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0204 GREEN DUNES DRIVE - Health
204 Green Dunes Drive Centerville P A = 245 025 E I UPC 12543 No. 533 HASTINGS,MN J u '1.�'lh'-safer l w gwi w TOWN OF BARNSTABLE LOCATION acq Grp 1�UnLS ` (�t SEWAGE # VILLAGE ___ _ 'ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 9:gpt o) LEACHING FACILITY: (type) UX� R-r /��oZ0 (size) /MA JAI NO. OF BEDROOMS BUILDER OR OWNER ��wArcJ To kArZ 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 leaching facility) ( Feet Furnished by 17AS12&4;iyn sy Gar c. i �„otl A � a O r 13 /a P.-r a a ss TOWN OF BARNSTABLE Sys ' oZ, LOCATION a� 6rf,&l 'N)ALS D" SEWAGE # -VILLAGE W. N MAISDOrT ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY C95S wl ry LEACHING FACILITY: (type) �OL✓ I,►fSLSO/S 3 (size) D`�x 0 NO. OF BEDROOMS S BUILDER OR OWNER cJL,,4r77 IJ okArZ 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 leacig facility) Feet Furnished by e%SOCITt yn -:s. fro system. a 3y 4ja J TOWN OF BARNSTABLE SYXr" 3 'LOCATION C)O`/ Crao, NA0 Or SEWAGE # "VILLAGE W• 14 /J4 t/11SnorT' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f M LEACHING.FACILITY: (type) YX(,� (,GO T J/ (size) I NO. OF BEDROOMS PODI BUILDER OR OWNER £�wA/� -kArZ 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 leac ng facility) Feet Furnished by.LAS4Lel e% FD�� �i pool WAa I OIL A B a 1-7 ly ;{ �o TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE, ..���----ASSESSOR'S MAP&LOTa�� UPS INSTALLER'S NAME&PHONE NO.,C /7�iZ SEPTIC TANK CAPAC= LEACHING FACILrfY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater.Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within.^00 feet of leaching facility) Feet F Wished by �; .O ��� ���� � � �' �6. �/� � _` V� � � _ - � �� , o a �� J 9s OOf/ � 'Q0s �� C� �- � , F � _ ;'�`°� _ _o �. .. I P. k lJ No. / �V f ,- . Fee THE COMM6NWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es Zipplication for 33i5po.5aY *p5tem Construction 30Crmit Application for a Permit to Construct( ) Repair(•Upgrade( ) Abandon( ) 2 Complete System ❑Individual Components Location Address or Lot No.�y �`.ie* K11) J ,(�G�- (,Owner's Name,Address,and Tel.No. c!6 StPy r��Q �fl f Assessor's Map/Parcel ys vZ s ,,��► ��'�_3�L IsaJ k/*S�wldO� if- 6��d Installer's Name,Address,and Tel.No. r �® i'(��r+l� Designer's Name,Address and Tel.No. / y41 L4lt lop?- Type of Building: Dwelling No.of Bedrooms � Lot Size sq. ft. Garbage Grinder W Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) &&0 gpd Design flow provided �`7 gpd Plan Date e, ara:z Number of sheets / Revision,,Date Title S Ile ��ah o 6 Z N— Daw�J D IZ- Size of Septic Tank /i�'Wo C ccC Type of S.A.S. & ' Sdd Ga L Gly�cvr d.W� Description of Soil J��•r Nature of Repairs or Alterations(Answer when applicable) �k!! �� ,r/rv�rJ Sy J"".1 og 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 He th. gned Date Application Approved b Date Application Disapproved by: Date for the following reasons Permit No. c_ Date Issued O .. ' r,...w�_ '�`7r�-..�-•���w�r- .. _ _ P . � -+-�-•.-ems .�,r y.'-y tyv.db"'•c�:Ts-"r.� v.„.��`i' No. Fee (DG THE COMMONWEALTH OF MASSACHUSE S Entered in computer: PUBLIC HEALTH DIVISION \TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for �MpPgal 4p5tem Construction Permit Application for a Permit to Construct(+) Repair(,.)/Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot/No.4�? G� i�i� 1 ),_) D/— Owner's Name,Address,and JTel.No. ���/ Assessor's Map/Parcel oV e�S Installer's Name,Address,and Tel.No. � �8�o�i�� La�� Designer's Name,Address and Tel.No. .1 4!t-a G 91-e 5/5 y��!r�./17 a�J r/'J'r11,// w Af x. Type of Building: /� f � Dwelling No.of Bedrooms lJ Lot Size1,'�.� ` sq. ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow((min.required) !v(p6 gpd Design flow provided �7 f gpd ` Plan Date AP,.4 36 JQO'7 Numbers of sheets / Revisions Date Title S'Ile ��Arl o-/' 2 off/ ll�,-rh j�i/w J 1`t w 1- f'7'e,.1w11 pd` Size of Septic Tank f eo 41574 L Type of S.A.S. & �a Gat CIQr(. Description of Soil OAR 7 Nature of Repairs or Alterations(Answer when applicable) s�r1l Ta �+'V/ S�1 "1 "� ,14 h Date last inspected: ' ~ Agreement: I 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 Health. ned Date -. S•'g i� Application Approved b Date Z I 1 G - Application Disapproved by: Date for the following reasons Permit No. J % ' Date Issued ;j i/ l 7 _ o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( v) Upgraded ( ) Abandoned( )by /3a/ �d f�i C4lJ T/✓cio-� at :>G�/ Gryvh Ar/w.) -'Y�It, w has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.n- dated , Installer /3�,�0�0/�i ��U) Designer +✓ Cr.,`4r #bedrooms Approved design-flow (r> `'7, gpd � G The issuance of this permit h)all/ Et Hk c]on rued as a guarantee that the system will function as designed' Date �1 -f l/ -,Inspector_ d� ��� 1Jcs i . - --------___- ———No. � -7 /,�_,� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1wigpont 6pgtem Congtruction Permit Permission is hereby granted to Construct ( ) Repair ( --l-o Upgrade ( ) Abandon ( ) System located at .2Q C/ ��...,, �u�r� /)/� 4/ ���/r 14 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. l Provided: Construction ust be completed within three years of th ate of this pe t. Date 5 if/7 App o ved by i a - t Town of Barnstable d� Regulatory Services Thomas F. Geiler,Director BARPMAML Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, NIA 02601 Office: 505-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit# �d7' /�qr Assessor's Map\Parcel " .�5— T-' n Installer: Designer: 0 W V\, e Address: � Address: l"I� �• l�'�l/l� 11� On /J�o, h/'�a�l� �w�'C was issued a permit to install a (date) (' ler) , septic system at -r— y�- based on a design drawn by (address) �bv� CA C ..�.N 0c.1dated ( esigne 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. H OF M,gSs9c DANIELA. yG� o OJALA (In ler's Signature) CIVIL N No.46502 _/C) �0 X, /S T E� �? �SSIONAL ENG f (Designer's Signature) (Affix Designers Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE wILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:HealtIVSeptic/Designer Certification Form 3-26-04.doc TOWN OF BARNSTABLE L!l CATIONS`"� a- r,e,� yiwlcl SEWAGE#.'Z VILLAGE ASSESSOR'S MAP&PARCEL T14S/2g INSTALLERS NAME&PHONE'NO. cs�as �, S�rL.cb•c�. SEPTIC TANK CAPACITY k' .. LEACHING FACILITY:(type)L-s6ld 02 1�e 5(size) NO.OF BEDROOMS OWNER Zdg_ e\\G -L PERMIT DATE: IS'-Ll 0-7 '.. 