HomeMy WebLinkAbout0017 ALICIA ROAD - Health 'socoa 'Road
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wrnmvY�- TOWN OF BARNSTABLE 72�Z 771'—36 y Z
LOCATION /77 LiCrA /Ta SEWAGE #
VILI:AGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER i2: L_ /�jr�,,•to�/Lfi2
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:- � " Zl. FZ � �
VARIANCE GRANTED: Yes No
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/ TOWN OF BMMTABLE
LOCATION / / C.f A SEWAGE #
VE LAGE 14`J f,1i11S ASSESSOR'S MAP & LOTo�91 a3 rl
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
/�LEACHING FACILITY: (type) i 6X(* (size)
NO. OF BEDROOMS
. BUILDER OR OWNER OWl C/ W I Ci►'�OYe r'
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leachi g facility) 1 Feet
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LOC:A'ITONn_17 � 0"� I SEWAGE "q
VILL:tiGE ASSESSOR'S MAP &/LOT 2 7-? g?3
INSTALLER'S NAME&PHONE NO. a,11 u 1-1
SEPTIC TANK CAPACITY /P m 2
,LEACHING FACILITY: (type) (size)3 3, !?73
NO.OF BEDROOMS
3UILDER OR OWNER
PERMIT DATE: l b 0 COMPLIANCE DATE: 1 a
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Town of Barnstable Health Inspector
Office Hours
Regulatory Services 8:30—9:30
Thomas F.Geiler,Director 3:30—4:30
• •ARNSTABLE,
MASS.: Public Health Division
,ot�o ,tA Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE
Date: l/13/09
1. General Information: Size of Property: 0.26 acres
Address: 17 ALICIA ROAD HYANNIS MA 02601 Map 292 Parcel 231
Name: FERNANDEZ,LUIS G Phone#: - 7.D f 1 l
2a. how many bedrooms exist at your property now?4
2b. are you planning to add any bedrooms?NO If yes,how many?
2c. how many bedrooms total are proposed at this property(including the amnesty unit)?3
2d.please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing
rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways.
Please label each room'clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone?
5 . Location of dwelling'is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?
6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?
7. Is a disposal works construction permit on file? YES or NO
8. If yes,how many bedrooms were approved according to this permit? Bedrooms.
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this prope
Special Conditions:
Sig e Date:
-7/,2 . --
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McKean, Thomas
From: McKean, Thomas .
Sent: Tuesday, March 24, 2009 11:52 AM
To: Dabkowski, Cindy
Subject: RE: Re 17 Alicia Rd Accessory Apartment
I have a question about the enclosed living/space/bedroom on the second floor. This would be considered as a 5th
bedroom. Will this bedroom be removed? If so, how?
-----Original Message-----
From: Dabkowski, Cindy
Sent: Tuesday, March 24, 2009 10:22 AM
To: McKean, Thomas
Subject: Re 17 Alicia Rd Accessory Apartment
Hello Mr. McKean
Please give me the status of the 17 Alicia Rd Hyannis application for accessory apartment. I will resend the
septic Questionnaire today for your approval if the site is eligible. The home owner would like to go to ZBA.
Cindy Dabkowski
Affordable Accessory Apartment Coordinator
Growth Management Department
367 Main St
Hyannis, MA 02601
508-8624743
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McKean, Thomas
From: McKean, Thomas
Sent: Monday, February 02, 2009 8:33 AM
To: Dabkowski, Cindy
Subject: 17 Alicia Road
What is actually proposed to be done to the second floor-convert the"launge" into a living room?
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S. Commonwealth of Massachusetts S /
Title S .Official. Inspection Form 520
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated.
6115/2000.Inspection forms may not be altered in anyway,
A. Certification
rmpoiUmt.
when n!g out 1. Property Inform tion:
forms to,u / t�
tx%nptrter,use .
.only the tab key Propeqy Add
to move your A L (J i Q fin)
cursor- et not Owners Na
use the return
key. 17 1/iGa
ers Address`
'h'[T State Zip Code
Date of Inspection:
Date
2. I ctor.
e e ifl or
- J-j,t(i
company Na e
�dn�
Cdylrown state Zap Code
Telephone Number
Certification Statement
1 certify that 1 have personalty inspected the sewage disposal system at this address and that the
information reported below is true,accurate and complete as of the time of the inspection.The inspection
was performed based on my training and.experience in the proper function and maintenance of-on site,
sewage disposal systems. I am a DEP approved system Inspector pursuant to Sec.' on 15*, 0 oft-?
Title 5(310 CMR 15.000).The system: c
es ❑ Conditionally Passes .❑ Fails 2
c-�
❑r,NpedsAirther Evaluation by the Local Approving A tft�
Irupectors Signature Date
J'l
The system Inspector shall submit a copy of this inspection report to the Approving AuthoQ(Boa�d
of Health or DEP)within 30 days of completing this Inspection. if the system is a *red system or
has a design flow of 10,000 gpd or greater.the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer,if applicable,and the approving authority.
****This report only describes conditions at the time of.inspection and under the conditions of use
at that time.This Inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5lnsp.doc•11/2004 TWe 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
ICommonwealth of Massachtasetfs .
IVTitle 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certifica •o (cont)
Pmpe%Address
A-Wj S
� s� Zlp Code
A C h o u i W 9,04 K Q C_�" O(p
Owners Name Date of kmpectlo
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) Sys m 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) Sy st Conditionally Passes:
❑ One or re system components as described in the'Conditional Pass"section need to be
replaced o pained.The system, upon completion of the replacement or repair,as approved by
the Board of eaith,will pass.
Answer yes,.no or determined (Y, N.ND)in the[]for the following statements. If"not
determined,"please e
❑ The septic tank is meta d over 20 years old*or the septic tank(whether metal or not)Is
structurally unsound,exhi substantial Infiltration or exlI tration or tank failure Is imminent
System will pass inspection if existing tank Is replaced with a complying septic tank as
approved by the Board of Health. �
*A metal septic tank will pass inspect( it is structurally sound, not leaking and if a Certificate
of Compliance Indicating that the tank is 20 years old is available.
