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HomeMy WebLinkAbout0021 ALDEAS AVENUE - Health 21 Al&as Avenue Hyannis - - 5 A= 20 -038- o \ i l TOWN OF BARNSTABLE `<LOCATION 7-1 AL DES- S AVE SEWAGE# 20177- 034 }r VILLAGE gWa�nn;5 ASSESSOR'S MAP&PARCEL Z'49- 03S '¢ INSTALLER'S NAME&PHONE NO. C3 4 a 6xCaJa..4 i o,n • y71 - Ol.S3 SEPTIC TANK CAPACITY /SSOO N 1 O LEACHING FACILITY: (type) 5005?Q,) yc Z (size) _]3x 25 x Z NO.OF BEDROOMS OWNER AQJ LUESKE7 PERMIT DATE: 72= 3T;711-l COMPLIANCE DATE: Z--Z 1`] 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') Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY A Zs $ A-Z' 3Z 32 • �q7 1v7 A3 . 4, [� 83 3 3#y . Ay - S y A 1.13 - �. - • -! _ � .-. .�. -, ice ... � -. _� .. .� � . �_. .r ` f - V No. Fee ,l/ 1 HE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS �pfication for 30isposal *pstrm Construction permit - 5"5" 6 ice! Application for a Permit to Construct( ) Repair( ) Upgrad 4 El Complete System Individual Components( Location Address or Lot No.Q i A L D G A S AV EVXJF`T�arne,Address,and Tel.No. Assessor'sMap/Parcel MftQ a6 1 I�/4eaL 03 Danit-i Lve�ok,-e 5o%-3g4- 1i 43 Installer' NaM_6\io, dress,and Tel.No. D`esi�ner's Name,Address,and Tel.No. `T3f Address, -con50&- y-n-Db VH- AbSc)6oA-e5 6DS6A?)3.001 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.rem gpd Design flow provided gpd Plan Date (� Number of sheets 2 Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 600 q0_1 14 lO ST. 1 20 A-b D)� �?� N I o OCt1 . LLhambe] cs Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board e t i ed d Date a1 17 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued lie Jam,• _ , f$ ,1 1 No. Fee 0 _11 A .!'`' .HE COMMONWEALTH OF'MASSACHUSETTS Entered in computer: 114 PUBLIC HEALTH DIVISION - TOWN OF.BARNSTABLE, MASSACHUSETTS Yes Zipplication for ;0iS`p6al '6pMem Construction Permit �` Application for a Permit to Construct( ) Repair( ) Upgrad• ftWff4�( ) ❑Complete System ❑Individual Components r Location Address or Lot No. p9 1 A L D C A S n\/E �e ame,Address,and Tel.No. Assessor's Map/Parcel M A P a 6 `� n 2 L E L 0 3 � 'JCI' l l c( L U�_-b� —e 5 0� 3 Q LI— 11 y 3 � Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. -T& B ixcC\\1c 1 (vn 50�- Lli� oL-' FE At )6cc, cIeS 5o(6 s33- vx) 41 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures .Design Flow(min.required) gpd Design flow provided gpd Plan Date I ' �C Li I ( � Number of sheets 2 Revision Date Title �I Size of Septic Tank Type of S.A.S. Description of Soil - i Nature of Repairs or Alterations(Answer when applicable) IJ 02 CI a t N I(J S 1 H Z v d h U K ( Z ) Liu, �J Date last inspected: + Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board oflTealt �i ed Date a / t-7 Application Approved by O k�SDate G r Application Disapproved by Date for the following reasons i Permit No. Date Issued r ---------------------------------- ---------------------------------------------------------------------------------------------------- 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate oU Compliance THIS IS TO CERTIFY that thhe"On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( by at Z A f _(^I r\\I ( V i'� ' has been constructe ac or ce � IJ with the provisions Iof Title 5 and the for Disposal System Construction Permit No d ted Installer �(obpP.T _(� 1_r U�.I Designer U �5��(1� ( ( #bedrooms C7 Approved design flow n J 3 (-) gpd The issuance of this ,ermit shall not•be construed as a guarantee that the system will ction as designed. _ Date -/1 ��� j `Inspector ----------------- -------- ---------------------------------------- ------- ----------------------------------- ------- No. 0� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon;( ) System located at _,4 G CC( C, A\�� I�i \1(�( ;7 0 l and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust be c rnp eted within three years of the date of this permit. Date f Approved by ti Town of Barnstable �" r0"ro Regulatory Services Richard V. Scali,Interim Director • enarrsrear� Public Health Division �F Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 11 0i Sewage Permit# Assessor's Map\Parce % l Designe : 1 Installer: Address: yi Address: r On q�V9 f"Y WR was issued a permifto install a (date) (installer) septic system at Ali kulA�7 pjf,. lql�� based on a design drawn by (address) 16 H44.1 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. Strip out (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. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in co reliance with the terms of the IAA approval letters (if applicable) DAVID (Installer's Signature NIASON ' No.1066 NI TAaN (Affix Here) V P EASE 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. QASeptic\Designer Certification Form Rev 8-14-13.doc DEEP OBSERVATION ROLE L0G' Hole# � Deptb bow sop Horbm son Heath salt Color Sall Cmar C�a•) ( U4 i ( ► Boat his �Vie DEEP OBSERVATION HOLE LOG Hole# Depth Uow Soil Hodmom Sap lwme sae color Sall Other SaFface cma (Emm) Moulins (Sumclum Sloan.Booldws, saraven f. /Qvk¢ j - zl�,5-ZZDH -AA DEEP OBSERVATION HOLE LOG Hole# Depth bwa Sail Hod wo Salt T"im a soil color Sap • Otba• Sure"(bL) (USDV (mow .steam Baoldm DEEP OBSERVATION HOLE LOG Hole# DqA 1Fow Sall Horlma Salt 9Ub" son CAN Soil ' Odtar swam(m.) tnsDA) MoWbS ammu ro,slom eaaWm i �2QS�I �fItQ Maul Above S00 year flood bosafty No Yes WWa 500 year booadtry No_� Yes Wittdo 100 yw flood bowduy No Yes Loth of Nahwa&Ocr 9WU X93J2H Maul Doe at loan floor float of ashiri y emming parviOtts=wW cxW in all areas obscomd dir x0mit the area proposed for the sail absorptimt system? If Wt.what is the depth of natarally oaiuring pard=matww? CAME& ,, /. I Car*that on /�4�'• M1(date)I have passed the soil evaluator mlafinatim approved by the ' Deparimatt Of Em romaolt P ad that the abave amlydi wall pafonmed by Im'Coblist0lit with the requited and deaeribod in UO CMR 15.017. Signadlro Town of B ble. Pf ry • ; I Pablic iff Division �0 Mien stnz� MA 02601 Dace Scheduled ::i . V oil Suitab' ' Assessriterrrl for Sew ge o at lPbsPormad By: / mow Ime � � {, vul�ea Br- �� 1 i LOCIMO " WORMATIQ,11T LaeatW Add =*. Z� r����uS r o+met s mma Aften AssessdsM Z.� arm v ����ec rraw RIWnm Land Use 7 2plrA�/ skpes(i) Smrfiee sEa�s ��� tlrocre open waorr eoa)► /2C Posdble we!Ana-Ot ° D�'g wls0er wen - wayft• PmpeVU i. © ft Omer R SBET ' -(Sbw name dtni=h*i0lK mat loc dms of t�a 60lw&pen oeM iocMe In p adWfY to 60w) / peplQ tD Bedtoct � Panat mat m W44 ) `1 =• `� Depth to a *. sesa bS Wmr In Roi9er Q weegtagllmr P1t�o°--,.---..�� animated seawndJPO Gmudw&W D t'R11 TION FURrS06L ffiGH'�ATI�R TAIL tV[emod Usefi aun&8 obi.eolm b. DqA to flap!ttttiWea �Rhy eplea from of do taus: tn. t Adl t meal wens_'. neWha wau WA A4 ..•._.,.- 41.td mrlws a tsNat:.._. .! rIIRCOLATr TW - Oaxcadan' I T1ntsu9" .._......... ..-•----- Depth of Pere 7!� A "P-1w) Tlmeatir -- Stum*`°'`nw- BadPteeoat � `� �,�• ' y� vita MlnJlopthOle '! j' i siresnusaalld slm — s�te>aa Ad�daeai7elft Neew(Y" Ownab.P oi�go}c DIM TO' e abnc now DlvWm _ . e testis to be co�tdacted witMn l0A'of w mast Brat notify the '= perooia� or to b & Ba�tabie on Division at least one�1)we�c prf . 