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 (ftcr r� G,► �_, °:n i, t o A wC �� Q Fee_--1-i---------- BOARD OF HEALTH TOWN OF BARNSTABLE App[icationArlVell Construction-Vernat Application is hereby made for a permit to C�n„st; ,ct ( Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel f�ga x _+ jac -- -- -- -------Owner Address `— --- -- Installer — Driller _ Address Type of Building Dwelling ------------- Other - Type of Building— ___—__________ No. of Persons------------------_--- Ir< Type of Well y -_----— Capacity--- -- —--——--- —-- Purpose of Well---- _ ------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed� �c�7�e1=------------ — ---f�-�— ate 7)14 4 Application Approved By _ -��?------------ -------__ date Application Disapproved for the following reasons:----------— - - —---—— - ---------- Permit NO. date o s air v�(� mil_ D - — Issued-- f--- --- ---------- - ------ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of ComPriante THIS IS TO CERTIFY, That ttk,eIn_diivid®1 We l Constructed (�'Altered (— ), or Repaired Installer at—'Q' Gr"' / /P U1CL� c'(h 61- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr tection Regulation as described in the application for Well Construction Permit No.waUU.feNTEE =-N& --Dated ���- � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- ---- -- -- - —-- Inspector-- - —-- - - - ----------- , . .« U - Vi/0. �0!�{ 2 I z Fee---/-- ------- ---- BOARD OF HEALTH - TOWN OF BARNSTABLE 0(pplicat ion,*orWell Congtruct ion Permit Application is hereby made for a permit to Constr ct (k, Alter ( ), or Repair ( )an individual Well at:, Le — —" ---- — — ! Assessors Ma Location _ Address P and Parcel �o f �/off - Owner "" Address RAP Installer — Driller Address '. Type of Building -/ Dwelling - w Other - Type of Building No. of Persons-------------------- Type of Well—y---�— —---- -- Capacity---- - - ----- - - ---— Purpose of Well---__!���5_�_I_!a1/-- — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The _Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to 1 place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed / --------- - ___7 0LCb�1__ ate Application Approved By ` — --- --—-— J -- -- date F Application Disapproved for the following reasons:------------ - —- --- - - ---- -------- — ---- ------�--------_--date - c/f Permit No. J a)b ro I�9 -- Issued--7��-4` ° -- ------ date --- ---- I, BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That a Indivi ual Well-Constructed (,4j-Altered ( ), or Repaired ( ) V Installer at 0'r�has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pr tection Regulation as described in the application for Well Construction Permit No.W a00S_-_2l6 __Dated016 �y�S� D ' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - -- Inspector-------- - - —------ BOARD OF HEALTH T WN OF BARNSTABLE ' Well Con!9truct ion Permit No. —W�OUS���O L ----Fee-` 'f Permission is hereby granted (57 to Construct (ki, Alter ( ), or Repair ( ) an Individual Well at: No. — -G'`P•FJe✓� -�'�-__ ----------- --- ---------------------------------- I Street as shown on the application for a Well Construction Permit / - --------------------- No.__lv_a SOS a I -------- DATE— 7 � Dated J °�------- Board of Health ' � �.i — ---- 4ir:; (Wd as - b Lo`r Sg prr V Vl ♦ � $AGkw�sp. 4 i a W aTByt "`� lE �C !oo• I04 ��. K Z RCS�`� \' 0 Pao_ tom N X" :.TAiuK ... - �0 /J� ONE S .v IBC Cm�/ Tp in/ I S ia/gC / 7oi L E i 11 Q IJQ � a LOT z o 7-OM _ Aga 1 -Z 3 N IA 1. 51 Aclet 1 D k N �• 0 1n N` I € 14 0 1 ro ExiSTr� 3 s Cr 1 10 0 ' � S �12 I v by�p \\ 4356b s� A� �W_) E k1AYJ I CERTIFY THAT THE PROPOSED SUILDINGs ooL SHOWN ON THIS PLAN CONFORMS TO THE ZONING LAWS OF- Z6&Q 5Z6LZ.: ...., MA. LEGEND DATE : EXISTING SPOT ELEVATION 0 0 PROPOSED SPOT ELEVATION �K°` Mas, EXISTING CONTOUR ---0--- �O� . dy�� CAUL A. a PROPOSED CONTOUR 0 DAVID P. LEVY NOTE: THE LOCATION OF ANY UNDERGROUND ® MARIANO al�.' u No. 10617 yl SEWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON No.l31i 15 ' O THIS PLAN IS APPROXIMATE ONLY AS DETERMINED �•�©�� FROM RECORDS AND/OR VERBAL INFORMATION. oc 'GISTE THE CONTRACTOR IS RESPONSIBLE FOR THE �s p Sr�F{yti� VERIFICATION OF THE EXISTING LOCATIONS IN THE FIELD. ENGINEER" O..EVY & ELDREDGE ASSOCIATES,INC. CLIENT : PAWO= P ST PLAN Tl � �uN p Ivc ENGINEERS- LANDSCAPE ARCHITECTS JOB NO, Io (,drSzo •� �aN cou/L `�4 D PLANNERS - LAND SURVEYORS DR. BY, IN $9 WEST MAIN STREET CtD.QYr ?►�S 8LG , MA CENTERVILLE, MA. 02632 IMT,01F.Z. SCALEr 40' DATE Io z4 8 f 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROT RECEIVED JUN 2 6 2003 TOWN O FBH NS TABLE TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 204 Green Dunes Drive W4xLH tamiLgwN MA 02672 145 Owner's Name: Edward Takarz Owner's Address: P.O. Box 623 ^a7: West Hyannisport, MA 02672 Date of Inspection: June 9, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 Needs urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 10, 2003 The system inspector shall submi 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I i Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 204 Green Dunes Drive West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 Inspection Summary: Check A,B,CM 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 i Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 204 Green Dunes Drive West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 204 Green Dunes Drive West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 1;Pd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 204 Green Dunes Drive West Hyannisport, AM Owner: Edward Tokarz Date of Inspection: June 9, 2003 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 i Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 204 Green Dunes Drive West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection(yes or no): 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 ✓(2) 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: System 1 -pit added 1/5/87;System 2-leach field approx. 