HomeMy WebLinkAbout0038 HALYARD WAY - Health 38 Halyard Way
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- Commonwealth of Massachusetts
VGTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
C&��, � ,�
Cw ner Cw ner's Name
information is 9 C/
T
required for every
page. City/Town State Zip Code Date of Inspect' n
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.
Mpo ou forms A. General Information
torms n
filling out for
on the computer,
use only the tab 1. Inspector.
key to move your
cursor-do not ✓
use the return. Na me of Inspector
key. `--/�,/ --- ,�
C)
Company Name
Company Address
& 5j4 g V-1
City/Town EO� 02.60_ /�^� State �0 Zip Code
Telephone Nu er j 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 16.000). The system:
❑ Passes ❑ Conditionally Passes Fails
❑ Needs Further Evaluation by the Local Approving Authority
P1 /�— /��& 64/NAC
Inspect 's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of Inspection and under the conditions of use
at that time. This inspection does not address how the system will perform In the future under
the same or different conditions of use.
d �)I?m
t9ns•3113 Title50fflcial lrepectl F Subsurface S"eDlsposal System•Page t of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System
Form -Not for VoluntaryAssessments
da 3P l7 Gi a✓pl G✓q
Property Address
Aw ner taw ner's Name
information is ,�r�` �
required for every Co (( A4
page. CiRFown State Zip Code Date of Inspdction
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/alwayscomplete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND) for the following statements. ff"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
Healt h.
*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):
t5ira•3M3 Tide5010cid Iris pectlonF arm Subsurface Sewage Disposal System-Page 2of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
d 3i? /l a l 0V d �/R
Property Address
Cw ner Cuv ner's Name /
information is C?� ✓�!Ile
e Q,�6 _ Sc A
required for every
page. Cityrrown State Zip Code Date of nspe tion
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system Is not functioning In a mannerwhich 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
Orr.-3113 Title 5 0tfidal Ire peclion F om[Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts `
Title 5 Official Inspection Form
B Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
S;
Oaf ner Cw ner's Name /_ �y
information is UZUJ�
C' 7'Y /�4
required for every QN � " {
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall unless the Board of Health (and Public Water Supplier,If any)
determines that the system Is functioning In a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all Inspections:
Yes
❑ Backup of sewage into facility or system component due to overloaded or
cogged 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
logged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than%day flow
t5inq.3113 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17
Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary
/Assessments
Property Address
Cw ner ON ner's Name +VVI
information Crequired for everyQ� � � � Z� � / —
page. Cky/Town State Zip Code Date of I specton
B. Certification Cont.)
Yes No
❑ quired 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.
I
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ W 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&U2. 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 sensitiw 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.
tUns,M3 TItle50fflclal lnspecticnForm Subsulace Sewage0lsposel System-Page 56M
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System70161a.'C'i
- Not for Voluntary Assessments
azb�'
Property Address ae Una L/V R�_
ON ner ON ner's Name
Information is rrequired for every - � �e�-�V'1`� ,Q ou`�a /
page. Cityfrown State Zip Code Date of Inspect on
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes
❑ mping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
❑ s 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?
Ltd 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): Number of bedrooms (actual): 330
r DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
t5lns.3n 3 Title 5 official Ire pection F orm Su"ace Sewage Disposal System•Page 6 of 17
' Commonwealth of Massachusetts
slow
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
S6
Property Address /
CcS1 441
Cw ner Cw ner's Name Z
/�/j/J,/
information is � i�y w ,//�
required for every
page. Cityrrown State Zip Code Date of glnpe�&m
D. System Information
Description: 6c, c %4 v
�N il
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes [ILA 000
Seasonal use? ❑ Yes Lf�No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes o
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•W3 Tile 5Official Inspection Form Subsurface Sewage Disposal System-Page 7of 17
Commonwealth of Massachusetts 4
19 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3F /ov, /r,"d
Property Address CIT
Ci //I/
Cw ner Cw ner's Name /�
Information is C'�e,4'k,VV/required for everyState Zip Code Date of I pec on
page. City/Town
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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 S m:
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/Altemative 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 VA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ns 3113 TltlebOtflcialhispeclonForm:SubsurleceSewageDisposel system-Page 8of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
rr J O /�G/C7ci/C� k a
Property Address
all—
O.v ner Ow ner's Name /_ p
informationisl�Ptn.t�✓(/6 � A4" �6,7oZ O
required for every
page. City[Town State Zip Code Date of hispedtion
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
/9�� 61`1017L
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan): A9
Depth below grade: feet
Material of construct%40
El cast iron PVC ❑ other(explain):
Distance from private water supply well or suction line: feet `
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):De th below rade: A:)_
p g teat
Material onstruction:
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: `� a
Sludge depth:
t5ins•3M3 TItle50fflda1 Ins pectionFomr Subsurlaoe Sewage Disposal System-Page 9of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address 3�F
ner Cw neT's Name Inf -1 0 d( 7-1
information Is / � �
required for every v State Zip Code Date of in ect(
page. Cityrrown
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle _
How were dimensions determined?
