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0011 ALICIA ROAD - Health
-- 11 Alicia Road _ Hyannis y A= 292 —230 KI 9 r 1 N r i I a ' 0?9a-.2.30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 11 Alicia Road Property Address Sandra Dosanjos r� Owner Owner's Name information is '/ MA 02601 05-01-2019 r required for every Hyannis page. City/Town State Zip Code Date of Inspection �. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. Rivers End Road Co �y Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 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 05 05 2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. Cityrrown 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 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding two leaching trenches. At the time of the inspection there were no visible signs of past hydraulic failure. 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 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. Citylrown 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 I 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 �e Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. Citylrown 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 ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 - page. Cityrrown State Zip Code Date of Inspection Co 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El ® 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. ❑ ED 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 • 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. Citylrown 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? 0 ❑ Has the system received normal flows in the previous two week period? ❑ 0 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? 1Z ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? Z ❑ 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? R ❑ 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 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 - page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: In 2018-18,300 cubic feet used and in 2017-20,600 cubic feet used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. City/Town 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t51nip.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n Title 5 official Inspection Form le Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 _ page. City/Town State Zip Code Date of Inspection D. System Information.(cont.) 4. Type of System: M Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool U Privy 11 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. l Other(describe): Approximate age of all components, date installed (if known) and source of information: A new leaching was installed on 06-14-2011 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): " Depth below grade: 21 feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): The inlet cover is under the deck I could not tell the type of sewer pipe. 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 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 - page. CitylTown State Zip Code Date of Inspection D. System Information (Cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: standard H-10 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 4„ Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? sludge judge Comments (on purnping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner have the tank pumped and then put on a maint. plan with a local septic pumping co. The Barnstable Health Dept. has a list of local septic pumping co. t5insptdoc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Alicia Road Property Address Sandra_Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. Cityrrown 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 purTiping 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): iDimensions: 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 c� Commonwealth of Massachusetts . �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Alicia Road Property Address Sandra_Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. Citylrown 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.): At the time of the inspection there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 c� Commonwealth of Massachusetts �d Q Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Alicia Road Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Frump 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. 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: ❑ leaching galleries number: leaching trenches number, length: two 38.25 leaching fields number, dimensions: J=► 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 I. c� Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Alicia Road V� Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 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.): At the time of the inspection there were no visible signs of past hydraulic failure. 