HomeMy WebLinkAbout0038 PUTTER LANE - Health 38 Putter Lane
Centerville F/R
A = 247 216
111 J� '►«Fo�
UPC 12534 '
No.21�53LOR ,
HASTINGS,MN
I
SEWAGE INSPECTIONS
LOCATION 38 %utte2 Lane DAJ§D /
VILLAGE , ma��• A S MAP &"LOT 247-216
-INS#PECTOB ao-seph P, Nacompke2; 12.
SEPTIC TANK CAPACITY 1000 aatgonz f Box
LEACHING FACILITY: (type) 2-LP"S (size) 2000 ga ionz
NO. OF BEDROOMS 2
BUILDER OR OWNERROPe2t 7ohn.6on
OWNER MAILING ADDRESS
Same
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is
required for every HyaRK1s Ma 1/28/2020
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:WhenWhen
fillip out f A. Inspector Information 5/5/4- ILt
on the computer,
use only the tab Chad Hathaway
key to move your Name of Inspector
cursor-do not Hathaway- Debarros
use the return key. Company Name
P.O.Box
151
Company Address
Forestdale Ma 02644
Cityrrown State Zip Code
few
774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
1/28/20
Inspecto' ignature Date
The system inspe7allit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is required for every Hyannis Ma 1/28/2020
page. CityrFown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1;2, 3, or 5 and all of 4 and 6.
1) 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:
This inspection is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
Information on care and do's and don't's can be found at town health dept or mass.gov
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is required for every Hyannis Ma 1/28/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
- ,p Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is H annis Ma 1/28/2020
required for every y
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is required for every Hyannis Ma 1/28/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 '/z 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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is Hyannis Ma 1/28/2020
required for every _y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
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?
H® El 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?
E ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is
required for every Hyannis Ma 1/28/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 design
Description:
per asbuilt and plan on file at BOH
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected?
❑ Yes ® No
Seasonal use?
® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: seasonal
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is required for every Hyannis Ma 1/28/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No.
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: pumped 1 year ago Debarros septic
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I
Commonwealth of Massachusetts
(p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
....... �� 38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is required for every Hyannis Ma 1/28/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 3'feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10,
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
no signs of poor venting or leaks
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is required for every Hyannis Ma 1/28/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 3
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1000 gal H10 precast
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
8'6"x4'6"
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? tape and sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
pump tank every 2 years under normal use. tees in place riser on inlet just below grade riser on outlet
partial
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is
required for every Hyannis Ma 1/28/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owners Name
information is
required for every Hyannis Ma 1/28/2020
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Db5 in good condition no carry overs 2"force main with 3 outlet pipe
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is Hyannis required for every Y Ma 1/28/2020
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.):
pump runs with weaping port
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
8) LC-6 precast
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is
required for every Hyannis Ma 1/28/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
55'x6'x1' system dry and clean System is elevated with pump system to achieve 4' of High ground
water seperation
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
f
Commonwealth of Massachusetts
�1 - ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
38 Putter lane
Property Address
Stanton
Owner Owner's Name
information is
required for every Hyannis Ma 1/28/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
i
Commonwealth of Massachusetts
@ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
v � 38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is
required for every Hyannis Ma 1/28/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
at
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Al .27
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A 31
A 4�
t2
-23
I C�
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LISA
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t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
...�,�: 38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is
required for every Hyannis Ma 1/28/2020
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
'Estimated depth to high ground water: 8'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: 2004
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
enineering on file. system designed of water encountered at 100" below grade. bottom of septic
2'6"subsurface
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
�P F. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
38 Putter Lane
Property Address
Stanton
Owner Owner's Name
information is
required for every Hyannis Ma 1/28/2020
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF MMTABLE
LOCATION A L/T T2 & L R y e SEWAGE # .26 Oy
VILLAGE^& V f1--42/� ASSESSOR'S MAP & LOT L 7 2/6
INSTALLER'S NAME&PHONE NO. .1- I?-In k C 0 M e—h S o�
SEPTIC TANK CAPACITY /,o oo — D 12(//Yl p CAIAA4 R f A'
LEACHING FACILITY: (type) L C.- C11AA4,1e,1,15 (size)
NO.OFBEDROOMS
BUILDER OR OWNER
PERMTTDATE: U` COMPLIANCE DATE: / d
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
Q4 '.�s� 1ST
Aj
i
i
!�j
No. .+0 Fee vO
t
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
�4 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
y
0[pprtcation for Zigool *potem Cong;truction Vermtt
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components
Location Address or Lot No. 3116 v . 2Y' Uz., O ner's N Address and Tel.No.
`6�(o o� "��LFi�OV1
Assessor's Map/Parcel (rj}, ((�
w q� C, d�loQ
Installer's
�I�(ame
tt �aAdddirgsss'and Tel.No. �fl� 77S'333� Designer's Name,Address and Tel.No(S�)
t;OK (Pi- tt'' �C Gsze�tl�2JeX't��� �� e1>Q4t)1 V►'�a.O 4
Type of Building: ��
Dwelling No.of Bedrooms o�c x'���^ Lot Sze sq.ft. Garbage Grinder( )
Other Type of Buildingy,�a No.of Persons —Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil,
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: ,-% ,vG ENGINEER MUST SUPE!-,V.ie
Agreement: :"STALLA.TION AND CERTIFY IN WRITi'Ja
- "" SYSTE11 WAS INSTALLED 1N STRICT
The undersigned agrees to ensure the construction and maintenance of the afone,deser bed on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and riot`to pface the system in operation until a Certifi-
cate of Compliance has bee ' u oar f Health.