Comments (on pumping recommendations, Inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
/ �h � I,S U�G/✓P C �
vev —
iY7Vve,�—
e,-
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5im-3113 TIUe50flIciel Inspection Form Subsurface Sewage Disposal System•Page 10of 17
1 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2F �q; a/d �✓�
Property Address
Ow ner ON ner's Name
information Is Ge lily(Ile- Aj� iV,6,?�required for every �/
page. Ckylfown State Zip Code Date of Insp ction
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
!sire•W3 TI0e50fliciei Ins pectonForm Subsurface SewageDisposel System-Pape 11 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments
a
Property Address
ON ner ON ner's Name
information is ev1' ✓(mil I A4
required for every — `
page. City/Town State Zip Code Date o Insp ction
D. System Information (cont.)
Distribution Box (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(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
On,W3 TOIe6offidd InspectonForm 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
>r J � rig'l / �.✓6f
Property Address
Om ner ON ner's Name
information Is �� ✓
required for every
page City/town State Zip Code Date of Insp ction
D. System Information (cont.)
Type: Cy b ( // �
leaching pits / number:
❑ 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.):
cpvl �t✓i
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t&ns•3113 Tille601flciel Inspecdon Form Subsurface Sewage Disposal system-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal S7.,
Form-Not for Voluntary Assessments
Z�
Property Address
Cw ner Cw ner's Name /
information is CQ,n ✓t/6`/ //"' 4
required for every 'e
page. Cityffown State Zip Code Date of Irispectibn
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
On.3/13 Tibe60111dal inspection Form Subeurfece Sewage Disposal System•Page U of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
30 l Gs/ (�✓G"
Property Address
Cw ner Ow ner's Name
information is t -Q(/I,k✓t1i �j� �,ea L/
required for every —f--
page. Cityf row n State Zip Cie Date of Insp ctb
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
Q:,
111ns•Y13 rarest vwpactm Fa m Saibnataoe SNOVGD POW SO"-Pape 15 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
S-F #-� /
Property Address
ner Ow ner's Name
inf / T ���
information is Ce0 �
V l�� /� 7`
required for every
page. 5 ffown State Zip Code Date of Inspec ion
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells // / y0 L
l�
Estimated depth to high ground water: 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: pate
❑ bserved site(abutting property/observation hole within 150 feet of SAS)
Checked with local B�� of Health-explain: ��i Ai�
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
J—,
l �/► y ✓7
q 4 . o l�
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51ns•3/13 Me5OfAcial InspectlonForm Subsurface Sewage Disposal System-Page 16 of 17
n
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Cw net Owner's Name
information is ` (e
required for every Slate Zip Code Date of Inspection
page. Cityfrown
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
S em Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
lone 3113 Me50fficlal IrepeodonForm Subsurface SewageD1spcael system-Pape V d V
EVE
Town of Barnstable
' Department of Regulatory Services
Public Health Division Date
MASSL /
161y 200 Main Street,Hyannis MA 02601
' Arf[)MA'tA _Aq
Date Scheduled_ � ,(� l : Time Fee Pd, U
Soil Sui ility Assessment for Sewage Disposal
Performed By: G (mil"'^'L Witnessed By:
WOCATION& G NERAL INFORMATIONLocation Address. L YAV-W Owner's Name
Address /-i-� C� o-
/Parcel: G
P V (T'
Assessor's Ma e+^ J
Engineer's Name 1p�r'
NEW CONSTRUCTION REPAIR Telephone# ���/—�`Z ,� a
510 96 / Qd s fNV�
Land Use 1. -apes( ) ` Surface Stone /
Distance's from: Open Water Body ft- possible Wet Area__$ Drinking Water Well %f t'' 't
i
Drainage Way d ft Property Line kU� ft Other ft
SI TCH:(Street name,dimensions of lot,exact locations of test holes c tests,locate wetlandsn proximity to holes)t `�
��CLo
(�
-
kA
G.
Parent material(geologic)
Depth to Bedroelt a!
Depth to Groundwater. Standing Water in Hole:_�/ Weeping froirl Pit Pnee UK2�
Estimated Seasonal High Groundwater 7 2
DETE TION FOR SEASONAL HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: /^ In, Depth to soil mottlas: in.
Depth to Nyeeg from side of obs,ha 2=In, Groundwater Adjustment ,_ ft.