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 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Alicia_Road Property Address Sandra Dosan os Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. City/Town 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 118 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Alicia Road Lf/ _ Property Address Sandra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 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 Z drawing attached separately ptrlvltr-� CIWL 4- c�J t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i TOWN OF B;7ARNSTABLE LOCATION SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL D INSTALLER'S AME&PHONE NO. � i SEPTIC TANK CAPACITY A5 7 LEACHING FACILITY:(type � �r (size) I . NO.OF BEDROOMS OWNER_ B PERMIT DATE:© COMPLIANCE DATE: ! I Separation Distance een 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 leachin facili Fee i FURNISHED BY i R4h� I I Uri-s1 ; 3 , y i t i c� Commonwealth of Massachusetts Title 5 Official Inspection Form u Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � ,. 11 Alicia Road Property Address Sanc;ra Dosanjos Owner Owner's Name information is required for every Hyannis MA 02601 05-01-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Z. Check Slope. 0 Surface water Z Check cellar Shallow wells Estimated depth to high ground water: 10 plus feet 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 ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: [J Checked with local excavators, installers-(attach documentation) U Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole to 10 feet to show 4 plus feet of seperation. 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 �e =. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Alicia Road Property Address Sanc ra Dosanjos Owner Owner's Name information is required for every Hyannis annis MA 02601 05-01-2019 page. Citylrown 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. ® S. 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 BARNSTABLE r LOCIATION � E1 � SEWAGE#&a/���2 VILsAkGE ASSESSOR'S MAP&PARCEL! d a INSTALLER'S AME&PHONE NO. SEPTIC TANK CAPACITY �ST LEACHING FACILITY.(type (size) pj NO.OF BEDROOMS OWNER_ - PERMIT DATE:© COMPLIANCE DATE: Separation Distance B een 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 facili ) Feet FURNISHED BY m -A3 - A F� 7 ` y . No. �l) l O Fee DU — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitatlott for BispoSaf Opstent Construction j9Prinit Application for a Permit to Construct( ) Repair(4;Upgrade( ) Abandon( ) ❑Complete System Ondividual Components Location Address or Lot No. L/,C� Oraltte,Address,and Tel.No. Assessor's Map/Parcel Tel.No. Installer's Nine,Address,and Tel No. i��ler�� �Y/9 Designer's 1 aame �i s aid � �JL 4�lDl7�L � �'1f� 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 Number of sheets Revision Date Title .� Size of Septic Tank � S/, /��O Type of S.A.S. / � 0 fj Description of Soil Nature of Repairs or Alterations(Answer when applicable) �A S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of tl ealth. �, d . / Date / Application Approved by Date /3 Application Disapproved b Date for the following reasons Permit No. 2.0 Date Issued 13 // ----�_•..-.....,.. ....ti --------..ti�.,ei.�.,;e,+.i..w:�:+rrra+Cl4+u Via.=..••--�rrn:.�r.�+w.�.•�-., '�,s�'-'.' "`�'~"�:`;ysyrro'� ' +^T'-� e i No. &..__ (Fee �U THE COMMONWEALTH OF MASSACHUSETTS Entere',d in computer: PUBLIC HEALTH DIVISION -TOWN OPBONSTABLE, MASSACHUSETTS Yes ftpfication for Misposai *pstem Construction i3errnit Application for a Permit to Construct( ) Repair(grade( ) Abandon( `) ❑Complete System [Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel d Installer's Name,Address,and Tel.No. i��l�r� /Y/� / Designer's Name t9ddress and Tel No.� /�`J }f7e t Type of Building: Dwelling No.of Bedrooms Lot Size Jsq.ft. Garbage Grinder( ) Other Type of Building �o No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 5 gpd Design flow provided y Q gpd Plan Date Number of sheets Revision Date Title - Size of Septic Tank /�S� //JIjU Type of.S.A.S. / ��/C- '�Q �s. Description of Soil Oft- Nature of Repairs or Alterations(Answer when applicable) d.'/rGf.PJ 22—,,,70X �A S Date last inspected: Agreement: • ,t� The undersigned agrees to ensure the construction and maintenance of the afore described on-site•sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of t1talth. y _ Id i�i v i` '�:.� Date Application Approved by I Vl Date /3 / Application Disapproved b r Date,.;;-:,,r' for the following reasons Permit No: -2 G// - Date Issued 4 (3 // THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance t THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) " Upgraded( ) Abandoned( )by 1 at / has been constructed in accordance with the provisions of Title 5 and the-for Disposal Systerrr onstruction Permit No..?UI/-/ . dated b / Installer i�i � Designer #bedrooms Y Approved design flow A �/ d gpd • The issuance of this permit shall not be construed as a guarantee that the system will fun tc�o�� designed. Date %V L, 1 Inspector _ No. 2d I I Fee THE COMMONWEALTH OF MASSACHUSETTS T PUBLIC HEALTH DIVISION=BARNSTABLE,MASSACHUSETTS .disposal Opstem` onstruction Permit _ Permission is herebyanted U to Construct .Repair Upgrade Abandon } l� ( ) P ( P!