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0257 ARROWHEAD DRIVE - Health
25TArr6wh6dd"Drive Y '�,HYa . nis f 270:-073001- i z 4 o x � I rk TOWN OF BARNSTABLE LOCATION,S`7 /C SEWAGE#o1O/O-O,,7 7 VILLAGE ASSESSOR'S MAP&PARCEL2'Z>-a 7,J.zV/ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY &eve LEACHING FACILITY:(type),! ' �' ie / / �!/i�rbr �/G�(size) 3'x 7/ X// 6 NO.OF BEDROOMS JJ 3 OWNER �iieri = PERMIT DATE: COMPLIANCE DATE: v2 d Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within _ 300 feet of leaching facility) Feet FURNISHED BY '` �� w. .. �- .A.. T ` J � ., � Y � ' � _ ` � i u - � _ � : _ : ��, _ � ..� � � `� �. . _ o . , ,. J ¢• • � � - .F No. f� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION'-"TOWN OF BARNSTABLE, MASSACHUSETTS Yet ZIPPliLation for �i8 OSal 6pstrin Construction Jhrmit Application for a Permit to Construct( ) Repair`( Upgrade( ) Abandon( ) ❑Complete System 2fndividual Components Location ddress X Lot No. Zs 111DiV rr Owner's Name,Address,and Tel.No. Z7 07 op/ 11 dllrl s Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �D �olf`1 Z 13z Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building n No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.ri4uired) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank J,A),rl ge Type of S.A.S. A�9 f Description of Soil X L/ A 7 ZY Z �'-j-low c Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board�eth. ��a Date fj Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued ------------------------------------------------------ _-..„�.,,,..,.,�-..rsw..w...,o-,..••:_,;..ry-,.r.SR.�S;tid+vJ=sa;teri�"a' .e,""�{,tWr��"'�.'yr��73anrwN'w.s`ys'�•r.V.q;nw�•..-.'•-,..•«...n«--�...-v-•- n-.v+�:r^Y^Sa:..^••-�;-;raw,i.�•+��y�-�.-.-...,,-.:...-,fy.�, No. kv 03, .. - .� Fee ! . .�!'� THE COMMONWEALTH OF MASSACHUSETTS Entered m computer: PUBLIC HEALTH DIVISION -'TOWN OF BARNSTABLE, MASSACHUSETTS Yes \ � ftPlication for Misposal Aopstetn construction Permit Application for a Permit to Construct( ) Repair(.Upgrade( ) Abandon( ) []Complete System Individual Components Location Address o Lot No. Z S' �J�/�Q�, Q�� Owner's Name,Address,and Tel.No. Z 70-0 7 r oo/ l ra7h te- 5704W/e Assessor's Map/Parcel fJ `j y , Installer's Name,Address,and Tel.No. ;c Designer's Name,Address,and Tel.No. dl' 0% i C', -26Z S/3Z Type of Building: or Dwelling No.of Bedrooms Lot Size `7 xj� sq.ft. Garbage Grinder(/ Q Other Type of Building No.of Persons Showers( ) Cafeteria(- ) Other Fixtures "Design.•Flow(min-.required) 3 " gpd Design flow provided 3. 7 gpd Plan Date �� ZO/Q / Number of sheets / Revision Date Title•.,$ , ✓� � Size of Septic Tank /S , Type of S.A.S. 42 Description of Soil 2- 7. 7 Z Z 7 rP�s�`iy?s i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: f l Y iThe undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in r,accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea th. - gn d / o Date ,Application Approved by 0 jI / Date " V v 7 Application Disapproved by Date for the following reasons /1 fl r- Permit No. E 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 f2/- 2�21,�2, l _�l�.5/ . ..•-,.. at 2�5 7 /��r�GrJ����° �', has been cons ct d in accor/d�ce with the provisions of Title 5 and the for Disposal System Construction Permit N�o ! �D 2lated r Installer (J(��f/J�� / Designer �._Sal (�G i /�✓ #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system w 11MIZ. 11 n as des//igned. Date a. I '0 Inspector fTT --------/ —�D�=_-- --��-----.- ..�.__ ___.-� -•-•-�-•---•- --------•-------------------------•--------------=Fee' / �(_� THE COMMONWEALTH OF MASSACHUSETTS - PUBLI HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS misposal .4pstem Cons trurtion.P ermit Permission is hereby granted to Construct( ) Repair(V<p Up ade( ) Abandon( ) System located at ? �/�G(,�i/ Q� l�/n, /`/�s�js and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to.comply with Title 5 and the following local provisions or special conditions. Provided:Construction mus?be coo pl/ed)within three years of the date of this permit. Date / ( / Approved by /� Town of Barnstable OFTME T Regulatory Services Thomas F. Geiler,Director • BARNSTABLE, MASS. Public Health Division i639• �0 A'FD''"Pr A Thomas McKean,Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form 2 V7- m/c�Date: 2Sewage Permit# v2D/O-e�)3 7Assessor's Map\Parcel -'00 f Designer: Installer: Address: 91..3 Ae-w 7z&-- e=,,4 Address: OZC, 7S— On :®;2 -X-Ie �����,�' �y �-✓ was issued a permit to install a (date) (installer) septic system at Z'�"l IP-96ev ff-6yt�� 'bo_ based on a design drawn by (address) IE dated I S /Z.6 10 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. MPHEN A. (Installer's Signature) . CIVIL ` No.35461 TER' (Designer's Signature) (Affi-I Design er's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH. THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Revised.doc Town of Barnstable Department of Regulatory Services Public Health Division Date �ArEo Mn��`b 200 Main Street,Hyannis MA 02601 d Date Scheduled �� t'� 0 "1 Time Fee Pd. U� Soil Suitability Assessment for Sewa e is Performed By: s���'r N.