Index Well# Reading Date: e__ Index Well level / Adj,tractor A4J,Groundwater Level Z—
PERCOLATION TEST DH1C 2_ /
Observation
Hole# 7 Time at h"
Depth of Pere Time at 6"
Start Pre-soak Time @ Time(9"-61')
End Pre-soak `/i l/ r7_-1 `/• ��
Rate Min./Inch 2 PC�! '
Site Suitability Assessment: Site Passed 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:1S EPTICIPERCFORM.DOC
r
DEEP.OBSERVATION HOLE LOG Hole# 9v
Depth from Soil Horizon Soil Texture Sdil Color Soil Other r
Surface(in.) (USDA) (Munsell)
. ) Mottling (Stnucture,.Stones;Boulders.
Consistency,%(3ravcl)
At
� .�r�� 2s s
DEEP OBSERVATION HOLE LOG Hole# 2 9 7--
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in-) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,% ra
.,^
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Muaseli) Mottling (Structure,Stones,Boulders.
Consistency,%Q
]DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
Consistency.
e
Flood Insurance Rate MU:
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes
Within 100 year flood boundary No,____ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring perviou terial exist in ali areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring per ous material? .
Ceftification
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of E ironmental Protection and that the above analysis was performed by me consistent with .
the required traini p tise an exp ce scribed in�10 CMR 15.017.
Signatur Date
QASEPT1aPERCP0RM.ID0C
n �
No. D`'" (���� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer_:—L,,'
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
RpPliLation for Misposal 6pstem Construction Permit
Application for a Permit to Construct Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No3�D�,l �y+2 r.9 4,IaW O erIs>Tame,Address,and Tel.No.
Assessor's Map/Parcel Imo - tim�v �6
Installer's Name,Address,and Tel.No. —2Z&T02rxD Desi ner's Name,Address f el.No.
Type bf Building:
Dwelling No.of Bedrooms Lot Size l OUD sq.ft. Garbage Grinder( )
Other Type of Building f No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �3C� g p d Design flow provided 92 gpd
Plan Date Number of sheets Revision Date
Title ( -
Size of Septic Tank QU Type of S.A.S. 2— 5D6 G' `clla
Description of Soil
Nature of Repairs or A erations(Answer when ap licable)
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 Environm 1 Code an not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. o y'732' Date Issued
No. Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(pplication for Disposal .6pstem Construction Permit
Application for a Permit to Construct X RepairKUpgrade( ) Abandon( ) ElComplete System ❑Individual Components
Location Address or Lot No & �Zy,42 0 4Ow er'ss N in ,Address,and Tel.No.
Assessor's Map/Parcel ��1 - ��v [(ih f. �1J/ �`rLc �� �/ �"y ,
Installer's Name,Address,aand Tel.No. Designer's Name,Addressl d el.No.
S as7�ci< �t
Type 4 Building:
Dwelling No.of Bedrooms Lot Size , UUU sq.ft. Garbage Grinder( )
Other Type of Building f No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided _?�a gpd
Plan Date/ 9-�(J-ZU�� Number of sheets Revision Date
�. 5i�� SPA= Title
Size of Septic Tank /Type of S.A.S. �—
Description of Soil
�2 G✓�-� 7'/2 �'
Nature of Repairs or A eration (Answer when ap licable)s
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 Environm al Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed , Date 9- //-/ /
Application Approved by G Date
Application Disapproved by Date
for the following reasons
Permit No. 20 I`T r Date Issued (� f
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFYAat the On-site age Disposal system Constructed( ) Repaired(�pgraded( )
Abandoned( )by
at 3�j ) has been con cted in ac o� �Ie
with the provisions Title 5 ee for Disposal stem Construction Permit No � da ed
Installer 'tj2 Designer
#bedrooms j Approved design flow gpd
The issuance of this p t hall b- �strued as a guarantee that the system w' do , design6d
Date Inspector
---------rr-----r1------f-�-----------------`------------------------------------------------------------------------------------------------------
No. nl U j�! r �j Feet)
v THE COMMONWEALTH OF MASSACHUSETTS -
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal *pstem nstrUction Permit
Permission is hereby granted to Construct( ) Repair( grade( ) Abandon( )
System located at o /
r
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. q
Provided:Construction must be completed within three years of the date of this permit.l
Date �' f / - Approved by / / V w L
r ,
ti
Town of Barnstable
�t r Regulatory Services
o,. Thomas F. Geiler,Director
,,, Public Health Division
9�Ar 1639. s`�� �
Thomas McKean Director
ED Mpl
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Date: 9',/?.'i4t Sewage Permit#2W- 32-0 Assessor's Map/Parcel 9�
Installer &Designer Certification Form
Designer: Installer:
Address: py/07 f 7Y9 Address-:-
On �- �/- /4 �D� fi"`jC�1� was issued a permit to install a
(date) 'nstaller)
septic system at 3B 4 C/9,W tlzl�e based on a design drawn by
(addre )
dated
(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. Stripout (if required) was inspected and the soils
were found satisfactory.