�' ( ) ( ) System located at I 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. ` J-4 Provided:Construction must be completed within three years of the date of this permit. Date / f/ �/ Approved by _ 1 f Town of Barnstable '"E' Regulatory Services Thomas F. Geiler, Director snaxsrnat,s. �,� Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,KN 02601 Office: 503-362-464-4 Fax: 503-790-6304 Installer & Designer Certification Form Date: 'l� ' 1 Sewage Permit# Assessor's MaplParcel Z� 230 Designer: O WV 1 /� Installer: Address: )(. Address: c?� 0n , as issued a permit to install a (date) ^ , /l (installer) /T, septic system at (/�,vl.A- IDA-0 based on a design drawn by (address) A4t-"" _ dated �0 'O • / (r-e.'v 6 l (designer) XI 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 an&'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 anv 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. yqV 1'ER -a (Installer's Signature) " No: 1140 I Rf NSiE�`� SOI TA��t'� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Desiener Certification Form 346. 4:'doc r i Town of Bdinstable. P# of� Department of Regulatory Services Public Health Division Date 6 g6 e$ 200 Main Street;Hyannis MA 02601 - a63¢ � 1 (,'f Date Scheduled `� ' Time Fee Pd. i I Soil S bility Assessyaient it for Sewage Disposal Performed By: . i Witnessed By: i LOCATION & G-ENF kL INFORMATION - 00 Location Address (,(L( Owner's Name 0e,M cle 11 k rk �°°� (t P,,�t-t c,l k R-o' :JIy"NK V` A Address 'tyot4lSI MA, Assessor's Map/Parcel: 2— l 41i5o I Engineer's Name Da-y-re,'1 M ,-r NEW CONSTRU(`TION REPAIR x Telephone# 50V 6 2 — Z Slopes Surface Stones 4 Land Use (90) ,•,� i LC�c/ ft Drinking Water Well 7 ?D`eft Distances from: Open Water Body /�" ft Possible Wet•Area g i 7 (00 ft Pro Line >l ft Other ft Drainage Way p-� I SKETCH:(Street name,dimensiods'of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) 141.85 FENCE10 01 �o ' \ Q I cV, ?3 I ASPHALT cyc 231 O t DRIVEWAY ! � 7 �\IV 1 N II L Q �a ory I`Y `QI O q �` - � V�N •� w IJ i Q 13i o o \\ ti=v \\ 0 11 1 M 01 J I \`\QQry \` �0�0 ; �/'i j mot® "CCSSeeAA" W; I \ v V � � h \�\�;\\•\\\•\ ;\ t— 2 0 1 i 0- -5 40, v S2013'19"E 140.55 —---— I i Parent material(geologic) Depth to Bedrock �✓ >q . I Weeping from Pit Face o✓2Q Depth to Groundwater. Standing Water in Hole:' I I Estimated Seasonal lIigh Groundwater N DtTE ATION FOR SEASONAL HIGH WATER TOLE Method Used: I in. Depth 10 soil mottles: In. Depth �blserve standing in obs.hole: in. Groundwater Adjustment it- Depth toiweeping from side of obs.hole: -777:- ; Adj.faelor Adj.Oroundwater Level,,,,°, index Well# Reading Date: Index Well level PERCOLATION TEST D,�tp.�---_ '1n1� Observation / I Time at 9" ' Hole# tl f 11 Time at 6" Depth of Pere - 13 Time(9"M61l) Start Pre-soak Time.@ 1l End Pre-soak I Rate MinJlnch. Additional Testing Needed(Y/N) Site Suitability Assessment: Site Passed Site Failed; Original:.Public i-e;iith Division Observation Hole Data To Be Completed on Back ***If percola>yitjn testis to be conducted within 1.00' of wetland,:you must first notify the Barnstable C&riservaticn Division at least one (1)week prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel (3 l��-al D QR-�1� Gi ll�N 6, �-�{ U r(/ 2t1. Cy Med d 2• �Ol DEEP OBSERVATION HOLE LOG Hole# Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency,%Gravel) V 1 ZS rl � San Loa 10 .Q-6/W 132 Mid S�►�P 2• DEEP OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel 4-3y G i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil ther Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. 'I Consistency. Gravel) 011-����3�u ► can �lg 43"-13icru� 2 Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary- Na Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification O �� I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required trakiing,expertise nd experience described in 3,10 CMR 15.017. Signature Date (0 11 Q:\.SEPTICIPERCFORM.DOC I Town of Barnstable Barnstable i SAMSTABM ► 1 I r ��r Board of Health 200 Main Street;Hyannis MA 02601 2007 Office: 508-8624644 Wayne Miller,M.D. F.Ax: 508-790-6304 Paul Canniff,D.M.D. .lunichi Sawayanagi August 29, 2007 Mr. Marlei DeMacedo 11 Alicia Road Hyannis, MA. 02601 Dear Mr. DeMacedo, During the meeting of the Board of Health held on July 17, 2007, the Board voted to uphold the original order from the Health Agent dated May 30, 2007. You are ordered to remove two bedrooms from the dwelling at 11 Alicia Road, Hyannis within sixty (60) days. You shall obtain a building permit before performing the required work. HISTORY The property owned by you located at 11 Alicia Road, Hyannis, MA. was inspected on May 23, 2007. by Donald Desmarais RS, Health Inspector for the Town of Barnstable because of a complaint regarding overcrowding. The following violation of the Town of Barnstable On-Site Sewage Disposal Systems Ordinance, §360, was observed: 360-20 (1): Criteria for Determining System Repair or Replacement There were a total of five bedrooms observed in the dwelling (three bedrooms upstairs and two bedrooms downstairs). However, the existing septic system