� ,y 4 posal Witnessed By: a.., W, R A l'.INFO Location Address LO CATION & GENE � J� Ik rra w��'I ('� INFORMATION V �Jr ky�^kswner's Name Ziz, , Address J S� C C e ��j NEW CONSTRUCTION t�J Assessor's Map/parcel: � •� (! �7 �73 - uU1 Engineer's Name Sk,�e �Ct r REP?:IIt Land Use- JZCj i Slopes Distances from: Open Water Bod Surface Stones �� y—�ft Possible Wet.Area ---,eft Drinking Water Well eft Drainage Way _ ft Property Line /ed y- -----�_ft Other ft S -TCH: (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetla nds In proximity to holes) IJ ti. \, p Parent material(geologic) �7.iTer r rl Depth to Bedrock -ems Depth to Groundwater. Standing Water in Hole: A-) /f Weeping from Pit Pace Estimated Seasonal High Groundwater 'u /if DETERM[NATYON FOR SEASONAL HI v WATER TABLE Method Used: .����'C <Gr-�Cc� uz —� GH W Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in. Depth to Boll mottles: Index Well 1F Reading Date: In, Groundwater Adjustment Index Well level Ad,factor ft. j Adj.Groundwater Ley, Observation PERCOLATION TEST Date 12- �y Hole# "3 Tbne of Depth of Pem Time at 6" Start Pre-soak Time @ Time(9"-V) End Pre-soak Rate Min./Inch �Z Site Suitability Assessment: Site Passed C� ------ Site Failed': Additional Testing Needed(YM) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- *'k*If percolation testis to be conducted within 100, of wetland, you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning, Q:�SEPTIC�PERCFORM.DOC DEEP.OBSE Depth from RVATION HOLE LOG Soil Horizon. Hole.# (USDA) Surface(in.) Soil Texture .Sdil Color Soil. Other .(Munsell) Mottlln ,r g (Structure,Stones;Boulders, _____ � •/S j on i to c °k revel .25 j1 i Depth from Soil Horizon Hole DEEP OBSERVATION HOLE LOG Surface(in.) Soil Texture Soil Color Soil (USDA) (Munsell) Mottling ther (Structure,O toncs,Boulders. Consisten %Gravel 1 Depth from DEEP OBSERVATION HOLE LOG Soil Horizon Hole# Surface(in.) Soil Texture Soil Color "---- Soil (USDA) (Muoscll Other Mottling (Strvcture,Stones,Boulders. Co i to c 9• G v I - Depth from DEEP OBSERVATION HOLE LOG Soil Horizon Hole Surface(in.) Soil Texture Soil Color Soll (USDA) (Munsell) Mottlln Other g (Structure,Stones,Boulders. Consistency. i blood Insurance Rate-Map: Above 500 year flood boundary No Yes _ 'Within 500 year boundary No ✓ Yes Within 100yearJloW boundary No t/ 'Yes Depth of Natura Occurrin Pervious Material Does at least four feet of naturally occurring pervious m area proposed for the so tterial exist in all areas observed throughout the il absorption system? If not, what is the depth of naturally occurring pervious material? Certi_fjcation / I certify that on (date)I have passed the soil evaluator examination approved by the . Department of.Environmental Protection and that the above analysis was performed by me consistent with . the required training peruse and experience described in�10 CMR 15.017. Signature Date / 7 Q:\U-PT1C\PERCrORM.DOC COMMONWEALTH OF MASSACHUSETTS . EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI,%: DEPARTMENT OF ENVIRONMENTA �PROTC' N c a� 'tom.....--,F..,-......a.afRs PARCEL .,0T �W TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 257 Arrowhead Drive Hyannis Owner's Name: Demick Feliz Owner's Address: Date of Inspection: 7/28/2004 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System: Passes Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: i` 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 257 Arrowhead Drive Hyannis Owner: Demick Feliz Date of Inspection: 7/28/2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: -, 1 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 app ved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the foll wing statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the se is tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank ailure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as app ved by the Board of Health. *A metal septic tank will pass inspection if it is structurally ound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is availab . ND explain: Observation of sewage backup or break out r high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or even distribution box. System will pass inspection if(with approval of Board of Health): br en pipe(s)are replaced o struction is removed stribution box is leveled or replaced ND explain: The system required pumpin ore than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval o he Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: P) Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 257 Arrowhead Drive Hyannis Owner: Demick Feliz Date of Inspection: 7/28/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by tZadlth 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 determie with 310 CMR 15.303(i)(b)that the system is not functioning in a manner which ' protect public health,safety and the environment: Cesspool or privy is within 50 feet a surface water Cesspool or privy is within 50 f t of a bordering vegetated wetland or a salt marsh 2. System will fail unless,the Board of Health(and Public Water Supplier,if y)determines that the system is functioning in a manner that protects the public health,safety and a ironment: _The system has a septic tank and soil absorption system(SAS)and t 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 one 1 of a public water supply. The system has a septic tank and SAS and the SAS is wit ' 50 feet of a private water supply well. _The system has a septic tank