1 ` ac�9-o3g Commonwealth of Massachusetts Title 5 official Inspection Subsurface Sewage Disposal System Form Form • for Voluntary Assessments 1 its Property Address Owner �e / � f.. information is ;0wne—rsN:a!S k-required for everypage• own State Zip Code Date of Insp ctio •• <r L 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. filling out forms Important:When A. General Information on the computer, S� Ia 0 9 use only the tab key to move your 1 Inspector: cursor- not O ZY �/� use the return key. Name of Inspector ��� -T--G Company Name Company Address rim Citylro " / ' 4 Oa 6 /� State S�? o�-qD� / ` � � Zip Code Ielepho Num r .-icense 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 an a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes Fails ❑ Nees Further Evaluation by the Local Approving Authority Inspect s.Signature Date The s "tem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Ins ection F Subsurface Sewage Disposal System Form -Not for VoluntaOrrn ry Assessments Properly Address Owner Owners Name L ��v'r information is / required for every �i P14tf page. City/Town State Zip Code Date of I B. Certification (cont.) P tion Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: ------------ B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.&is Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name information is required for every �41 r page. CitylTown / C State Zip Cade Date ofl sp do B. Certification (cont.) I ❑ 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 El Y ❑ " N ❑ ND(Explain below): El obstruction is removed El ' ❑ N El ND(Explain below): El 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F Subsurface Sewage Disposal System For -Not for Voluntary Assessments / /r✓�� // Property Address � �V Owner Owners Name information is required for every A,1 t page. City/Town /� �—tt State Date of spe Ion B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *' This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Cri pplicable to All Systems: You mus dicate"Yes"or"No"to each of the ollo� wing for all inspections: e No C,e�Ss p / � ` ❑ Backup of sewage into facility or system component due to overloaded or logged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to overloaded or clogged SAS or cesspool ❑ S c liquid level in the distribution box,above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Asssees'sments Property Address !� Owner Owner's Name � �ke, information is / - pageed for every / aa60 page• City/Iown / S State Zip Code Date of nsp tion B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year obstructed pipe(s). Number of times pumped: y NOT due to clogged or ❑ Any portion of the SAS, cesspool or privy is p vy 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 p vy Rhin a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ;/"",Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / ` �eg Owner Owner's Name z/� information is required for every -►,✓1Nl S /��/ `6 O/ page. City/Town State Zip C— ode Date of In pec' n C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ mping information was provided by the owner, occupant, or Board of Health ❑ re any of the system components pumped out in the previous two weeks? ❑ e system received normal flows in the previous two week period? ❑ Have a volumes of water been introduced to the system recently or as part of s 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? ❑ 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? Ej Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The ize and location of the Soil Absorption System (SAS)on the site has 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): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t i Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �� Icile Owner Owner's Name lea- required information is for every �� page. City/Town State Zip Code Date of nsp ion D. System Information Description: ce VO �i Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No information in this report.) ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes [I No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ap( v� Property Address �-S Owner Owner's Name ^tA e information is required for every page. City/Town State Zip Code Date of nspe ion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: / Source of information: �v Was system pumped as part of the inspection? ❑ Yes �o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system e cesspool � ve w cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessmentsy /g/QIeGs' Property Address v �� Owner Owner's Name L (4e 11_"1 information is / - required for every ���f /��/� /3a�n page. City/Town !/—_ —_� State Zip Code Date of In ped n D. System nformation (cont.) Approximate age of all com onents, date installed (if known)and source of information: �t I�IGr Were sewage odors detected when arriving at the site? ❑ Yes o Building Sewer(locate on site plan): Depth below grade: feet �Ier�iaonstruction:st iron 0 PVC ❑ other(explain): Distance from private water supply well or suction line: ` U \ feet Comments(on condition of joints, venting, evidence of leakage, etc.): to Septic Tank p (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ' ❑ metal ❑fiberglass ❑ polyethylene Y El 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: Sludge depth: t5ins.doc-rev.6/16 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for� Voluntary Assessments Property Address eG y Owner Owner's Name _ oZ— Y e-Z40Z�- information is required for every �� f �}�`fool page. Citylrown (/v State Zip C Date of I spec' n 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.): Grease Trap(locate on site plan): Depth below grade: feet Material.of construction: ❑ concrete ❑ metal ❑fiberglass El polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - for Voluntary Assessments rProperty Address �No, ?lj Owner Owners Name 'r �— information is required for every l page. City/Town D. System Information (cont.) State Zip Code Date of Ipest' n Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present:. ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F Subsurface Sewage Disposal System Form -Not for Voluntary Asset ments Property Address / l ea`f Owner Owner s Name 64� information is required for every aPJ 4!1 d �q / / page. Cityrrown �T r2 60 S / spe io D. System Information (cont.) State Zip Code Date of 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: } r � . t5ins.doc-rev.6/16 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Owner -z- 4M4 Properly Address information is Owners Na—me 174C .. required for every f page. CitylTown State D. System nfor Zip C� Date of I pectt / ion (cont.) Type: 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.): O G mot/ U CEO Ot N G Cesspools (cesspool must be pumpe as part of inspection) (locate on site plan):/ Number and configuration r Depth-top of liquid to inlet invert / Depth of solids layer Depth of scum layer �r Dimensions of cesspool ✓ 6 �� Materials of construction 00 G Indication of groundwater inflow ❑ Yes No t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Dis osal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M lcl-ec- OwnerProperty Address Owner's Name 'e information is required for every page- C Y1Town z� State Zip Code Date of In pecf n D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate'on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name (14 e"' information is required for every Gi d l f f // page. City/Town —�- .