was designed for three (3).bedrooms total only. You are ordered to remove the two (2) bedrooms from the basement by removing entrance doors, by removing the beds, and by opening all door-way entrances (by partially removing walls) to each room in the basement to a minimum of five feet wide openings within sixty(60) days of your receipt of this letter. Any structural changes must be done with a building permit. Si ely, ayn Mil r, M.D, Chairman BO OF HEALTH TO OF BARNSTABLE Cc: Ms. Fomanda McCarthy CA Q:\WPFILF.,S\McCarthyl 1 AliciaRoadHearingDecision.doc oFTHEr Town of Barnstable Department of Health, Safety, and Environmental Services snxnsrnaLE, 9�A "S. ,�r Public Health Division 'F1639. � 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health May 30, 2007 Francisco and Marlei DeMacedo 11 Alicia Road Hyannis, MA. 02601 NOTICE TO ABATE VIOLATION OF THE TOWN OF BARNSTABLE CODE,4360-20 M The property owned by you located at 11 Alicia Road, Hyannis, MA. was inspected on May 23, 2007. by Donald Desmarais RS, Health Inspector for the Town of Barnstable because of a complaint regarding overcrowding. The following violation of the Town of Barnstable On-Site Sewage Disposal Systems Ordinance, §360, was observed: 060-20 (I): Criteria for Determining System Repair or Replacement There were a total of five bedrooms observed in the dwelling (three bedrooms upstairs and two bedrooms downstairs). However, the existing septic system was designed for three (3) bedrooms total only. You are ordered to remove the two (2) bedrooms from the basement by removing entrance doors, by removing the beds, and by opening all door-way entrances (by partially removing walls) to each room in the basement to a minimum of five feet wide openings within fifteen days of your receipt of this letter. Any structural changes must be done with a building permit. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in the issuance of non-criminal ticket citations of $100.00 each. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health - <A Cape Cod Five BarnstH i gh 508 790 4860 1='_ 01 r � �y s Fax Cover Sheet To: Thomas A. McKean Director of Public Health . rom: Fernanda McCarthy Re: Property located at 1 I Alicia Rd. Hyannis MA 02601 •c.� � as Pages: 2Ln Y `n Comments: Contact information : Please call 508-534-9882 or `908--160-4366 with any questions. + "Thanks li �_;••ID 7 0;7 : 44A Cape Cod Five BarnstH i gh 508 790 48 P_ 02 ,[rill luni 6"' 2007 To... Thomas A. McKcan Director of Public Health b.e: l l Alicia Rd. ' • _ I lyanilis MA 02601 This letter is in response to a visit and a lullow lap letter we received front your of -e rz ardillg our property at 11 Alicia Rd. I would like to request a hearing to discuss the-rExluirell1ClltS made by you ill the letter to remove the two bedrooms located ill the ba:_crnent of lny house. When the health inspector was at my property the requirement tic .Yladi:;• was that we stop using the rooms as bedrooms by removing the bells, which we hare:; clone so, but he explained that it was line to have the rooms and use it as a family room of an office. Ill the letter the requirement was made that we remove the beds, but also the doors and open the entrance ways to live; feet openings, I was hoping to discuss these requirements. As a matter of safety, there arc two elitraalces to every room, removing the doorways would be an inconvenience to enjoying those areas of out•house both as all of].*'-,,(,; and as a family room, since they lead to the stairs and the laundry area, both of wh, ,:h can be a problem if our children are playing downstairs and we don't want then,to so rn to those areas. We have also always made sure that we have lilnctioning smoke a,al :ins and carbon monoxide detectors throughout the basement space for safety. At this time I would like to request to be able to keep the existing doorways, as we helve agreed to only use these spaces for entcrtainnient pu[lioses, and to discuss what siel,s would be necessary to properly tLLlll the downstairs space into sleeping quarters it) the Culure. I understand that we are [lot to use the basement as sleeping quarters and we h,nre stopped doil,g so, but I would like the above requests to be taken into consideration anti reviewed to be discussed at a hearing. Thank you for your attention to this matter. Sincerely, daughter Fol-M6de) Maceilu - owner r h'' oG • may. � �`Z,� �..� TOWN OF BARNSTABLE LOCIATION �� /! G r� SEWAGE # VILLAGE SESSOR'S MAP & LOT INSTALLER'S NAME & 'PHONE NO. ��_laxk, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) K NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: �Lo DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No / 4M 1000 NieO THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .-U. ✓l!u..OF... ..�• ......................... Appliratiun for Disposal Works Tonstrudiun Permit Application is hereby made for a Permit to Construct ( ) or Repair (c aan Individual Sewage Disposal System at: ...............1.1.___. L-= - =•--•••--: ...................... ....................... .........................._............. Location- dress - or Lot No. .............S . ....... ---------- ••---•---•-••--••---••- Owner Address .........................