and SAS and the SAS is ss than 100 feet but 50 feet or more from a private water supply well". Method used to determine stance "This system passes if the well water analysis,perfo ed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that t e well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitroge s equal to or less than 5 ppm,provided that no,other failure criteria are triggered.A copy of the analysis ust be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 257'Arrowhead Drive Hyannis Owner: Demick Feliz Date of Inspection: 7/28/2004 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 _Z 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 and overloaded or clogged SAS or cesspool �[ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _jZ 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. _Z Any portion of a cesspool or privy is within a Zone 1 of a public well. _jZ Any portion of a cesspool or privy is 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 sysiem 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 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 sign flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteri above) yes no the system is within 400 feet of a surface drinking wat supply the system is within 200 feet of a tributary to a su ace drinking water supply the system is located in a nitrogen sensitive a(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in S ction E the system is considered a significant threat,or answered "yes"in Section D above the large system h ailed.The owner or operator of any large system considered a significant threat under Section E or failed nder Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contac the appropriate regional office of the Department. r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 257 Arrowhead Drive Hyannis Owner: Derrick Feliz Date of Inspection: 7/28/2004 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? _XZ" 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? _.Zl_ Was the facility owner(and occupants if different than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 257 Arrowhead Drive i Hyannis Owner: Demick Feliz Date of Inspection: 7/28/2004 - BUILDING SEWER(locate on site plan) Depth below grade: of I � Materials of construction:_cast iron v/40 PVC_other(explain): Distance from private water supply well or suction line: A4A Comments(on condition of joints,venting,evidence of le kaa ge,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: \' a') Material of construction: ✓concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 'R k ..� Sludge depth: Q Distance from the top of sludge to bottom of outlet tee or baffle: 31' Scum thickness: t " Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: " How were dimensions determined: ,Q, 5 F,SU-e�. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fibergl polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba e: Distance from bottom of scum to bottom of outlet ee or baffle: Date of last pumping: Comments(on pumping recommendations, in t and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leaka e,etc.): . Page 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 257 Arrowhead Drive Hyannis Owner: Demick Feliz Date of Inspection: 7/28/2004 TIGHT or HOLDING TANK: (tank must be pumZtinspection)(locate on site plan) Depth below grade: Material of construction: concrete metal_fiberylene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working der(yes or no): Date of last pumping: Comments(condition of alarm and fl t switches,etc.): i DISTRIBUTION BOX:_jZ(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ©it Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): t 1�\ems\ S7 W� C»1���� .. V��i`� ��.ti Q� �Q \���� A✓Jr'vl C1 l/�Ca..1�'' 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,con tion of pumps and appurtenances,etc.): Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 257 Arrowhead Drive Hyannis Owner: Demick Feliz Date of Inspection: 7/28/2004 SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: Type caching pits,number: e leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): (� L,,�s,,�`r� \e L��e.� � � �'� -4.•a�,,,�, ',y.uG.t=��j u.7� �n�c.�.� ciys—�,r' CESSPOOLS: (cesspool must be pumped as part of inspection)(I ate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydra is 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 evel of ponding, condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 257 Arrowhead Drive Hyannis Owner: Demick Feliz Date of Inspection: 7/28/2004 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. U 1 p 3.3 3 6 0 Page 11 of 11 OFFICIAL INSPECTION,FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 257 Arrowhead Drive Hyannis Owner: Demick Feliz Date of Inspection: 7/28/2004 SITE EXAM Slope Surface water Check cellar✓ Shallow wells Estimated depth to groundwater j�{_feet i. Please indicate(check)all'methods used to determine the high ground water elevation: _IZO btained from system design plans on record—If checked,date of design plan reviewed: �93 Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _IZAccessed USGS database-explain: �,,� o,:�a��zs.r _ k-.;p C_ You must describe how you established the high ground water.elevation: LA S� I • DATE.10/31/00_—_ -- — PROPERTY ADDRESS:•_,2_57 Arrowhe ..91.3.Y�.._ -----�Zfr9y---------------- on the above date, I Inspected the septic ,system at the above address. This system consists of the following; 1 . 