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. Stripout (if required s ected and the soils
were found satisf tort'. a;J%A OF `e
DAVf
D.
x
n FLAIAERTY JR.
stal r' ignature) No. 1211
lQ
1PFG/STERN
;4 M TARO'
e(Designer's Signatu (Affix Designer tamp Here)
ZA
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:\office forms\designercertification fonn.doc
r TOWN OF BARNSTABLE ry
LOCATION /� 1 '/A a n �>}U SEWAGE# 3 (�(
VILLAGE_���rC�r.7�/j L LPASSESSOR S MAP.&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) j!�L �,�,.,[4 4size)
NO.OF BEDROOMS
OWNER 4 ; . QAT 1 L
PERMIT DATE: 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 ow,
site or within 200 feet of leaching facility) J'� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
I
r 1600
O
A 133 _ -z3 1221
l
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MMAR 2 1 2005
TOWN OF BAHNSTABLE
j HEALTH DEPT:
TITLE 5`
"t OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION q4
Property Address: 38 Halyard Way
Centerville 'Ht2CcL
Owner's Name: Hamciuist LOT
Owner's Address:
Date of Inspection:o 79
Name of Inspector:(please print) W i 1 1 i am E_ •Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
_Centerville, MA
Telephone Number: t508) 775-8776_
CERTIFICATION STATEMENT.
1 certify that 1 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.lam a DEP
approved system inspector pursuant to Sect' n 15.340 of Title 5(310 CMR 15.000). The system:
Passes - "
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails t
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh 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 approXing
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 1
Page 2 of 11 Y s
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 Halyard Way_
Centerville
Owner: Ham uist
Date of Inspection: 5 o -
Inspection S Mary: Check A,B,C,D or E I ALWAYS complete all of Section D
A. Sys m Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. Syst Conditionally Passes:
On or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.T e 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 s tic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,a bits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the -
existing tank s replaced with a complying septic tank as approved by the Board of Health.
•A metal sep'c tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating th t the tank is less than 20 years old is available.
ND explain:
Obs Nation of sewage backup or break out or high static water level in the distribution box flue to-broken or _
obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval o Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND ex p ain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass spection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rzmond
ND ex lain:
Wage 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 Halyard Way
Centerville
Owner, Hamquist
Date of Inspection: .:I-/
C. Fu er Evaluation is Required by the Board of Health:
Co ditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing t protect public health,safety or the environment.
1. Sys( m will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
syst m is not functioning in a manner which will protect public health,safety and the environment:
esspool or privy is within 50 feet of a surface water
esspool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh
2. Sys em will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system s 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
s face 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 frortl 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.
Other:
0
3
Page 4 of 11 +e
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 Halyard Way
Centerville
Owner: Hamquist
Date of Inspection: —
D. yslem Failure Criteria applicable to all systems:
You ust indicate"yes"or"no"to each of the following for all inspections:
Yes o
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
Clogged SAS or cesspool
Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
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 I00.feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 f et from a private%-Ater
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 forma
(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. arge Systems: -
T be considered a large system the system must serve a faci!ity with a design now of 10,000 gpd to 15,000
gp
Yo must indicate either"yes"or"no"to each of the following:
(Th following criteria apply to large systems in addition to the criteria above)
yes o
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 h ve answered"yes"to any question in Section E the system is crosidered a significant threat,or answered
"yes"in Section D above the large system has failed.The(Mmer or operator of arty large system considered a
signific t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. he system o«-ner should contact the appropriate regional office of the Department.
4
Pge 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 38 Halyard Way
Centervi e
Owner: Hamquist
Date of Inspection:
Check if the following have been done.You must indicate"yes"or no as to each of the following:
Yes o
.Pu ping 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 I
Were as built plans of the system obtained and examined?(if they were not available note as N/A)
G/ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
f� Were all system components,excluding the SAS,located on site?
i/_ Were the septic tank:manholes uncovered opened,and the interior f P p o the tank inspected for the condition
of the/baffles ortees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
a _ 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
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 38 Halyard Wa
P Y Y
Centerville
Owner: Hamquist
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. ,.S Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): G
Number of current residents: Al
der
Does residence have a arba a (yes or no): U
g g Y Lf,
Is laundry on a separate sewage system(yes or no)1 d[if yes separate inspection required]
Laundry system inspected(yes or no): e)
Seasonal use:(yes or no): !
Water meter readings,if available(last 2 years usage(gpd)): 2004 — 7 2 , 0 0 0
Sump pump(yes or no): O 2003 — 62, 000
Last date of occupancy:
COMME/ad
USTRIAL
Type of ent:
Design fld on 310 CMR 15.203): gpd
Basis of dw(seats/persons/sgft,ctc.):
Grease trt(yes or no):
Industrialolding tank present(yes or no):
Non-sanie discharged to the Title 5 system(yes or no):Water mngs,if available:
Last dateancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: ,d 0
Was system pumped as part P(the inspection(yes or no):_
If yes,volume pumped:__gallons--How was quantity pumped determined?