�:........ _ ............................................... Installer ddress Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms••�------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a`k Other—T e of Building No. of persons............................ Showers — YP g ...-•----------•............ ............P--�- (----).......Cafeteria ( ) dOther fixtures •........................•-•••-•-•-•• ••....•-••-•-•••--••-•••......---•••...........--••••• ......-•-- Design Flow............IS-6...................gallons per person per day. Total daily flow...... ..0......................gallons. Septic Tank—Liquid'capacity............gallons Length................ Width................ Diameter--.--........... Depth................ x Disposal Trench—No..................... Width.................... Total Length................... Total leaching area....................sq. ft. 3 Seepage Pit No........./......... Diameter........IV.... Depth below inlet.....6a............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................--. 44 Test Pit No. 2................minutes per inch DQth of"Test Pit.................... Depth to ground water........................ a --•---------------------------•---...................-------•--....-----------......--------................-----------------------------------•-••------_... 0 Description of Soil........................................................................................................................................................................ U -•--•--------------------------------•-- ------------------- ----....... .--•-............ -....... . ........... ---........ .--.------------- -................................ -----------------•-----...------•-••--....------•-•--------•-------------------------------•--•--•------------•------------------------------....--------•--..........-•------•-••-•••••......--•--•--•- U Nature of Repairs or Alterations—Answer when applicable......A-10)0....O.V... ...... .....ay"-K_ - ' • �.� '� ark.- 'r •-------------------------------•-------....-----------•----------------...........-••---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITA L� 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 b the board of health. Signed....--- .. .. -------------------•. ........................� Date Application Approved By.............. .. .......................... Date Application Disapproved for the following reasons----------------------------•----...------------------•--------••-------------------..........................._ . ......•......................•---•-•-------•-•-----•----•._....--•--------....------------........----._.......---•----•------------------------•---------------------•---------...-•••-•••..........__ Date Q PermitNo........ ...1..'.._�......J_�.......-----•--..... Issued....................................................... Date No.— ..... Ficz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................... .........OF............................................................................................. Appliration for 11isposal Works Tonstrudian Ifermit Application is hereby made for a Permit to Construct or Repair ( -)--an Individual Sewage Disposal System at: .............. ...............Location.Address..... ......................... .................................. or................ ----------*...................*------ ' ' ... Lot'Ko.' Owner .................................... -------------- ---.... .............................................................................. ....................................... ............... ......................... ................................... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria aOther fixtures Design Flow..........: . ................................gallons per person per day. Total daily flow._.... .. ........................gallons. Septic Tank—Liquid capacity............gallons Length................ Width....._.......... Diameter.........._..... Depth.............__. Disposal Trench—No..................... Width............._...... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No.........f'__...... Diameter......... ..... Depth below inlet.... ........ Total leaching area..................sq. f t. Z Other Distribution box Dosing tank ,-A Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit....._.............. Depth to ground water..................._.._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 P4 ............................................................................................................................................................. Description of Soil........................................................................................................................................................................ W U ......................................................................................................................................................................................................... W Z ......................