1 -1000 gallon septic tank. 2 . 1 -Distribution box. 3 . 1 -1000 gallon precast leaching pit. Based on my Inspectlon, I certify the following oondltlom, 4 . This is a title five septic system. ( 78 Code ) 5 . The leaching pit is presently dry. �® O 73 Q / 6 . House has been- vacant for -2-months. 7 . The septic system is in proper working order at the present time. SIGNATURE;,/ Na m e :_I P �jUs s m tz tr_.�Lr�------ Company; Joa•Qh_P _ 8acoober_6 Son , Inc . Address :_ BoxV66--_�-- __Centerville Na—,-02632-0066 Phone ... 508_775_3338_______ THIS CERTIFICATION OOES NOT CONSTITUTE A GUARANTY OR WARRANTY J6SEPH:66Contor-Y1110, OMBER & SON, INC- Tanks-Of ools•l.9achfloIds L Instsllsd /�+ 71 $ or Connsotlons �� P.O. Box MA 02632.0066 % � �7 �t> �, 0 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 257 Arrowhead Drive NameofOwner Shelly Bancer Hyannis,Mass. 02601 AddressofOwner: 74 Head Of The Pond Road Date of Inspection: 10/3.1 / 0 Marstons Mills,Mass. 02649 Name of Inspector:(Please Pnnt) -P-Mannmher j r I am a DEP approved system inspector pursuent to Section 15.340 of Title 5(310 CMR 15.000) Company Name: ,T M a r-om he r & S a r1 1 p s. Mailing Address: B ems-6 6--Ge n t e r y-i- l e, s s-6 2 6 3 2 Telephone Number: 508-775-3338 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-gite sewage disposal systems. The system: I ��_/ Passes, � ._7 Conditionally Passes _ Needs Further Evalua)ion By the Local Approving Authority _?FailsInspector's Signature: Date:The System Inspectorbmit 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 otEnvironmental Protection. The original should be sent toots system owner and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS 1 revised 9/2/98 Page IofII ��! Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Pr,pertyAddress: 257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Date of Inspection: 1 0/3 1 /0 0 INSPECTION MARY: Check A, B, C, Or D: A SYSTEM PASSES• I have not found any information which indicates that any of the failure conditions described in 310 CMR 1-5.303 exist. Any failure criteria not evaluated are indicated below. commETITs:The leaching House has been vacant or 2—months. - 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 NO). 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. 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 or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed '/ distribution box is levelled or replaced 4V D- The system required pumphig-more than four-imes a yeardue to broken or obstructed pipe(s). The system wilhpess^ inspection if(with approval of the Board of Health): - broken pipes) are replaced obstruction is removed revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Propw1yAddress:257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Date of Inspection: 1 0/3 1 /0 0 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 the public health, safety and 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.YALL.P.RQTECT THE PUBLIC HEALTH AND SAFETY AND THE ENWBONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a.selt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the pr.e;sas ce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prop"Addrws:257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Date of Inspection: 10/31 /0 0 D. SYSTEM FAILS: You rqust 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. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No / Backup of-sewage irtlofaciR"usYetem component-due tto an overloaded or•clegged-S:AS•or•cesspool. -�---••=.' � J� 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_th di§tribu ' n box abo a outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in_cosepeol is ass than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped JOL. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. r Any portion of a cesspool or privy is-within a Zone I 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-then 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for »coliform bacteria, volatile organic compounds, ammonia nitrogen-and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: /ZLL The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system-iswitWn 200 feet ofatfibuiary-toa eurfeo"rir,k A9 W ter•suPply-••• _ . . .__._.... .. ._ the system is located in a nitrogen.sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infognation. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST p,op"Address.257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Date of Inspection: 10/31 /0 0 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No • Pumping information was provided by the owner, occupant, or Board of Health. _ -None of the system components haraboen poaipod4or••atJeast two%vo"e su*tire•systam has daeaasceiaiwgwuaW 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 N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. K All system components�,3�cluding 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 orr the site has been determined based on: _✓ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / 115.302(3)(b)) L - _ The facility owner.(and.--pants.if different lrnm oyunerl.