HomeMy WebLinkAbout0025 ATHLONE WAY - Health 233 Megan Road
Hyannis P
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TOWN OF B STABLE
LOCATIO SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCE
INSTALLER'S NAME&PHONE NO. e�0i ;
SEPTIC TANK CAPACITY 'fr
LEACHING FACILITY.(type) ize)
NO.OF BEDROOMS
OWNER
PERMIT DATE:--3---5— 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 Facili (If any wetlands exist within
300 feet of leachin ifi Feet
FURNISHED BY
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No. /��� 13 10 Fee G W �
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[pplication for MigpOgar *pgtem COngtrUction Permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No.t;�?13 lNe V/J Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's N Addr and Tel.No ` Designer's Name,A dress and Tel.N �q(�e
TV IR/��, ,2 _
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) ] gpd Design flow provided __5 gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. `—
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) sz
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and,mainte`na`nce.of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of HeaO.
Signed Date
Application Approved by _ Date Z I
Application Disapproved b - Date
"for the following reasons
Permit No. Z O t aj /3(p Date Issued l 27-12=0/3
---- — -----------------------_—=_—== — _--- --_
�.... ,:.
No. �C7, 7 (3 t " � Y ' Fee
THE COMMONWEALTH OF;MASSACHUSETTS Entered in compute
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplication for XhoogdY.�&pgtem Conotructi`on Permit
Application for a Permit to Construct( ) Repair(Oxupgrade( ) Abandon( ) 0 Complete System ❑Individual Components
Location Address or Lot No../C Owner's Name,Address,and Tel.No., / /—
Assessor's Map/Parcel fx§iLoc,
Inst ller's Name,Ad
dre s,and Tel.No. A 10 Desi ner's Name,Address and Tel.No Ali' i'�� /&Gic� 5 3
Type of Building:
Dwelling No.of Bedrooms Lot Size ��� sq. ft. Garbage Grinder ( )
Other Type of Building 1 �S' No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �j j�� gpd Design flow provided jDc=,Z,t) gpd
Plan Date V Number of sheets Revision Date
Title
Size of Septic Tank f Type of S.A.S.
p YP
Description of Soil
VI ,
Nature of Repairs or Alterations(Answer when applicable) feu
F
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 y
Compliance has been issued by this Board of He lfh.
Signed 1 / G�-�' Date L
r Application Approved by I r j ( Date Z 2 Zo 13
Application Disapproved b Date
for the following reasons
Permit No. 20 12 -- /3(o Date Issued y,Z Z/Zg i3
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage-Disposal System Constructed ( ) , Repaired ( j/� Upgraded ( )
Abandoned( )by ♦�/ ji r �
at '`�! has been constructed in accordance
r i
with the provisions of Title 5 and the,or-DisposaTSystem Construction P it No. �1�`J' dated .� Zr�l3
Installer /�� ;r✓ p !� .� ',� Designer
#bedrooms �j Approved design flow__�3 gpd
The issuance of this permit shay not be construed as a guarantee that the system will fun io"n'`as designed.
Date �� �CG° 1� Inspector z_
�:. No. �� ��b - --
,-• -- Fee�J��._--.-.--�-.-.--•
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Digoal *p.5tem Confstruction Permit
Permission is hereby granted to Construct ( ) Repair .( !/fUpgrade ( ) Abandon
S ( )
stem located at ~'�
Y " e- fj
and as described in the above Application for Disposal System Construction Permit.The applicant3ecognizes his/her duty
to comply with Title S and the following local provisions or special conditions. l
Provided: Construction must be completed within three years of the date of this permit.
