Loading...
HomeMy WebLinkAbout0038 ARBETA ROAD - Health 71 , 38 ARBETA-ROAD;yHYANNI&4 �, A=269 176 --- - - 1 a e �r1t� lE - o II ° o / I TOWN OF BARNSTABLE =ti.•T* _ OCATION,39- A Rb8J,:Z M SEWAGE# Zo t,3 — �I2 VILLAGE r& y►dA 6S `'�- ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&,PHONE NO. aaecru' 61' e SEPTIC TANK CAPACITY C� ( j LEACHING FACILITY:(type)�w i-�e ��•� �r�e (size) NO.OF BEDROOMS OWNER P4+r;C,k, and i<e rr y' Ca-,aey PERMIT DATE: COMPLIANCE DATE: Separation Distance�etween the:13 l/?tiC�no�^-lwQ��s Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility�nCttt Q!t J3W Feet Private Water.Supply Well and Leaching Facility(If any wells exist on e ' site or within-200 feet of leaching facility)' `�l Feet Edge of Wetland acid Leaching Facility(If any wetlands exist within ®"' 300 feet of leaching facility) F �Y°' / iFeett FURNISHED BY 6 4V,J, L.LL 0 � � � � .s. � 00.�� A � e co . J �m I i _ F Town of Barnstable P# Department of Regulatory Services (y DAMWAaI : Public Health Division Date vx MASS i43g �� 200 Main Street,Hyannis MA 02601 • Arfv►u+,l - . Date Scheduled Time - Fee Pd. SCOU Suitability Assessmentfor Se a e Dis o f v fFVI� D, Cp(JG.H wZ Performed By: �� � ""' I Witnessed By: / LOCATION& GENERAL INFORMATION Location Address `/,,1 Owner's Name (y b AP OCET14 P-6 7�N V*S :address l ii AS(41.�� p P��PE�sct.r c�rA or<f 3 Assessor's Map/Parcel: p2�9 /`��j Engineer's Name G40�cnE - S CL� NEW CONSTRUCTION REPAIR _ Telephone# `Q�—'67 7 —9 F 17 Land Use P-e e,14 t'(A (�)o) Surface Stones Slopes y d t1 Q 11 P Distances from: Open Water Body t 00 4 ft Possible Wet Area '1�D ft Drinking Water Well (�� ft I Drainage Way 2-66 + ft Property Line `f v + ft Other f[ SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) LOT 6 � Q o tA° (4) ft ® �� �t 3 5722, Parent material(geologic) rQ .q�u1 OV� 5� Depth to Bedrock 11 P Depth to Groundwater. Standing Water in Hole: 4&9 Weeping from Pit Face Estimated Seasonal High Groundwater _� bL DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: 171t9 it Q 5 h Depth Observed standing in obs.hole: In. Depth to soil mottles: 11 Pile 4t In. (T� ►) Depth to weeping from side of obs.hole: In, ©roundwater Adjuatment ft. L dex Welt# Reading-Date: -index'Well levci ''Adj,factor— Adj.Groundwaterl_cvel e PERCOLATION TEST bate S1V 13i3 Time it A►h Observation , Hole# Time at 4" L4 lh Depth of Perc CD ;h Time at V K`q Start Pre-soak Time @ —#v Time(V-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) `V Original:iOblic Health Division Observation Hole•Data,To Be Completed.on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conselivation Division at least one (1) week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# L Depth from Soil Horizon Soil Texture .Soil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,,Boulders. ortsistency.%'Gravel) Lo201 to�� 31Z N�hP Fr ;��cP.• 34--t3$ C MPd�t,�h �tgal 10 `s Lnyse DEEP OBSERVATION HOLE LOG Hole# ?- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.). (USDA) a(Munsell) ',Mottling (Structure;Stones,Boulders. Consistency,% v A- 34 , 10 �P, 54 odsP ' 34- t_. C- ���M1i�6ti) /'MIA to DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil"exture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulders. Con t to c O i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil 1, Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. T Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No— Yes ._ Within 500 year boundary No %/ Yes ' Within 100 year flood boundary No.V Yes . Death 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? *C s If not,what is the depth of naturally occurring pervious material? Certification +t�v 1� 5 I certify that on 1.t (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 training,expertise and experience described in 10 CUR 15.017. -NN OF,yqss9 Z4A �Z, ZU l� moo`' DAVID Signature Date/ v D. ipp COUGHANOWR O ENSE� � Q:\SEP-nCU'ERCFORM.DOC / F E N S 0 No. D3 �� yv Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpplitation for Wposal 6pstem Construction j3Crmit Application for a Permit to Construct( ) Repair(x) Upgrade.( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. 3 g A BETA W� Owner's Name,(Address,and Tel.No. t-1Y� W[j I S IPA- TUC t<_V, Ke�&N_ C..AC" Assessor's Map/Parcel ;L(cq 1 1-71, IS 5 ST &PP49ZCu, M A Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.502-364-0%9 C.A96W,'b 6 C-00 -TZ�61 �NUtaDU®►t sEt. 193 ; T M A:9 6-1-P X R..I �-t..0 CURk. S �OcaJ t c11 Type of Building: Dwelling No.of Bedrooms Lot Size t(o (V"f sq.ft. Garbage Grinder( ) Other Type of Building RES tD(= 't A[ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 o gpd Design flow provided 3 q gpd re Plan Date a -;L-1 ` A013 Number of sheets l Revision Date Title 3s APu3c-mA M>b 1`Wi4WL) S Size of Septic Tank i 000 6�4.E, &J Type of�S+.A.S. p tp E Q:I:?l �1atcJ� Description of Soil U/w1 � � t�/ 5�� wAyj Nature of Repairs or Alterations(Answer when applicable) USA �_Cw.61S, ♦W kx �`oO } A-) SWriC_ A jj c cF T SM.)@ AAM POZEC961Ei) pI P& tom. PGAxll 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 Boar of Hea S' e Date s o17 ��13 Application Approved by v Date :7_/2 Application Disapproved by C Date for the following reasons Permit No. '0���a�y Date Issued No. �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �•�'' PUBLIC HEALTH DIVISION TOWfk OF'BARNSTABLE, MASSACHUSETTS Yes ZIPPlication fl®r-4, fool sal *stem Construction vermit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System dividual Components i Location Address or Lot No. 3 06 A R2jE71 'Rly A , Owner's Name,Pddress,and Tel.No. VAYA1JIll l S.i Q.4"rA1 CK 6 Ke*SL%4 CAS" Assessor's Map/Parcel 0L(09 �'7 :($ 1 AStk_&_V57 P61DP6Zt5 _ M A Installer's Name,Address,and Tel.No. 501 i;-4-7?=�$� 7 7 Designer's Name,Address,and Tel.No.SOg-3(.4-O%9 Cr0.tpE�t1� EtstaWrLts6S [,LC- I I C-0-o -tt�N S v1?oLJ#cQV T#VL. S c�u T M t4-O _6 ,41 k t cL- cla. S t c1 I Type of Building: Dwelling No.of Bedrooms 3 Lot Size (0(V t sq.ft. Garbage Grinder( ) Other-•=• -Typq of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 o gpd Design flow provided 3 3 oZ gpd Plan Date -1"r -;;Lois Number of sheets Revision Date Title 3Q A9j3c_:za R04b IIII 4IJOI S i Size of Septic Tank 10&0 d4.c-O0 Type of S.A.S. p lF C- A:iih _- m&jc Description of Soil � Z& WA ) i Nature of Repairs or Alterations(Answer when applicable) U5f-- R&i S'7(2.f7t IWQ7 rt' � -,ti) 1;4-a b n- d o)c To t_j.��(1.6- i=I&tv or Dow?