Si ed Date D, -ho—
Application Approved b Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. �Q Q 7 L'f �t �o
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 00
i Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
.- 2pprication for Mood 6rmm Conotruction Vermit
Application for.a Permit to Construct( )Repair( )Upgrade( )Abandon( . ) El Complete System ❑Individual Components
Location Address or Lot No. �. One 's Name,Add s and Tel.No.
y; ma, , ��� ► sober+- ��1,n Son
Assessor's Map/Parcel �t{') �i 33 '({� (SE, ' f
wQthFx�� C+_,D(0j0q'
Installer's Nam Address,and Tel.No. �� �7S'���g Designer's Name,Address and Tel.No(SJ� "O 37�
Co x U '
c�rl(€'ru'�I�L �'1� .tea 31 a "5�i Gcb�l►�err��ic�hw�y t.u aa�A.ons
Type of Building: iir f,�„
Dwelling No.of Bedrooms `��x's�"`� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Doe_` / No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
t
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and.not to place the system in operation until a Certifi-
cate of Compliance has bee issued y' 's% oard.o Health.
Si ed ,/" ,� Date SZ 19 .
Application Approved bye ___. Date AL Ll
Application Disapproved for the following reasons
r Permit No. ��`'� `� Date Issued
- r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by S•t . M.Poo"L e r os d 50y) 11
at 31�) t?v_ffvx- t m, - AQICJ,Vm 1G has been constructed in accordance
with the provvi�ions of Title 5 and the forDisposal System Construction Permit No. �Od y-0 y�` dated �/)e.
Installer i' �2lC Lb p�` 5,Dn Designer EA'-VXL0eA4LAaA. t
The issuance o this,permit shall not be construed as a guarantee that the stem ill function dbsigne
Date �. ) i 10LI Inspector � �h 1
.... . . r ,00`7 "�' ---------------—------------
No. —FeeTHE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mi0po5al *pOtem Construction Vermit
Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at Ze fi�,r- (gi 41p rt R I Mix ,
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction m st be completed within three years of the dateE
i
Y pe, pit.
PP
Date: Q Approved b
FEB-12-2004 01 :39 PM JCENGINEERING 508273 0367 P. 02
Town of Barnstable
Regulatory Services
Thomas F. Geller,Director
Public Health Division °
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
InstaUer &Desigger Certitica 'on Form
Date: y 1 Z —Q 'Y
Designer: J77PC. Installer: ..��P_
Address: y_ C lgAZ Xry /f?&,k-AYAddress: 8 D X
On (�,�"U'�6GtNfrpa � ( � . was issued a permit to install a
(date)- (installer)
f
septic system at .3 Rj 14* J....DIY')e f-�t.,/ based on a design drawn by
(address)
® I)
A e-- dated 121
(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 relocations 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, Platt revision or
certified as-built by designer to follow.
C CM
q QpI�1f2C.i�IIL
(Rat a's Signature)
CIVIL.
No 41WI
b
LE (Designer's Si (Affix Designer's Stamp Here)
ASE RET TO BARNSTABLE PUBI:IC HEALTH DIVISION. CERTIFICATE
®k I PIL1A1qCE WrLL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTARLE PUBLIC I RALTH DIVISION.
T
Q.Iicalth/sentte Dc—,ioner certification Post
• TOWN OF BARNSTABLE �L�4
�• LOCATION ,3 Pu7 re R L Aiyy SEWAGE # 26 OV- Qyk
VILLAGE / y Ail/^/ I S -r' ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. ZM A C 0 A/t S e-16
SEPTIC TANK CAPACITY A 0,aa - A 0o a z2 LAV. C11AN1/Y f A7
LEACHING FACILITY: (type) -II .�- CY C11 ANl/3e''5 (size)
ac
NO.OF BEDROOMS Xi�1�'^T 3E?�esi�h
BUILDER OR OWNER a&AA3 0'
PERMTTDATE: 2 D COMPLIANCE DATE: /a
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
1 �
-�9 i A 39 (
FAILED INSPECTION
D ATE :6 126103
` PROPERTY ADDRESS:38 Put.te2 Lane
-----------------------
--- Nri �nniz (laze_
--
--------------- ------ JT -
On the above date, I Inspected the septic system at the above address,
Tnis system consists of the following;
1. 1- 1000 ga eion eept.ic tank.
2. 1-Diet2.igut.ion Sox.
3. 2- 1000 gaiion /22ecaet -feach.ing 1?ite.
Based on my Inspection, I certify the following conditions:
4. 7h.ie .ie a t.itje dive ee/zt.ic eyettm. ( 78 Code
5. The ee/2t.ic eyetem .ie .in hyd/zauiic �a.iiaae.
6. Both of the ieach.ing /2ite aae .in hydzaaiic �a.i-Pu2e.
7. R new 2each.ing a2ea need.6 to ge .inetaiiad
SIGNATUR
'name J . P , Macomber Jr .
1-' orTipany : j4ggph _p ggm�tt d_ Son, Inc .
RECIE E
A cords s : __�Q� _rz�------------
-_Ce-ru-eLYLI-Le. Na . _Q.2.632- 0066
'UL 21 2003
TOWN OF BARNSTABLE
Pnpne : 508- 775- 3338 HEALTHDEPT.
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
IOSEPH P. MACOMBER & SON, INC,
Tanks CesspooIs•Leachllelds
Pumped & Installed
Town Sewer Connections
P.0 Box 66 Centerville, MA 02632.0066
775.3338 775.6412
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 38 10ut.te2 Lane
blv,s.t_ NgnnnIAannf�
Owner'sName:/?nRonf 7nhnAnn
Owner's Address: Sam¢
Date of Inspection: 6/2 6/o 3
Name of Inspector: (please print) ao.6el2h 1). Macom&e.¢ a2.
Company Name: 2. P. ('lc comge2 9 Sort Inc.
Mailing Address: /3n x 66
('onfoa))IPPo MnAA. 02632
Telephone Number: 5 nQ_?7 5_2 2 38
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 Further Evaluation by the Local Approving Authority
Inspector's Signature: aiN -0,efiAff.