(� State Zip Code Date of spe tion D. System Information (cont.) Sketch Of Sewa isposal System: Provide a view of the sewage disposal system, including ties to at least two rmanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where p is water supply enters-the building. Check one of the boxes below: and-sketch in the area below drawing attached separately /C� 3 a 14/ SlY t5ins.doc•rev.6/16 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 15 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner information is Owner's Name /� h I v�6 required for every page. City/Towr1 State Zip Code Date of nsp tion D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 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: Date ❑ served 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: G - Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 v i , Commonwealth of Massachusetts Title 5 Official Inspection F Subsurface Sewage Disposal System Form -Not for Voluntary Asset ments Property Address 4 lcle� Owner Owner's Name Ile— information is required for every page. City/Town State Zip Code Date of In ecti E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked :M,�1-nnsMtion S mmary D(System Failure Criteria Applicable to All Systems)y s)completed Syst Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 i Locus ASSESSOR'S MAP: 269 GENERAL NOTES: PARCEL. 038 < > .; REFERENCE: PL. BK. 40 PG. 29 1. VERTICAL DATUM: Assumed_________ 2. MUNICIPAL WATER IS AVAILABLE. Q FLOOD ZONE: X Town of Barnstable i 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT c v #25001 C0568J(07/16/14) SYSTEM UNLESS OTHERWISE NOTED. Q LL- v 0 4. ALL PRECAST UNITS TO CONFORM TO °o AASH TO: H_1_0_& H_20 3: %- N 5. -PIPE PITCH-1/4" PER FOOT UNLESS OTHERWISE NOTED. 6• ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE W est Main Street U a WITH MA ENVIR. CODE (TITLE 5) AND LOCAL REGULATIONS. LOCUS MAP N.T.S. '. 7. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES x 100,56 Y PRIOR TO CONSTRUCTION. 100.52 x 100,68 M 100,2� J LEGEND: , O_ PROPOSED CONTOUR LLJ 99 PROPOSED SPOT GRADE Edge of iN'. . . . . x 100,48 — 40 - EXISTING CONTOUR r 100,53 S 84.1500„ x 100,26 ,F Q X 30.23 EXISTING SPOT GRADE TH-2 1 E a TEST PIT ' 114.64' 25 1 25100.47 100,24 �012 �100.18 ® EXISTING WATER SERVICE 100,05 TH-1N o ©X o WORK LIMIT LINE rn 5 O 'DO. 3 0 Water Shutof (� ' w 1 0,43 Deck ' on LaFrance ve. cn 10 0, 0 #21 a Q X. x 'TOF=102.07 ? 100,13 3� �� OF Mgff9� �n (Assumed) 000.06 Q ti • `c¢o 10 6, (Block) C VON H .34 ONE r N moo U 1°° o,dui U No, 1068 N 99.87 _ w o 100,2� p o �F�ISTER�� p x 100,24 100.14 T...E.. co X4 Rla� r *Approximate location of 1 0o Lot 32 100,09 '` 99,97:. 99,96 original cesspool. Confirm ioo,24 ` 7 6,328f S.F. 99,8 100X if backfilled. 100.08 32, 100.55 10p'Q0 NOTE: This plan is to be used for septic N 84*15'00" W 2FT OAK UIR MAG FND BM ❑RP system purposes only and is not to be 100,05 � used for any other purpose. X 100,19 x 100,30 , X 100.19 ° 99 5 21 ALDEAS AVENUE V ft' , HYANNIS, MA i associates PREPARED SEPTIc SYS DESIGNS, FOR: Dan Luebke ,�v v o Bed Benchmark set: Bath FLOOR PLAN Magnetic Nail 320 Cotuit Road 27 Hialeah Avenue 2 g Sandwich, MA 02563 N.T.S. EL.