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable...__,"....... ..................... I ............................................ ........ ......I..............,................ ... .................... .............1........................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I A'1Z 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. Signed..., .................................................................................. ................................. Date Application Approved By.................�, -,,:...... ........................... ....................................... Date Application Disapproved for the following reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date Permit No........ ........:�4, Issued....................................................... ............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......1�............................................................................ Tertifiratr of Tom plianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by............................................................................. ................................................................................................................ Installer at.................................................... . ............................................................................................................................................... has been installed in accordance with the provisions of TITLE_ 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...............I....... ....... dated_....._.._._._..._.........._...._.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF...................................................... ............................... No. /'LL.'. FEE.�'................ Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................. Street as shown on the application for Disposal Works Construction Permit No..:_:................ Dated.......................................... .......................................... ............................................................. Board of Flealth DATE................ ........../..................................................... O� V�j No......o_k FEic 2................ THE COMMONWEALTH OF MASSACHUSETTS. BOARD F HEAL H . �/ OF..... ....... -------------------------- Appliration for Disposal Works Tonstrnrtinn Vamit Application is hereby made for a Permi to Construct ( or epair ( ) an Individual Sewage Disposal Syst at� ........--••-_.. . Location-Addre or Lot No. ...V.. O nerd ----------•-••-•--------------------------- w Address -----------------••-------------------•--•._ Installer Address U Type of Buildipg, Size Lot...... feet Dwelling X-No. of Bedrooms....____._ _________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building a g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ..- Design Flow................ _____ _gallons per person per day. Total daily flow......._ .__._...gallons. w Septic Tank Liquid capacity_fii)gallons Length................ Width................ Diameter---------------- Depth.--.----__.---_ x Disposal Trench— ____________ Width_____. e : _.._ Total leaching area.... sq. ft. 3 Seepage Pit No______ _____________ Diameter �ep el ow le __.__.______.__ Total leaching are, ft. T Z Other Distribution box ( ) Dosi g 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 De th of Test Pit.....................Depth to ground water......................... P4 --------•- ----------- •--••• • •- -- - Descriptionof Soil--------------. - -.------•--•----.....-•-----------••--•-------...••---------•_.... x w V Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' by board h. Si - D e Application Approved B �_� l�l� �' f-- ------_�-_. PP PP Y F �- Date Application Disapproved for the following reasons-....................----------------------------•-----......---_--...---------_--_-----._.._.__._...-........... ....-----•----•-------•------...--•-•---•-----•-•----•---------------•-•--------------••-•----------------------•-•••---••-••---••-•-----•---••-•••-••-••-----•-•-•••. -----••------•-------------- Date PermitNo......................................................... Issued.-nx L-- ---- Da �n /d7 ` Y No.....YI-Ge.TS_ FEE....2................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........OF..... Lr��sLC : Appliratiun for Rapoottl 10orko Tunstrurtiun Prrutit Application is hereby made for a Permit to Construct ( )� or Repair ( ) an Individual Sewage Disposal System at wr}y A/ oratLionA- ddr or Lot No. -•-----•-•----------------•------------...--------------------------•-••-•--•-•-•---•--•-•------•. O ner'` Address . .........-•••-------•. •-••••....••--•--••-•••--••••--••••-••-------•----•---•---••......--•••--•--•-----••-••-••......•- n tiller Address Q Type of Building Size Lot.......J.0..-- eet V Dwelling eNo. of Bedrooms................ .. -----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) Cafeteria ( ) Otherfixtures ................................................................................................. Design Flow....................... .