ND Explain:
t5insp.doc•11/2004 Me 5 OMdW i nspectiOr1 Form-Subsurface Sewage Disposal system-
Page 2 of 18
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certif cation (cons)
Property dress
� f-J ' 0 J
IT" C" iA state 0'P Code
1 &410 6,�(—'el
Owner's Name Date of Inspection
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 pipes)or due to a broken,settled or uneven distribution box_System will
pass inspection If(with approval of Board of I-I.eaith):
❑ broken pipe(s)are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
k
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine If
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CIWIR
15.303(1)(b)that the system Is not functioning In a manna which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water Q
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or It marsh
Lgnsp.doc.1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetw
Title .5 Official. inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal'System Form
A. Certification (cunt.)
PMPWAddress
AIL-zv
state Zip code
IrA c,� 0 J-#A RJ-�J4 (�D
Owners Name Date of hispectibn
C) Further Evaluation is Required by the Board of Health(cont.):
2. System will fai niess the Board of Health(and Public Water Supplier,if any)
determines that the ystem Is functioning In a manner that protects the public health,
safety and envtronm t:
❑ The system has a eptic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surfa water supply or tributary to a surface water supply.
❑ The system has a septic k and SAS and the SAS is within a Zone 1 of a public water
supply. /
❑ The system has a septic tank and and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS-and th 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 D certified laboratory,for
coliform bacteria and volatile organic compounds indicates that the is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen' equal to or less than 5
ppm,provided that.no ther failure criteria are triggered.A copy of the a tysis must be attached
to this form.
3. Other.
t5vup.doc•1112004 TMe 5 Official Inspection Form:Subsurface sewage Disposal System.
Page 4 of 16
i
Commonwealth of Massachusetts
logTitle 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cunt. JJ
,addressVC0 , 0.2 0
City - ) ZlpCode
1 'j
- 7
OX s Name M of i
D)System Failure Criteria Applicable to All Systems:
You must Indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
dogged SAS or cesspool
❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overoaded or dogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or dogged SAS or cesspool
❑ Uquid depth In cesspool is less than 60 below invert or available volume is less
than%day flow
❑ Required pumping more than 4 times in the last year NOT due to dogged or
obsbvded p4*s).Number of times pumped:
❑ (� Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ 1 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ T Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private wafter 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 analysts.[This
system passes If the well water analysis,performed at a DEP certified
laboratory,for coliform bacteria and volatile organic compounds
Indicates that the well Is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen Is equal to or less
than 5 ppm,provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form.]
Yes No
❑ The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 GMR 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.
15rnsp.doc•1112004 Titre 5 Official Inspection Form Subsurface Sewage Disposai system.
Page 5 of 16
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cunt.)
M)Prope
wIA�� oa o
M
O � ae co
n C� L�y�� ��P►��
Owners Name Da of I
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,0 gpd to 15,000 gpd.
For large systems,you ust Indicate either"yes'or'no'to each of the following,in addition to the
questions in Section D.
YES NO JW14
❑ ❑ the system within 400 feet of a surface drinking water supply
❑ ❑ the system is 200 feet of a tributary to a surface drinking water.supply
❑ ❑ the system is loca n a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA)or a ma Zone II of a public water supply well
If you have answered Tres'to any question in Se n E the system is considered a significant threat,
or answered'yes"in Section D above the large syst has failed The owner or operator of any large
system considered a significant threat under Section E 'led 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.
t5insp.doc•11/2004 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System
Page 6 of 16
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Forth
B. Checklist
- /)� R i 0 fA
P ress
C mown JA State Zap Code
Owners Name Date of Inspect) n
Check if.the following have been done.You must indicate`yes'or"no'as to each of the following:
YES NO
O( [I Pumping information was provided by the owner, occupant,or Board of Health
❑�l(( Were any of the system components pumped out in the previous two weeks?
( ❑ Has the system received normal flows In the previous two week period?
❑ Have large volumes of water been Introduced to the system recently or as part of
this inspection?
❑ Were as built plans of the system obtained and examined?(If they were not
available note as WA)
❑ Was the facility or dwelling Inspected for signs of sewage back up?
❑ Was the site inspected for signs of break out?
❑ Were all system components,excluding the SAS,located on site?
] ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
(` inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ Existing information. For example,a plan at the Board of Health.
❑ Determined in the field(if any of the failure criteria related to Part C is at Issue
approximation of distance is unacceptable)[310 CMR 15.302(3xb))
t5aisp.doc.I M2004 Tide 5 Offdai Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
I
Commonweafth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System
Information
/ 7
P TAddress .v Or2 6 01
s� Code
74 oy,ti Jn'J K1 �c / g/ S
Owner me s Na
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms):
/�D j e
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Is laundry on a separate sewage system fif yes separate inspection required] ❑ Yes No
Laundry system inspected? ( Yes ❑ No
Seasonal use? ❑ Yes ( No
es
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes No
f e—ta
Last date of occupancy
CommerciaUlndustrial Flow C ditions:
Type of Establishment:
Design flow(based on 310 CMR 15203 . casoru��,(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:
Last date of occupancy/use: Date
other(describe):
tsinw.doc•11=04 Title 5 Off inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form.
C. System Information (cont)
Property/A/ddres$ 0 0?1 O /
�1Yt/c�J�lay� SQy f
cnyR �(O U"lNJ ►�Vi a� �� Zlv code
er's Name Date of Inspection
General Information
Pumping Record$: A ONP
Source of information:
a
Was system pumped as part of the inspection? ❑ Yes No
If yes,volume pumped: sue$
How was quantity pumped determined?
Reason for pumping:
Type of System:
mil Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes,attach previous inspection records,if any)
❑ Innovative/Aitemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components,dat i stalled(if known)and source of information:
U
Were sewage odors detected when arriving at the site? ❑ Yes No
Misp.doc-1 WON Tile 5 Offidal bspection Form:Subsurface Sewage Disposal System
Page 9of16
Commonwealth of Massachuseft
Title 5 Official. Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt).