Reason for umping: _
TYP OF SYSTEM
_Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
—Other(describe):
,
Approximate age of all components,d e installed(if known)and source of information:
15 8`
Were sewage odors detected when arriving at the site(yes or no):-Zb o
6
A, { Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOIIAIAT10N(continued)
Property Address:_ 38 Halvard Way
Centerville
Owner: Tiamaui st
Date of lnspectlon: �/�'
BUILDING SEWE locate on site plan)
Depth below grad
Materials of con ruction:_cast iron _40 PVC_other(explain):
Distance front rivate water supply well or suction lute:
Comments(on condition of juunls,venting,evidence of leakage,etc.):
SEPTIC TANK:,_(locale on site plan)
Depth below grade: 9 )
cti
Material of construon: ✓concrete nnetal fiberglass--Tolyetltylene
_othcr(explain)
If tank is metal list age:_ Is a
certificate) ge confirmed by a Certificate of Compliarnce(yes or no):_(attach a copy of
¢ r
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet Ice or battle:- —
Scurn thickness:1-3
Distance from top of scum to top of outlet Ice or baffle:
Distance Gorn bottom of scum to bottom of outl t Ice or baffle:
I low µ•ere dimensions determined: A, c-a i,y.✓L
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structwal integrity,liquid levels
as related to outlet invert,evidence of leakage,ctc.):
GREASE TRAP:_(I to on site plan)
Depth below grade:
Material of eonstructi t:_concrete metal fiberglass_polyedlylene—other
(explain): —
Dimensions:
Scum thickness:
Distance from I of scum to top of outlet lee or baffle:
Distance front ottont of scum to bottom of outlet tee or baffle:
Dale of last p mping:
Conunents n pumping recommendations,Wet and outlet ice or battle conditiu:►,structural integrity,liquid levels
as related oullcl invcrl,cvidencc of leakage,etc.):
I
7
ti A
'agc 8 of I 1 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _ 38 Halyard Way
Centerville
Owner: Haman st
Drtte of lospectloo: e-/ —a ''
TI
GHT or 110E G TANK: (tardc must be pumped at time of inspection)(locale on site plan)
Depth below gra c
Material of cons ruction:^concrete_metal_fiberglass_polyethylene other(explaut):
Dinunsions:
Capacity: _gallons
Design Flow. gallons/day
Alan»presc (yes or no):
Alarm Ievel: Alann in working order(yes or no):—
Date of last umping:
Conunents condition of alarm and float switches,etc.):
DISTIUBUTION BOX: if present must be opencd)(locate on site,plan)
Depth of liquid level above outlet invert:_
Conunents(note if box is level and distribution to outlets equal,any evidence of solids carr)•over,any evidence of -
leakage into or out of box,ctc.): d2 e
PUMP CHAM/orr
locate on site plan)
Pumps in worki or no):Alarms in works or no):
Connents(notf pump chamber,condition of pumps and appurtenances,etc.):
i
Page 9 of I I
f.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 Halyard Way
Centerville
Owner: Ham uist
Date of Inspection: .6
SOIL ABSORPTION SYSTEM(SAS): y (locate on site plan,excavation not required)
If SAS not located explain why:
Typ a l
leaching pits,number:
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.): , -
J6e S�dhV
CESSPOOLS: ( sspool must be pumped as part of inspection)(locate on site plan)
Number and config anon:
Depth—top of liq d to inlet invert:
Depth of solids I er:
Depth of scum I yer•
Dimensions of esspool:
Materials of c nstruction:
Indication of oundwater inflow(yes or no):
Comments( ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): _
PRIVY: (loc a on site plan)
Materials of cons coon:
Dimensions:
Depth of solid
Comments to condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 Halyard Way
Centerville
owner: Hamqu i s t
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
Ll
F-
1
KD
v
V �
y Y t
10
Paoe=I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 Halyard Way
Centerville
Owner. Hamquist
Date.of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water��� 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 ISO feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
5- 6-T6 2
11
` ��
�
� No_�"� �� -�� ^ � X �� � L� YmB_
|
THE COMMONWEALTH orwAssAoxussrrs /
y BOARD QF HEALTH
Application is hereby made for a Permit to Construct (1,<or Repair an Individual Sewage Disposal
1.4 ]K Address
T}peofBo�6' Size �
Dwelling--No. of Bedrooms............2.........................Expansion Attic u/O -76artage Grinder (^&l
Other--Type of Building ------------ No. ofyersouo----------- Showers ( ) -- Cafeteria ( )
.� ' ~..^ ~" -.-'-.__--_---_---'-.-_'._---_--.-_--'-.--
Deo��� '�aD000perp�csouyerduv Tot� du�v8ow.