Date:
The system inspector shal 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.
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 I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 38 Pul-tea Lane
e a , .
Owner: /2oge2t o n.6on
Date of Inspection: 6126103
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: QjIV
des
! have not found any information which indicates that any of the tallure.crit�ir))'a described in 310 CMR
in 15.303 or 310 CMR 15.304 exist. ny fallure criteria not'evaluated are.indicate"elow.
Comments: -
it
Jhe .two .Peach.ing p.it,6 ate .in hydaau.Plc ,Pa.iiL�ae. 'R ,;new,
PonrhIng a/tPa need-6 to ge in.6-ta-e-Eed.
i
B. System Conditionally Passes:
alb One or more system componenu 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.
iUD 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:
AL)0 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:
,-'V The system required pttmping 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
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 Ilui_z`_e2 Lane
Uezt Hyannizpoat, Na,6,6. .
Owner: Roge2t johrz,3oa
Date of Inspection: 6126103
C. Further Evaluation is Required by the Board of Health:
_,d,A) Conditions exist which require fiuther 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:
A 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:
/t 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.
�Q The system has a septic tank and SAS and the SAS is less than 100 feet but 50 eet 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 coli form
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 I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 38 Pu.t..t`_e2 Lane
6)ezt RyannizpoAT,-ftz.6.
Owner: /2oP-eltt o nzon
Date of Inspection: 3
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for al ,inspections:
Yes No
_ _Backup of sewage into facility or system component due to ove ed or clo eed SA 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 distributi box above outle to ert due to an overloaded or clogged SAS or
cesspool ��`�
squid depth in eessPeel•is less than 6"below invert or available volume is less than �day flow
equired propping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
— �of times pumped�.
�y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
wvater supply.
y portion of a cesspool or privy is within a Zone 1 of a public well.
]��y
y portion of a cesspool or privy is within 50 feet of a private water supply well.
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.)
/�.C, (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 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.
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—I WPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 38 P uttea Lane
Oezt RganniZE , N7azz-
Owner: /2ogeat 2ohn.3on
Date of Inspection: 6126103
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?
Y — Were all system components,lwluding 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:
Y e;/ 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 Cis at issue approximation of distance
is unacceptable)(310 CMR 15.302(3)(b)J
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 %u.t.te2 Lane
Oee.t K ann.ie oat Naze.
Owuer809e2.t o neon
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):,jA11f
Number of current residents: 3
Does residence have a garbage grinder(yes or no):4J6
Is laundry on a separate sewage systemes or no)AJ (if yes separate inspection required)
Laundry system inspected (yes or no): S
Seasonal use: (yes or no): 2001=60, 000 ga Uone=16 4. 39 91'D
Water meter readings, if available(last 2 years usage(gpd)) t?2one=24 9. 32 C/�!�
Sump pump(yes or no): 6
Last date of occupancy: —""
COMMERCIAL/INDUUS"T"RIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seats/persons/sgft,etc.): eo
Grease trap present(yes or no):M
Industrial waste holding tank present(yes or no);,J
Non-sanitary waste discharged to the Title 5 system(yes or no):A0-
Water meter readings, if available: /f
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 4—,9r
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped:_gallons-- Hpw was quantity pumped determined?
Reason for pumping:
T DE OF SYSTEM
Septic tank, distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
/Vo Shared system(yes or no)(if yes,attach previous inspection records, if any)
/0 Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
42D Tight tank Qt Attach a copy of the DEP approval
/(/Q Other(describe): „�()!�
Apamx trt}6e a 2e����omponentsbdateled Of known)and source of i formatioq:��
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 38 Putte2 Lane
8' nt7�Lt� t'laz 3
Owner: RoPP.,f 9nhn .(nn
Date of Inspection: ' 4 4�,G7
BUILDING SEWER(locate on site plan)
d
Depth below grade: A0
Materials of construction:_;cast iron _Z40 PVCWO other(explain):
Distance from private water supply well or suction line: !d )i
Comments(on condition of joints, venting, evidence of leakage,etc.):
vented thaouyh .the zoo/ vents.
SEPTIC TANK: Zoocate on site plan)
�r
Depth below grade: �
Material of construction: ('concrete f.�/ metal.l,Q fiberglass,0ynolyethylene
A)pother(explain) ltv
If tank is metal list age:_D is age confirmed by a Certificate of Compliance(yes or no):WM (attach a copy of
certificate)
Dimensions:91d"�,t� 41 �'0p4 Vr'1�%�
Sludge depth: //' �r Jf
Distance from top of SI dge to bottom of outlet tee or baffle:
Scum thickness: lI `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: 4?PA 1/na
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of.leakage,etc.):
even q Z-3 eaae.
TnPo7 R n� al7i, in ( 2u C.tu24L-Q-Q G,e( /�(?,O llnd
and .shows no evidence o� eeakage. L-iqu-d eeve.Q at .the ou.tiet
.invent iz 51'
GREASE TRADIlocate on site.plan)
Depth below grade: .t,;*
Material of construction;, concrete?��metay(, _fiberglass polyethylene lother
(explain):
Dimensions:
Scum thickness: It/If
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scuqi to bottom of outlet tee or baffle:_ H
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.):
g1Lpahe ta¢R l,3 not /Zaezent.
7
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress:38 /gut t ea Lane
Vezt Huann-i.312olLt, Ma-6.6.
Owner:Ro&e2t lohn.6on
Date of Inspection: 6126103
TIGHT or HOLDING TANK- (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:_A
Material of construction:.aconcrete Agmetal fiberglass -UA polyethylene 4other(explain):
eA+9
Dimensions:
Capacity: allons
Design Flow: A64 allons/day
Alarm present(yes or no):
Alarm level:�i� Alarm in working order(yes or no): WA
Date of last pumping: 4)h_
Comments(condition of alarm and float switches,etc.):
Tight on hoid.ing tank.3 ate not /22ezent.