= 100.0 (Assumed) 508.e33.0041 West Yarmouth, MA o�c Bed 1 02673 Q\ Surveying by. Terry A. Warner.P.L.S. 22 `egg Road Norwich, MA 02645 DATE REVISED SCALE SHEET NO. � 1 st Floor 2nd Floor c1108> 432-009 01/24/17 1" = 20' 1 of 2 .l Provide Riser over D-box NOTE: All components to be marked with NOTE: To prevent breakout, final to within 6" of final grade magnetic tape or similar prior to final cover. T.O.F. (Full) EL. 102.07 g grade of EL. 98.3 to be carried (Cover to be watertight) out a minimum 15' beyond edge F.G. EL: 100.1-100.24 F.G. EL: 100.4 F.G. EL: 100.3 Maintain Min. 2% slope over leach facility to of leach facility. Existin f- reventBondingF.G. EL: 100.3 Install risers w/covers over inlet and Min. 2" of 1/8" - 3/4" Washed Stone or Inspection Port within 6" to grade outlet to within 6" of final grade Geotextile Fabric L=16' (Access Covers min. 20 diam. per Code) �• Exist. invert 4' SCH 40 P _ L=15 L-10, 3/4' - 1 1/2 Double Washed Stone Cast Iron 4 to, 4" SCH 40 PVC " 4" SCH 40 PVC Top of Peastone or Geotextile Fabric EL. 98.3 ®S=2% 2% EL. 98.32 t+' =19' 1 s ®130 0 24" Eff. Depth ®S=1.3% 0.5%MIN p EL. 97.75 " EL. 97.43 aaaBaea 95.03 EL. 98.0 Install Gas Baffle EL. 97.6 PROPOSED DB-3 EL. 1 Use 2 - 500 Gallon Precast Chambers H-20 DISTRIBUTION BOX (H-10) with Double Washed Stone 6.05' (Install PVC Inlet & Outlet Tees) Watertest for levelness 4' Ends, 4' Sides PROPOSED 1500 GALLON if more than one SEPTIC SYSTEM PROFILE (25 x 12.83 x 2') H-10 SEPTIC TANK outlet EL. 89.25 N.T.S. Bottom of TH-1 SOIL LOG ADDITIONAL NOTES DESIGN CRITERIA V Number of Bedrooms:Existing 2, Min. Design 3 Bedrooms SOIL EVALUATOR: DA VON HONE, R.S. S.E. #2517 1 Contractor to confim soil suitability prior to installation. Contact BOH and DATE: J INSPECTOR: JAANUARYID R.S., BOH Design Sanitarian in the event of varying soils from original soil test. Soil Type: Class I 2 244,, 2017 10:00 AM PERMIT: #15252 Percolation Rate: <2 min/Inch PERCOLATION RATE:<2 MIN/INCH IN C1 2. Pump and remove Failed Cesspool and Leach Pit. Any contaminated materials within 5' of proposed Leach Facility to be removed. Replace with Daily Flow: 110 G.P.D./Bedrm x 3 =330 G.P.D. TH - 1 TH - 2 clean fill per Title 5 specifications. Confirm original cesspool filled. Design Flow: 330 G.P.D. (Min. Required) EL.100.25 EL. 100.39 3, Water line to be sleeved at any sewerline crossings and within 10' of any Garbage Grinder: Not Allowed septic components, as needed, per Water Department requirements. Loamy Sand Loamy Sand Contractor to verify location of water line prior to construction. Leaching Area Required: (330)/0.74 = 445.94 S.F. 10YR4/3 10YR4/3 14" 99.08 9" 99.64 4. Distribution Box to be placed on 6" crushed stone or compacted, level 330 G.P.D. x 200% = 660 G.P.D B B base. Septic Tank Required: Minimum 1500 Gallon (Proposed) Loamy Sand Loamy Sand 24" 10YR5/8 98.25 24" 10YR5/8 98.39 Use 2 - 500 Gallon Precast Chambers H-10 with Double Washed Stone: 25' x 12.83' x 2' Medium Sand Medium Sand �' C1 SEPTIC TIES 2.5Y5/6 2.5Y5/6 47" Bottom Sidewall Area: 2(25' + 12.83')2= 151.32 S.F. Bottom Area: 25' x 12.83'= 320.75 S.F. Total Area: 472.07 S.F. 25 Desi n Flow Provided: 0.74(472.07 S.F.)= 349.33 G.P.D. N 6' 21 ALDEAS AVENUE L' O O 27 Deck # HYANNIS, MA 21 1° associates PREPARED 132"1 189.25 120" 190.39 O 1 TOF=102.07 FOR:sEa Dan Luebke nc SYSTEMo�cHs No Groundwater Observed No Groundwater Observed 320 cotuit Rood 27 Hialeah Avenue 2 San with, MA 0 563 <9r, @ 13:00 min. PERC RATE: <2 MIN/INCH C1 Horizon West Yarmouth, MA I, Amy L. von Hone, R.S., hereby certify that I am currently approved by Surveying by: 02673 the DEP pursuant to 310 CMR 15.017 to conduct soil evaluations and Terry A. Warner.P.L.S. that the above analysis has been performed by me consistent with the 22 Long Rood requirements of 310 CMR 15.017. 1 further certify that I have Harwich. ►w 02645 DATE REVISED SCALE SHEET N0. successfully passed the Soil Evaluator's Exam on November, 1994. � � 2-s3os 01/24/17 1" = 20' 2of2