1985;System 3-pool house system 10129186 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#1 West Hyannisport, AM Owner: Edward Tokarz Date of Inspection: June 9, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Cesspool acting as septic tank Depth below grade: 5" Material of construction: concrete _metal _fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x 7'T x 10'bottom to grade Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 2" 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: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The liquid level in the cesspool was up to the outlet tee. The cover was 5"below grade. Recommend pumping every 3 years for maintenance. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#1 West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#1 West Hyannisport, IvL4 Owner: Edward Tokarz Date of Inspection: June 9, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'(1000 gal.)H-20 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The pit had 1'6"of water on the bottom. The scum line was at the same level. There were no signs of failure. The bottom to grade was 10'. The steel cover was to grade in the driveway. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#2 West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: _ ✓ (locate on site plan) Cesspool acting as septic tank Depth below grade: To grade Material of construction: concrete _metal _fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x S'T x 10'bottom to grade Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: I" 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: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The cesspool had 4'6"of water on the bottom. Scum/sludge were minimal. No outlet tee was present. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7a OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#2 West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8a OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#2 West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3 flow diffusors-approx. 28'x 10'per information available leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation,etc.): The leach field was not dug up. There were no signs offailure. The bottom to grade was approximately 6. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9a A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#3(Pool House) West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present. The liquid level was even with the outlet invert. Scum/sludge were minimal. Very little use. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7b 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#3(Pool House) West Hyannisport, M4 Owner: Edward Tokarz Date of Inspection: June 9, 2003 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was under an asphalt driveway, I used a video camera to inspect the D-box. The D-box was level and no solids were present The steel cover must be brought to grade for access per Health Department. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8b OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive SYSTEM#3(Pool House) West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 4'x 6'(600 gal.) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Typeiname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): The pit was dry and clean No scum line was present The pit was under an asphalt driveway. I used a video camera to inspect the pit The steel cover must be brought to grade for access per Health Department. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9b Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 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. 10 Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Green Dunes Drive West Hyannisport, MA Owner: Edward Tokarz Date of Inspection: June 9, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- feet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 20'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 f 04 a ct a cb Q� a SY s��• 3 . tpoo1 -lousc, A � a. y WA t I A b p 3 , ra RV ' O a 1-7 ly D 9 D y ya 3a Y ��/ � aZ �°� DATE:_'-� .?% 5 . PROPERTY , ADDRESS:_':?90 -y/.—e�.A' ;7un;�h .D.7.j AZ _ -fell ` ~•� - On the above date, I Inspected the septic system at the above address.. This system consists of the following: � . 6 '.x8 W.iih 14000 gal..�on. 12.i..t.,. •2. :,1-•6 'x10 92ock ce�>s;?001 :vi.th ov-ea,ziow -b?.a- .ch. f.Lot�� �.i_��u.d�o.2a 3 „1 ' R igh•ij. aea.R. Based on my Insoaction, I certify the following conditions: 1 . Thii .i6 n^t Z 7'�'4 .�2h'4�10ne.h ahou.?.h 02 �u+r..�n_.c1. �1�r..a. a:ce.y 'h3. ,�g2ce:l ti, do :lon.e ih,a ;2.i_z:st �oeek of Oc:�o.� 2.z.. Zecc`hon ooz. w•._t.ia�r_g a.2.e the ma��ave. 0-<�2•z le1e, a.,?.d .0Qr)we.a.,,) .L - CG-7 ,- .C1cg'..`C!/+b'f,.�2Q�•�!b. �,t;�m .i.4 ..i.n• ,^2 �n_:�t' t<to^•iC './t'� 0 'dd t(7.L ''h/2. /?.ae.sertt :tinle, 5IGNATUR!7: t Name: J_P.M_acomber Jr ._______ . z— -- J.P_Macoc)ber.—& Son Company: rInc . ---- A d d.r e s s:--$eac—b4—' -- -- Centcrvi1leLMass__0.2.632' ` Phone:---5Q8.-.J..7�3338----.— = '•�I . THIS CERTIFICATION DOES NOT,CONSTITUTE A GUARANTY OR WARRANTY i .IOSEPN P. MACO�RBER & SON,. INC. TankrCeupoolrLea�hfleld: i . Pumped & lniUlled Town Sewer Connection: P.O. Box 66' Centerville, MA 02632-0066 775.3338 77"412 s SrWAGE DISPOSAL SYSTEM I?.IE:17 " "' : .. . A dress Of Property. 290 172wva ld.?at. Ryan.a-i J,2on:t: 812.6t, lJi..G __ aria Dace.� I- Date name .� �_� Date of Inspection 8122195 • PART A MiUCKLIST Check if the following have been done: / Pumping information was requested of the owner, occupant, and Board of health. 