Pr
C R / State zip Code
n L) 4'J Dc�d'lo�
owner's Name Date of inspection
Building Se r(locate on site plan):
Depth below grade. / feet
Material of construction:
❑cast iron ❑40 P ❑other(explain):
Distance from private water supply w or suction line: feet
Comments(on condition of joints,venting, of leakage,etc.):
Septic Tank(locate on site plan): /!
Depth below grade: feet
Material of construction:
Lkd ncrete ❑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:
Sludge depth:
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 1
How were dimensions determined?
t5lmv.doe-11/2004 TMe 5 official InspecUm Form:Subsurface Sewage Disposal Systern-
Page 10 of 16
Commonwealth of.Massachusetts
Title 5 Official .Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information cont.)
pm ; sr
J ]` State �- MP� '
�r�M4 0 OVA �✓2 iv � c �� o�
Ownees Name Date of Inspedbn
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 �A ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee baffle
Distance from bottom of scum to bottom of outlet tee battle
Date of last pumping: ��
Comments(on pumping recommendations,inlet and outlet tee or ffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank st be pumped at time of Inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fibe lass polyethylene ❑other(explain):
t fispAoc I M2004 Title 5 OMdal Inspection Form:Substaface Sewage Dlsposal System
Page 11 of 1e
Commonwealth of Massachusetts
Title. 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (co t)
-- /-f) A4-c, ,�,
P 7)VMdress
state 06
n 00, (?Z 23p code
Ownws Name Date of hispec Lion
Tight or Holding Tank(cont.)
Dimensions:
Capacity.
Al
Design Flow: ;0 gWbns 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,
Distribution Box(if present must be opened)(locate on s' plan)
D ' V:
"V
Depth of Bgwd level above outlet irnert
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. A ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
Mup.doc•I W004 We 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (c nt.)
C'r' SIT _
Prope Address /AAA r f 0.2601
Cityffo I State Zip Code
4 G�t o c>(A 44� � c f Y c�
Owners Name Date of InspecUon
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located,explain wh :
3 Zo - , e-S %) IL /I s,
Type:
❑ leaching pits number.
❑ r.
leaching chambers number
U--/ leaching galleries number.
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number.
❑ innovative/altemative system
Type/name of technology:
Comments(no condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of
vegetation, etc.): Alz
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cons)
P ddress
�,� ` Gu.7 Sr f Dot (co j
Cdy ,/� State Ztp Code
nG D O "�n1 jl
Ownefs Name Datewin4ectUn
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration'
Depth—top of liquid to inlet Inv
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 p ding,condition of vegetation,
etc.):
Privy(locate on site plan):
6 Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil,signs of hydraulic failure,level of po g,condition of vegetation,
etc.):
I
t5insp.doc•11/2004 Two 5 Official Inspection Form:Subsurface sewage Disposal System-
Page 14 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cunt.)
U09
Propejqd1ress
'� '- Sate j
1�n r
Owners Na� code
me r Date of Inspectich—
Sketch Of Sewage Disposal System:Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet
Locate where public water supply enters the building.
om
(A o
A
7 r o 7.
t5ansp.doc•1112004 L
r7 1(/4w w'" S Ot al Inspection Form:Subsurface Sewage Disposal Stem
Page 15 of 16
Commonwealth of Massachusetts
Title 5 .Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information cont.)
!ic(A
Property Add ss �� S 00, 0 1
.✓VV ��
Ci wn �j n� // Stat� c Zip Code
o0,A (`�
Owner's Name Date.of Inspectio
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water. 3 a
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:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
3
You must describe how you established
the higp ground elevation* �--
4 �1 � � L 64 /74 ;�wl r'l 7,v Ili T
t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
TOWN OF BARNSTABLE BAR-W 3915
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager ) �� �.�l�C'(x:�trc�
Address of Offender F' All t Cd MV/MB Reg.#
Village/State/Zip l' y(jA)A)1,--a Mai' COON
Business Name ? m; on / 20
Business Address
Signa ure'of Enforcing Officer
Village/State/Zip Location of Offense l'+ AT -Ic to Ed HU'Ou 4 �� ( -pl V.
L1 (00 J Enforcing Dept/Division
Offense �" Gud ,qjoa -+Q1tV 1 1P/lX'1'0 IMF A1wi5 (z1 An ICmrh� a
Facts Np ( '�`t 05�1 C1►J�CQ Y� ►5� 0�J 'Y V `�-1 1 ly 'v
iti Anf
This will serve -hly as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORDJREG.-PROD. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
David B.Mason,RS,Certified Title V Inspector,50"33-2177
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION f yo2 a,3 j
.rtC;+o
Property Address: 17 Alicia Road,Hyannis,MA i {{
Owner's Name:K Dacosta Ala/
Owner's Address: ,MA #
Date of Inspection:November 1,2006 22 rn
o
Name of Inspector: (please print)David B.Mason C
Company Name:—N.A. ry
Mailing Address:4 Glacier Path ry r
East Sandwich,MA 02537
Telephone Number: 508-833-2177
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Appro ng uthority
F ' s
Inspector's Signature-
� Date:
The system inspector shall submit a copy of this inspection report to the Approving A on (Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments: System as inspected appears to have operated based on occupancy level. Tank should be
pumped as a matter of maintenance. The information as identified represents only the condition of the system on
November 1, 2006 at 4:00 PM. Increase in occupancy may result in hydraulic failure. Covers of components must
be brought to within 6 inches of grade.
****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.
f
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 Alisia Drive
Owner.Dacosta
Date of Inspection: November 1,2006
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
i
3. Other:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 Alisia Road
Owner:Dacosta
Date of Inspection:November 1,2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X 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:Parking area should be defined to prevent parking on septic tank and pump chamber.