Date L( 2 21Z0 63 Approved by
MAY/06/2013/MCN 03. 10 FM SandwichTownOffices FAX No. 1 5C8 833 OC18 P. 001/031
Tb'o n 6f Balrnstable
�°'"�'' ► Regulatory Services
rr; Thomas F.Geiler,Director
,* 1�PAHLE t
l\ ArUAn
Public]Health Division
Thomas McKean,Director
200 Main Street,Hyannis,Mk t}-P601
Office: 503-362-4644 Fax: 403-790-6304
Installer& Desimer Certification Fon n
Date; 1� Sewage Permit# Assessot's MaplParcel �� �
Designer: Gattiv
s Installer: lz�
Address: TO N q b 1 Address: G
wtr..i� CQ�
On te) (installer) ed a permit to install a
septic system at M eM n F3" - based on a design drawn by
j ,�,,„ ( address)
L "� !��C`1 dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which, may include minor approved changes such as lateral reiocation of t"Je
distribution box ancL 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.
pFsoc�
D R yG
(installer's Signature) r v No. 1140
SNITW
(Designer's Stg'ttantre) (Affr< Designer's S€arnclp Here)
PLEAD RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH 'IH FogM AND AS-a.CARD ARE
RECEIVED $Y THE B�\RNS"I'�\BLE PURL[C HE L'T'41 DiVISI N. TH.4�[K Y4U.
Q:HealthlSepticMcsi_uer Certification Form 3.26.Odoc
i
'own of B�-nstable . , -
Department of RegnIatory Services
! Date
' Public Health Division
s6 M tee$ , 200 Main Street,Hyannis MA 02601
9.Date Scheduled G' Time�D Fee Pd.
`oil Suitability Assessr'ient for SaVaRw. Disposal
V 6 Performed By: I � c Witnessed By:-
i
LOCATION & GENERAL INVY'ORMATION
S CR� C[b R�S✓P"
Loation Address � Owner'sNac
33 Owner's of&)P/Nw Address w e—s-F P�Mtt A,r—Lk-
Assessor's Map/P4rcel: I Engineer's Name. yl
N REPAIR
Telephone#
g 36 t
NEW CONS172U�'I'IO
Land Use �P, ( �`►'" 1 1'��� Slopes(%) U Surface Stones
2 y Possible Wet Area 2�Oft Drinking Water Well ft
Distances from: Open Water Body ft Poss
i
a ft Other
Drainage Way , ft Property Line C O ft
SKETCH:(Street name,dimensiods of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
Se e— 0 Y-ol
- .4 9 ral 3
I
. I
I
i
I
i
I
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Parent material(geologic) �L t" e I Depth to Bedrock '
Depth to Grouudwaldr. Standing Water in Hole:' ! , I Weeping from Pit Face
j�
Estimated Seasonal Figh Groundwater
D#,TERM NATION FOR SEASONAL HIGH WATER.T"LE
Method Used: !'
_ ln•
Depth Qbperved standing in obs.hole: - in. De pth to soli mottles:
tt.
Depth tolweeping from side of obs.hole: in. Oroundwatt r AdJuattitent
� ! _ A .f:►etor,.,,._,r� Act:(JrnundwaterLevel,,,,e,
Index Well# Reading Date: Index Well lev6I -- � ti.
I •
PERCOLATION TEST . Date —a. T4ze
Observation
Time at 9" -.--------
Hole#
Time at 6" ..--
Depth of Pere
O Time(9"-6")
Start Pre-soak Time.@ 10
End Pre-soak V ' EY
Bate Min./Inch
Additional Testing Needed(Y/N)
Site Suitability Assessment Site Passed Site Failed;
Original:.Public I e$lth Division Observation Hole Data To Be Completed on Back—
I '
***If P ercolag6n test is to be conducted within 100' of wetland,.you must.first notify the
Barnstable C44servation DiNision at least one (I)weak prior to begimmng
DEEP;OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil : Other .
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel
Q"-�Ll
�,t�-3' �I ,�-. � .mot. ��r< •����-� I�' .