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. :I/All � he site was inspected for signs of breakout.. system components, aitcluding the SAS, have been located on the site. The 6044_ manholes were uncovered, opened, and the interior•e-€- s•ept+e-t-a-Pk was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum, _ZThe size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if di.fferent from owner) were provided with information on the proper maintenance ,.of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORM PART B SYSTEX INFORMATION FWW CONDITIONS: ' If residential number of bedrooms number of current residents at S garbage grinder, , yes ,or no �S laundry connected to-..system, yes or no ' . M seasonal use, yes or no If nonresidential , calculated flow: Water meterreadings;. if available: 7993=49, 000 ga.Q�,t�2.b=�3'9, 7' y?D j 1;29►=?7,;� DO�� 1.�.2vn.t;=1021 . 9.=(%lPp .>�.z.1.� �C.�er. h�st.en �.r• .u.Fe "� Last date of occupancy GENERAL INFORMATION Pumping records and source of information: ' A16 System pumped a,s part of insPec ion, yes or no if yes, volume pumped Reason for pumping: ' ' , Ty a of system Septic tank/distribution box/soil-absorption system Single cesspool.. Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) •' Approximate age of .all 'components. Date installed, if known. Source of informtioon:. _ . . 1.. ..,:_..- --.._............_......__......_._._......._._._:._.._..- --.... . � N : .j Sewage odors detected when arriving at the site, 'yes or no i draft 1113195 9 SUBSURFACE SEWAGE DISPOSAL.SYSTEIII INSPECTION FORM PART B SYSTEAI INFORIIIATI0N FLOW CONDITIONS If residential number of bedrooms • number of current residents .)jg garbage grinder, yes or no laundry connected to system, yes or no ,gyp seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: 199?='8'•, 000 gaVlon.6=1339 . 73 g.2.9c,!oaz day Spn.in_kl-ea b-6.tzm 1994=•313.-000 vae-gon.6 1021 . 92 ga.elonz pea day. tn_ u:ast date of occupancy fi o u.a.e. o c.cu/2 s zd. GENERAL INFORMATION `. ..Anping records and source of information: 3/17/'9:5 ND System pumped as part of inspection, yes or no if yes, volume pumped , 0 Reason for pumping: Dacel' hr.i io2 u.7.2rn� 2 ;o.e,3 �iJ!nf.s Lem nimnor� t_h- 4i2 [doe% ,Lot wa.n.t to Itu.i.n P�awrz,z A,e:-La ��.t .h.i..s .t...ime o� Type of system NO Septic tank/distribution box/soil absorption system Single ces4ol a Overflow 4j"X'I?.ze r_.a s t !'erl chin g ,,2 i i . NU Le c:4 t lcen ch. ;j ow m.in_.i nax 3 A10 Shared system (yes or no) (if yes, attach previous inspection records, if any) SO Other (explain) Approximate age of all components. Date installed, if known. Source of information: e h� n I`.P i 3�^ G� �o' n!^0�. �k3 eS ELi�2 jaet�fi'�°"f��,C•15 'f � .... / Sewage odors detected when arriving at the site, yes or no CIA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORK . PART B SYSTEM INFORMATION continued ' SOIL ABSORPTION SYSTEM (SAS) : Y " �- (locate on site. plan, if possible; `excavation not� requi.red, but 'may.•be - approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits . and number �7 La a c h i t_. leaching chambers and number n leaching galleries and number n leaching trenches, ' number,' length ; 28'x10 leaching fields, number, dimensions overflow cesspool ,!,., number 0 Comments: �? ;'1:1in ce-6s�oo.9. " (note condition of soil, signs of hydraulic failure, level of ponding., . condition /of� veget�ioJn�2�repomm��ndu?ons for mainte ancg qr repairs etc. 9 o� R-an._ing egeta zon. 2C z"r!a`, Nr. n,..2.2ded G.t fimo CESSPOOLS (locate on site plan) : _ number and configuration 2 1-6 ' ,t8' 1-•6 'x10'• &.fo•c.k c.e..sapo-oX,. depth-top of liquid: to inlet invert , r000a wee ` depth of solids layer �,A,;a, ?n,,,e2 te.- a.-,?.d aoa,4t depth of scum layer , ,,,,c, dimensions of cesspool materials of construction indication of groundwater inflow (cesspool must be pumped as art of ins ection. P not P inspection.) Dic_ purr..p. ul...'..2.6 &a•,Ru;n;?erl. IiAht wzzk oA _•c . x I Comments: (note condition of soil, signs of hydraulic failure, level 'of condition of vegetation, rec9pnendations inteponding, Sa:z-1 �z�z ! , .a. cveJ�. No:: slgn.d o , y, 2uu %c �icp# nance or re pairs,etC.) OIL. on:,.ing. A.."'_0_ Vo_geta'. Lon. nonv?zat. Nn .g.e,,¢i..2.; nee. e... c�. . <, t._.i.7s .:.m.e.. i • PRIVY: ,N(JN(F- (locate on site plan)__ .. ..._.._.__._._.._............. ..__........__.._......... .... ......... ._...... ........_..._._. .._...._._.... _. ... materials of construction NO V, i dimensions depth of solids ------------------- Comments: (note condition of soil, .signs of hydraulic failure, - level of.ponding, condition of vegetation, recommendations for maintenance or repairs,r' l'7 AIF SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM PART B SYSTEM INFORMATION Continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two perma nent Went references landmarks or benchmarks , locate all wells within loop Vs oo,y , O i 1 DEPTH 'TO GROUNDWATER ' depth to groundwater method 'of determination or approximation:' '—iTrZD'ffC Zr4 E n 1 n n ni-1 1 rl. T .'v�l h .i..r't.!S�!L er2C� C12 � f7!�t7•_ 7 /..l.L_ea, 1 Peon nn Pjj7p %f �f22 �3i226�2 P CG.?. �('L ��,• i 12 SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM l PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) _ V Backup of sewage into facility? Discharge or podding of effluent to the surface- of the ground or surface waters? NO Static liquid level in the distribution box above outlet invert? - yes Liquid depth in cesspool <6" below invert or available volume< 1/2. day flow? _ Required pumping 4 times or more in the last year? number of times pumped OAIC,e- Septic tank is metal? cracked? structurally •unsound? substantial infiltration? substantial exfiltration? tank failure- imminent? Is any portion of the SAS, cesspool or privy: /VQ below the high groundwater elevation? . M within 50 feet of a `surface water? Q within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh. (cesspools and .privies only, not the SAS) ? _,- within 50 feet of a private water supply well? 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 stater anal; for coliform bacteria, volatile organic compounds, ammonia nitrogeni-- and nitrate nitrogen. TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION h ---- _.... -.._. .. __._......_.._..- - _.._... ..........__..._... ---- - -,,TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 29 n�� � /7>>n �.