__-...._._gallons per person per day. Total daily flow.............. .. gallons. - a WSeptic Tanky Liquid capacity/"_0.gallons Length................ Width---------------- Diameter---------------- Depth_---_----.--_- x Disposal Trench—No..................... Width-------C----/>--- 1 Len g ' ....�--_./-� Total leaching area--------.---_--.-.--sq. ft. Seepage Pit No.•-••r-0 Diameter/ el ��= , '--- Total leaching area_ _ _ sq. ft. Z Other Distribution box ( ) Dosiftg tank ( ) aPercolation Test Results Performed by --------------------•--- Date Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-----__--_-_--___-_-.--- (T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... epth to ground water........................ 0 Description of Soil............. U •--------------------------------------------------------------------------------------•-------------------------------------•---- W ------------------------------------------------------------------------------------•--•-••-•-•---•------------•-•-----------••-------•-•--•-••-•--•----------------••••------------------------•-•---. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------•------•--•........................•-•-------•----..................•-••••••-•--•••••-•••--•• ----------------------------------------••-•-----------•-------------•.-----------•--------•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' by the board o h 'th. Si e ------ �' D to Application Approved By....', --, .._... ...... !_ � '� ..a �D�ate Application Disapproved for the following reasons:..................... � •-•-•-•---•--------------•---•-•-•--------......-----------•-•-----------••---. ......--•••-•••-•••-----•-•-•••--•••••-••••••-••••••---------•••-••---••--••--•-•........•-••--••••--••--------•--••--••-••------------•-----------•------•••-•-------•---••••-••-------•-•-••••••.••-•• , � Date Permit No.-••-••••••-••••.....-•••--•-••----•---• Issued_: ._.. ...7............... Da e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �; OF....... . e4 • (9rrtif iratr of Tompliana TH IS :TO ERTIF hat the di'vidual Sewage Disposal System constructed ( or Repaired ( ) a►- by---•- e •----------- G� �- ---------------------------- Installer 2 has been installed in accordance with t e provisions of Article 2I of T e tate Sanitary Code as des ibed in the application for Disposal Works Construction Permit No................. _...._._. dated...��__ .. _ ...__..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION 'SATISFACTORY. �-��+�t.�i�� � /.O 7 DATE...............3-- --- y— .................................. Inspector:.:.. - THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD O HEALTH � .. . .........O F--- ,s No...... .. ........... :. . .r FEE-.- ,�.•------------- - - �i��>v�ttl urk - Chun rnrti " �rrinit � . Permissio- i erdby granted_',...'- y4._ _ ---__- � _ . . .. _ •fo Cons rucV ) or Repair an Individual S rage ^ s-osal System 4 at 1\ +( ...--••• •• - .Sr p..... �I �� .. r'. n-. w treet �'2 a as shown on the application for Disposal Works Construction e it N .. .. . Dated------ ......... - .. . ................................. d of alt DATE-------. ... ------- ---------------------------------------••...--- -a— /1D 7 FORM 1255 HOBBS & WARREN. INCPUBLISHERS _ H'YANNIS 46.9/"� 1 Z�"� ROUE 28 G V W G ! LOCUS y 11 ALICIA -�'�- ROAD UPOLE PARCEL ID: 9 f 292/230 W �-` PARCEL ID: n AREA=13,385t S.F. - r'� 292/229 LOCUS MAP LOCUS INFORMATION I i i i i i PLAN REF: 261/37 TITLE REF: 24813/69 G PARCEL ID: MAP 292 PAR. 230 Lon- 0• #11 i _ - 47.6 FLOOD ZONE: "C" PARCEL ID: COMMUNITY PANEL: 250001-0005-C DATED:08/19/85 292/231 ` '; EXISTING ; Lot DWELLING TBM: COR BLHD SEPTIC SYSTEM TOF=48.42 ;" ELEV.=48.00 Ex15T. I ,000 SAL REPAIR P L A N 5EPTIC TANK LOCATED AT: 11 ALICIA ROAD GENERAL NOTES: D1 d's H YAN N I S, MA. I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ; /�' EX15T. MACH PIT5 PREPARED FOR BOARD OF HEALTH AND THE DESIGN ENGINEER. , 46 (NOTE 10) 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE F R A N C I S C O D e M A C E D O LOCAL RULES AND REGULATIONS. �\\ - �� ' 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR TOP TANK=46.0 _ - -- " s� DUNE 08, 2011 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE \� '- `;OAK ' �"I g3� REVISED: JUNE 13, 2011 DESIGN ENGINEER. 24�__- �� 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING \� ���'� o Zn Of FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 8 � S 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. `` ® nsp ports 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF ` DA ✓� THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 24 TREE E HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 36 OAK TH—1 -� �� No. 1140 � 46.4 38.25 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. T 7 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED ® RHOD. ® 46 jam- C/ TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. Lvt 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY TH-4 �� PARCEL ID: THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING DK' 292/191 I CONSTRUCTION. 