>Aceraprduided.with infnrmatiorian t►&4ump -maintanameg^f Subsurface Disposal,Systems. , revised 9/2/98 Page 5orii , i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAdd,ess:257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Date of Inspection:( 0/31 /0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: //0 g.p.d./bedro Number of bedrooms( esi n : � Number of bedrooms (actual):. Total DESIGN flow � Number of current residents Garbage grinder(yes or no): Laundry(separate system)/k or o If yes, separate inspection,requirad Laundry system inspected es or no) Seasonal use(yes or no): Water meter readings,if avgUable(last two year's usage(gpd) /'/ o�%�� t'r' �14' p•�� Sump Pump(yes or no): Last date of occupancy n`A0" ry&, COMMERCIAL/INDUSTRIAL: Type of establishment: l Design flow: d ( Based on 15.203) Basis of design flow lid Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or nold Non-sanitary waste discharged to the Title 5 system: (yes or no)-,d,# Water meter readings,if avail ble: Last date of occupancy: �� OTHER:(Describe) Last date of occupancy: r GENERAL INFORMATION PUMPING RECORDS and sour Se ol i formation: �9% A//10/ 'I~ System pumped as part of inspection: (yes or no)_ If yes, volume pumped: 0_. .gallons Reason for pumping: TYPE O SYSTEM Septic tank/distribution box/soil absorption system Single cesspool V(Z Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) 1/A Technology ets. Attach copy of up to date operation and maintenance contract Tight Tank 417 Copy of DEP Approval Other ���. APPROXIMATE AGE of all components, date installed{if known)-and source of•information: s Sewage odors detected when-arriving at the site: (yes or no)2!0 revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) NopenyAcki,ess:257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Date of Inspection: 10/31 /0 0 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction:Al2!cast iron 240 PVCO other(explain) Distance from pr*vate water supply well or suction line_0 — Diameter Comrents: (condition of joints, venting,evidence of teakage,-etc.) -- Joints appear tight No evidence of leakage- System v SEPTIC TANK: ? (locate on site plan) Depth below grade: /0 Material of construction:�c ncrete Ld metalJ&Fiberglass.*Polyethylene0b other(explain) If tank is (natal,list age Q'Js.age.confirmed by Certificate of Compliance, 1 (Yes/No) Dimensions: ! P ArvAr //�0 Sludge depth. Distance from top_afjludge to bottom of outlet tee orbaffle,'t Scum thickness:.(, Distance from top of scum to top of outlet tee or baffle:[ .a� Distance from bottom of scum to bottogi of outlet to or baffle: How dimensions were determined: utlet te (recommendationi for pumpitt�, tjpq}g ' es or-baffles,,depth of liquid level-in relation t_o o_utlet invert, structurel-integrity, evidence of leakage,etc.)--1-5=: �11�55l1�- I Pum the � [two t r n`-e -- —ou - e ees� are--i-n- -7 p ace Liquid-depth`a hP nitslof inuPrt is 51 " Mhe tank is GREASE TRAP: f leakage. (locate on site plan) ,Q Depth below grade: Material of construction slQconcrete 14netal,�Fiberglasa/ ;PPolyethylen&4other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of spym to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is not present revised 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Date of Inspection: 10/31 /0 0 TIGHT OR HOLDING TANK• )L(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grader Material of construction concrete metal v�FiberglassdrlD Polyethylena44other(explain) Dimensions: - Capacity: A gallons Design flow: gallons/day Alarm present lem Alarm level:Alarm in working order:YesAh)9 NoW Date of previous pumping: _( Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanks are not present DISTRIBUTION BOX:z (locate on site plan) Depth of liquid level above outlet invert: d Comments: (note-if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — — Distribution No evidence of solids -Carry over.No evidence of leakage into or nut of the hQX_ PUMP CHAMBER:Z,rie. (locate on site plan) Pumps in working order:(Yes or Not-12!!! Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump rhamher is not present revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Adaress,257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Dace of Inspection: 10/31 /0 0 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields, number, dime 'ons: overflow cesspool, number:Alternative system: i Name of Technology: Comments: ( ote condition of il, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) `Laomy sand to boney sand to fine No signs of hydraulir ai ure or pon inq Soils are dry mhP 1PAoh,�pit is dry at this time-vegetation is normal CESSPOOLS: (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 (cesspool must be pumped as part of inspection) 4 Cesspools are not DrPSPnf Comments: (note condition of soil, signs of hydraulic failure, level of.pending,condition of,vegetation, etc.) Cesspools are not present PRIVY:. (locate on site plan) ..