DEEP;OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel)
3-7 t�_1Z)el Sao d 2 S° (°/`
13
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel
f I I i
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color _ $oil ther
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consisten Gravel)
E
Flood In.—urance Rate'Lmap
r Above 500 year flood boundary No Yes
Within 500 year boundary No_/ Yes
Within 100 year flood boundary No— Yes '
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the
area proposed for the soil absorption system? �_
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on 1A Cl (date)I have passed the soil evaluator examination approved by the
Department of Environ enta Protection and that the above analysis was performed by me consistent with
the required4raining,expertise and experience described in 30 CIVM 15.017.
VYSignature Date a� 1Lk�.
Q:\.SEPTIC�PERCFORM.DOC
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IN
:q;`
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CO
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m0 F F I C I
CO Postage $ M
O Certified Fee
tmark
Return Receipt Fee ere
l7 (Endorsement Required)
O '
Restricted Delivery Fee �r
O (Endorsement Required) d
r=
E:3 Total Postage&Fees
� Mr. & Mrs. Fernando Cruz
233 Megan Road
Hyannis, MA 02601
Certified Mail Provides:
o A mailing receipt i
o A unique identifier for your mailpiece
o A record of delivery kept by the Postal Service for two years
Important Reminders:
e Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
o Certified Mail is not available for any class qt international mail.
u'NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
e For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted-Delivery.
a If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,-detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
I -
SENDER:,COMPLETE;THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signatur
item 4 if Restricted Delivery is desired. X ❑Agent
■ Print your name and address on the reverse G ❑Addressee
so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is deli different from item 1? ❑Yes
1. Article Addressed to: If� �(d i address below: U No
f z tio��
Mr. & Mrs: Fernando Cruz Z
233 Megan Road
Hyannis, MA 02601 3 Type
Certified Mal�Express Mail
j ❑R ❑Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
12. Article Number f 7 212 1212 0.000 2843 1877
(Transfer from service label)
P&Form 381.1,February g004 Domestic Return Receipt 102595-02-M-1540,
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
e
Town of Barnstable
Public Health Division
I 200 Main Streety
Hyannis, MA 02601
"�
s tar Town of Barnstable Barnstable
Board of Health1659.
BAMSTAHL& 200 Main Street, Hyannis MA 02601
En MAt a�� 2007
Office: 508-862-4644 Wayne Miller,M.D.
FAX: 508-790-6304 Paul Canniff,D.M.D.
Junichi Sawayanagi
CERTIFIED MAIL #7012 1010 0000 2834 1877
January 9, 2013
Mr. & Mrs. Fernando Cruz
233 Megan Road
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5.
•
The septic system located at 233 Megan Road, Hyannis, MA was Fast
inspected on 12/13/2012,by Chris Nardone, 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 (31'0 CMR 15.00) due to the following.
• System is in hydraulic failure.
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:
PER ORDER OF THE�OARD OF HEALTH.
f
Thomas McKean, R.S., CHO.
Agent of the Board of Health
•
Q:ISEPTIC\Letters Septic Inspection Failures or Future EvaU33 Megan Rd. Hy Jan 9,2013.doc
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,. 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owners Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector: 2
only the tab key
jit V
to move your CHRIS NARDONE
cursor-do not Name of Inspector
use the return
key. BRIDGE HOME AND SEPTIC INSPECTION SERVICE
Company Name
27 TIFFANY CIRCLE
Company Address
WEST BRIDGEWATER MA 02379
I lfeww Cityrrown State Zip Code
508-580-0465 SI 571
Telephone Number 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 t6--9. ction 15 340 cig
Title 5(310 CMR 16.000).The system:
-�
❑ Passes ❑ Conditionally Passes ® Fails
is
❑ Needs Further Evaluation by the Local Approving Authority
12-13-2012 ry s
Inspectors Ignature 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.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-11110 Title 5 Official Inspection Fo u dace Sewage Disposal S tem•Page 1 o 17
. t
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M ,•'t 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is MA 02601 12-13-2012
required for HYANNIS i
every page. CityrFown 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):
t5ins•11/10 Title 5 Official Inspection 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
r 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owners Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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.