& System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
_N_The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
_N_ Observation of sewage backup or break out or high static water level in the distribution box due to broken
or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
N_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system
will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICTAT. TNCPFCTT0N FORM- NnT FnR Vnl,TINTARV ACCFCCMF.NTC
Page 4 of 11
PART A
CERTIFICATION(continued)
Property Address: 17 Alisia Road
Owner:Dacosta
Date of Inspection:November 1,2006
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for AL inspections:
Yes No
_ _X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
NA— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ NA_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ _X Any portion of the SAS,cesspool or privy is below high ground water elevation.
—X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ _X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—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
" idered a
yes" in Section D above the large system has failed.The owner or operator of any large system cons
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.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
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Page 5 of 11
CHECKLIST
Property Address: 17 Alisia Road
Owner:Dacosta
Date of Inspection:November 1,2006
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X_ _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X_ _ Were all system components,excluding the SAS,located on site?(INCLUDING THE SAS)
X_ _ 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?
X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
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Page 6 of 11
PART C
SYSTEM INFORMATION
Property Address: 17 Alisia Road
Owner: Dacosta
Date of Inspection:November 1,2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):4_ Number of bedrooms(actual):4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):440
Number of current residents:_6_ -
Does residence have a garbage grinder(yes or no):NO(Not Allowed)
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no):NA
Seasonal use: (yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)):2005;23000gpd 2006;29,000gpd
Sump pump(yes or no):NO
Last date of occupancy: Current
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gPd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:Mashpee Board of Health
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:Maintenance pumping conducted after inspection
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe): With pump chamber
Approximate age of all components,date installed(if known)and source of information:approx. 2 years
Were sewage odors detected when arriving at the site(yes or no):NO
i
'OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS--
CTTRCTTRFACF CFWAC�F T)TCP(1CAT, CVCTFM TNCPFC'TT0N FORM
Page 7 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Alisia Road
Owner:Dacosta
Date of Inspection:November 1,2006
BUILDING SEWER(locate on site plan)
Depth below grade: Approx.30 Inches
Materials of construction: _cast iron _X 40 PVC_other(explain):
Distance from private water supply well or suction line:_NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition
SEPTIC TANK:N.A.(locate on site plan)
Depth below grade: 26 Inches
Material of constriction: X_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: Typical 1000 gal.
Sludge depth: 4 inches
Distance from top of sludge to bottom of outlet tee or baffle: 28inches
Scum thickness:variable 0 inches to 6 inches,
Distance from top of scum to top of outlet tee or baffle:0 inches
Distance from bottom of scum to bottom of outlet tee or baffle: Not applicable no scum at outlet tee
How were dimensions determined:actual measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.)inlet tee is PVC.Outlet tee is PVC and appears in good
condition. No evidence of leakage. Structure of tank appears adequate.Effluent level with outlet tee. Maintenance
pumping is required.
GREASE TRAP: N.A.
Depth below grade:_
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Page 8 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Alisia Road
Owner:Dacosta
Date of Inspection:November 1,2006
TIGHT or HOLDING TANK:—N.A.—(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:_YES_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:Level with 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.): There is no indication of solids carryover,dbox is in good condition Dbox is 9
inches below grade to risers.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Page 9 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Alisia Road
Owner:Dacosta
Date of Inspection: November
SOIL ABSORPTION SYSTEM(SAS): —X_(locate on site plan,excavation not required)
If SAS not located explain why: ,
Type
leaching pits,number: 1 Pit;6 foot depth leach pit with approx.2 feet stone.
_X_leaching chambers,number:—3_
_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.):leaching is 48 inches below grade. Riser is not present.Chambers are an H10 rate pit. No indication of
ponding nor increase growth of vegetation.
CESSPOOLS:_NA (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:_N.A._(locate on site plan)
Materials of constructiow
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `
Page 10 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Alisia Road
Owner:Dacosta
Date of Inspection: November 1,2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
o
� zI
2 ZS, 1 t
3 50 to, 57
147 , 'x25 �
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
J 1 • Page 11 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Alisia Road
Owner:Dacosta
Date of Inspection:November 1,2006
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water_20_feet
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed:
X Observed site(abutting property/observation hole within 150 feet of SAS)
X Checked with local Board of Health-explain:Recent Test Holes Existing engineer records with BOH
X Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting
site topography does not indicate ground water to be within 4 feet of bottom of leaching facility. Test holes in the
area on file do not indicate ground water within 20 feet of grade.
I
i
Health Complaints
25-Mar-05
Time: 3:15:00 AM Date: 3/18/2005 Complaint Number: 17975
Referred To: DONALD DESMARAIS Taken By: SHARON CROCKER
Complaint Type: CHAPTER II HOUSING
i
Article X Detail: ILLEGAL OPERATIONS
Business Name:
Number: 17 Street: ALICIA ROAD
Village: HYANNIS Assessors Map_Parcel:
Complainant's Name:
Address:
Telephone Number:
Complaint Description: CALLER COMPLAINED HOUSE SOLD OVER
PRIOR YEAR. WAS A SINGLE FAMILY
DWELLINGS. NOW APPEARS TO BE
OVERRIDDEN WITH PEOPLE LIVING IN IT
AND DOING WORK ON HOUSE INSIDE.
(1 OF 6 HOUSES IN AREA ALL BAD")
Actions Taken/Results: D.D WENT AND SAW TWO SEPARATE
LIVING QUARTERS. ONE DOWNSTAIRS
AND A SEALED OFF STAIRWAY UPSTAIRS.
2 BEDROOMS UPSTAIRS, 2 BEDROOMS
DOWNSTAIRS. THE GIRL DOWNSTAIRS
SAID KEILA IS THE LANDLORD AND HER
PHONE# 2 KITCHENS_
WILL INVESTIGATE FURTHUR. :ON-3/25/05-a
DDAND,DS WENT TO-SAID LOCATION TO ,
DETEMINE LOCATION OF SEP.TIC,SYSTEM
AS IT APPEARS TO BE UNDER THE
DRIVEWAY.- WE SPOKE WITH THE
TENANT, AND SHE SAID THE OWNER
WOULD MEET US THERE SHORTLY. DD
AND DS MEASURED OUT THE LOCATION
OF THE SEPTIC PER THE ASBUILT CARD.