// Materjals of construction: �� Dimensions: N Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is not present- revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 257 Arrowhead Drive Hyannis,Mass. / Owner: Shelly Bancer Date of Inspection: 1 0/3 1 /0 0 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) • 5lutrbh h �aau��oj LSD 0� revised 9/2/98 O' Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 257 Arrowhead Drive Hyannis,Mass. Owner: Shelly Bancer Date of Inspection:1 Q/3 1 /0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater&Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site�(Abuttin roperty bservation hole, basement sump etc.) etermined froconditions Checked with local Board of health Checked FEMA Maps Checked pumping records /-'ChChecked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used; Water Contours Map. Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11of11 ••n.n.•..-w•T--1-r-..wr w►•wA�r�1w.wwr�.w nw+wwr+.l�wwn 1An1/ w'�n�w T TOWN OF AARNgTRBLr, UOARD OF HEALTH SUBSURFACE SFHAGF, DISIUSAL ,SYSTF.M INSPECTION FORM -' PART D — CERTIFICATiUN -•�n�..... ,-.dn-.��w.r+,+,Tn�w�ww.-+�+����w.t�w-�+w�uwrr�w�� ww w-.-.-.r-�. _ -TYPE OA PAINT cLEAALY- PHOPERTY INSPECTED STREET ADDRESS _ 257 Arrowhead Drive Hyannis Mass 026ol ASSESSORS HAP , DLOCK AND PARCEL # OWNER' s NAME ShPI I y b4cer PART D - CEsRTIFICATIOH NAME OF INSPECTOR Joseph P. Macomber Jr, COMPANY NAME Joseph P. Macomber &"'Son, Inc. COMPANY ADDRESS - Box 66 Centerville MA. 02632-0066 $cr•.t Town or City >it�t• t P COMPANY TELEPHONC ( 508 1 775 - 3338 FAX ( ) CCRTIFICATION STATEMENT I certlfy that I have personally inspected the sewage diepos "I system nt this nddress and that the information reported is true , accurate , and omplete ns of the time of .inspection . The inspection was performed and any recommendatlo►1s regarding upgrade , maintenance ) and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , ,check one-: System PASSED The inspection irhich I have conducted has not found any information which indicates that the system fails to adequately protect public heel Lh or the environment as defined in 310 CHR 16 - 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED; The inspection which I have con hcted has found that the system fails to protect the iitiblic health and the environment in accordance with Title 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this Inspectio form . Inspector Signatur Date no copy of this rtification must be provided to the OWNER, the BUYER ( where •pp11o&b1* and the DOARD OF HEAL111 , I ( the inspection FAILED, the owner or��operator shall u O pgrade ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 16 . 306 , partd . doc i 101 4*wv�� (D) LOCATIONS S [ W-AACE PERMIT NO. V I L L A C t Yel �2 Mig lorM" R'S N A IIIE & A f R _ OR OWNER DA T E P ERMIT I S S U E D _ -3o ? DAT E COMPLIANCE ISSUED �'� ' o C^' 4* Uo Z � I � I } TOWN OF BARNSTABLE .00ATIONr ,�/� �' ✓� �� SEWAGE # VIL LA(,,E l/I1-� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY -etV LEACHING FACILITY: (type) - 1 (size) NO.OF BEDROOMS BUILDER OR OWNER ' PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of 1 achin facility) Feet Furnished by " �;, . ,,�._, ,;; w � ��� � " - ,' °� ` �,�� �. � � s s� � ? °��\o\ \� � � � � �� � �� � \,` s 3 _ o �_ �. _ � _ r ,.`' z y:�` e, _ >i� ,�' .. . �-� �. ye'..Q �� .. __ J _ - o. .-��.�' � •, 2L 700' 0 7 30- 00 FES.� ...s••......... H COMMONWEALTHF TS BOARD - OF HEALTH ,� 1� 11-...��. n....-......oF........��.0 -4. 5:?.� ` -...........................10cS\ ?. Appliratiun for Diipuiittl Works Tunitrurtiun Vamit Application is hereby made for a Permit to Construct ( V� or Repair ( ) an Individual Sewage Disposal System at: Y , �S1 U'�?. 1....---.0I VIC..... �k(Y -- .___�------I --------------.. Locati .•Address ••� o•Lot No. . .cccvnP. .....Y, .......... ,.1<.:�------------------------- ----�.a .n,o --�_�............................................. Owner Ad ess wU .. .. ..... ....................... Installer Address .... 3 � Type of Building 3 Size Lot._`.. ..._. ....Sq. feet ., Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder `4 Other—Type of Building No. of persons............................ Showers - Cafeteria a Other fixtures ........................•-..._.__. W Design Flow................,_\Z..................gallons per person per day. Total daily flow-.-....... 3,� ..................gallons. WSeptic Tank—Liquid'capacityVPQPgallons Length..............•. Width................ Diameter--------........ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit. No...................... Diameter.................... Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosin tank. ) nn ~' Percolation Test Results Performed by-. C.R.,( .............. ....................... Date._.k�.':__a --C3 •.... Test Pit No. 1................minutes per inch Depth of Test Pi .................... Depth to ground water......................... G% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•- • - -.._-_•••••................................•••_.�. •------=•--•--•--.......................................................... V ` O M•- Description of Soil.........C�----!�..._...\..-_�...... �" �_u��_-��--�--- ---•-----•=------------------------------..--•--------------._....---------- U .---------------•----.---_--.•...•...-...H•.-._.1.`k•-•-•••-.6he. ----•--. .!:�n..C.?-.-•-•••...---•-••-•---•-------._._...••••••---------------_______... ---------------- U ' 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 iIli U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the\\board of health. ' ned---- --I� ..... ^:... r,---••••-_._.. �... .....? ..._...... D APPlication Approved BOF .: .........:.........