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of W
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , ' 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every 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:
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 1/day flow
t5ins•11110 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s '' 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. City/Town + State Zip Code Date of Inspection
B. Certification (cont.)
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 II of a public water supply well I
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•11/10 Title 5 Official Inspection Form: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
233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Citylrown 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 gpd x#of bedrooms): 330
t5ins-11/10 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
233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owners Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
SEPTIC TANK AND LEACHING PIT
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
Water meter readings, if available last 2 ears usage AVER 140 GPD
9 ( Y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NOV 2012Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. City/Town 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: NO HISTORY
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owners Name
information is required for HYANNIS MA 02601 12-13-2012
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1974
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 25
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
GOOD CONDITION
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
7 FT L-5FT W-5FT D
Sludge depth: 20 IN
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ' 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. CityRbwn State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 10 IN
Scum thickness
2 IN
Distance from top of scum to top of outlet tee or baffle 4 IN
Distance from bottom of scum to bottom of outlet tee or baffle 14 IN
How were dimensions determined? PROBE
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 SOUND TEE AND BAFFLE IN PLACE LIQUIDS AND SOLIDS HAVE BEEN UP AND OVER
OUTLET PIPE
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
t5ins-11/10 v Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y` 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Citylrown 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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: ONE
❑ 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.):
LIQUIDS HAVE BEEN UP OVER TOP OF PIT IN THE RISER PIT IS IN FAILURE
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-11/10 Title 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
233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every 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•11/10 Title 5 Official Inspection Forth: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
233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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
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t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
j
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 8 PLUS
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
DEPTH OF BASEMENT DRY AND ELEVATIONS OF LOT
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
233 MEGAN RD
Property Address
MIRIAM CRUZ
Owner Owner's Name
information is required for HYANNIS MA 02601 12-13-2012
every page. CityrFown 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
t5ins-11110 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I�
f
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=22789
r. tic r�k� o
- �
BAMNSTAII
Logged In As: Parcel Detail
etaIl Wednesday,January 9 2013
Parcel Lookuo
Parcel Info
Parcel ID 291-244 DevelopeeY LOT 20 I
Location 233 MEGAN ROAD Pri Frontage 180
Sec Road _ I Frontage
Village 1 HYANNIS {; �! Fire District IHYANNIS
Town sewer exists at this address
Asbuilt Septic Scan: Interactive All"T5
2912441 Map
Owner Info
Owner ICRUZ, MIRIAM D& FERNANDO , . Co-Owner
___�__ - _
Streets[233 MEGAN RD ( 5treet2���
city FHYANNIS ( State[M-A1 zip,02601 Country
Land Info _
Acres 10.30 Use Single Fam MDL-01 ] zoning I RB Nghbd 0104
Topography Le Level
Utilities Public Water,Gas,Septic Location
v Construction Info
Building 1 of 1
Year 1974 Roof Gable/Hip wail Wood Shingle
Built Struct..
Living- Roof AC '
Area 11157 Cover Asph/F GI s/Cmp Type None
ff Int Bed,
Style IRanch I wall Drywall ( Rooms!3 Bedrooms
_ n ,
In
Bath
ModelEResidential Floor Carpet Rooms 1 FullAt
Heat Total .