� L1niu� 4L,,it fgannii.nnat- ASSESSORS MAP, BLOCK •AND PARCEL # OWNER' s NAME a i��. i.am D jc PART D - CERTIFICATION NAME OF INSPECTOR 206z .h 1') Mo - - COMPANY NAME Son rrtc COMPANY ADDRESS 13ox 55 e.nt"-2t.�iP2n_, ."l�.s.s. 026.32 Street Town or City State LIP COMPANY TELEPHONE (50R ) 775 - 33M FAX ( 508 )77 -1573 z . CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XXaY.+'X System PASSED The inspection which I have conducted has not found any information which indicates that. the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to . protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as °specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector_ Signature Date 812.519, One copy of this cert.ificatidn must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or"'operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as _provided in 310 CMR 15 . 305 . partd.doc • c ..-._...---- -- Cc^^mcnwearn cf Masse^�.:serrs ExecuTNe office cr Envircnmemc.hffc,a Department of Environmental Protection ' Water Pollution ConTrol Tecnnccl Asswonce and training Sections YAULAM F.Weid C.O.Wn r Trudy Cox* S.a.wry,EOEA • Thomas 8.Powwo A4"Cort.n.W"W 06/12/95 ATTN: Joseph P. Macomber, Jr. Joseph Macomber and San PO Box 66 Centerville, MA 02632- Dear Joseph P. Macomber, Jr. , _ I am pleased to inform you that you have attended training, met the experience qualifications,, and have passed the Title 5 System Inspector exam, pursuant to 310 CMR 15 .340. The passing grade for the exam was 39/52 or 75%. This is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15.340. You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following address: Kimball Simpson. D.E.P. Training Center 50 Route 20 Millbury, MA 01527 Thank you very much for your time and consideration in this matter. Sincerely, Kimball T. Simr.?,on, DEP Training ;ter Director (2405) Roue 20 ot aodloury, MA 91'•." FAX 5U-755.925J a Tel.unune 508-756-77-91 Whiter - Conservation SAVE Tips . . . ME. CHECK FOR LEAKS Water Loss in Gallons Due to Leaks Leak this Loss Per Day . Loss Per Month Size 120 3,600 • 360 10,800 • 693 20,790 • 1,200 36,000 ~1,920 57,600 3,096 92,880 ® 4,296 128,980 ® 6,640 199,200 6,984 200,520 8,424 252,720 9,888 296,640 11,324 339,720 0 12,720 381,600 14,952 448,560 TOWN OF BARNSTABLE LOCATION�a-"A SEWAGE # +� Vx ;LAGE r��p ��- ASSESSOR'S MAP LOT i` INSTALLER'S NAME & PHONE NO. � � 71 SEPTIC TANK CAPACITY zed c?6 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS_X,,,,?t�) PRIVATE WELL O PU�WATE BUILB£tiIt OR OWNER �b lo .. DATE PERMIT ISSUED: _ �- ,02.2/ e.X L DATE COMPLIANCE ISSUED: j '�- VARIANCE GRANTED: Yes No 'x - - _ ��v� �nvvs� ���i. � Z � �� � � .�� `1\ � A � ` / 6 �r �� ��� � � `�'Z� �� ����� ASSESSORS MAP NO: PARCEL NO.- .......... ................. THE COMIMONWEA474.;H OF'MASSACHUSETTS BOAR® E -HEA T ......OF..... e. � ---- ----------------------- /c AVpfiration for Diapaout Works Tonotrurtion ramit Application is hereby made for a Permit to Construct ( or Repair an Individual Sewage Disposal System t: ...C.d....Oer_-_7_Deears .........../A .e-. -----_0 ------ Z o on, &Z 'on I Address t_No. . ............................... ..................... ...... ........... Owner�w ' Address ..... If....................... ........... . ....................... Installer Address Type of Building Size Lot___- .. .... ---------Sq. feet Dwelling—No. of Bedrooms___---_-____ ------------------_--------Expansion Attic Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) PL4Other fixtures .................................................................................................................... e� ----:>--2- Z-5------------------------------- W Design Flow.............. .............gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid*capacitv_l.�"�.gallons Length................ Width----__--___-____ Diameter____._........_. Depth........_....... Disposal Trench—No...................... Width....._.__._..___._.. Total Length................._.. Total leaching area--------------------sq. ft. Seepage Pit No.-COKA...... Diameter____________________ Depth below inlet.................._. Total leaching area........:.........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date-----------------------------------_.... 1_4 Test Pit No. I________________minutes per inch Depth of Test Pit._____.....__....... Depth to ground water-.___._____-_-_-__---._. G%, Test Pit No. 2................minutes per inch Depth of Test Pit__..._.........._... Depth to ground water_.-___-_..-____----__-_. W ---------------------------•------•-----•---------••----•------•----------------•----••---------••--........................................................ 0 Description of Soil-------...77.7:�=s.... . ............................................................................................................................. U ....................................................................................................................................................................................................... W ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L 11 1-h, of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the of health. ............. .......... ...... ...................................................... 7.a. __ql .... ..... ............ ........ ..... Application Approved By-.--:- .7.!�................ ................. .. ..... ................ ........... Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo_- ...... ............ Issued....................................................... Date NdZC�....1.1 YmB............................. W-1 Ec 6`MMONWEALTH OF MASSACHUSETTS BOARD OF HEA , Tl� ......OF...Ae io-2 --,� _/ I......................... Appliration for Di-qposal Works Tomitration Permit Application is hereby made for a Permit to Construct (p-)-`or Repair ( ).an Individual Sewage Disposal System,at- 4- 6L lkle:•"_............/Ju, .torzr................ ?........................... ... ,r- ion-Address t No. Owner Af ------ --- . ......... - ow Address e. -.1-i------------------------ ................................ ............ ......................................... 3it - Instaier Address C11 Type of Building Size Lot__t U ....3...(----------Sq. feet Dwelling—No. of Bedrooms-----------4...............................Expansion Attic Garbage Grinder �_l 04 Other—Type of Building ............................ No. of persons._.__________________.____._ Showers Cafeteria <a4Other fixtures .................................................................................................................. -,>---- '5-------------------------------- W Design Flow_.__.___.. ................gallons per person per day. Total daily flow...........................................gallons. 1:4 Septic Tank—Liquid capacity_/_p"..gallons Length________________ Width__.__.__.___.__. Diameter__.__-_______-__ Depth___._____.___.. Disposal Trench—No_ ____________________ Width______.__.___.__._._ Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.&KA------- Diameter.................... Depth below inlet_.__..__.___________ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...........................................:............................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit_..__.______________ Depth to ground water........................ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.____.:________._:_____ ................................ .............................................................................................................................. 0 Description of Soil---- ........................................................................................ - --------------------------------------- U .............................................................................. .......................................................................I.................................................. ----------------------------------------_................................ ......................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable.................................................................. ............................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with, the provisions of TITLE 5 of the State Sanitary Code—* The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Aoa�r I,d of health ...........I........................................ .......Z........4 pate Application Approved B ..... .. .......... ............ ... ............ Date Application Disapproved for the following reasons:................................................................................................................ ...........................................................................................................................................................................................I------------- Date Permit No. 4;;R...... ......I...La.a............. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ?..............0 F..A�se,.1 e /4�k ............. Trrtifiratr of Tompliatta THIS IS TO "RTIFY, Tha e Individual Sewage Disposal System constructed (400<or Repaired ......................... ------------------------------------------- ----------------------------------- Inst.li n............ .......................vngf�......— 4 ia:::� 4- ---------- .......7------------------- has been installed in accordance lance with the provisions of TITIE 5 of T Sanitary he State Sanitary ode as described in the 7� -2 application for Disposal Works Construction Permit No. ........ // ..... dated--------/.7(%/------ ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCT 4ON SATI F_A J=ORY. ................... DATE...................... ......................... Inspector... .4---------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH 7 ..................................OF..............................I I ..................................................... Dispo-sA31arks Toniit'Td qtprrmit Permission is hereby granted......... .................................. to Construct ) or Repair ) an Individual Sewage DispPS4.System at No........ ....... ....... ...... _4___/-------------------- ---------- reet , W St as shown on the application for Disposal Works Construction Zprmit_Nja� D a,-e d ... ..... .................................................... ---------- .............. Board of Health IsQ.ATE.............. 0. ........................................ FoR v ,1255 HOBBS & WARREN INC., PUBLI'%HERS /O/ S 7o o8'S;0 N LOT 1007 P? tot �➢' Dtgr Coo' Z t0' BbA ti I � ON t 5 ini K oiJL l3u /�li•/�o © TO � Q LOT z o 7oT-A _ aez-A = w- t - 3 N. n t , c N to 13I Acet-s 0 o n � d c EX'STr� 31 s T DtjE�L�� 5641 U zo�iE r;D_ I �qo w ro S �rz v 43s&0 `'F A4, cIAC_ E wAY� I CERTIFY THAT THE PROPOSED BUILDINGsdQmoL SHOWN ON THIS PLAN CONFORMS TO THE ZONING LAWS OF,AE S;�gc.� MA. LE_ DATES EXISTING SPOT ELEVATION 0 PROPOSED SPOT ELEVATION �H OF M� EXISTING CONTOUR ---0- -- � sJ1 PROPOSED CONTOUR 0EVY "` r PAUL A. a NOTE: THE LOCATION OF ANY UNDERGROUND C M CIVIL l!^ NOL1 617 y SEWERAGE,WELLS, OR OTHER UTILITIES SHOWN ON No.31 15 THIS PLAN IS APPROXIMATE ONLY AS DETERMINED FROM RECORDS AND/OR VERBAL INFORMATION. �ocNoISTE THE CONTRACTOR IS RESPONSIBLE FOR THE FS a VERIFICATION OF THE EXISTING LOCATIONS IN =" THE FIELD. REGISTERED E N LEVY a ELDREDGE ASSOCIATES,INC. PAOPOSED CLIENT PLOT PLAN xt Zoo 4 bUQ VC-- ENGINEERS- LANDSCAPE ARCHITECTS JOB NO. I (LOTS coU2r ►' �g- D� ,PLANNERS - LAND SURVEYORS OR. BY, WtS� IN 889 WEST MAIN STREET CHKD.By A SY� MA tMERYILLE, MA. 02632 T►..OF, SCALE DATE �,� � a='C W �•� � �,. � � � � - v �S of °� �� cD 04 cd"2k1_-'S 'tyi MU lk oj e Aj.t� .; '� ice • W h o' . ,:1r�,�►:Q \ f:t c- �tic�.. afy. ttG�t� Q ''.^� \ V - � �� Q Qcc ry :W; V �.. o: .• o4k s�yv�+ b 1 ilk lu Al 4 h u u 3�� t v �,Q'.� q ktir-+r�-• � � Q/ FAO c�` 3, n sl Y.W 2 w . .. ::...._.•.:10 _.O. • � n V4. Q- -aRO Ob �� ��"" , ..*" ..'�,r s �` Or• ;i.: � ••\f _ i► � '�Y�; - plc , �; Rk A k kVU :0� MA It oIt � ® ,, � 14 i � <P ASSESSORS POP No: ,�,-� THE COMMONWEALTH OF MASSACHUSETTS 1— 6 t] BOARD F I-IE T l Cfl.Gc ,T ... ...............OF....� .��:..�5..�.