(-c Snk kuD P6V FcA&fEb p1 P r Peg_ Pcat) 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 t Compliance has been issued by this Boar of Heal � S' e , Date 8'�0�7 "013 Application Approved by Date �%1 7_ i 7 Application Disapproved by . Date for the following reasons r ' /Permit No. :2 O/ 3 K y - Date Issued --------------- ---------------------------------------------------------------------------------------------- ---=----- TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliante THIS IS TO C,ER�TIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by eJ�le StS l-(�C. at Y2S AARETA _401fc- XJI S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2 V 13- y dated R 07 InstallerCA1P6L,LNQG u-C. Designer ECy_?ccFF �A�✓(Q4fV�( #bedrooms Approved design flow 'Z t gpd The issuance of this peizr►i sh�tot be construed as a guarantee that the syste will fun do as e igned. Date �(( 1111....E Inspector 41 ------------------------------------------ --__--- -----------------------------------=-----------------------------------=-------------- No. Fee )h r� . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at 3 a A(Z 1;TA p,0 47) tiyAmm and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must be 1completed within three years of the date of this permit. Date Approved by A 4j:�� OLELYR INSTALLATION OF THE SEPTIC SYSTEM THIS PLAN IS INTE�DED S DEPICTED ON THE PROPERTY INCLUDING PLACEMENT OF ADDITIONS. S,EDS. FENCES EOROSWIMMING POOLS. OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. ILEGEND TING 1 VARIANCE REQUESTED 100 EXISTING GAL l 1 MAY BE GRANTED IMMEDIATELY BY HEALTH AGENT SEPTIC TANK _ OR HEALTH INSPECTOR. ' LOT 6 � 310 CMR 15.221(7) - COMPONENT EXISTING DEPTH TO FINISH GRADE. 36 in LEACH PIT AREA = 11610 sf t MAX REQUIRED - VARIANCE •TO p 48 in .OF COVER REQUESTED. t TEST® ASSR MAP 269 PCL 176 H-20 D-BOX PIT TREE �� `) 1 GAR 12-M *L2-P EXISTING MINIMAL (� 1 G R I$-C CONTOUR GRADING OT . 40� PROPOSED A OWED -40 52 C4 �p�o r114.67' p0 �. X bO 1 THIS ISA o�`� �� � �-0 COLOR CQ Q� R Q PLAN O• /\0// 7 USE COLOR PLAN ONLY FOR INSTALLATION / FULL DETAIL IS BEST VIEWED IN FULL COLOR \ ,y0� Aq G 9TEq`/ r150.51' LF qs� 'L�, / O PROPOSED LEA CHI NG °9%F� WA GATTE FIELD \ 4y -SEE. DETAIL ON BACK ® J /O ft I i N 52PLAN / v ° BENCH MARK VENT / 10 SCALE: I in = 20 ft _ _ PIPE �. TOP OF FOUNDATION ELEVATION = 53.67 0 20 40 35.22' BARNSTABLE GIS DATUM 0 10 20 F • L O. W p ' 'F`%) 00 F U L C TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE SCH. 40 PVC AND TO PITCH AT l/8 in/ft MIN* VENT EL = 53.67 +- b in OF FINAL GRADE PIPE o��o 52.00 D��L>OW � i , A* INSTALL 2INSPECTION 4_ft USE SCH.;40 PERFORATED ' �/ �p USE H-20 -PORTS-TO WITHIN 3 in MAX PIPE IN FIELD AND PITCH �WO��OIIV� - OF FINAL GRADE.4. AT 0.005 ft/ft EXISTING �10000 00 GALLON ................................................... SEp�0� TANK L0 48.10 47.87+- in EXISTING SEE DETAIL ON BACK EXISTING TONE 48.00 A° CHM FEW + 48.27 BASE - -SEE DETAIL ON BACK w 0)=7 fc • EXISTING 72 ft 47.37 0 b) 4 ft NO GROUNDWATER Lo BELOW HYANNIS. . MA r- C) 12 ft MOTTLING OBSERVED 40•27 s s `tH OF MqS ��N OF R4S • 10 s � DAVID S9DyG � DAVID s9`'yG SEWAGE DISPOSAL m< m D. ° D. �, �� �'b SYSTEM PLAN N COUGHANOWR COUGHANOWR N -TO SERVE EXISTING DWELLING LOCUS Q EST No. 1083 No. 461 Q PATRICK AND WEST �° m �FGISTE� gPPR0�0 KERRY CASEY Mgih ST Sq rl `SO/I �O� �G �T OWNER(S) OF RECORD AFET m r�®N� � 38 ARBETA ROAD NOT � �• - HYANNIS, MA • X To �J(6us f Z?, Z ( 3 43 TRIANGLE CIRCLE PROPERTY ADDRESS SCALE SANDWICH MA 02563 FOR SURVEYOR'S CERTIFICATION REFER TO 'SKETCH PLAN OF LAND (�'J DATE: AUGUST 2 7. 2 013 IN HYANNO C U S M A PJSWEETSERIRLS ON FILEIWTH TI ENBARNSTABLEMBUIILDING DEPARTMENT. 508 36 ^n-O87`i PG.1/2 I JOBS' ETE-3741- SOUS TEST LOG PE RC* 141 BUST 12, DESMN \JAL `JULA U MNS SOIL EVALUATOR: DAVID D. COUGHANOWR. LSE-461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. SEPTIC, TANK:>330 GPD X 2 DAYS = 660 GALLONS TEST PIT 1 NO GROUNDWATER ENCOUNTERED USE EXISTING 1000 GALLON SEPTIC TANK IF IN PERC AT 60 in - 2 MIN/INCH IN C SOILS SOUND STRUCTURAL CONDITION. IF NOT. INSTALL ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER NEW 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) 5177 INCHES HORIZON TEXTURE (MUNSELL) MOTTLES DISTRIBUTION BOX: USE 3 OUTLET H-20 D-BOX. 0-16 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: THE LEACHING FIELD DEPICTED 16-34 B LOAMY SAND 10 YR 5/6 NONE LOOSE BELOW CAN LEACH: 48.94 = 449.9 34-138 C MEDIUM SAND 10 YR 4/6 NONE, LOOSE Abotsdw = 0 40.27Abot Atot = 449.9 sf Vt = 0.74 x 449.9 = 332.9 GPD TEST PIT 2 NO GROUNDWATER ENCOUNTERED INSTALL THE LEACHING FIELD AS CONFIGURED BELOW ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER - Vt = 332.9 GPD > 330 GPD REQUIRED 5175 INCHES HORIZON TEXTURE (MUNSELL) MCTTLES 0-14 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE D#5 TR§BU T§O nN1 LOX DBE3 H-20Y 14-34 B LOAMY SAND 10 YR 5/6 NONE LOOSE DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL 48.92 AND DETAIL FOR 2 FEET BEFORE PITCHING DOWN 41.25 34-126 C MEDIUM SAND 10 YR 4/6 1 NONE I LOOSE _______ 2 y� TANK �p/� NOT TO 12 In 1 0o 0o GALLON SEE 1/ §C I/ L'�N SCALE MIN DIMENSIONS AND DETAIL000(\ ., FROM - TANK Lo U TO C) 6 ^ SAS SEPTIC TANK IS TO BE PUMPED DRY � N � .� � ������� AT TIME OF INSTALLATION AND IS TO BE EXAMINED FOR STRUCTURAL 6 in STONE BASE INTEGRITY. INSTALL NEW PVC OUTLETTEE EQUIPPED WITH A GAS BAFFLE. 21in CROSS SECTION VIEW ma I in NOT np 22 MM ^�pp THE AREA OF A RIGHT TRIANGLE IN TAPER TO L�LS�OW�UVO TWO DIMENSIONS IS EQUAL TO ONE SCALE AREA HALF REL DD CAL CS NON HYPOTENUSE SIDES (A=%2F THE PRODCT OF THE b•h). TWO 0 S ft- 8 in 30.11' 8.5 b' 21.55 a cn \� 5: IVo A = 344.8 sf o 0 8 ft-6 !n A 20.03' w 1.82 INLET CENTER OUTLET �'o DD COVER COVER COVER A= 33.5 sf q r - A= 3.1sf ji, 3 IN DR VFLOW LINE FROM =_ BUILDI1O i� 14 D BOX TO 48 in � NOTES LIQUID GAS LEVEL BAFFLE 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 2) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). 3) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. SEPARATION BETWEEN INLET & OUTLET 4) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW TEES NO LESS THAN LIQUID DEPTH PUMPING OF FLOW HE IXTUSEPTICSTANKPPLIANCES, AND BIANNUAL CROSS SECTION VIEW 4) INSTALLER MAY MOVE VENT PIPE TO A DIFFERENT LOCATION. D§S T� UV �LS ALL DISTANCES ARE TO LEACH FIELD IN DECIMAL FEET NOT CORNERS IN FEET AND INCHES. A AGGREGATE TO BE 30.11' DOUBLE WASHED AND FREE OF IRONS, FINES. 2 w AND DUST IN PLACE. A B to 1 23.9 23.0 2a4' 2 53.9 46.7 5 3 56.9 42.6 z ^ 4 40.3 22.7 p 0 25 2• p 5 26.5 16.0 o� �ry b 8 m O 22.0' w z in - t w 3• 20.03' SEWAGE DISPOSAL SYSTEM PLAN I C A S E Y 38 ARBETA ROAD HYANNIS. MA AUGUST 27, 2013 ETE-3741 PG 2/2 of°Bar>astable '0F ;�R"egulatofy Services �. Richard.V, Scali,Interim Director g Public Health Division S � i679• �0 • Thomas McKean, Director 200 Main Street;Hyannis;iV1A 02601 Office: 508_862=4644 Fax: 508-790 6304 Installer_& Designer Certification'Form Date:9 ^-a►3 Sewage-Permit4 Assessor's MapTarcel2�, i Designer: EC.o i ed�, En y�sc�►ne�rat: Installer: .(' �p¢� �� ��'rn ���'i �-�LQ f Address AS T2, i viC1 c.;ccl•e 'Address: 1 �-3 c-� ''► {���'��' S^ Sq,n�,)`.cU " rnA. otjco3' LNI►�s r !►1"� c2 -(k • CK�cr �i'�s was:issued;a�perrriit to irstall a on $-a - �3. Cc. ,�1e ,? 