THE OWNER WAS TOLD THAT THEY
CANNOT PARK ON THE SEPTIC, UNLESS
1
i
Health Complaints
25-Mar-05
THEY MAKE IT H-20 AND VENT, WHICH SHE
DOES NOT WANT TO DO. SHE IS GOING
TO MOVE THE RAILROAD TIES OVER THE
AREA AROUND THE OUTSIDE EDGE OF
THE SEPTIC SO NO ONE PARKS OVER THE
SEPTIC-.- _. __
Investigation Date: 3/21/2005 Investigation Time: 11:00:00 AM
2
- r
No. � / I Fee / CJ --
t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:V-11
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pprication for �Digogal 6potem Confstruction Permit
Application for a Permit to Constrict( . 69X,pgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. / Q G Owner' N e,Address and Tel.No.
/MeL . cD A to 0 1
f
Assessor's Map/Parcel y 3
In taller's Nialne,,A 47 ss,and Tel..No. Designer's Name,Ad s and Tel.No.
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 /`� � gallons per day. Calculated daily flow gallons.
Plan Date / 3iD B Number of sheets / Revision Date
Title
Size of Septic Tank /®D Type of S.A.S. 3
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1
r �
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 Certifi-
cate of Compliance has been issue this Board qMealth.
Signed r Date /12 Z 6
Application Approved by Date �=f `
Application Disapproved for tle following reasons
Permit No. a� — Date Issued
�i
.- --------------------------
No. UO 7 r l ~ Fee /U U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
` ► PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, ET MASSACHUSTS- f
Ytcatton for Migpogar.-*pgtem Congtruction Permit
_ Application for a Permit to Construct( Repair( Upgrade( )Abandon( ) El Complete System O Individual Components *�
Location Address or Lot No. /7 QQ,,,," Owne ' Name,Address and Tel.No.
Assessor's Map/Parcel r a g a a 3 /
In taller's Name Add ss,and Tel.No. - Designer's Name,Ad Tess and Tel.No.,ass u/C. /✓C L= x M dh
Type of Building: '
Dwelling No.of Bedroorts Lot Size sq.ft. Garbage Grinder( )
Other Type ofT.uild g lea . No. of Persons Showers( ) Cafeteria( )
Other Fixtures JJ /
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date—al / 9 Number of sheets ! Revision Date
Title
Size of Septic Tank /D O Type of S.A.S. 3
Description of Soil C9=AW i n 3 r!. 0 !
Sb
Nature of Repairs or Alterations(Answer when applicable). ..,.to
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.6:of the Environmental Code and not to place the system-in(operation until a Certifi-
cate of Compliance has been issue this Board 1-Health. ,
.. i.�' 7,, /
1,ry,.Signed Date /.,2 .? 16
Application Approved by "V`- !Date •2 (i
Application Disapproved for the following reasons
Permit No. -),D t7 y— � Date Issued I tiy1
THE COMMONWEALTH OF MASSACHUSETTS n� L.,
BARNSTABLE, MASSACHUSETTS M
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( Upgraded( )
Abandoned( )by w
at /`7 Ya.c.tµ has been constructed in accordance
with the provisi ns of Title 5 and the for Disposal System Construction Permit No. 26o(1-017 dated o t
Installer Q Designer 04oC /-I, v
The issuance of this1permit shall not be construed as a guarantee that the sy tem wAll unction s designed.
Date �� /t)`'� Inspector , 1'1�✓-
---———— ————————————————————————————————
No. )U o Fee 40 _
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
1=igpoga1 pgtem Congtruction Permit
Permission is hereby granted to Construct( )repair(--**')Upgrade( )Abandon( )
System located at_ /7
r
and as described in the above Application for Disposal System Construction Permit The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Cons7ctiop must be completed within three years of the date of thine nit.
Date: / 7)L� Approved by /lam �4:, (/F(-.
i
town oii tsarnstaate
°FSNE ram' Regulatory Services
P�
ti
Thomas F. Geiler,Director
RA&ftABM
�0
Public Health Division
i639•
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: /2 b
Designer: ,.�5 f Installer:Al fv-�-�f f I
Address: . n Address:
550 (,d)
GJ, V wt 6vt,� A- 621�
On 0 4 �' z,M- j' t G was issued a permit to install a
(date) (installer)
septic system at 41t c to based on a design drawn by
(address)
-/V A dated
(desi er)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
r
F H 9F�A,ps9
(Installer's Si e) WINSLOW tiN
chi SPOFFORD ai
,o #20363
Q
11
esign 's Sign ) (Affix Designer's Stam
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/Designer Certification Form
f
I
„
TOWN
nO_F',BARNSTABLE
LOCATION 17 � �%9e i SEWAGE # _. "q—6 V_7
VILLAGE�'�ie —�— ASSESSOR'S MAP & LOT a�'� 3/
INSTALLER'S NAMt&PHONE NO.- ^ �-c� Z . C771 —7-;r 10
.� SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) 3 3.S N 1 a r !?3
-NO.OF BEDROOMS
BVMDER OR OWNER
PERMrrDATME- J 2- 6 0 COMPLIANCE DATE: 1 0
Separation Distance Between the:.
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Welland Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished b
LTL)
2 cP5 ' 2-3 '
_y-7 1 ® p y �3r1
5— 6y
- � e
i
f
FAILED INS
PECTION
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
NOV 2 9 2004
TITLE 5 TOWN OF BARNSTABLE
HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARYYA9SESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A Q
CERTIFICATION1?-
Property Address: 1 `] A I i e CA KCIA J ''ARCEL 2-3
[SVAwn;S MA. LOB` �Q3
Owner's Name: Ma+h P kJ K,2.lnk5
Owner's Address: I
L-,
Date of Inspection: I f-a L-o y r
Name of Inspector:(please print)%t o+4, Io e i l
Company Name: '7i vno 44 vv k p✓y-l I cn,` Q0 Y
Mailing Address:00 ko x fne(
Telephone Number: 771/^ q S N-702 72
CERTIFICATION STATEMENT '
rn
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,acourate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMI215.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
01
Inspector's Sjgnatur� Date: 1/'416-e'1
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or.