�... Appliration for Elhipotittl Workii Tonotrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair .( Individual Sewage Disposal Sys earl D �bCd --.............................•--•-..�:�.q....................'S .,�_c.t�'....... _r, 2c-tJ �. ............. -7 l• tion•Address or Lot No. Owner � Address W •�, s ) s ©_ S .............................. 45 ............................................................ Installer Address Type of Building Size Lot____ .Q _.�....... Sq. feet Dwelling—No. of Bedrooms........... ........:....................Expansion Attic (*td Garbage Grinder 114 a Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fiS U ------------------------------------------------------------•-----------------------------------•-----------------•-••-••----••--------•••-•----•--- W Design Flow................ ............................gallons per person per day. Total daily flow.............3__3_jC�..............gallons. WSeptic Tank—Liquid capacit)OyQ0.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ---•--•-----••--•--•-----•---•-••---•--•--•--•--•••--••...-••----••-......--••--•---•----•..........................••---•-.....---••-•----•-.....------•-••- 0 Description of Soil......................................................... W. U --------------------- -------------------- •------------------------------------ _------------------------- -•-------------•---••---•----------•------------•-------- •----------.... .......__._..__...... W •-•-•-----------------------------------•--•----•------ ----------------•--•----•-----•....••----••----•-•- ----- --------- Nature of Repairs or Alteratio s—Answer h a licable__.__.�.�_ U P (._��___ . ------•-----•••-•••--- ��__0...........�'---•- tom '=`-��--------------=-----•-•----•--•-------- 1i=�� Q.Ctito .a�.... - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITi U 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been.issued by the rd of health. Si ned_ - - --................. ApplicationApprove == ............................................................ ................................... Date Application Disapproved for the following reasons:..................................................................-......................................... __ --------------------•---......------------....--•----------....------------•-------...-----•---••--•--•-----•-•--•---------•----.._..-.---------•-•------------•------------------------•------...------ Date PermitNo....................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS ..� BOARD OF HEA TH '7.--"----.....OF.... !'...:G !, '?.�J..f.'-^.. ��...............•---•--•..-- Applirtt#inn for Dinpnsttl Works Tonstrurtinn rrrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( j�'an Individual Sewage Disposal ........ ............. .�:S :..... c--- ` .Q .......----�'=�=.�:".'���::..�:�..��:�:................. Loca'on Address - "^. or Lot No f --... r..i I-r�.,}. �.. L:.+� _t:. .. -- ---------------------•... -- -. ._» .. .... .. .- Owner ! r P _--t r SC:�'--1--:--•-----------•--------•-----•--- .....---• ......................................................nda ress - -s. �- ._....�.----.... -- Installer Address J! f ,. c C 4 Type of Building �( Size Lot..___t._e...................Sq. �eet . V Dwelling—No. of Bedrooms.............3.............................Expansion Attic Garbage Grinder Other—Type of Building No. of persons............................ Showers a YP g --------•----•---•-••---•-•- P ( ) — Cafeteria ( ) dOther fixtures�....................................................................................................................................................... W Design Flow................ .........................gallons per person per day. Total daily flow..............-?�..a.a.............gallons. WSeptic Tank—Liquid capacity jAOQgallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.............._..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ••••-•-•---•-----------••---•....................•••...••----•---•••-------•••--•-•••------.......••......................................................... 0 Description of Soil.........................................................•.............................................................................................................. x W ....•.•----•-----------------•.•--.---.____.-•••-•----__._ •--•-.....•.-•....----_ v K U - P .Q. 1l = P =cats " Wc^� '1 - - - Nature of R�e�a>rs or Alteration AnswerRhR ash le.__.__._... . Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLS 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee, issued,'b�y then b d of health. Sied. ,r. .... !..7 ...................................... ....... Application Appro ev d'Bx ... ...... .:: .. ...... .......... _ ... Date Application Disapproved for the following reasons:---•---------------•--•----...---•----....------.....-•-----------•-------------•-•-•-•••--••••-•----.......__ ....-----•...............•---....------............-----•--•---..........--•---------------•-----------.....---•-•------......---•------...-•-•-•------•--.....--•-•-----.....--••-•......-•••--•----•-- Date PermitNo...................................................------ Issued.................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE TH C?to rn t/. !`1-5 .1 .........................O F................... 77 ............ .... ................................ (Irdifirtt#r of ('10Mplittnrr T, IS TO CENT FY .That thr Individual Sewage Disposal `System constructed ( ) or Repaired by......... c ...........�............................................... • -..__..._......-------------- Installer ....._----- 1 ." 1.... V I �i at._.. . ... c -c."1. .t... has been installed in accordance with the provisions of TITLE 5 f The State Sanitary Code as escrijed ip the application for Disposal Works Construction Permit No. :_:__ P_ ..... dated......__.__ ;r__. . .: .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. o �7 vt DATE....:..... �� 7................................. Inspector........-----......------.-�.r.".........