10. EXISTING PITS TO BE PUMPED, CRUSHED, AND FILLED. re38f ea ,.� 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION �O 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY r eserve area ¢ AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY D A R R E N M. MEYER, R.S. 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING a 14. ALL PIPE TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC. OTHERWISE) �46.3 F " P.O. B 0 X 981 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW --'��--- , FOR THE USE OF A GARBAGE GRINDER --'-`_r 63•�4 EAST SANDWICH, MA. 02537 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING S84•03 30„W ' PARCEL ID: (508)362-2922 292/072 i SHEET 1 OF 2 J 1333 NOTE: TO PREVENT BREAKOUT, THE PROPOSED DESIGN CRITERIA NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:43.49 FOR A DISTANCE OF 15' AROUND THE NUMBER OF BEDROOMS: 3 BR EXISTING/4 BR DESIGN (PROP. NOT IN ZONE II) SEPTIC TANK PROPOSED D-BO PROPOSED S.A.S. /PERIMETER OF THE S.A.S. SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN IN X T.O.F. EL.=48.42 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER DAILY FLOW: 110 G.P.D. x 4 BR DESIGN FLOW: 440 G.P.D. OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) F.G. EL.=47.50t F.G. EL.=47.50f F.G. EL: 46.5t F.G. EL: 46.40(MAX.) PROPOSED SEPTIC TANK: USE EXISTING 1,000 GALLON CAPACITY LEACHING AREA REQUIRED: (440)/0.74 = 594.59 S.F. 9" MIN COVER/ DISTRIBUTION BOX: DB-3 (3 OUTLETS (MINIMUM)) Am L - 10't ' 36" MAX COVER ' L = 32' L 1O'(MAX INSTALL TWO INSPECTION PORTS (MIN.) PRIMARY S.A.S. • S-1 R (MIN.) EL s 91.8 O S-1 X (MIN.) • S�1% (MIN.) 4'scH40 PVC a'scHao PVC a'scHao PVC USE 2 TRENCHES 6- 160OBD ADS BIODIFFUSER H-20 UNITS-NO STONE 10" „ 8 11.2" TO AND EXTENDED WITH 0,75' W/ CONTOURED WEDGE LSEWER 48-uouiD INVERT TRENCHES: (GENERAL USE APPROVAL FOR 7.88 SF LF OF BIODIFFUSERS Fyn INV.= 44.79 (BIODIFFUSERS) 12 UNITS x 6.25 LF x 7.88 SF/LF = 591.0 SF PROPOSED INV.=43.40 N (WEDGES) 2 UNITS x 0.75 LF x 7.88 SF/LF = 11.82 SF GAS BAFFLE D-BOX 2 TRENCHES OF 6 UNITS AT 6.25' NIT + .75' WEDGE = 38.25'/RO Arm INV.=43.6 DB-3 INV.= 43.10 SOIL ABSORPTION SYSTEM (PROFILE) TOTAL DESIGN FLOW PROVIDED: 0.74GPD/SF(602.82SF) ARE46.086 2.82 S0 GPD req'd EXISTING 1.000 GALLON SEPTIC TANK LET �TRESTORE VEGETATIVE COVER o TO LL WITH CLEAN PERC SAND TO TOP OF CHAMBERS 75" NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS PRIOR TO CONSTRUCTION EXISTING SUITABLE '' ' '' •'••'""•'' ' '' 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=43.49 MATERIAL GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 43.10 INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 42.16 310 CMR 15.221(2) 2 83' 6.00' 3 REPLACE EXISTING 1,000 GALLON SEPTIC 2.83' 5' MIN. ABOVE BOTTOM OF I - 76" 01 TANK WITH 1500 GALLON SEPTIC TANK T.P. EXCAVATION OR G.W. IF FAILED, DAMAGED, OR UNDERSIZED. (6.56' PROVIDED) USE 2 ROWS OF 6 16008D ADS PROFILE 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TEST HOLE EL.=35.6 - BIODIFFUSER UNITS-NO STONE W/ WEDGE GAS BAFFLE AS REQUIRED SEPTIC SYSTEM PROFILE AN OFsfq TYPICAL SECTION 16" N.T.S. s•TA 11.2" M SOIL LOCI P#: 13304 t Y/ e 1 o. 1140 DATE: JUNE 6, 2011 �34"� I RECIp SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE #1614 SECTION END CAP NI TAR�a� •(D 6131 � 1 WITNESS: DON DESMARAIS, BARNSTABLE BOH 16"" HIGH CAPACITY (H-20) BIODIFFUSER UNIT Elev. TP-1 Depth E 0v. TP-2 Depth Elev. TP-3 Depth Elev. TP-4 Depth 46.60 0" 46.60 0" 46.70 0" 46.70 0" MODEL 16" HICAP A LOAMY SAND A LOAMY SAND '4 LOAMY SAND A LOAMY SAND 10YR 3/2 B 10YR 3/2 t0� 3/2 03 10� 3/2 8" EFFECTIVE LENGTH 75"LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT B 46.10 6" 46.10 6' 46.03 8" 46. B B TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY SANDY LOAM SANDY LOAM SANDY LOAM SANDY LOAM 44.27 C 1 28„ 44.27 C 1 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. ,OYR 6/8 1 GYR 6/8 28„ 44.20 C 1 30" 44.20 1 GYR 6/8 1 30"1 GYR 6/a SIDE WALL HEIGHT 11.2 OVERALL HEIGHT 16" SANDY LOAM SANDY LOAM SANDY LOAM SANDY LOAM OVERALL WIDTH 34" 4640 TRUEMAN BLVD IOYR 6/4 1GYR 6/4 IGYR 6/4 10YR 6/4 13.6 CF HILLIARD, OHIO 4JO26 43.10 C2 42" 43.10 C 42" 43.12 C2 43" 43.12 C2 43" CAPACITY (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC. MEDIUM SAND MEDIUM SAND MEDIUM SAND MEDIUM SAND PROPOSED SEPTIC SYSTEM SITE PLAN 2.5Y 6/3 2.5Y 6/3 2.SY 8/3 2.5Y 8/3 PERC • 4,.,G PERC; 0 40.80 11 ALICIA ROAD, HYANNIS, MA 5.60 3 132" 35.60 132" 35.70 132" 35.70 132" PERC RATE <2 MIN/IN. ('Cl" HORIZON) PERC RATE <2 MIN/IN. CCI- HORIZON) Prepared for: DeMacedo NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN DARRENM.MEYER,R.S. Bao-Teak 6bv&onmentel NTS D.M.M. • 1, Darren M. Meyer, R.S., CSE, hereby certify that 1 am currently approved by MADEP pursuant to 310 CMR 15.017 POBOX98f (508) 364-0894 to conduct soil evaluations and that the above analysis has been performed by me consistent with the DATE: CHECKED requirements of 310 CMR 15.017. 1 further certify that I have EASTSANDWICH,MA02537 SHEET posed the Soil Eval. Exam in October, 1999. �?�29� 06/0$/11 D.M.M. 2 Of 2 2 REVISED: JUNE 13, 2011