5 -(date) (installer-- t septic system at 3$' 42 b ra -Rated + + �5 based on a-design drawn by (address) i CCOL'�Vi��,r�v►rc�. r►L dated, .B` Z'6 -•2oc3 (designer) cerrary that the septic system referenced above'was installed substantially;accorcing to the design;which may include;rninor,approved changes such as lateral relocation of the distribution' box and/or septic tank: Strip out (if required).was inspected and. the soils were found'satisfactory. ! I certify that the septic system referenced above was-installed with major changes f greater than 10' lateral relocation of the SAS or any vertical relocation of any component; of the septic'system) but in accordance with State.&Local Regulations. Plan revision or- �. certified as=built by designer to'follow: Strip out(if required) was inspected and'the;soils' were found satisfactory. - com he,terihs,of I certifythat the system referenced above wa p,• Che'M approval'letters (if applicable) ��` _.-'Mgssq� �, T�OFi S c t moo`' •DAVIM L,'SGN �o�' , 'DAVIDi D ot t ! .COUGHANOWRi N " CO_UGHANOWR staller's Signature t rNo d'1093' q �r 4 _ _ ► `r ENS �p FVALUP SgN1YAR�PN(Designer's Signature) ( x Designers Stamp Here), PLEASE.RETU12iV TO BAR PUBLIC HEALTH DIVISION. CERTIFICATEt OF COiVIPLLA1NCE WILL �dOT BE ISSUED Ut�iT�L BOTH THIS �FORNI AND AS=, BUILT CARD-AR RECEIVED BY THE BAR.NSTABLE PUBLIC HEALTH DIVISION:; THANK YOU: QASepti6Designer Certification Forn Rev 8-14-13A= l Town of Barnstable Barnstable Regulatory Services Department 1 aica i • "M `ter Public Health Division I �- I 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2850 9309 June 12, 2013 Mr. & Mrs. Patrick Casey 1.8 Ashley Street Pepperell, MA 01463 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The.septic system located at 38 Arbeta Road, Hyannis, MA was last inspected on 5/29/2013 by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Lines have some roots, soled carryover and half of field is holding water. Leaching field is not leaching. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. 1 PER ORDER OF THE BOARD OF HEALTH c ean, R.S. CHO Agent of the Board of Health QASEPTIC\L.etters Septic Inspection Failures or Future Eval\38 Arbeta Rd Hy Jun 2013.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 5 I 38 Arbeta Rd ' Property Address Patrick Casey Owner Owner's Name information is Hyannis MA 02601 5-29-13 required for every 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. ' r Important:When A. General Information ,,,allttllr►►ru filling out forms TN OF on the computer, use onlythe tabInspector: , I :0� ,.. key to move your 1. } Y If- vVl U U =�r JAMES cursor-do not James D.Sears =�' -,- use the return _y; SEE°o�,� key. Name of Inspector 's CapewideEnterprises,LLC CIP alp:- Company me P Y Name ���ii F•5 I N SP�G 153 Commercial St. '���umnuuo�l���``�� Company Address Mashpee MA 02649 , Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number R License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-30-13 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ..X7. '' ;• _ , "' R. ,!***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. tsins•3113 r' '.} , Title s Offiael Fan:Subsurface Sewage Disposal System•Page 1 of 17 ; Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y,'N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. , 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5iro-3/13 Tit 4 5 Official hspecbon Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 38 Arbeta Rd Property Address Patrick Casey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 pale. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) - ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is"failing to protect public health, safety or the environment. - 4 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner Owner's Name information is required for every Hyannis MA 62601 5-29-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. . ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that'no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters - ® due to an overloaded or clogged SAS or cesspool 0 ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in ceeapolel is less than 6"below invert or available volume is less than%day flow oC�i4c,/�iN G' t5ins•3113 Title 5 Official Irtspeclion Forth:Subsurface Sewage Disposal System•Page 4 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, - or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. , t5ins•3113 TAIe 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner owner's Name information is Hyannis MA 02601 5-29-13 required for every H y , page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 for example: 110 330 , ( p gpd x#of bedrooms): t5ins-3✓13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner owner's Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 tank D Box and two leaching trenches. i Number of current residents: 3 i Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 000GaI's ,-9 Water meter readings, if available(last 2 years usage(gpd)): 201 2011-9 000Ga1's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No - Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No , Y. r Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner Owner's Name information is reequiredquired for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) - . Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 38 Arbeta Rd Property Address PatrickCasey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: Tank 1976 Permit#76-21 / Leaching 1996 Permit#629 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 20" Depth below grade: teat 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.): Pipeing is 4" PVC SCH 40 Septic Tank.(locate on site plan): 10e Depth below grade: feet Material of construction: i ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) f . If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach'a copy of certificate) ❑ Yes ❑ No Y 1000Gal. Precast Dimensions: r ; Sludge depth: t5ins-3113 Title 5(Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 2T' Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 1 T' How were dimensions determined? Asbuilt-Past ReportSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and cover's at 10"below grade Woutlet baffle. Center cover for pumping. No sign of leakage. 