DISTRIBUTION BOX:Zif present must be opened)(locate.on site plan)
Depth of liquid level above outlet invert: Q,tlW
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.):
77)1 Aifl l a.iif i nn any hriA Lan Prz1P,7a A Thono .i.6 evidence ole
_ 69.9 ;d4 &64%%6,—bti3'6�b. Nn oI).irJvnro n;& Leakage. .Ln-to o2 out o
the Sox.
PUMP CHAMBER!iLe,(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.):
P tt m 7v--e4 d m&elm-41s R a 4 790e
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress:38 P utte2 Lane
Ue.s yann.c-6po2 , Pla.s•s.
Owner:/2oge2t lohnzon
Date of Inspection: 6126103
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate ou site plan,excavation not required)
_2-700 aa2.Pon .eeach.ina R.it s. Both ate .in hudaauiie la.iivae.
If SAS not located explain why:
Located: See 12age 10
Ty
leaching pits,number:/
.4�0 leaching chambers, number:
,,�&leaching galleries,number:
leaching trenches,number, length: Q
leaching fields, number,dimensions:
overflow cesspool, number:0 �--�
4Z 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.):
Loamu .6and to medium .ine nand. Both o� the ieaeh.ing pit.6 ate .in
h1S dnniiP r ea.i.P ltp So a wet Vegetation ih oamai R new
2each.ing aaea needz to ge .inztaiied.
CESSPOOLSI"(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.):
rP,iA120n.P.6 a2n_ not R2ehent.
PRIVY(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids: Aw
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Po )iy lb not noAonf_
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properry Address:38 P a.Ue2 Lane
Owtscr: Rn0. o ?I �nhn.son
Dstc of Iospcctioo: 6�L26 In 3
SKETCH OF SEWACE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system Including tics to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where publlc,vater supply enters the building.
�L
. � b
10
Page 1 I of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 38 Pat tee Lane
OP-Al HUnnizi, i?e)1? , Nazz.
Owner: 1?nOv1?j Znhn.tnn.
Date of Inspection: (1 jh/O ?
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water lie feet
Please indicate (check)all methods used to determine the high ground water elevation:
4 Obtained from system design plans on record-If checked,date of design plan reviewed: 4 -
Observed site(abutting property/observation hole within 150 feet of SAS) —T-
AM Checked with local Board of Healh-explain: 1019
Checked with local excavators, installers-Cartach dogumentation)
Accessed USGS database-explain:. 7Tjf 1`/ .AA
You must describe how you established the high ground water elevation:
1.3ed: Gahzetu & ( I-Ue2 Nodee. 12116194 C//tound wa.te2 eieva.t.ion.s agove aea .Peve.2.
lsed: 11SGS - QIAPaua 'o v Tune 1992
L.sed: 11SGS-- 7onhnirn0 O.uUelin 92 nnn 1 POnfo 12 4nnrin-P nringD_b n4 alLound -
Leaching
Pit ,�
Groundwater: feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore,the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is oiyq
feet.
11
�.•17AT n•r�►-�t—s.n. am•n�r�.n rwrr�rr•.w++r�►.r.+wn.+ ne*a�+r.�.'�n w.n
Ba/tnzta�Qe ... -...F
TOWN OF BOARD OF HEALTH
0 SUBSURFACE SFWAQE DISPOSAL SYSTEM INNSPECTION FORM - PART D •- CERTIFICATION I
• •rn.-ram-•r.... ._..A
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 38 Putte2 Lane Ne.6t Hyann.ihpoat, flas-s. '
ASSESSORS MAP, BLOCK AND PARCEL # 247-216
OWNER' s NAME Roge•ct avhnson
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
--COMPANY NAME J P Macomber & Son Inc".`
COMPANY ADDRESS Box 66 Centerville Mass. 02632
Street Town or City 3tat9 tIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578
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
omplete as of the time of -inspection . The ins ection was
P 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 :
System PASSED ,
The inspection «hich 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 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
JJ this form.
y \
r System FAILED*
The inspection which I have con cted has found that the system fails to
Protect the jiublic 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 ,
e
Inspector Signature Date
6copy of this certification must be provided to the OWNER, the BUYER
Dn
Where applicable ) and the 130ARD OF HEALTH.
* If the inspection FAILED, the owner or"'operator shall upgrade
he ayste
within one year of the date of the inspection, unless allowed ortrequiredm
otherwise as provided in 3.10 CMR 15 . 306 ,
partd , doc
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates cost $30.00 for 4 years. _A Business Certificate ONLY REGISTERS THE BUSINESS
NAME in town (which you must do by M.G.L.- it does not give you Oermission to operate.) You must first obtain the necessary
signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., 367 Main Street,
Hyannis,MA 02601 (Town Hall) and get the Business Certificate that:is required by law.
Fill in please: Date: �a7
r �.. .,,
� r , APPLICANT'S NAME:
s `En� �" YOUR HOME ADDRESS: 36 �t. c�- n/
r;
BUSINESS TELEPHONE # HOME TELELPHONE#:
.h
.NAME OF CORPORATION: FID #
NAME OF NEW BUSINESS TYPE`OF BUSINESS ►-,ds�a�i r�
IS THIS A HOME OCCUPATION? NO .
ADDRESS OF US NES G ci r Div - MAP/PARCEL NUMBERZt'I (Assessing)
When starting a new business here are several things you must do to be in compliance with the rules and regulations of the Town of
Barnstable. This form is to assist you in obtaining the information you may need. You MUST GO TO 200-Maims t.lcorner of Yarmouth Rd,
& Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been,informed of any permit requirements that pertain to this-type of business.
