' --- H-20 LOADING LOGGED BY: J.E. LANDERS-CAULEY (OR APPROVED EQUAL) NUMBER OF BEDROOMS................... 3 WITNESSED BY: DONNA MIORANDI SOIL ABSORPTION SYSTEM G.P.D.BEDROOM................................ 110 G.P.D. TOWN OF: BARNSTABLE TOTAL DAILY FLOW............................ 330 G.P.D. PERC RATE: 30 MIN/IN**Per DEP Policy _ GARBAGE DISPOSAL.......................... NO SOIL CLASS: II ( 0.33 GALS./S.F.) NOTES. LEACHING REQUIRED........................ 330 G.P.D. LEACHING PROVIDED........................ 359 G.P.D. GROUND WATER: NONE ENCOUNTERED 1. ELEVATIONS BASED UPON BARNSTABLE GIS. SEPTIC TANK REQUIRED................... 1000 GAL. ** See attached Sieve Analysis report from Tibbetts Engineering Corp.,for C2 layer. 2. TOPOGRAPHY BASED UPON BARNSTABLE GIS. OF SEPTIC TANK PROVIDED................... 1.000 GAL. 0" 97.3 TEST PIT#1 0" 97.1 TEST PIT#2 3. PROPERTY LINE INFORMATION FROM BOOK 235,PAGE 149. �cA� O/A O/A 4. NORTH ARROW NOT TO BE USED FOR SOLAR ORIENTATION. p� G' 8" E 8" E 5. ALL PIPING TO BE CAST IRON OR SCHEDULE 40 PVC. NORMAN SIDEWALL AREA................................. 325.33 S.F. t 6. ALL SYSTEM COMPONENTS TO BE INSTALLED IN ACCORDANCE c GROSSMAN BOTTOM AREA.................................... 763.75 S.F. LOAM LOAM WITH SEC TITLE V AND LOCAL BOARD OF HEALTH REGULATIONS. ` No. 2705 05 10YR 5/6 7. NO CHANGES TO LOCATION/ELEVATION OF SYSTEM COMPONENTS CIVIL TOTAL AREA........................................ 1089.08 S.F. �� 10YR 5/6 �� �o '��ISIER� � TOTAL AREA X 0.33 G.P.D./S.F*.......... 359.40 G.P.D. 32 B 32 B WITHOUT WRITTEN APPROVAL OF ENGINEER AND BOARD OF HEALTH. *Per DEP Sieve policy, Cl. II soils, uncompacted SILT LOAM SILT LOAM 8. NOTIFY ENGINEER 24 HRS.IN ADVANCE FOR AS-BUILT INSPECTION. 3S/0,y�I 10YR 5/8 10YR 5/8 102" C-1 88.8 102" C-1 •88.6 Revise per written BOH comments 09127107 jth 1N Of Af4.Sf\ .. *NOTE. EXCAVATE TO ELEVATION 88.6, OR LOWER, Sieve Analysis Revise soil log and S.A.S. elevations 09/27 � AS SOIL CONDITIONS REQUIRE, TO REMOVE ANY TOPSOIL from C2 layer E j B o REVISION DATE BY - � NORMAN In SUBSOIL,SILT, CLAY OR OTHER UNSUITABLE MATERIAL SANDY LOAM** SANDY LOAM ** GBiOSSMAN 7, BENEATH THE BOTTON OF THE SOIL ABSOORPTION 10%COBBLE 10/o COBBLE SHEET NO. . No. f 2775 t Jaqueline Alderson DATE a• SSYSTEM YSTEM. COBBLE FOR F AROUND THE FOOTPRINT OF THE lOYR 6/4 1 OYR 6/4 2 OF 2 152" C-21 84.6 152" C-284.43 PLAN NO. LAO No groundwater;No mottling #39 Westchester Way,Barnstable 09/18/07 H-1007-2