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 15ins•3113 7Me 5 Official Inspection Form:Subsurface Sewage 01sposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins 3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 11 of 17 ' ' r Commonwealth of Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner owner's Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): D Box is 16"x16"-17" below grade,w/two line's out Some solid carry over. Box is solid. I i I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): I *If pumps or alarms are not in working order,-system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: . r t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address ' Patrick Casey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2@4'x3O'x2' I ❑ leaching fields number, dimensions: 4 ❑ 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 two trenches 4'x30'x2'camera both lines. Line's have some roots, solid carry over and half of field holding water,field not leaching 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 t5ins-3113 PTitle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta,Rd Property Address Patrick Casey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner Owners Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately —�`'g B ; /4 .2 g -a , 32 -7 e /9 -3 -- 13-5 30 . i t5ins-3113 Title 6 Official Inspection Fomc Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Arbeta Rd Property Address Patrick Casey Owner Owner's Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N O fe eett Estimated depth to high ground water. 3 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: You must describe how you established the high ground water elevation: G.W. Per past report 2-7-08 30+'. .M • ' r Before filing this Inspection Report, please see Report Completeness Checklist on next page. 3 t5ins•3/13 s Title 5 Official Inspection forth:Subsurfim Sewage Disposal System•Page 16 or 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °< 38 Arbeta Rd Property Address Patrick Casey Owner Owners Name information is required for every Hyannis MA 02601 5-29-13 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t,< ''t5ins•W 3 Title 5 Official Utspection Form:Subsurface Sewage Disposal System•Page 17 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form 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 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: y forms on the computer,use 38 Arbeta Road QLOI� Oto only the tab key Property Address to move your Today Real Estate cursor-do not use the return Owner's Name key. 1533 Falmouth Road Owner's Address " Centerville MA 02632 Cityrrown State Zip Code l Date of Inspection: 02/02/08 Date 2. Inspector: MR. ROBERT A. DRAKE Name of Inspector KCJ ENGINEERING Company Name 66 GREENVILLE DRIVE Company Address FORESTDALE MA 02644 Cityrrown State Zip Code 508-477-5048 r 1 C.G= V Telephone Number 1 r'r1 r. Certification Statement: :y _ I certify that I have personally inspected the sewage disposal system at this address.�and thatpe 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 main nance of on site sewage disposal systems. I am a DEP approved system inspector pursuant aln 0 0YR - Title 5(310 CMR 15.000).The system: �N OF MqS �P� sqc O ® Passes ❑ Conditionally Passes a aalsaEF A. z DRAKE 2 CIVIL ❑ Needs Further Evaluation by the Local Approving Authority 9 No.41642�0 A — 2--7-0 s A�, �c/S1 Inspector's Signature bate rSS�pNAL The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or ' has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *'"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1,of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form M A. Certification (cunt.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Septic Tank and D-Box appear to be structurally sound and working properly, tees are inplace, no ponding around the leaching field. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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: 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2of16 s I Commonwealth of Massachusetts Title 5 Official Inspection Form i ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 38 Arbeta Road Property Address Hyannis MA 02601 City/Town State Zip Code Today Real Estate 02/02/08 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 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: I ❑ 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: 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 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityfrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory,for 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: 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State ZipCode Today Real Estate 02/02/08 Owner's Name Date of Inspection 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 clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 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. 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes"or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. .38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6of16 i Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: YES NO ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? I ® ❑ 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(3)(b)] 38 Arbeta Road-T51NSP1.DOC.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7of16 Commonwealth of Massachusetts Title 5 Official Inspection Form = Not for Voluntary Assessments � Subsurface Sewage Disposal System Form C. System Information 38 Arbeta Road Property Address Hyannis MA 02601 City/Town State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No ZooG ; 13,(,ao I(�3 Water meter readings, if available(last 2 years usage(gpd)): 243 gpd Sump pump? (!' ❑ Yes ® No Last date of occupancy: approx. 10/07 Date Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.):. Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8of16 I . Commonwealth of Massachusetts Title 5 Official Inspection .Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A 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: House built in 1976. New leaching field installed in 1996 according to Town of Barnstable records. Were sewage odors detected when arriving at the site?. ❑ Yes ® No 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityfrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 2'00' +/ feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Sewer pipe appears to be in good condition. No signs of leakage. Septic Tank(locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene Elother(explain) Tank cover approximately 12" below grade. If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No certificate) Dimensions: 1,000 GALLON Sludge depth: APPROX. 11" Distance from top of sludge to bottom of outlet tee or baffle APPROX. 20"+/- Scum thickness APPROX. 7"+/- Distance from top of scum to top of outlet tee or baffle APPROX. 12"+/- Distance from bottom of scum to bottom of outlet tee or baffle APPROX. 10"+/- How were dimensions determined? MEASURED IN FIELD 38 Arbeta Road-T51NSP1.DOC.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- 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.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank appears to be structurally sound, concrete tees are in place, water level in tank is at the invert of outlet pipe. Grease Trap(locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection Tight or Holding Tank(cont.) N/A Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: bate Comments(condition of alarm and float switches, etc.): i Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert At invert of outlet pipe. 