Authorized Signature
COMMENTS:
2. BOARD OF HEALTH MU:'
This individual has bee inf rmed of the permit requirements that pertain to this type of business. HAZARDOUS
Authorized Signature"* MUST COMPLY WITH ALL '
COMMENTS: HAZARDOUS :011 ATIONS'
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has beer, inforrped of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:y
I
TOWN OF BARNSTABLE Date: 2//25/90
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: MS ��unc�SU,�i r1 Q
BUSINESS LOCATION: Grc i INVENTORY
MAILING ADDRESS: —? t2 . ,6o,Y TOTAL AMOUNT:
TELEPHONE NUMBER: Cat rS"
CONTACT PERSON: a- pS � � pS
EMERGENCY CONTACT TELEPHONE NUMBER: �� 4 lig"�-`'o=o1k IVISDS ON SITE?
TYPE OF BUSINESS: S :n
INFORMATION/RECOMMENDATIO S: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hkardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach) O 2 I�,•�I 11
Spot removers&cleaning fluids
(dry cleaners) O �'h"�S 7
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Sign re Staff's Initials
TOWN OF BARNSTABLE,
LOCATION 1-16 l r LYE � SEWAGE
VILLAGE LJ. ASSBSSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. �� �� h7liCO�-�@��'=�,
SEPTIC TANK CAPACITY
LEACHING FAC`.ILITY:(tyge)_ (size) 7GL
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: re� —
VARIANCE GRANTED: Yes' -NO .
i
t u
L'
IV
;, a J( r�
No.__ �_�f...� Fizs.... ....2.0/ 0.
THE COMMONWEALTH OF MASSACHUSETTS
*4
BOAR® OF HEALTH
Town-----........OF.......Barnstable
Appliratiou for Di-qus al Murks Tonstrurfiurt rumit
Application is hereby made for a Permit to Construct ( ) or Repair XX) an Individual Sewage Disposal
System at:'
38 Putter Lane West Hyannisport
........ _ . .......................... ...... --- i�-...
Johnson Lo ...
Location-Address or t o-
O
W J.P.Macolnberwner Address
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling��No. of Bedrooms____.__.3.................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................. Showers ( ) — Cafeteria ( )
a
� Other fixtures ----------------------------------------•--------------
W Design Flow............................................gallons per person per day. Total daily flow............................................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 ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
(� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....__-__-___________-.
a .-••••••--•---------•--•-••••---•------•-••-••••---••--••-----•-••••-•--••......----••-•.....................................................................
Descriptionof Soil .--------•- .................................................................................................................
x
w
UNature of Repairs or Alterations—Answer when applicable......X.-.l.QQO-_-gallon---pit.........................................
•-------------------------------------------------------------------------------------•---------------•-------------------.------------------•--------------------------------......__............---•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 1y
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en issue the oard of; a1
Signed ..!� 'Se -
pop
Application Approved By................ ........ ...:. ---------` -----• '
D e
Application Disapproved for the following reasons---------------------•----------------------------------------------------------------------- ..................
.....................................••-•---------••-•--•----••••••-•----•••••••-._...•-_._._...----••••••----•--•...-•-•---•----•-•-•--•---•--•---•------•--•----•--•-----•--•-•----•-••••---•••-•-----
Date
PermitNo........ j'-= ------•-•--------------- Issued........................................................
No...... Fx$.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. To-rn......._____OF.........B-a.rnstable
--------------------
Xpli iration for Di-spoil al Works Tomlrnrtion 11nutit
Application is hereby made for a Permit to Construct ( ) or Repair (3(X.)V an Individual Sewage Disposal
System at:
..8_ Futter Lane West Hyannisport
.................. • -.-.-----..-----•------•••-------------
Locati
Jon-Address or Lot No.
c'r�l ;on
Owner Address
W J .P.Pn��:oml��r
Installer Address
Type of Building Size Lot............................Sq. feet
aDwelling--, No. of Bedrooms..........3................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.....__.......`�y---------- Showers ( ) — Cafeteria ( )
Otherfixtures ---------------------------------••------------......---•------------
W Design Flow............................................gallons per person per day. Total daily flow............................................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 ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date..------------------------------------.
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water.._._-..__-_-._._._-----
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_.._-..-.--.____._-----.
9 •--••---•----•-•-------------•-------••---••-••-••-•----------•--••---------•--••••••---------•-•---........--------•-•-•-•-•--•............................
0 Description of Soi........................................................ r;f?
x ......------•---------•--•-----------------------•--•---•---•-------•--------•---•------•--------•-•••----------•
W
UNature 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'ITL v 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.
by � .
Signed.:_.. =......••••...........................................
Application Approved By............................... •-x--�-•z•--ry.•...e ................................vJC� '......•-•--.•-- ••-------- ..............
`
•
Date
Application Disapproved for the following reasons:--------••-•--•-•--•----•--------•-•----•-•-----•-••---•---•------•----------------•--•-••-------•-----•-••-••-
---------••-•-•-•-•----------•-----------------------•-•-------------••-•--•--------....---•-------------._....---•-•-----------------•-•---••--••-----•---•-•-----------•• .............................
Date
Permit No........� �. ,-ji'._-----•------------------ Issue(L-------------------------------------------
------ ....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstab
.. ..............................O F........ . ......... 1,-'
..............................................................
Trrfifirate of TontpliFanrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (c,5,)
by
J P.Macomher
=------------------------•--•-------.....------....---------------.........-----------------------------...-----...-----•------............---•--------............._..........---...._
38 Putter. pane West r1,7i1nisportInstaller
at......................................................................--------------------- ---------••••--•---•---...•-•••--•-••---••--•---•----•••----------•-•---••-••-•-••--------------•-------
has been installed in accordance with `the provisions of TITIE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.......�`__'_f �--�-�__-____ dated.-- Z.—.-'?-_"?`_��...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..................... ........tl_ _-.. ............................ Inspector............... .. .....................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- .�
i ..f,• -•-`•---•--.._._ FEE...........:.............