DEP)within 30 days of completing this,inspection.If the system is a shared system or has a design flow,of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
i
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Page 2 of 11
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: Q A LCe A f,2wi d
Owner: IhW Av tJ Ke_IM5
Date of Inspection: 11-a k-a 4
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: .d///a'
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: X1/4
One or more system components as described in the"Conditional Pass"section need to be replaced or
,repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 A):c vA t&-,A d
K s YRnn�
Owner: MA44.W-w IA-puMS
Date of Inspection: L -,16-o y
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
i
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 11 A l Og A KoA d
u V Aei n e:S /v%&+
Owner: f&t/T k e,-j Nye lvKS
Date of Inspection: 11-2 6-61
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
�C Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
�f Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
// clogged SAS or cesspool
�liyt Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
// cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
--g 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.
K Any portion of a cesspool or privy is within a Zone 1 of a public well.
°� Any portion of a cesspool or privy is within 50 feet of a private water supply well.
1Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.[This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
�[ S (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems: �'
To be considered a large ystem the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone H 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 17 A lte id 2cuA J
Owner.• /AAR e�.� �l-�lo►�_g
Date of Inspection: t(^a 6-o y
Check if the following have been done.You mast indicate"yes"or"no"as to each of the following.
Yes No
— Pumping information was provided by thediice an Board of Health
— Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period'?
— Have large volumes of water been introduced to the system recently or as part of this inspection?
g _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
— Was the facility or dwelling inspected for signs of sewage back up?
— Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS,located on site?
— Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of constriction,dimensions,depth of liquid,depth of sludge and depth of scum?
— ,_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_ Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)] -
t
Title 5 Inspection Foam 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 11 A 1k c..A -Rvr*d
N Yh4n:S
Owner: fav) N+eIrKS
Date of Inspection: t 1^a t'O y
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): Ll
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): qo
Number of current residents: e
Does residence have a garbage grinder(yes or no):/o
Is laundry on a separate sewage system(yes or no):Ae [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):Lu
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):AV
Last date of occupancy:
COMMERCIAL/IND USTR LUAU/4
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: /✓ 4AJ, e
Was system pumped as part of the inspection(yes or no):eM
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Pff2
Were sewage odors detected when arriving at the site(yes or no):/l
Title 5 Inspection Form 6/15/2000 6
i
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 7 A B C e.i 4 Rood
Owner:N(.4&-e u) Aclms
Date of Inspection: I 1-a&— �{
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ' (locate on site plan)
Depth below grade:/ L
Material of construction: concrete metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: /l 1641
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: A7"
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: /7"
How were dimensions determined: on 5►k
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
gja.ry- pAu5,eA Lqued Ipoul A[ wacud etik or s(Jsl.il Y tcctw, ,Jo Eye-de„ce-
�� lea izay�
GREASE TRAP:IV
ocate on site plan)
Depth below grade:
Material of construction: concrete metal_fiberglass_polyethylene_other
(.explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
I
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 A1�c))A 14,ad
F4VAAn,5
Owner:- HR-65
Date of Inspection: &,24'0`1
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:4—A (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:4(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
I
Title 5 Inspection Form 6/15/2000 8
i
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
i
Property Address: 17 n ke4 A Rcsrd
�1 van n-'s MA
Owner._,yyaftit,u 14 ft5
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:I
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. :A; anRs �n.p�Y a+ T,r►.� 2nsPe eon, t�an�e al Jo Iaa�a V.ACUm hwe e•L leacl.�.0 .et in4dk-4Qf
o a 5 O e: cx �Q.Jurtn)V 2�
44W.1tvj J.t Tgek hit ikk A-A 6ZZ , A p�UJ-o
CESSPOOLS:A*(cesspool must be pumped as part of insgection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer-
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:A/*(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.):
Title 5 Inspection Form 6/15/2000 9
i
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 At-'e.» ttggj
14 X Ann iS
Owner: fie.Im.5
Date of Inspection: If-,2t—oq
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
6ACk 09 aamc
� 6
f
O � i
i
a 30'
g a 31 i
I
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 41#C4 A RvAa_
19
Owner:
Date of Inspection: 11-N6^0 4
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Y Accessed USGS database-explain:Ipa W uteQlZ a�a�r,-r s►
You must describe how you established the
nhigh groonA �und water_1 ar s
elevation: Oft-AAA-
Title 5 Inspection Form 6/15/2000 11
No......Lai..[%........ 21..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
...........OF...... ..... ..............................
Appliratinn for Disposal Works annstrnr#inn Vrrmit
Application is hereby made for a Permit to Construct (Vr Repair ( ) an Individual Sewage Disposal
system. :l. %'� ri...�C ... ...................................................
GC .... .z z3 J a
:.l .- K. ....... .... z
...... .... L cation-A-14
ddress ............. ............................................or Lot No.........:....._..........................
. •• 0 r� r Address
a .............�,�,. . ...... ......... ...................................................................................---......------
Installer Address / /)
U Type of Buildi>�g/ 2� Size Lot....1!-_3_.z v-.Sq. feet
LJ
Dwelling No. of Bedrooms.............x...,....._..___..__._......Expansion Attic ( ) G• age Grinder ( }
0-1 a Other—Type of Building . No. of persons............................ Showers — Cafeteria
a' Other fixtures ..........
W Design Flow_jr....................... .... ......gallons per person per day. Total daily flow__...___.........___. __.. gallons.
tic Tank
� Disposal Trench LiquidNocapacity.l�gal�hns Length Total Lengthidth.::•-----::--•Total leaching area.-Depth................
ft.
x Seepage Pit No.....�.............. Diameter.�.c.. ....... below inlet.....4i........... Total leaching area. v . ft.
Z Other Distribution box ( ) Dosing tank ( ) _
Percolation Test Results Performed by.......................................................................... Date........................................