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.): No signs of carryover or leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 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 (cont.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection 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 why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2-4'x30' ❑ 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 field appears to be working properly, no signs of ponding and vegetation is normal. 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form i Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityfrown State Zip Code Today real Estate 02/02/08 Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration N/A 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.): Privy(locate on site plan): Materials of construction: N/A i Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 38 Arbeta Road Property Address Hyannis MA 02601 City/Town State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3 I R (�Ack. �3 I L As Qz = 3z1 � 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15of16 Commonwealth of Massachusetts o ' Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 38 Arbeta Road Property Address Hyannis MA 02601 Cityrrown State Zip Code Today Real Estate 02/02/08 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 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: You must describe how you established the high ground water elevation: Barnstable GIS Groundwater Maps indicate high groundwater elevation is at approx. = 22'+/-,t GIS Contour Maps indicate that the ground elevation is approximately at elevation 52.0' approx. 30'+/-above the groundwater,table. 38 Arbeta Road-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Town of Barnstable Of IME 1 Regulatory Services IARNSrABLK ; Thomas F. Geiler,Director Public Health :Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 . Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system.in the future nor does-this Division agree with any technical observation s and interpretations contained within this report. i In addition,by receiving this report the Town of Barnstable Health'Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. i r ' ..:'cam \ , • :t1i ` All" COMMONWEALTH OF MASSACHUSETTS Jq�j _— - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 0�999 _ DEPARTMENT OF-ENVIRONMENTAL PROTECTION • • -ONE'WINTER STREET, BOSTON MA 02108 (617) 292-5500 -,.WILLIAM W. STUBBLEFIELD ,M 1 CERTIFIED TITLE 5 INSPECTOR `545 W;Fal'Hwy. P.O'-Box 460 TRUDY CORE secretary West Falmouth, MA 02574-0460 '(,]�•�(J Z ARGEO PAUL CELLUCCI (508) 540-6171 ^ DAVID B. STRUHS Commissioner Governor' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 7 PART A A ^ A "CERTIFICATION 'I r Address of Owner: 4,7y_f6Gr. ,C14 CE 4_ /11d�,ft`dCC� /�yd 'Date of Inspection: /��j0�9 Name of Inspector:(Please Prirft) 1 am a DEP approved system inspector pursuant to Section 15.340 of Titie 5(310 CMR i 5.000) Company Name: r Mailing Address: Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewa disposal systems. The system: F _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Lrocal Approving Authority.• "_ i. :> >.•t''S'. Fails Inspectors Signature: }• 1` Date: The System Inspector shall submit a copy of this inspection report to the Approving�Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection_. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. r ' NOTES AND COMMENTS 1 7A�f e �s��v.(c 1'✓om cv,tQ� , s2 /A - /T 1,5 ' r - revised 9/2/98 Page Iof11 • ❑ '�. .« �.-. :-�� `i Primed on Recycled I'e In•i .. s• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A ,.� /J CERTIFICATION (continued) Property Address: 3�' �/"�cT.d P YY'/yAv-N/S,*4- Owner: Date of Inspection:1_/6 DAe INSPECTION SUMMARY: Check A, B, C, Or D: A. SYS ASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to.be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND)- Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. i • _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to.a broken, settled o!uneven distribution box. The system will pass inspection if(with approval of the Board of .Health). broken pipes)are replaced obstruction is'removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Bard of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: J N,/� �� '` O dc� i�y.ffn/N/S� /�I�• Owner: ,owV/Q S,d0V0 Date of Inspection: /�f3o�9B 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 th stem is failing to protect the public health, safety and the environment. .. , 1) SYSTEM WIL SS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDAN TH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONI N A MANNER WHICH WILL PROTECT THE PUBLIC TH AND SAFETY AND THE ENVJRONMENT: ----- —Gesspool.or-privy-is wi 1 -50 feet of.-surface-water—. Cesspool or privy is within 5 t of a bordering etated wetland or a salt marsh. 21 SYS WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES T THE SYSTEM IS CTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: :The system has a septic tank and soil absorption system(SAS)arid the SAS is within 100 feet a surface water supply or - tributary to a surface water,supply., _ system has a septic tank and soil absorption system-and the SAS is within a Zone" a public 'water supply well. _ The s tem has a septic tank and soil absorption system and the SAS is within 50 f t of a private water supply well. The syste has a septic tank and soil absorption system and the SAS''is1•ess-tha 100 feet but 50 feet or more from a private water ply well, unless a well water analysis for coliform bacteria`a volatile organic compounds indicates that the well is free from p ution from that facility and the presence of ammonia trogen and nitrate nitrogen is equal to or less than 5 ppm. Method ed to determine distance (approxi ation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART A CERTIFICATION (continued) Property Address: 3�' �.�,1Ze�-.g ,�n�' ,�ya�,�• ,�. :. Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. a basis for this determination is identified below. The Board of Health should be contacted to determine what will be nec ary to correct the failure. Yes No Backup of sewage irttofacility�or system componenr due-to an overloaded or-clogged Sor•cesspool. Uisc arge or ponding of effluent to the surface of the ground or surface waters a to an overloaded or clogged SAS or cesspo Static liquid le I in the distribution box above outlet invert due to an ov loaded or ciegged SAS or cesspool. Liquid depth in ces ool is less than 6" below invert or available v ume is less than 112 day flow. Required pumping more n 4 times in the last year NOT d to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorptio ystem, cesspo or privy is below the high groundwater elevation. Any portion of a cesspool or privy its wi in 1 feet of.a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is w' in a one I of a public well.. Any portion of a cesspool or priv s within 50 fe of a private water supply well. . Any portion of a cesspool o privy is less-than 100 fee ut greater than 50 feet from a private water supply well with no acceptable water quality nalysis. If the well has been a lyzed to be acceptable, attach copy of well water analysis for <coliform bacteria, Vol a organic compounds, ammonia nitr en and nitrate nitrogen. E. LARGE SYSTEM FAILS- You must indicate either "Yes" or "No" to each of the following: The following Grit a apply to large systems in addition to the criteria above: The s ;n s rves a facility with a design flow of 10,000 gpd or greater (Large System the system is a significant threat to public health and ty and the environment because one or more of the following conditio exi Yes No the system is within 40 at of a surface drinking water su y the system is within 200 feet of a • utary to a surfa drinking water supply the system is located in a nitrogen sensitive a (Interim Wellhead Protection Area- IWPA) or a ma ad Zone II of a public water supply well) The owner or operator of any such system shall upgrad he system in accords with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised -/98 Page 4ofII i Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: 0/98 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No' _ umping information was provided by the owner, occupant, or Board of Health. >_�Plone of the system components have been pumped4or"at,least two weeks an&(he'system hasbeen,receiving•noTmal flow ------------� —rates--during that period. Large-volumes of water have not been introduced into the system recently or as part of this / inspection. '• ✓// As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. _ _V The system does not receive non-sanitary or industrial waste flow. _✓_ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption,System on-the site has been determined based on:" Existing information. For example,.Plan,.at B.O.H. " Determine'd.in the-field (if any of the.failure,criteria related to_Part C is at issue, approximation of distance is unacceptable) ('15.302(3)(b)I The facility owner and occupants,if differeat from owner) were provided.with information on the.proper.maintananrA�f SubSurface Disposal Systems. I ' revised 9/2/98 Page 5ofII Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION Property Address: �8�-�i' T� �� f.��/✓/s� I1�Ge% �260/ Owner: A V/U F$.ri✓O Date of Inspection: /a/3v1g, FLOW CONDITIONS ... RESIDENTIAL: + Design flow:�g.p.d./bedroom. 1 Number of bed looms(design): Number of bedrooms(actual): 3 Total DESIGN flow_ Number of current residents:_ Garbage grinder lyes or no):_(Q Laundry(separate system) (yes or no):_IW: If yes, separate inspection.required Laundry system inspected kpowor no) p --Seasonal use(yes-or-no);-HO• Water meter readings,if available(last two year's usage(gpd): �G�L/�F[DD/�VF � ;iye Sump Pump(yes or no):AL Last date of occupancy: NBft' CO M MERCIAL/INDU STRIAL: Type of est ment: Design flow: d ( Based on 15.203) Basis of design flow -- 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: OTHER- (Describe) Last date o upancy: GENERAL INFORMATION PUMPING RECORDS and source of information:' System pumped as part of inspection: (yes or no),&Z> If yes, volume pumped: gallons Reason for pumping: TYPE OF TEM 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) I/A Technology etc. Attach copy of up to date,operati•on and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed{if known) and source of information: ✓W roVG A&AI I K& /diV�C .VOTICNV0eA1 1. Sewage odors detected when arriving at the site: (yes or no) NV revised 9/2/98 Page 6ofII I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_ of a n) Distance from private water supply well o n line Diameter • Comments: (con o joints, venting, evidence of leakage,�tc.) SEPTIC TANK:_ (locate on site plan) , Depth below grade: Material of construction: _concrete_metal _Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is.age.confirmed by Certificate of Compliance_(Yes/No) d00&Ak. Dimensions:S.7I��X ��� X•� �Dr�W _ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 33 Scum thickness: Z i. Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum•to bottom of outlet tee or baffle:► How dimensions were determined: ;PA/A Irrkle. E TA=^ rytdJd3✓✓G Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid le e6in relation;to outlet invert, str ctural integrity, evidence Iof leakage, etc.) 'off ,0 fe' GL LIle-I*r 'MatGl I GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal _Fibergla 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: (recommendation for pumping, condit' o inlet and outlet tees or baffles, depth of liquid level in relate to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7ofII z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFORMATION(continued) Property Address: -qy /�Y�¢T.b M, ,,d,v,016!m Owner: /J4vi0 sa.vv 7 Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at.time of, inspection) (locate on site pla Depth below grade:_ Material of construction: concre metal_Fiberglass_Polyethylene_other(explain) Dimensions: _—_E ac;ty:------ gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and floa Rches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: l, (note.if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Lu ST. Fd !sJ A0 e S ! LO Gu/T.fJ 4�eel,/ ���r»; ��i�i�Lc O rsf/D✓�fi A/ LOG. 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 appu enanc/c.) revised 9/2/98 Page 8of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C p �f /� SYSTEM INFORMATION(continued) Property Address: 34 ,4,Ae,,--V Aa,4�, Owner: Date of Inspection: c SOIL ABSORPTION SYSTEM(SAS):_- (locate on site plan. if possible; excavation not required'•Iodation'may be approximated by,non-intrusive methods) , If not located, explain: Type: leaching pits. number:_ leaching rham6eis, number:_ galleries-number:.__ r--- -- ---- leaching trenches number, length: leaching fields, number, dimensions 71 overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) A.0 S4N A� �ti�i22GK�C__ /SUNG d��QQ�s[Ql�t9 ✓Q�GT.bTIAs! r!L•tlu/N �(L�? CESSPOOLS:_ (locate on site plan) Number and configuration. Depth-top of liquid to inlet inve Depth of solids layer: Depth of�scur6 layer: „ " Dimensions'of.cesspool: Materials of construction: ' Indication of groundwater: inflow (cesspool must be pumped as part of in ection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condi ' f vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: _Di nsions: Depth of solids: Comments: (note condition of soil, signs hydraulic failure, level of ponding, condition of vegetation, etc.) • revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 8�r IJ�T10 AYA.VwlS, �.