Septic Tank—Liquid cupacity-_--.gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench--y{o .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit 0o.------.-. Diaoeter.-------' Depth below inlot-------'--' Total leaching area..................sq. f t.
Z Other Distribution box ( ) Dosin
'- Percolation Test ]leonito Performed ---'_ ater-Tcxt Pit No. l- _.-.minutes per��6TDept of TestIi�--'- '.-- Dpth to v -_----_.�14 Test Pb No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0
-----`—'-''---'-------``----------------`-`---'`-`-------`---`---'---`----`--`----`-`-----
'-g'-_----.
� The oodecbigoe6 agrees to install the a{ucedeucribcd Individual Sewage Disposal System io accordance with
�
the provisionsof TL ITHL4 5oE the State Sanitary Code— The undersigned further agrees not 6o place the system in
operation until a Certificate of Compliance has been issued by 6 board
S itn
Date
ApplicaApplicationx� ut�uo Aonroved Dy_- ____ �~_���_a_.....
"*=
Application Disapproved for x o�o//owi,g reasons:................................................................................................................
----------------'-----'--------'-''----'----'----'--------------------------------------'----------
Date
Date
PF
No................-....... Fxs..........................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Allp iraation for Disposal Works Tomitrnrtion ramit
Application is hereby made for a Permit to Construct (4-l"or Repair ( ) an Individual Sewage Disposal
System at:
/ Locati n- dress / r. No.
a
Installer Address e
UType of Building Size Lot/� ....../....Sq. feet
�-� Dwelling—No. of Bedrooms..............-............................Expansion Attic �(f�j Garbage Grinder 411:�)
aOther—Type of Building ............................ No. of persons........_................... Showers ( ) — Cafeteria ( )
Other,fixtures ..............• --------•---••-•-•.--•-------•------.---------•--•-••----------------- --------- y -
W Design Flow........ .............................gallons per person per day. Total daily flow------<J. ___.___._......_._..gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--------........ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter....---..---........ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dos" -nk ( ) ~�
aPercolation Test Results Performed by.. `_-��-r' _.$!_..._ ✓ 1---J_......... Date-.. 9 1 -=--- - -------------------.
1.4 Test Pit No. I................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......--................
...............;-11----:•f------------ f ................1=..............................................................................
D Description of Soil_.v..__ .._._... 1_ .'y'.. _____ - - -�'
x �- • ----------•--•----------------------- ---------------------
`/ r j �..a. �--. .....................-�,.::. .,...._..t
Yr.
UW ------•----•------------------------•------------------------------------------•-----------------------•----------------------------------------------•------------------------•-----------------------
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 board of health.
SL d-•--•... :�':Y.:YSr^... .... `._. .-----
Date
Application Approved BY---•---- ------ •. ....�,,,1`S.."`a 7--y--.�•--
Date
Application Disapproved for e f ollowing reasons:. -----•---•----•-----------------------------------------------------------•...........-•--
--.....---•------------••--•-----•--•----••-----•-••-----------•--------------------•----...-•----------.--------=-.......--------------------------------------------------•--------•------------------
Date
i
PermitNo......................................................... Issued........................---------------------------•--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Il.�C"/.....OF... �.-.. ....................
01rdif irate of Tuntplia tta
T��cS I$ TO CERTIFY That the Individual Sewage Disposal System constructed (L-<Or Repaired ( )
by ....:•..0................ �•------•---•----------........................................................................ ---------------. -----------------
Installer /
atfs. f-�-----------------• ...................................� .{ r..i �../ ..........c. ...........................................
has been installed in accordance ` ith the provisions of1TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........................................ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUE® AS A GUARANTEE THAT THE
\SYSTEM WILL JUNCTI N SATISFACTORY. Co
DATE............... __ .................................. Inspector........... --•- -
�V
THE COMMONWEALTH OF MASSA H SETTS
BOARD OF HEALTH
.............. �'1G
No...._..._.' .J� FEE---......
Disposal Works T11nn#rnrtion unfit
Permissionis ereby granted......................................................................................................................................
to Construct (' orb par' ( -) an Individual ewage Disposal System l
atN r...................................................... Street
as:shown on the application for`-Di sposal Works Construction Permit No.3�.111--- Dated...� .........
befd o alth
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CATION
SEWA � E PERMIT NO.