Disposal Work.5 Tonn#r ion rrntit
J,P.1,lacomber
Permission is hereby granted ----••-•------•--------•------------------------------------------------------------------------------•---------
to Constru t ( ) or Repair X) an Individual $e,%,age Disposal System
38 Pu ter Lan west Hyanrei,;o6 '
atNo.. --------------•- ------------------••--••-----•-----•--•---•-•-•--•--••--•-•--- .........................
as shown on the application for Disposal Works Construction Sit I >_s _ apt - 7-----------
----.......-•--•----------------------•------•-•-------....---•---•-•---•--------• f=-•--------•-.._
Board of Health -
DATE...........................................................................•...
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
1
TOF= PROVIDE PRECAST CONCRETE EXTENSION PROVIDE PRECAST CONCRETE EXTENSION 5" DIA. OUTLET(S)
95.26' RISER WITH CONCR
ETE FINISH GRADE OVER CHAMBERS 96.3396..50
2"SCH. 40 COVER TO WITHIN RISER WITH CONCRETE COVER TO WITHIN PRECAST CONCRETE REMOVABLE COVER - GENERAL NOTES
6"OF FINISH GRADE OVER OUTLET COVER 6" OF FINISH GRADE OVER OUTLET COVER TO WITHIN 6"OF FINISHED GRADE 96.50' SLOPE @ 2% MIN. OVER SYSTEM
FINISH GRADE @ FND. EL.= 92.7'-93.8' FINISH GRADE OVER TANKS EL.= 93.9'-94.6' TO D-BOX FINISH GRADE OVER D-BOX= 4"SCHEDULE 40 PVC MIN SLOPE 1% 3/4"T(O 1-1/2" DOUBLE WASHED STONE TO CROWN OF PIPE 1. UNLESS OTHERWISE NOTED, ALL SYSTEM( COMPONENTS AND CONSTRUCTION
20" MIN. ACCESS COVER 2"OF 1/8"TO 1/2"DOUBLE WASHED STONE METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE
ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES.
(TYPICAL FOR 3) 3s"MAX. 4" PVC OUT TO 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
EXISTING 4" 36"MAX.
C.I. DRAIN PIPE EACHING FACILITY PLACE RISERS ON ALL CHAMBERS OF HEALTH AND THE DESIGN ENGINEER.
„ TOP OF SAS- 95.33' 95.50' H-20 SEE PLAN
l ! a"SCH. 9"MIN. - ( ) TO 6"OF FINISHED GRADE 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL
6.. 3° 2" DROP MIN. 3„ ao PVC 94.50'
3" DROP MAX. 9 36"MAX. BREAKOUT EL = 95.00' BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED.
�- SLOPE 1%min. 4. TO PREVENT BREAKOUT, THE PROPOSED FINISH GRADE SHALL NOT BE LESS THAN
10 L-a' ELEVATION =95.50' FOR A DISTANCE OF 1 5'AROUND THE PERIMETER OF THE SAS. UNLESS
48" 14" ALARM ON -
LIQUID INV. OUT= O jc�.
� � A 40 MIL GEOMEMBRANE LINER IS PLACE/AT LEAST FIVE FEET FROM S.A.S. AND THE TOP OF
LEVEL 90.30 uMP oN L-3, SLOPE @ 1%min. O o00O ao THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
90.25' INLET TEE tr PUMP 6" 1, 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
95.00' 94.83' j _
OFT- 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
ANOM -L- 7. LOCAL BOARD OF HEALTH TO BE NOTIFIED PRIOR TO BACK FILLING WHEN
12.3' OUTLET 6"CRUSHED STONE �jy 3.5' 3 5� 1.5' 1.5' SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS NOT TO
TEE 90.25' � }-�L"J 6"CIRUSHED STONE 6.0'(typ for 1)
OVER MECHANICALLY '
GAS BAFFL INLET TEE OVER MECHANICALLY 55.0' (NP ) BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH.
COMPACTED BASE BAFFLE COMPACTED BASE 8. ELEVATIONS BASED ON ASSUMED DATUM OF 100.00'MSL OBTAINED
LENGTH 8'-6" WIDTH 4'-10" DEPTH 5''-7" LENGTH 8'-6" WIDTH 4'-10" DEPTH 5'-7" 5 OUTLET DISTRIBUTION BOX TO GROUND WATER ELEV.= 88.50' 6.0'
93.50' FROM A NAIL IN A UTILITY POLE AS SHOWN ON PLAN.
BE INSTALLED ON A LEVEL STABLE 9. CONTRACTOR SHALL VERIFY ALL UTILITY ILOCATIONS PRIOR TO CONSTRUCTION
1000 GALLON SEPTIC TANK 1000 GALLON PUMP CHAMBER 5'MIIN.
BASE. FIRST TWO FEET OF OUTLET THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE
PIPES TO BE LAID LEVEL. 8 - LC-6 CHAMBERS AT 1-888-DIG-SAFE AND ANY OTHER APPLIICABLE AGENCIES. REPORT ANY
TANKS SHALL BE INSTALLED ON A LEVEL STABLE BASE DISCREPANCIES TO THE DESIGN ENGINEER.
CROSS SECTION VIEW 10- ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE
TANK & TYPICAL CHAMBER PROFILE
1000 GALLON SEPTIC STRUCTURES SHALL BE MADE WATERTIGHT.
11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR
1000 GALLON PUMP CHAMBER DISTRIBUTION BOX DETAIL CHAMBER DETAILS ZONING REGULATIONS. OWNER/APPLICAINT IS TO OBTAIN SUCH
DETERMINATION FROM APPROPRIATE AUTHORITY.