-••-•-----•-•---•--••--................. A THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H ���..."' � ..............................`..........OF.. 1. :....................................................................... F>as..... ............... �.-M-- �itt�nnttl�a = x-Its �un�t��tr#�n �rrntt� . Permission is hereby granted......_. :•-----.--"---•-•----�•--�~-------•--"` .-------------------------------_...._ to Construct � q��Re air { an individual Sewage-Disposal S stem � j� Go (. vi y at No.... ) -p C_.e Q .--: _ -�'... .... t`� c ._ .r .lc!.+.. <..r.................. Street gyp' as shown on the application for Disposal Works Construction Permit Na�.-�.•- ' Dated'._!`-'1 �r 4� v � � z � Board of Health DATE.------.`•• •... •--•---------------•--- ----.....•----........_...._••---- FORM 1255 - SULKIN, INC., BOSTON . lip 'ter ;� T % �� I i 1 ....... 44 st All I�0 � `,1, i 1� � • n1 t. 1 � P,FOJoof 13 c O� x , o I J `^In off . ry 10 ci M / ?9.Gr � /7,7• � , V cvvEe I Pilo ��_ •� pis I` � a 2 V� ELDREDGE A L ,"1' I-ie7� : OruGi..rat L.•`fs,,p Go./,-7 'Pu�rS Aro. Z 5i oci"Cc us 57XdL r J 14-1� a v G2oss,ti` 7zt� �7crs�r�G } r r _ DwE2c.i.. � — QcRGT--S.TATt/S DF• 77YE5E 1�Q2:Ih o�Gf1�E 1�/2�a5�� ONcs/ CERTIFIED PLOT PLAN ' ! r ry Tlrar -M,5 ,5 nor ��� 2y0 Du!ves AK/vE IN 7Xe /4�) Yz--?r - moo aor-6 -6'Fr-A'eT> rey 7xe �coTS ZO 4- 6� y►ro ee��er�/ IN °�� s SCALE, /�� DATE, 3- 31- 86 (FLQRCQGE GI EE 1NG .! CLIENT t•gENB2/c' Y 1: CERTIFY-THAT THEt ' —E SHOWN ON THIS PLANAR4 LOCATED E819TER!<D REOISTEREO JOB N0. �� � ON THE GROUND .AS INDICATED AND CIVIL LAND CONFORM`; TO THE YONIN LAWS , ENOINEER 8URVEY0 DR. _ r.rs OF:BAit"STABL ,MASS. CH.BY, _. . / i� 712 'MAI N STRE-E,T ! 8 �f %.,•1' H YA N Fl I S, M AS S. 814EET—/ OF A E..., ' . REG. LAND SURVEYnR TOWN OF BARNSTABLE . L 0—r ;tO LOCATION e-�V-e-1 SEWAGE # D � 1(4,7 F,O VILLAGE Q'ik? ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 5o�t Sot,. 77 1-3 61 b SEPTIC TANK CAPACITY 1i000 y.tLloliS LEACHING FACILITY:(type) L gatJ, (size) (,000 NO. OF BEDROOMS 3 PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER �i.�` o►c e DATE PERMIT ISSUED: y- DATE COMPLIANCE ISSUED: g VARIANCE GRANTED: Yes No �C of vo 'vb QOG��� • . t t 3 t SYSTEM PROFILE NOTES LEGEND TOP FNDN. AT EL. 24.2' " o� ACCESS COVER TO WITHIN 6 OF FIN. GRADE (NOT TO SCALE) ACCESS COVER TO WITHIN 3" OF FIN. GRADE 1. DATUM IS APPROXIMATE NGVD 100.0 PROPOSED ,SPOT ELEVATION ACCESS COVER (WATERTIGHT) TO WITHIN 6" OF FIN. GRADE /F2-2 MINIMUM .75' OF COVER OVER PRECAST /� 2% SLOPE REQUIRED OVER SYSTEM 2. MUNICIPAL WATER IS EXISTING 100x0 EXISTING SPOT ELEVATION - 22.0 *. 2" DOUBLE WASHED PEASTONE RUN PIPE LEVEL OR GEOTEXTILE FABRIC 3. MINIMUM PIPE PITCH TO BE 1/8 PER FOOT. F7 100 PROPOSED CONTOUR ° A=*22.1' FOR FIRsr 2' -0 B=*20.7' PROPOSED 1500 Crol will Beach Rd. 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO 100 EXISTING CONTOUR GALLON SEPTIC 18.71' H- 10 ' 18.96' 8' M 19.0' TANK (H- 10 ) � ` , 18.45 w EXISTING WATER LINE �' B► 18.62' 18.2' [:] moo O 0 0 0 5. PIPE JOINTS TO BE 'MADE WATERTIGHT. c EXISTING GAS LINE 0 0 0 O MIN. ( SLOPE) �6" CRUSHED STONE OR MECHANICAL 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH NRniucket CATv EXISTING CABLEVISION LINE COMPACTION. (15.221 [2]) 0000 o aaoo DEPTH OF FLOW = 4' 1 1 2' m 0 l� 0 0 0 O O (] c 16.2 MASS. ENVIRONMENTAL CODE TITLE V. Sound TEE SIZES: ( x SLOPE) ( x SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO o C.O. PROPOSED CLEAN OUT INLET DEPTH = 14" , BE USED FOR LOT' LINE STAKING .OR ANY OTHER PURPOSE. LOCUS OUTLET DEPTH = 14" s 8. PIPE FOR SEPTIC SYSTEM TO SCH: ;40-4" PVC. Is1 A=86'FOUNDATION SEPTIC TANK 9' D' BOX 25' LEACHING 6.2' 9. COMPONENTS NOT TO BE SACKFILLED OR CONCEALED B=49 FACILITY WITHOUT INSPECTION BY BOARD OF HEALTHAND PERMISSION OBTAINED FROM BOARD OF HEALTH.. LOWS MAP 19)2�' 10. CONTRACTOR SHALL' BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION . SCALE: 1" = 2,000'f BOTTOM TH-1 EL. 10.0' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. ASSESSORS MAP 245 PARCEL 25 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND LOCUS IS WITHIN FEMA FLOOD ZONE C REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. AS SHOWN ON COMMUNITY PANEL #250001 0008 D DATED JULY 2, 1992 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LOCUS IS LOCATED IN AP OVERLAY DISTRICT LEACHING FACILITY. of EXISTING SEPTIC TEST HOLE LOGS SYSTEM IN THIS G App` TO REMAIN APPROXIMATE AREA ENGINEER: DAVID FLAHERTY, R.S. FCAGSrp WITNESS: DON DESMARAIS, R.S. NF PO p� P / DATE: APRIL 20, 2007 q n0 PERC. RATE _ < 2 MIN/INCH j SYSTEM DESIGN. CLASS 1 SOILS P# 11751 GARBAGE DISPOSER IS TO BE REMOVED co DESIGN FLOW: 6 BEDROOMS 0 110 GPD 660 GPD - ELEV. ELEV. Q 4 �s 3• USE A 660 GPD DESIGN FLOW 0" 22.0' 0" 22.2' w - - SEPTIC TANK: 660 GPD (2) = 1320 S A w LS 23 •': Tl-L-1 -,r 22 / USE A 1500 GAL. SEPTIC TANK „ 1 OYR 4/2 10YR 4/2 t. , 8 21.3 g" 21.4' LEACHING: B B .. SIDES: 2 (58 + 10.83) 2 (.74) = 203 GPD BOTTOM 58 x 10.83 (.74) 464 GPD " 10YR 5/6 10YR 5/6 TOTAL: = 901 S.F. _:. ._ 667 GPD 39 18.9 Z. __. r: : : ; K' / USE (6) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) Z.Z.Z.Z.Z.Z. Z. G_� %CP; titi WITH 3.5' STONE AT ENDS AND 3' AT SIDES C C cri G \c G'_JG LP' J ' MS MS .< r C.O. c M A ti s c v APPROVED DATE BOARD OF HEALTH t N I 10YR 7 4 10YR 7 4 PAVED `mac J ' y DRIVE /GP ,A " 14 4 132 10.0 11.2 �G NO GROUNDWATER ENCOUNTERED `tiry � EXISTING 6 BR DWEWNG I N TOP OF FNDN EL. 24.2' �H ` TITLE 5 SITE PLAN GPD ; OF PAVED DRIVE (LOCATION FROM GIS) I 204 GREEN DUNES DR. \ (WEST HYANNISPORT) - BARNSTABLE MA PREPARED FOR O BORTOLOTTI CONSTRUCTION/ BENCH MARK - TOP OF 7 ° FOUNDATION EL. = 24.2 \ I JOSEPH DELLO RUSSO \ `3y� v O`er DATE: APRIL 30, 2007 \ 0� J \ i Scale: 1"= 20' \ LOT AREA \ 59,843t SF / 1.4t AC ( 0 10 20 30 40 50 FEET 3tK off 508-362-.4541 fax 508 362-9880 H OF 44S. a` ���(H OF MgSsgc 'sc o�' DANIEL tiG OJALA ^: A. do wn cap e engineering., inc. DANIELA. N � u+ CIVIL n OJALA - 2 No.40s80 CIVIL ENGINEERS TEG,� t ,NF S �o� rr` LAND SUR 1/E YORS 0 0-7 ONAL f ✓DATTE / DANIEL A. OJALA, P.E., P.L.S./ 939 Main Street - YARMOU THPOR T, MASS. DCE 07-077 07-077 BORTO_DELLORUSSO.DWG (DDF) i9