•----•-•------........................__.... ---/ !_•- ate-------------- Application Disapprovedreasons:................................................................................................................ ••••----------•--••-•--•...---•-•----•••.............•-•-.•...__....._.....---•••------••--••-------......._..............-•---•------•••----••----•-••••-•--•---••-----•--.-..•-•...._.._-•-•••••------- Date PermitNo.......................................................... Issue(L....................................................... Date --- ----- FEc.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��.u. !". ..........OF........� .................................................. Appliratiun for Dhipouml Workii Tomarttrtion IterrAft Application is hereby made for a Permit to Construct ( VJ or Repair ( ) an Individual Sewage Disposal System at: ` _�Nm.c r\u.i. � ....... 1 u.1I'�:,...�C` 4� ......j_.'Z ----- ---------------------•---------.....-----•---......_................. Locati Address �� 13 �or�Lot No. gym . . ..................................... ............._.......... ------_..........._.......•••-•------•-••••••......... ............. Owner -1 dd esf s w ..�.. A ...........................:..... ..._ ......................:........ . a .......... Installer Address QType of Building Size Lot..�i...1J.�._..Sq. feet U Dwelling—No. of Bedrooms............'��...........:................Expansion Attic (IJ Garbage Grinder (►J)3 '4 Other—Type of ,Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .................................. •----------•••----........----•---•--.._.... . ...................................................... W Design Flow................\ Q............._....gallons per person per day. Total daily flow..........33.Q..................gallons. WSeptic Tank—Liquid'capacity. a�N61Ions Length................ Width................ Diameter................ Depth./.............. x Disposal Trench—No. ...................... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No.............:....... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin tank ) n Percolation Test Results Performed by.. CLV. 12A.. .............T_... ._._.._....___.___. Date_.L�.' '_ ? ....... a ff Test Pit No..1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... f% Test Pit No. 2................minutes per .inch Depth of Test Pit.................... Depth to ground water........................ ----•••........-•---•-----------•----------•-.......•---•................:....... ODescription of Soil.........O'A...... .Ct_M...... ....... .. .... ..... ... .... ... ....................................... ------•-•-'-1- \.,A..........(�Ne..6.._...... n.��.........:••:--••-•----•-•---•-•...._...-••-----------------------•- x ------------------------------------------------------------------------------=-----•----•------------- -----------------------------••------------------......---------------------------------------- UNature of Repairs or Alterations—Answer when:applicable..:__...:._:...........:.....:................................................................. ...................................-......................................................................................................................................0...........---•----......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage'Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed--- .. ....................... `a ��` =3--.... Date Application Approved BY...............................................................................................--- ........................................ Date Application Disapproved for the following reasons:................................................................................................................ ....................................-.................................................................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........OF........ ?.o-11.�.5. :�� ?.1 :.............:.............. (9rrtif irate of Toutplittnrr THI4 IS TO CERTIFY That the Individual Sewage Disposal System constructed ( 6)***o'r Repaired ( ) taller at 1`�. _.. �Ct..c.. ..►�h C! ��------------------n. --.......--- ................................................... has been installed in accordance with the provisions of TITLE 5 of The Sta e Sanitary Code as described in the application for Disposal Vorks Construction Permit No......................................... ' dated................................................ THE ISSU C OF THIS CERTIFICATE SHALL NOT BE CONSTRUE A GUARANTEE THAT THE SYSTEM �DIF F TION SATISFACTORY. DATE.: ..................................................... Inspector ....... ----......-•---.._...--•-----------•---..._____........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ........... ....................................... No. ........ FEE........................ �iu�ou\\ttIIl Turku �onutritrtion permit Permission is hereby granted........ r)_.n.4?.._.__...._.�3 Y•��� f to Construct G/5. or Repair ( ) an Individual Sewage Disposal System O at No........�.z' .'.__.....�..........._IC. .( C_sue W__Ir1�'`ti.s,- ......