NOT TO SCALE
NOT TO SCALE NOT TO:SCALE 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
- - - -
_ _ LOCATED UNDER PAVEMENT, DRIVES OR(TRAVELED WAYS IN WHICH CASE
B'M. uti�iry Pole MAP 247 *NOTE: WETLANDS FLAGGED BY HORSLEY& DESIGN DATA �' • 111° ' ' TEST PIT DATA
THEY SHALL WITHSTAND H-20 LOADING.
•
*NOTE: DUE TO SITE CONSTRAINTS, THE CONTRACTOR SHALL NOTIFY THE Elev.=100.00' LOT214 WITTEN, INC. ON NOVEMBER 11, 2003. If 0 •� • 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND
DESIGN ENGINEER A MINIMUM OF TWO DAYS PRIOR TO INSTALLATION FOR A Assuried N/F OSIMO 1
� • ' AGENT: Samuel White FINES.
SYSTEM STAKEOUT. DESIGN ENGINEER SHALL NOT BE RESPONSIBLE FOR PUTTER LANE • '�� • SOIL EVALUATOR: Samuel Philos-Jensen 14. WHERE REQUIRED, CONTRACTOR SHALL (REMOVE ALL LOAM, SUBSOIL AND
FINAL LOCATION IF CONTRACTOR FAILS TO NOTIFY FOR SYSTEM STAKEOUT. c6(FND)
�
cB (ao�wIDELAvouT) NUMBER OF BEDROOMS (ASSESSORS) 2 i...� � ` &� r • UNSUITABLE MATERIAL IN AREA BENEATH( AND FOR 5 FT. ON ALL SIDES OF
(FND/BROKEN) REBAR i MAP 247 NUMBER OF BEDROOMS (DESIGN) 3 , '✓''� * :J DATE: October 31, 2003 LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN
(FND) 62 LOT 215 ' r J.7 • 4
6A Lg3 N/F MANLEY (PREVIOUSLY DESIGNED FOR 3-BEDROOMS) {) TEST PIT#: 1 COARSE SAND FREE FROM CLAY, FINES OROTHER UNSUITABLE MATERIAL IN
DESIGN FLOW 110 GAUDAY/BEDROOM ACCORDANCE WITH 310 CMR 15.255(3).
MAP 247 - ` TOTAL DESIGN FLOW 330 GAUDAY + `� ELEV TOP: 96.83'
i 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
DESIGN FLOW X 200 % = 660 GAL/DAY y • ,
LOT 214 ELEV WATER: 88.50 SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
MAP 247 ~` �' USE EXISTING 1000 GALLON SEPTIC TANK •
N/F OSIMO _ •I• . . • . PERC RATE: <2 Min./In. 16. PROPOSED PROJECT IS LOCATED WITHIN:
LOT 128002 CB {, • •J� r •
N/F GALLANT (FND/HELD) ' ) INSTALL 8 - LC-6 CHAMBERS + •�• ASSESSORS MAP 247 PARCEL 216
N , / ,� • • •; DEPTH OF PERC = 32„_50"
00 ' T • 17. OWNER OF RECORD: ROBERT A. & ELAINE M. JOHNSON
MAP 247 MAP 247 SIDEWALL CAPACITY '
LOT 129 ' LOT LENGTH +WIDTH 2 1' HIGH 74 GPD/S.F. GAUDAY • f • .•••' TEXTURAL CLASS: 1
N/F FRETSCHL AREA=25,888t sQ.FT. ( )( )( ) ( ) _ "� . ,� ,, ADDRESS: 33 MILL STREET#1 G
w (55.0'+6.0')(2)(1')(0.74 GPD/S.F.)= 90.2 GAL/DAY • !I i1 �� + 0" 96.83' WETHERSFIELD, CT. 06109
♦ ,� # • ""Pilo u _ Loamy Sand
CB(FNDIHELD) / , q FEMA FLOOD ZONE C,B N # 250001 0008 D
BOTTOM CAPACITY . . sa • '� 1 10" AS SHOWN ON COMMUNITY PANEL PUTTER LANE MAoP247 !►�,, WAMF /;/ . - � � � � � �- ��...�� 10YR4/4 g6.00
(40'WIDE LAYOUT) N/F MACHADO ( LENGTH xWIDTH ) (.74 GPD/S.F.) - GAL/DAY • « . w
MAP 47
(55.0'x 6.0') (.74 GPD/S.F.) = 244.2 GAUDAY '""-' �' I B Loamy 10YR 618 Sand 18. PLAN REFERENCE:
2 ° • 1. PLAN ENTITLED"SUBDIVISION PLAN (OF LAND IN BARNSTABLE W. HYANNISPORT
LOT 131 ♦�« • •° ' s 24" 94.83' MASS. FOR W.E.D. REALTY TRUST"SCALED 40 FEET TO 1 INCH ANDDATED )