VILLAGL
C all, ("c
I N S T A LLER'S NAME A ADDRESS
vE o o$
0UILDER D 0WMER
�7W _
DATE PERMIT ISSUE
ABATE COMPLIANCE ' ISSUED
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4
LOCU S DATA
Q s s
EXISTING LEACHING PIT AND < V�LOCUS 922�'
CURRENT" OWNER CLAUDIMAR F 1 _ LAKE
DASILVA D-BOX TO BE PUMPED, CRUSHED = - i ^X 98.1 p ,
AND REMOVED FROM SITE IN �' \ 86 UA I,/ WEQUAQUET
ACCORDANCE WITH TITLE 5 O \ \ �10�
PLAN REFERENCE 389-27 BENCHMARK\ P CORNER OF �o
CONCRETE
DEED REFERENCE 19724-164 N P� cgs \ \ ELEVATION 98 93H N 70
ZONING DISTRICT RC—GP \� PROPOSED 25.0' x 13.0' '/ 6At C \\ \ 98.1
28
„ J�l LEACHING CHAMBER G � ' 9s \ p LOCUS MAP
FLOOD ZONE X SYSTEM ��1 \ �% \ NOT TO SCAE:
EXISTING
98.6 X/ SEPTIC TANK �s \ / 14-0125
ASSESSORS MAP 194 I ,c
PARCEL 090 / TO REMAIN
OVERLAY DISTRICT ZONE II
LOT AREA 15,001f S.F. �,)
/� � UTILITY POLE %� '/ � co
�' �
SITE & SEWAGE �\ 0 101'
REPAIR PLAN \\ b ° `moo LOT I�3
N 9
�j
#"CJ TT
'�/ DL \ 29.0. 21
HA L YA RD WA / i\ DTH #2 #38
N EXISTING
BED
\ -� 3DWELLINGM
CENTERVILLE, MASS g� \\
DATE: SEPTEMBER 10, 2014
95.5
OWNER/APPLICANT: cab
CLAUDIMAR DASILVA
38 HALYARD WAY �� \ °�• �� ,,E�P�` LOT 12
CENTERVILLE, MA 02632 9&< � jam '°�� 15,001t S.F.
g'� �-� •p ,�g Off.
SHEET 1 OF 2 2 \ 1
�( 6
PREPARED BY: ��.��"°F�s O \ s
ED
EAS SURVEY, INC. A.
o WARD \
141 R T. 6 A STONE \\
� o� �No'2898 ��o \ LOT 11 , p 20 30 40
SANDWICH , MA 02563 \
PH. (508) 888-3619
CELL (508) 527-3600 9 \
EAS.SURVEY@YAHOO.COM GRAPHIC SCALE:
1 INCH = 20 FEET
I " ,
SYSTEM DESIGN
RAISE COVERS TO WITHIN 6" OF FINISH GRADE DESIGN FLOW
TCF = 99.36 END RISER 3 BEDROOMS AT 110 GPB/D ,I• GPD
FINISH GRADE RAISE TO WITHIN 6"
GRADE 98.0 ELEV. 98.3 FINISH GRADE OF FINISH GRADE
e / ELEV. 98.5 ELEV. 98.6. - s
/� //,&� GROUND ELEVATION 98.7 REQUIRED SEPTIC TANK
97 3 ///ate /.�� 2.6' COVER �\ �� �� x'� /-� ��� / �
2.7 COVER ___330 x 2__ _ __66.OAL--1
v' EXISTING 4" PVC 31'C�DS=0.02 TOP ELEV 96.0 DOUBILEIWASHED4" SEPTIC TANK PROVIDED = _1_ 0_GAL..
�• SCH 40 = 2 MI-'�N-3 MAX 4" PVC SCH 40 11'®S= 0,p1 00000 0 o O 00 00 o PEA STONE
,,. INV.= EXISTTNG INV• o o 1 OR FILTER FABRIC
96.23 .10"TEE 14"TEE INV.= O O O O O O SIZE OF LEACHING FACILITY R IRED
INSTALL 96.03 6" O 00 00 0 o O 00 00 N 3/4" DOUBLE
GAS BAFFLE 3 OUTLET WASHED STONE DESIGN PERC RATE < ____MIN./INCH
4'-1" LIQUID LEVEL H-10 DB3 TWO 5'-0"x8'-6'x3'-O" CHAMBERS LONG TERM APPL. RATE_2•74_GPD/S.F.
INV.=95.41 %NV.=95.13 H-10 j Ci
0 w SIZE OF LEACHING SYSTEM PROVIDED:
INV.=95.24 S.A.S. (13.0' x 25.0') a
DATUM: e e o 93.13 330 _ 0.74 SF/GPD = 446 S.F. MIN. REQ.
^
VERTICAL DATUM: \,_EXISTING 1,0 0 GALLON f USING 2 CHAMBERS WITH 4' STONE AROUND
ASSUMED SEP7rC--TANWT0 REMAIN BOTTOM OF TH 2 = 86.0
.J BENCH MARK USED: NO GROUNDWATER ENCOUNTERED SIDEWALL = 2(13.0+25.0') x 2 = 152 S.F.
CORNER OF CONC PORCH BOTTOM = 13.0' x 25.0' = 325 S.F.
ELEVATION 98.93 CONSTRUCTION NOTES: TOTAL LEACHING AREA = 477 S.F..