• Owner: JA,viO faS�O.vO Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: - include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) PIN 1.6 C • revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /� l/SYSTEM INFORMATION (continued) Property Address: 3g�r.G�crq /O.Oeq/ yw'Awl S, I�y�`'`. Owner: A29, 10 /-464, tO Date of Inspection:` NRCS Report name Soil Type_ Typical depth to groundwater _ USGS Date website visited Observation Wells checked Groundwater depth: Sh allow_ Moderate Deep _ SITE EXAM--------Slop.e_.-_.— ____.-.-. _ Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 14_Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions V Checked with local Board of health Checked FEMA Maps Checked pumping records CCn cked local excavators, installers V Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ev�O r�vN ,tzr c�i�2,�pG S/ ' I revised 9/2/98 Page II of II TOWN OF BARNSTABLE LOCATION �S fd .,r�s �. .S f" SEWAGE # n VILLAGE ASSESSOR'S MAP,& LOT 2nh 2. 17,E INSTALLER'S NAME&PHONE NO. raL"tM SEPTIC TANK CAPACITY �oo LEACHING FACILITY: (type) 313X V 3e 2 (size) Ja..," NO.OF BEDROOMS �l BUILDER OR OWNER Fri AAt n PERMIT DATE: 1 f-3-7-Z/ _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 f cility) Feet a_ Furnished by ._ ', F. .__-- _ � w .� `c c i n ;� W^ '�. i F ., 176 6 r. No. A` Fee -a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS .Application for Migpogal bpztem Construction 'Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. i Designer's Name,Address and Tel.No. C ac. 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 °3-30 gallons per day. Calculated daily flow 3 5D gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil A4 S14 (1-0 Nature of Repairs or Alterations(Answer when applicable) i 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 vironmental Code and n t to place the system in operation until a Certifi- cate of Compliance h ea th / Signed - Date Application Approved by Date Application Disapproved for the following reasons Permit No.�_��� Date Issued *�-t,a..v-^rwLy..r1..J«t�,� st.:. ,,. :�''��t�...'r"".:. — �. , `'3-'a.`t-' !•v ��i�� .r... :.r�,.�,._, .. .. -., �. .i �. M No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: lie . PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS � �Zipplication.,for Migpogal bpgtem Congtruction Permit ' Application for a Permit to Construct( )Repair(l )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 Q► �Z Owner's Name,Address and Tel.No. »� Assessor's Map/Parcel _ W ���4 C �,/� ' ►�4S 1`I Q 7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. X4) aQ Type of Building: t « Dwelling No.of Bedrooms __7_1 Lot Size sq.ft. Garbage Grinder( ) Other T1 pe of Building No: of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �L�317 gallons per day. Calculated daily flow^2 ) gallons. Plan Date T Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil al u t(� a: ✓ ;yam,. � f �� Nature of Repairs or Alterations(Answer when applicable) 00 Date last inspected: y_ 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 bye n.isskted-b• Boar �Heallh Signed Date_ J'j ,11 Application Approved by Date Application Disapproved for the foll ing reasons Permit No. q/_ / `J '. �. Date Issued ——— — ———.————————————-— ————THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired ( )Upgraded ( ) Abandoned( )by ` %Ocv+ SQ A 7 iz!Z_4 1 r- at A\0 - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No 4 dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system ill function as designed. ~`'Date / =9G, Inspector _ --------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS � 1 llhgogal *pgtem Congtruction VermiV _,,�,y..�« Permission is hereby granted to Construct( air( )Upgrade( )Abandon System located at A 2&0 «t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to ,y,pomply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: / ; - Approved by NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only., CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT WITHOUT DESIGNED PLANS) I, "—d f J ,hereby certify that the application for disposal works �e G pp p construction permit signed by me dated l- ; � 1 ( , concerning the property located at 3'T `2. � —r meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: LICENSED SEPTIC S STEM INSTALLER THE OWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert r i I . bx r,. LOCUTION ' 5EW&C;E PERMIT U0. VILLAGE IM57QLLER 5 U&NIE UDDRESS BUILDER 'S Q &MF- ADDRESS DISTE PERNAIT ISSUED 76 D ATE COMPLI W-ACE ISSUED : �7 L � J NoV./...yam..........-/...... FEE.(N.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD O/ F HEALT 15l7'Vv.. ........OF...........,1.�?: .......... Appliratiuu -fur 43iipuiitti urkii Tomitrurtiuu Vrruiit Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: g - OiE --?�.-..----•. ............... s ....................................................... W �n e-ram-.. ?> � ll. l�/.�%� a -� = . Installer Address U Type of BuildiEype Size. Lot...f J. !_.0.._....Sq. feet �-, Dwellingo. of Bedrooms---------------3---------------------__Expansion Attic ( ) G:tirbage Grinder (140 aaOther — of Building ............................ No. of persons...........6............. Showers ( ) — Cafeteria'( ) dOtller fiat s -- --------- -------------------------------------------------------------------------------•--... W Design Flow__............. : ....6...............gallons per person per day. Total daily flow.........,f..T1-__________...__.....gallons. WSeptic Tank Liquid capacity_. gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No-----5_IV�._ Diameter---,���.-___- Depth below inlet____---_:�_��a¢r�i .F� �.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) " /0—7. 2— 7 Percolation Test Results Performed by.......................................................................... Date------------------------------------.... Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water........................ G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ P4 T... = _ �.__.. .... ---- - Description of Soil _-=---------------- ---- - --•• { -----------­---- U �- 1..... ........_���r4-L ----------------•-•------•------•--•---------------••----------------------•--••-••-------------..............••-•----•-•---••--------------------------------------------•.-• ' W UNature of Repairs or Alterations—Answer when applicable________________:......:----------------------------------------------------...................... -----------------------------------------------------------------------------------------------------------•------------------------------------------------------.._......._.....---------------------' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI-of the' State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of healt 7 Sign ............ --- ............................... Date Application Approved By----- ................ ------------ .............. -. ----------- Application Date Disapproved for the following reasons:................................. .............................................................................. .......................................................