��.n U`� -N ✓1 ✓� t� - Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... + ` ........................•--••---•••-••-•---••-•---••---.....-•-•--....................---.._-•---------- Board of Health DATE....d.-,1. .:.........-•................••--•---•.......... FORM 1255 A. M. SULKIN, INC., BOSTON ,i 5%Q6Lc. FAMILY - ;3 B�oR�oM ! !j 1.10 GARBAGE 6Q'WDE2. :L0W = IIUX 3 - 7306.Po /oO.op SEPTIC, TAtiK = 330x15o% = -4956.P. 0 1 I �� use 100o GAL. if o15Po5A►- P►T v5E tvoo GaL• i 4,93a S.r- (� S�DGVdAt_L A2Gh. = ►�o S.F. Q: ?I BOTTOM AQIF— j�o 6.F. I. 0 = 5O G•PQ -T oT A I- C>S 51 P D. kA A00 '! 7oTAL. DA i L`( FLOV( = 33o G PO, Jr �. °I. PaZCOLATION RATE - I"IN ?-MIN of-LtrSS � OF 4 \ . .; ���� MSS 33_ RICHARD J ALAN Z 4 AT21� 1f r -- -.!9 BAX.:ER to a1 j :.�i��:GJ. �SA IZ- w/ca✓c• m✓�Ps TE`�T'�� Z7�� - 99 d •ToP FND=loo.o I' I loov INY. DIST. t)jv GoL.S G /J'T JUG��OiCr BOA VT�G t 000 ItJ� 9S. L TANK. . - LEAcu PIT INV. INV. WITW 1'/3/9 J�L • �C17. WA.,%4 D . 41V27 C:1=2TfFIGD PLOT PLAW At,WIA7Zr-o�;' N o SCALE S CA L E V A►T r= - f =�� - ►z�/is�83 t P L-A I•t RE F 62E.1-4 C.1r t G E R.T I.1+Y 'THAT ?N 1= FOci�I•p�T)o ti1 5No µ(N - NEREOI.1 GOMPL`(S 1rJITN T HE S i o�t_It•t� �[v7--- / A W P '5 6T 2ACK R.6 Q v I tZ i=M 6 NTH o !F -t N s= i l -TOWN Or- r��4�A C NC IS ��oi >oL.s��/�G� TtJl>/%/!,/✓�Gs��-�� I ILOp.T W MAW T E GCooD P�Lbl-11,4 -5�" ZZI/9�Z3 DATE Z 71 83 I� i I r n' BA)k+sv-t Wys INC. SZ•E61�S7�ZS•'D'I-AN o 5 u V-Y E`(oeS "Tull PLr�.r.i 1 S NorT aN5c n o►d AN- d3TE2YILL.E i! !�15 rovM�NT >vovEY F -ryc_ ns=rSETS SuoutJ) ! lt�Det,+� .xx».. *r4....n...x..a-,. ., .. x _"-M""" • 1 3 4 _ , , r r s. y x ex .h 0 , ACCES5 COVERS MUST BE WITHIN INSPECTION 9-.MINIMUM. 6' OF FINISH GRADE INVERT EL E VA T I ONS . DES I GIN CR l TER l A GENERAL NOTES : PORT 3 MAXIMUM COVER INVERT OUT SEPTIC TANK: 98.0 DESIGN FLOW FIRST 2 TO I. THIS LAN S FOR THE DESIGN ANDCONSTRUCTION BE LEVEL INVERT 1N DIST. BOX. 97.57 3 BEDROOMS .AT ll0 G.P.D. PER P l D l A INVERT OUT 'DI ST. BOX. 97.4 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4` DIAM PIPE INVERT IN LEACH CHAMBER: 97.32 CLEAN SAND BACKFILL • NO GARBAGE ,GRINDER 2. _VERTICAL DATUM IS ASSUMED. FOR.'BENCH MARKS , o AROUND AND 2 OVER CHAMBERS BOTTOM OF LEACH CHAMBER. 96.4 98.0 9T.4 Jt SET. SEE SITE PLAN. a :GAS 96.4 ADJUSTED GROUND:WATER: N/A BAFFLE 97.57 •� 97.32 SEPTIC TANK REQUIRED; l0 HIGH CAPACITY INFILTRATOR OBSERVED GROUND WATER N/A 3 OUTLET 330 G.P.D. X 20OX - 660 GAL. 3. ALL CONSTRUCTION METHODS`AND MATERIALS AND EXISTING CHAMBERS 1N TRENCH FORMATION BOTTOM OF TEST HOLE *l: 90.3 t MAINTENANCE OF THE SEPTIC SYSTEM SHALL D-BOX SEPTIC TANK PROVIDED 000 GAL EXISTING r, 1000 GAL CONFORM TO MASS. `D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6- CRUSHED STONE OR SOIL ABSORPTION SYSTEM REQUIRED. BOARD OF HEALTH REGULATIONS. COMPACTED BASE DESIGN PERC, RA TE f 5 M l N/I NCH PROFILE • NOT TO SCALE SOIL TEXTURAL CLASS I 4. ALL ..SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO "VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: I0 HIGH CAPACITY INFILTRATOR CHAMBERS IN TRENCH. 62 LF x 7.79 SF/LF 5. ALL ,SEWER PIPE SHALL BE SCHEDULE 40 OR 483 SF x ;74 GPD/SF`- 357 GPD APPROVED EOUAL. TIES - 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED SOIL TE 7-S I T P I T DA TA ® PRECAST CONCRETE AND WATERTIGHT. D-BOX SHALL I ND I CA TES �_ I ND I CA TES BE WA TER TES TED TO CHECK FOR LEVEL WHEN THERE sr E _ PERCOLATION OBSERVED IS MORE THAN ONE OUTLET. °CKAD ` TEST = GROUNDWATER ' 7. BEFORE CONSTRUCTION CALL 14P "DIG-SAFE 100.4 100,9, TP , 1 P+�12787 TP #2 36. 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. � S ��s' �S 19, �r rock _ - AOF FOR LOCATION OF UNDERGROUND UTILITIES. HORIZON TEXTURE COLOR NOR I ZOO TEXTURE COLOR 0' 100.3 0` 100.3 o f srQc,�Ao - 4 LOAMY IOYR LOAMY IOYR 8. EXISTING LEACH PIT TO BE PUMPED DRY AND SAND 3/3 �` SAND 3/3 99.8 7- BACKFILLED. 6• d TP+I .......... TPr2 EXISTING I '� t 1 n LOAMY IOYR t� LOAMY IOYR LEACH PIT i �' D SAND 416 D SAND 4/6 ` 24- -------------=-------- .....,... 98.3 22- ... 98.5 10 HIGH CAPACITY l' MED-COARSE IOYR - COARSE-COARSE IOYR 'AYFD h INFILTRATOR CHAMBERS D-BOX •2-14' NO!,LY5 1 ' oR�P� 1I C I SAND 6/4 C � SAND 6/4 } yw l ry 12' HOLL Ir IOC.B i EXISTING 100.i t 100. 1 44 SEPTIC TANK 1r d c12- HOLLYf SM. CORNER BULKHEAD ~.! EL•100.73 / ! NO WATER NO WA TER L O l ! rb 120' 90.3 120' 90.3 1 14. 930} S. F. r' ` '� / �' DATE: DECEMBER 14. 2009 TEST BY: .STEPHEN HAAS I WITNESSED BY: DAVID STANTON $r""�,E �' PERC RATE: f 2 MIN/INCH /V 7>o sAoCr, i o A. 9" E / y 'CB/DH FND / 7� ! ! SEPT / 0 SYSTEM 0E5 / (3A/ } i 2S7 ARRO'WHE•.4D DR !' VE . . _ "AP 270 • PAR =L 073 -- OO / RA I r H YA /V/V / SAoI 1. PR -EPA RAED F'0R ' l t nOUTf?e / LEGEND LEA IV T A l�/ E Y ® CB CONCRETE BOUND SCAL E / " - 20 JIA /VU,AR Y -5 20 I 0 -W WATER L I NE �,I W t7 HYDRANT 0 a L OC S !� -G GAS L I NE 0 OHW- OVER HEAD WIRES EA0Lr. E S JRVEY I NG 1 NC \*,, ! # LIGHT POST - 923 Raute 6A tis r -E- UNDERGROUND ELECTRIC LINE i -•��. ' � � ;=� Y a r mo u t !-i p o r t MA 02675 H -T- UNDERGROUND TELEPHONE L I NE - / //-'' ��` r �1��� ( 5 O 8 ) 3 6 2--8 1 3 2 GC<,�„ ! l 1 , CTV- UNDERGROUND CABL EV I S!ON LINE r;`� t ( 508 ) 432-5333 +40.4 SPOT ELEVATION f40- EXISTING CONTOUR ' 4(-Z- PROPOSED CONTOUR V S P 0 /0 20 40 L OCU MA JOB NO: 09-117` F/ELD:CFWlRBW CALC: SAH/CFW CHECK: CFW DRN: SAH i ,