14-0125 477 S:F x 0.74 = 353 GPD .
1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND 353 GPD PROVIDED > 330 GPD REQUIRED =
ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING
SITE 8c SEWAGE
WORK ON THE SITE. 23 GPD RESERVE
2. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE J NO (GARBAGE DISPOSAL / GRINDER ALLOWED)
REPAIR PLAN WITH DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT
IS TO OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. P#14481
�(3 3. VEHICULAR TRAFFIC, PARKING OF VEHICLES AND PLACING
/j` (S? ',�/n MATERIALS OVER THE SEPTIC TANK, DISTRIBUTION BOX AND D.T.H. #1 0 D.T.H. #2 0
HA L YA RD WAY S.A.S. AREA IS PROHIBITED DATEGROUND ELEV. 98.9 GROUND ELEV. 98.0
GENERAL NOTES: NO GROUNDWATER NO GROUNDWATER
IN 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS :I CERTIFY THAT I AM CURRENTLY APPROVED BY THE
DEPARTMENT OF ENVIRONMENTAL PROTECTION TO FILL
FOR SUBSURFACE DISPOSAL OF SEWERAGE. ��
C E N TE R VI LLE, MASS 0 SUBS CONDUCT SOIL EVALUATIONS AND THAT THE RESULTS 14
2. AT LEAST ONE ACCESS POINT OVER TANK TEES SHALL BE OF MY SOIL EVALUATION ARE ACCURATE AND IN A A
DATE: SEPTEMBER 10, 2014 ACCESSIBLE WITHIN 3„ OF FINISH GRADE, WITH ANY REMAINING
ACCORD. WITH 310 CM 1 . 00 ROUGH 15.107. LOAMY SANG LOAMY SAND
ACCESS PORTS BROUGHT TO WITHIN 12" OF FINISH GRADE. 10YR 4/3 10YR 4/3
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE _ .�_wt _ 18" 6"
OWNER APPLICANT: CAPABLE OF WITHSTANDING H-10 LOADING UNLESS EDWARD A. STONE, CERTIFIED SO R EVALUATO B B
OTHERWISE SPECIFIED. LOAMY SAND LOAMY SAND
CLAD D I M AR D ASI LVA 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION 10YR 6/6 10YR 6/6
OF ALL UTILITIES PRIOR TO ANY EXCAVATION. �� ESN of M,ys INDICATES DEEP EL. = 96.6 �� EL. = 95.7
38 HALYARD WAY 5. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE ssc 28 28'
OR WITHIN 6 OF GRADE SHALL BE MORTARED IN PLACE. DTH #1
CENTERVILLE, MA 02632 Davl `� TEST HOLE
6. FINISH GRADE SHALL HAVE A MINIMUM OF 0.02 FEET PER
FOOT OVER THE S.A.S. AND DISTRIBUTION BOX. O FLA R
7. SEPTIC TANK SANITARY TEE'S SHALL BE CONSTRUCTED OF �J INDICATES 48"
SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM OF 6" ABOVE p P-1 48" PERC TEST
SHEET 2 OF 2 THE FLOW LINE AND SHALL BE ON THE CENTERLINE AND I -01STE MEDIUM SAND_ MEDIUM SAND
LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES. SAN�TAR\P NO MOTTLING 2.5Y 7/4 2.5Y 7/4
8. THE INLET PIPE INVERT ELEVATION SHALL BE NO LESS THAN NO WEEPING
PREPARED BY: 2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT
ELEVATION OF THE OUTLET PIPE. NO G.WATER NO G.WATER
9• THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES 144" INDICATES ADJ. GROUNDWATER EL. = 87.4 138 EL. = 86.0
E A S SURVEY INC. 144"
10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS NO OBS. GROUNDWATER
BAFFLE, 4 INCHES IN DIAMETER AND CONSTRUCTED OF 4" PVC B.O.H.
141 R T. 6 A 11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND DON DESMARAIS
`SHALL BE SLOPED 1/4 INCH PER FOOT MIN. EXCEPT FOR THE NO OBSERVED GROUNDWATER SOIL EVALUATOR
SANDWICH , MA 02563 FIRST TWO FEET OUT OF THE DISTRIBUTION BOX WHICH SHALL DEPTH TO BOTTOM OF HOLE 144" ED. STONE
BE LEVEL BACKHOE OPERATOR.
PH. (508) 888-3619 12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION VARIANCES REQUESTED RODNEY FISHER
1
CELL (508) 527-3600 TO EAS SURVEY INC. FOR B.O.H. AND DESIGN ENGINEERS REVIEW SOIL TYPE:
'. PERC RATE: <2 MIN. PER INCH
AND APPROVAL. NONE EAS.SURVEY@YAHOO.COM 13. MAGNETIC TAPE ON ALL COMPONENTS. LOADING RATE: O_74 GAL/SF/MIN