•------------.......-•-•-•--••-------•--------........--•-•-••---•---------•--•-•----•--•--•-•-----------•--........_.....•-----------....--.----- Date PermitNo.......................................................... Issued........................................................ Date No.------••..I. // THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA1 TH ...OF...... .. ..:......... ... ..... ............... ...... .. Appliration -for Bhipoottl Works Tonotrurtion PPrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location Ad c or ISo. t .--- . .......... ............... ....../...4. '1 . Owne ddress .............. -- --- ---- Installer Address cra t' 1 UType of Building Size Lot...�j(t� .......Sq. feet Dwelling. No. of Bedrooms_______________ rba e Grinder . .. .......................Expansion Attic ( ) G:t� g (�Uf aOther— ype of Building ____________________________ No. of persons----------�_._........... Showers ( ) — Cafeteria ( ) dOther fix s ..................................................................................................... W Design Flow._!............. ' ....b.....___...._.:.gallons per person per day. Total daily flow........ WSeptic Tank-f rL.iquid capacitv_I gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area_- .p._-__._..__._.sq. ft. Seepage Pit No-----QN.6... Diameter___00..... Depth below inlet........-_ ,ry- a P '�-�/--����e � - --�--sq. ft. z Other Distribution box ( ) Dosing tank ( ) — /0-- 2 7 6 aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...................... �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to .ground water__.__._..__.___---__:._. ai ............ ..- 7 O Description Of Soil..... ........................................ U ............._..........----•-----•----•-•••-•••-••----•----......•--•••--------•••-------•••-••......------------•---•----•-•......-••--•--•---_: w x •••••-•••-----••-•••••------••-•------------------------•••---•----------------------•----•--•••-•-•--------------•-..........--•••-•--••---•---------------••-••---.........-••••.........-•-••........ 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 C de—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of hea . �0 SigX_A �_ � '" . ` �G•� Date Application Approved By--- GL % -✓- `;� "1-/- Date Application Disapproved for the following reasons:------................................................................ - ----•--------- ------------ _ ...............•-••----.._...._..---...._............:-------•---...-•----------•---•-•---•-•-•------••-.-•----••-•-------------•-••------------••••--•-•....•--•----------------...........-----•--••-- Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS ,^ BOARD O' HEALTH .........11..I� v(� ' . OF......IeC. jq .......................................... uprrtifirate of (uomplinnrr THI• S T5 ERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by.. f .:-- ......... -•--•-• ---------------------------------------------------------------------•-•------------- • '' '� ;col�ieVof X has been installed in accordance with the provisions of!;"�r�i The State Sanitary Code as described in the application for Disposal Works Construction Permit No. _�-_ �_______________ ......�.—�Z._,�--__ _�.. ........ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A-GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. .., Ins ector �: ..- _•........... .. - � THE COMMONWEALTH OF.MASSACHU'SETTS BOARD HEALTH / .•.• ..L/' vl�.'.!..............OF.....41 +6!:::;?XZ, ...--..,........ i5po l rkg ClIonotrurtion Vrrmit Permissiot ereby granted... .. --'--- --- -••------------- ------•--•--..._....._.......... ------.......------......••--........_..........--... to Construct A r Repair ) a Inwtduaige Dis sal S stem atNo. = Y� ..................................------------------------------------ treet _ as shown on the application for Disposal Works Construction Prm�No ............ . . Dated...._(_rP� _..I.._____._._... �� - ZIP -- ---------------------- 70—­ oar Health Ey DATE...........------'�--��......................................:. \ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - `. i,a.f-�1y, ��..•V I..tf,tl:.:i:! } i '�.r'.. , ..�_ . .. --_ - . . _�.; Y''_ .'�#.:i''.y, X'�t,.i.�.� d �•lr s#Yh- ; r�Su is L 47�T` t } � - V_ !_ bpi_ vS n [I'Si,{� 'i� '�?� ►•1 ,1 1'`T•7 y 1 a_� T, t- /-.•.� , L 1A t i i I. 1. t 4 w tr `) klZ` N r.-"<<£�q 3. f 'Ji•• +'tjy a- -1 Ir'•> � ,•- + ..f.. -.� ' i _, T .j'. t.�.: .SF.n.-f.i, i � j k *:',�IIY• _,# ,.I.,i�.t ��7�n� �.l, �8 K _ 't ; 1/ '.R ;Ia,..� t� .. 'f l�V' •4 V ti _ ' '. ,y j ,.., .. } r.t [ +t}. '.` •�.o,^ '�L'1i'F ^�• .1 . 151, :77, ,,7.. ''�iF•.-i'vl '� ,•+- ' 1 t ' �• ' �7 ' { J.,>t, ! ii i` - A.: m .{ r , ,-,.•,� t -4..t•<. h . St � ,�^.��,y,�.fit'. "�' i r r �'•_ L;t ¢� � ly - ,s. ' y �., % F� hhi - �.4 Jyy;�f,�*�k `�yt 5.�..t I `,h� � � 1 •J •• .. + n •� ; F i x. .�.r�;•�..$�,'�'t_'^ y. �;.•.j��,-.,, 44 1 r TDL A O .1.I� 5 � CiliNd ST.E�tr.- C T I �Q. _ CU� p t •',•..,.� • J, ,TM1 �. 'Ilq 1�;7(0 .-J.R, �.W�..G`.'�rJ�.� .._.. -_ .. - _. O+ 1 t r r[ i'+ ..�• r�4j _ �. . EC?".�I G�I h•!^7t E R _ qT ,s��.�-;.. .t '-.. _ .�.;.;-•,.� ..;�E�k.i•I�P :.ART -(Wq-5S. -. - . - - . -- �-� '` :.�;� Y I .• S_H PF HT IS FL,k J'i' "ED °oi\t TH C GR0uN.lD AS Y: tAW6 `6F NE- C)WkA. OF AND` "G; ?- }C Lit; ♦ -=" a(. 3'-1- '7 ,_t yr+ , i 1 } - Tk, but a r, r 4 kSt.S�r,jy'►.:z t'.1.1. +-� it �+3.i- �-, -' , , 'K _ 5�,�_ � � ir�' 1 , !+•.y-♦,a+i j I .p.. t•' ._ .. _ i Vl•Y". .,� _''T'�. ,:s . Yam• � j1r 10 1'-�*iJr3"."yr�' cis �,, 'k, ;� v � +,,. .r. .1.,�':�' i w4,�-�.•�# ��„• - --t --{-— -—-, --- -- ---- - --- - -- -1 i_._ �,+..-�` �t +t-.6•��,�h e t jA .�`�.axC[>I�iX-•.St�a;M'� •l. 'w , � . ! - --- / '� ,e. lK-t, }I•� o ° tlE{ 00 "^ + tid tO .. mot',_ ; -�• ..,I. - a._.\ -7_ .\ O. _. - \.._•__.- _._ _. ....a..__- �. < -+. ._d._ "' 19 Tv ��}- ' s.•`,:j r-i- ylo �z9 � � '- � - if � - - -. _ ' .,_.... ..:.>.,,�,,._,�„ '��,Fy�r. ft 5-1 It �•-•+ a 1�I 1 , 1 1 , t M.. -TAIL; ���l T[�.1.'a_�T I�1..3 GO R t 1 1 1 p,RY:1� �q7L,-, ..,� c .�.�',_��i.',��TSE.R. � i . .� . �' F9tn�u.' �-.• 3� � J, "_.1 �. F M r V i 1,V C L 1.... �r A �, �.' —' � _�7: F1�.�Sl'�ALE T__:::• t t a �- 1j DEt�1.iI�t )� -MASS, of Mti ' r ,� . F• ;.�-�s�����4'.��E�'C��' L.TNaY��.T+-� _��c,5�(E��AYior.l- ��;�_ �,� . ..•_ 01 Syvc� { i y �= Tt•4T5_; �'LA1�! :S LED_O THE. GPN)utdD /-: ... ' �©• ; � n , t a .,,.� .���� �� 1;.1A<..t S �0 THE �W!•.1..c'�F• ~_ ,..-� ss •<� �"" r��,�-� 'rr �-��.�T=��l-ST�2 U�T�-b:A-[V D'�'"�� TF-;i _._ ._.. . - - - � .�s�-3 �•- lip (�� 1.,.�� .t+t'"w�A;�#• �F �4 � i'y'�. ` �>�-'11 � � t_i �1 ' '... " �• � T r --i �ri .a ri1� `. ,{•"�a , k, `i ,-` f-i. obi •q1';•`' iE�„� '.i , •t'y" S•„ ; ,1 a.:;, 7.. , _ .. 1 +✓ , i ' 1 l Gp-_ItyI !V 4 r �+ � 7'F�"�L.I:a ( � W' ( A�1...�•.� t , - ,S /g!r� - Q�J. "�r 7F-{75 ti. s F a.ji� 1 k r�. r7*'• 4 • i{ar vl1 z ; 1 `... - <} -f