,o CB (FND) N/F MEHREZ TOTALS: + 000 +�" ,• -- r • •
0 TOTAL NUMBER OF CHAMBERS: 8 ,1(4 • Med.Sad DECEMBER 21,1973. PLAN BOOK 281 PAGE 13.
PROPOSED VENT (LOCATION TO �� LOCUS-S TOTAL LEACHING AREA: 451.9 SQ.FT. • • . . • C1
O PROPERTY • 2.5Y 7s 19. DEED REFERENCE:
BE FIELD VERIFIED BY OWNER) K���n i TOTAL LEACHING CAPACITY: 334.4 GAL./DAY • 1 •. • 32 94.16
` ��+ y • ! � •' 1I ;• . 1. BOOK 2779 PAGES 235-236
SCALE: 1" =60' j DOSING & STORAGE REQUIREMENTS 20. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.1� >�aF� •' ' '• so" ```' 92.66'
. 11
REROUTED / 01 ` �•.1ti�� • �F ; ' 21. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
EXISTING WATERLINE TO BE
62 DESIGN FLOW: 330 GPD l ��II rIl• r • ( i ?--- •
EXISTING 1000 GALLON }�rr� °---`" FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
SEPTIC TANK ' REBAR ' I MAP 247 DOSING REQUIRED: 4 CYCLE I DAY L , 'Pil II (1 • Me( Sand FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
FND 2 330 GPD/4=82.5 GAUCYCLE " w„!s��' 11 4 • "� C2
T 215 DISTANCE REQUIRED BETWEEN PUMP ON AND PUMP OFF FLOATS:
N/F
REMOVE AND REPLACE UNSUITABLE MATERIAL c �c 82.5 GAUCYCLE / 250 GAUFT = 0.33 FT/CYCLE
5'AROUND AND BENEATH LEACHING FACILITY �� , ^� I �J (USE 0.4'TO PROVIDE FOR BACKFLOW) 100 Mottli►g @100"
5°'
88
TO C-SOILS WITH CLEAN, COARSE SAND / �'- `� 2p N °S� LOCUS PLAN- "
12,y STORAGE REQUIRED ABOVE WORKING LEVEL: 330 GAL. LEGEND
(7) J"' �S� 2S w STORAGE PROVIDED ABOVE WORKING LEVEL:625 GAL. SCALE: 1" = 1000' 120" 86.83'
PROPOSED 8-LC-6 i200* - EXISTING CONTOUR
LEACHING CHAMBERS � ,^�
50 PROPOSED SPOT GRADES
PROPOSED 1000 GALLON I _
PUMP CHAMBER i
r� PROPOSED CONTOUR
/ N
INSTALL 1-1/4"PVC TO HOUSE. JOINTS TO BE MADE EXISTING ELECTRICAL UTILITIES
EXISTING DISTRIBUTION BOX WATERTIGHT. WIRE PUMP AND FLOATS TO SIMPLEX
AND PIPES TO BE REMOVED 4 '�
' °� CONTROL PANEL No. 1-CC2 NEMA-1 MFG. HOOVER
INSTRUMENTS. EXISTING WATER LINE
PROPOSED DISTRIBUTION BOX ' 100• w r 41L HC
( ) NEMA 4 JUNCTION BOX CORROSION RESISTANT& HOISTING CABLE 7 x 19 STAINLESS STEEL TEST PIT LOCATION
1
PROPOSED LEACHING CHAMBERS O • ' w o LIQUID-TIGHT CABLE CONNECTORS SUPPORTED 118" DIA. / 1,760 LIB. STRENGTH
UNDER DRIVE TO BE H-20 �� 72� a' CONNECTORS SUPPORTED BY 1-1/4" PVC CONDUIT, EXISTING 1000-GAL SEPTIC TANK
PVC
PROPOSED 40MIL 9rO / JOINTS TO BE MADE WATERTIGHT G BALL VALVE w/UNIONS SCH. 80
' �� � •• � BALL
FISHER CO. MODEL NO. 56060
GEOMEMBRANE LINER (3) PROPOSED 1000 GALLON PUMP CHAMBER
Tca
3" 2"SCH. 40 TfO D-BOX
o "SCH. 410 TEE w/CLEAN-OUT CAP 4"SOLID SCHEDULE 40 PVC PIPE
1>0, #38 �g'r ALARM ON ❑ DISTRIBUTION BOX
DRIVEWAY r
�' h EXISTING PUMP ON 2-BEDROOM o N �� 0 LC-6 LEACHING CHAMBER
o P
(4) 2 BALL CHECK VALVE SCH. 80 PVC 100
DWELLING/ uM
P.S.I. FLOWMIATIC MODEL No. 208S
.'. ?�B•
TOF=95.26' "'
2 WIDE ANGLE CONTROL FLOATS 1/4"WEEP' HOLE IN DISCHARGE PIPE
DECK (BARNES 073618) V2"SCH.TP1 P1: PUMP ON/OFF 120 ACTIVATION 40 PVC. DISCHARGE PIPE
2: ALARM ACTIVATION BARNES SE411 PUMP .4 H.P. 115 V 2" REV. DATE BY APP'D.. DESCRIPTION
96x83 (5) DISCHARGE PASSING 1-1/2"SOLIDS OR
EQUAL PROPOSED SEPTIC SYSTEM UPGRADE
PREPARED FOR:
f j HC (2) '
1000 GALLON PUMP CHAMBER ROBERT JOHNSON
(s) o q 60, SWING TIES LOCATED AT
MAP 247 ^' "`�• RESERVED FOR
f LOT 129 LP DESCRIPTION HC (1) HC (2) BOARD OF HEALTH USE 38 PUTTER LANE
F FRETSCHL 18.0' HYANNIS, MA
N/ �/ ' PUMP COVER IN (3) 19 6
j
EXISTING LEACHING PIT AND .- / PUMP COVER OUT (4) 24.1' 15.3'
SCALE: 1 INCH = 10 FT. DATE: DECEMBER 18, 2003
SPOILED SOIL TO BE REMOVED / D-BOX (5) 28.6' 21.0'
0 5 10 20 40 FEET
c etr�'
q" LEACHING CORNER(6) 57.5' 38.2' EFRVuST `'
EXISTING LEACHING PIT S�. 9�" ENviN 1 ';r' x� �oH/v��' " PREPARED BY:
TO BE PUMPED AND �2'� --'" f nLLFTiON AND CITIFY I� �'� c
? LEACHING CORNER(7) 27.9 39.7
0'00 `-
FILLED WITH CLEAN SAND ` S�';,TCM WAS INSTALLED i � � cHUHc",« JC ENGINEERING, INC.
-TrI `'/`'
No "` 2854 CRANBERRY HIGHWAY
42807
EAST WAREHAM, MA 02538
SITE PLAN- 508.273.0377
Drawn By: DS Designed By: DS Checked By:JLC JOB No.568
SCALE: 1"= 10'