W
Test Pit No. 1................minutes per inch Depth,of Test Pit.................... Depth to ground water___.___________-_-_____.
f� Test Pit No. 2................minutes per i ch '.Depth of Test Pit___-- ...._.___.... Depth to ground water........................
O
Description of Soil............... :. • ••-•�• ----•-- -------------------------------------------------------------•-•••-----••---••---
W
'74 •--••--••-••-----•...............•---•-•--------•-•-•-------•---•---•••----•-•••-----•-•--•••---•-....__..--•---------------------•------•--•---•••••-•-------•--•----------..................••--__..__
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 1I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has a ssue the boar of health.
Sig -r- -- - -�----------------------------------------------- ................
Da
te
Application Approved By....... f------••---• -•-•• .Z. te._..7..,,� !
Application Disapproved for the f ollozving reasons:.......... --- ........... -----------------------------------------------------......------------------------•.
Date
PermitNo......................................................... Issued.- _..Flo ----............
Da-t
No......( •---••-• FimE.... ................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® PF HEAL.-TH
........... OF......
g � ,�:� ...:........... .........
Appliration for IN-gpos al WorkB Tonstrudion VYrntit
Application is hereby made for a Permit to Construct (11<or Repair ( ) an Individual Sewage Disposal
System at
.. ...............•-.............-•--
- LotN-
cation-Address or Lot Ao.
...... '...._. —Address -•...................................
a ......... ,�. ... 2 ........':. ...........................................
Installer
� Address
d Type of Buildin Size Lot---././_-?..,Z-J Sq. feet
aDwelling No. of Bedrooms...............�2._........................Expansion Attic ( ) GafGag Grinder ( }
pi Other—Type of Building ............................ No. of persons............................ Showers ( ) afeteria ( )
Q' Other fixtures --------•-------------------------------•----• .. ,N
d .
------ -----
W Design Flow.........................fir ..._0------_:gallons per person per day. Total daily flow.................... J"_. -.-.-gallons.
04 Septic Tank l-Liquid capacity_ft:r,Tgallons Length................ Width................ Diameter..............`'t-Depth................
W Disposal Trench—No. .................... Width.......... ;_ : Total Length Total Total leaching area. .._ ..._sq. ft.
Seepage Pit No.....I-------------- Diameter./tI.d...-.•�epth below i let.__..(✓._......... Total leaching area-....._..� q. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test -Pit...... Depth to ground water........................
G4' ...... --------------- ----•----••- a�• --•-
-----------
Description of Soil ,' µ
- `
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 bAen issued b the boar of health.
}i � Date
7
Application Approved BYE'-=� '�' . he �(''-d.•"�':-.....---• _
to
Application Disapproved for the following reasons-.........................7-..------•-------------.-------.---------..-----------------•-•----------------
.......................•-----.........--..--------......---------------•--..........-----------•..-•---
Da
te
Permit No......................................................... = -.._ ,.. Issued.---------` --,�" `
Da e f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i
�.. -
(9rrtifirntr of (9ompliattrr
T II IS TO C RTIF ', That the ndividual Sewage Disposal System constructedr Repaired.( )
byM!1 �--3 �....................... .....•--•----------------------•-•---•----------.._....--•---......-----------•--....
Installer
*+ - ---.---- - =-------------------------•--------.....------------......--
has been installed in accordance with the provisions of Article NI of T/h� State Sanitary Code as described in the
application for Disposal Works Construction Permit No...................t?--t�---......... dated... �.,� ._ - A?_._....
THE ISSUANCE OF THIS CERTIFICATE' SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
DATE..--•••••----...--• . Inspector- = = �
SYSTEM WILL FUNCTION SATISFACTORY. �0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAOR%%,,
No.......�.''�.....--- FED
�i.��so� orko�C�ono -ttr�irr �C�erTYti�,
Permission is h eby 'granted �t ! ...................................................
to Construct >/ Repair ( an ndividual Se is is 1 System
at No. .:n :.>(..�.,a:. b. .1 ... ! .�; ..._... _ Eis1/'
rect
'. as shown on the application for Disposal Worls Construction P5er lit No... .. . .,... . ated.... , ..--..
.... ......... .......
Buard of Hcalth
DATE................................................................................
FORM 1255 Hoess & WARREN. INC., PUBLISHERS ,
I
h
STANDARDD NOTES
1) THIS PLAN IS FOR THE INSTALLATION OF A SEPTIC SYSTEM.
2) ALL INSTALLATION PROCEDURES AND.
MATERIALS SHALL CONFORM TO 310 CUR 15.000, THE STATE ENVIRONMENTAL CODE,
TITLE; 5, AND THE TOWN OF ` �'-� --- SUBSURFACE DISPOSAL REGUI..,ATIONS.
3) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE OF AVAILABLE PROPERTY INFORMATION WITH RECORDED DEEDS
0.0 ' \ \ OR ZONING REGULATIONS.
O4J TOWN iWATER,;DOES NOT SERVICE THIS PROPERTY
2 5) THERE ARE O EXISTING WELLS WITHIN 200' OF THE PROPOSED SOIL ABSORPTION SYSTEM.
R� \
6) ALL COVERS OF SYSTEM COMPONENTS SHALL BE BROUGHT TO WITHIN 6" OF FINISHED GRADE
Ul \ 7) ALL SYSTEM COMPONENTS SHALL REMAIN ACCESSIBLE FOR INSPECTION NO STRUCTURES SHALL BE LOCATED DIRECTLY
_ x s't Water ej" UPON OR ABOVE THE COMPONENT ACCESS LOCATIONS, WHICH WOULD INTERFERE WITH THE PERFORMANCE, ACCESS, INSPECTION
�
\ PUMPING OR REPAIR.
Line \ Il 8) NO DRIVE WA I; PARKING OR TURNING AREA, OR OTHER IMPERVIOUS AREA SHALL BE LOCATED ABOVE A SOIL ABSORPTION
\ SYSTEM, EXCEPT WHEN VENTING HAS BEEN PROVIDED.
,� Q 9) SEPTIC TANKS GREASE TRAPS, DOSING CHAMBERS AND DISTRIBUTION BOXES SHALL BE PLACED ON A' 6" STONE BASE
EXI s t Gas � � _ \ �� � � � TO ENSURE STABILITY AND PREVENT SETTLING.
.- y \ 10) OUTLET DISTRIBUTION LINES SHALL REMAIN LEVEL FOR A MINIMUM OF THE FIRST TWO FEET OF THEIR LENGTH.
Line
11) ALL SYSTEM COMPONENTS SHALL BE CAPABLE' OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10'
OF DRIVEWAYS OR PARKING OR TURNING AREAS, IN WHICH CASE H-20 COMPONENTS SHALL BE USED.
S i \ 12) ALL BUILDING SEWER LINES SHALL HAVE AN INNER DIAMETER OF 4" AND SHALL BE CAST-IRON OR SCHEDULE 44 PVC.
t, - \
13) THE DEPTH OF THE TOP OF ALL SYSTEM COMPONENTS;SHALL NOT EXCEED 36" UNLESS VENTING HAS BEEN PRO TIDED-
\ 1 14) IN THE AREAS OF EXCAVATION, EXISTING GRADES SHALL RE REESTABLISHED UNLESS NOTED AS PROPOSED CONTOURS.
15) IF SOILS ARE ENCOUNTERED DURING THE EXCA VATIJN OF THE SOIL ABSORPTION SYSTEM, THAT DIFFER NOTABLY FROM
\ (, THE DEEP OBSERVATION HOLE LOG, CONTACT THE ENGINEER BEFORE PROCEEDING.
-Ie�d #17 \
� 16) CONTRACTOR TO ,'VERIFY LOCATION OF ALL UNDERGROUND UTILITIES.
TOF EL = 100. 0
DEEP OBSERVATION
DESIGN DA TA .MOLE LOG
� ���'.! �,. .l �T' Test dole #1
dNumber of Bedrooms: h eo (Es oil o , soil
..� 1 - Garbage Grinder: .NO � ft Horizon Texture or
\ -(� � 1.�• (USDA) (M,uiaell)
1/e (q c(PDesi n Flaw 4 4 0 0-12" `1?,a Fill
`. Proposed 4-a gLoamy 10yr3/3
Q 1 12 -16 yG.7 A
� � �. (110 Gal/BR/Day x Number of BR) ���� B Loa Sand 7 5yr5/6
1� �o Q Septic Tank: Exis ting .1, 00 16 „ 3B Sand
(Minimum = Design Flow X 200%) Gal
38 -144 �� c� C CoarsSan"d 2,5y7/4
'XI S t1I7 g p .
�\^ , Leaching Area: Dee Obs Hole Date:
� \�- � nmill 12/01/04
000 ,Graf -� �" V Sidewall: wit s�a B3r. Ed Stone
1, 1
_. _.._. 11S X — t x —Ft) Pere Rate: � 2 MI /In
S— Tangy �"
� - O e� • Geologic Material- OUfiiYASfI n
mil,
(2 Sidewa �3s�F + Soil Survey Description: CARVER
- � t,J
X 2 Endwalls x `I' --fit) , Depth to Standing Water NA
( -----
• _ .r, ,.._ --.__. ... - ;:; :, =- __ .� _ -- ____- . �_ _ri.�_
Depth to Weeping Water. NA
to Mottliug(Color).• NA ,
Bottom. .
)+� Est Seasonal High G1: NA
.�
{ ✓ USGS Observation Well: NA
- __—Ft x r-Ft) Date of Iasi Measurement: N
rt) Comments: fj C+ 4#�t+'r v
�-' Long Term Acceptance Rate (LTAR): �. 74 •� Y
• '
y.Leaching Area Ca acithalse to , (Sidewall Area + Bottom "Area) x LTARExistin Leach Pit -within 6 » d-
s
(to be pumped/filled v R 0 finish gra de
and or .rem o ve d a s .re q ul.re d�
FA CILITY
Pl?C�l�0,�ED LEA CHING
A OF
�,o e 500 Gal Chambers -W.*th WINSLOW
stone all a -round
sbM
Total area -_ '12 85 x 33. 5 (g ) * sum
p°
98' 45
\ 3 , ^0 �)
84 a�
PROJECT LOCATION 17 Alicia Road
Hyannis, MA 02601
ASSESSORS MAP 292 LOT 231
Ike
TOP OF
FOUNDATION Raise covers to within 6 of j� APPLICANT-
EL
c1m
kjnish grade install risers as needed �"" Matthew G �e1mS
G. GROUND SURFACE E " _
17 Alicia Road
GROUND SURFACE EL_ • ' . �
„ Hyannis, MA 02601
MlN
OUTLET PIPE LEVEL .
FIRST TWO FEET VENT REQUIRED
TOP ELv un
C 2'MIN-3'MAX MIN 2' LAYER DOUBLE WASHEDl,o� PREPAREDB
1/8'-�1/2' STONE
D—BOX 24
A & M Land Se rvzces
15 Sunset Dr
INVERT EL 14 4r , EFFECTIVE
' ~ / IN L SIDEWALL ,
J A INSTALL =c t South Yarmouth MA 02664
Ct� L GAS f 6» STONE' BASE INVERT EL �r (508) 394-2723
INVERT EL FILTER l .
W I L
c'13�S Proposed o'1 3 . Three Five Hundred Gallon 3i4y- 1 1/2' DOUBLE
INVERT EL Conc C ambers (or similar) WASHED STONE
D - Box INVERT EL 5 SCALE.- 1" _ , DATE.• No v. 30, 2004
Existing ('?)gloel} W/ TO
� BOTTOM EL
t A- 1,000 Gal Septic Tank
- (Typical) t� f I '' ELF`b BOTTOM OF TEST HOLE REV.
LOCUS MAP
33.5' 17 Alicia .Road
, J DWG. N0. 3169.d w SHEET 1 OF 1
Hyannis, MA 42601
L ._
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