Grade Average Type rHot Air I Rooms,° Rooms -:
stories!i Story Heat Fuel F ation Poured Com �0* � a
Gross Area 1231 4�_---_�)
Permit History ....-- ---- - -----
http://issg12/intranet/propdata/ParcelDetai1.aspx?ID=22789 1/9/2013
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=22789
IIIssue Date I Purpose I Permit# I Amount I Insp Date I Comments II
- Visit History
Date Who Purpose
10/18/2004 00:00:00 Paul Talbot Meas/Est
02/05/2001 00:00:00 Paul Talbot Meas/Listed-Interior Access
10/15/1987 00:00:00 ML Meas/Listed-Interior Access
- Sales History
Line Sale Date Owner Book/Page Sale Price
1 11/27/2006 CRUZ, MIRIAM D& FERNANDO C181674 $100
2 07/02/2004 PINHEIRO, MIRIAM D C173597 $280,000
3 06/30/1999 ARMSTRONG, HELEN M C153793 $1
4 05/01/1975 ARMSTRONG, EDWIN J&HELEN M C64333 1 $0
- Assessment History_______
Save# Year Building Value XF Value OB Value Land Value Total Parcel Value
1 2013 $87,500 $25,500 $0 $67,400 $180,400
2 2012 $87,500 $25,200 $0 $67,400 $180,100
3 2011 . $113,500 $3,200 $0 $67,400 $184,100
4 2010 $113,400 $3,200 $0 $103,700 $220,300
5 2009 $111,800 $2,600 $0 $140,400 $254,800
6 2008 $130,200 $2,600 $0 $146,200 $279,000
8 2007 $129,500 $2,600 $0 $165,200 $297,300
9 2006 $113,400 $2,600 $0 $166,400 $282,400
10 2005 $106,700 $2,600 $0 $132,500 $241,800
11 2004 $86,600 $2,600 $0 $112,600 $201,800
12 2003 $78,700 $2,600 $0 $30,100 $111,400
13 2002 $78,700 $2,600 $0 $30,100 $111,400
14 2001 $78,700 $2,600 $0 $30,100 $111,400
15 2000 $57,000 $2,300 $0 $19,500 $78,800
16 1999 $57,000 $2,300 $0 $19,500 $78,800
17 1998 $57,000 $2,300 $0 $19,500 $78,800
18 1997 $51,400 $0 $0 $19,500 $70,900
19 1996 $51,400 $0 $0 $19,500 $70,900
20 1995 $51,400 $0 $0 $19,500 $70,900
21 1994 $50,500 $0 $0 $23,400 $73,900
22 1993 $50,500 $0 $0 $23,400 $73,900
23 1992 $57,500 $0 $0 $26,000 $83,500
24 1991 $69,000 $0 $0 $42,300 $111,300
25 1990 $69,000 $0 $0 $42,300 $111,300
26 1989 $69,000 $0 $0 $42,300 $111,300
27 1988 $49,500 $0 $0 $19,600 $69,100
28 1987 $49,500 $0 $0 $19,600 $69,100
11 29 1 1986 1 $49,500 $0 $01, $19,6001 $69,100
Photos
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=22789 1/9/2013
9 RE DEiVA D
ECOJECH MAR 1 0 2004
Environmental
www.eco-tech.us TOV�H�LTH DEFT.ABLE
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
— t ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM 3
PART A {
CERTIFICATION
Property Address: 233 Megan Road
Hyannis MAP Z-9
Owners Name: George Armstrong PARCH
Owners Address: P.O,Box 2455
Hyannis,MA 02601 LOT �
Date of Inspection: March 5, 2004 C,
r7l
Name of Inspector: (Please Print) David D. Coughanowr,R.S.
Company Name: Eco-Tech Environmental
Mailing Address: 43 Triangle Circle
Sandwich,MA 02563
Telephone Number: (508)364-0894
CERTIFICATION STATEMENT:
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP
approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature �• �G"�"`"'—"" �S Date: MaVA
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
Inspector's Note—> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5, 2004
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR
5.303 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.
Answer yes,no,or not determined(Y,N,or ND). in the_for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not),is structurally
unsound,exhibits substantial infiltration or exfiltration,or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level 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 Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced.
ND explain
The system required pumping more than four 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
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5, 2004
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 and environment.
1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2) System will fail unless the Board of Health(and public water supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety,and environment
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed by 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
3
Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5, 2004
D)System Failure Criteria applicable to all systems:
You must indicate either"yes" or"no" to each of the following for all inspections:
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
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high groundwater elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed by a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form)
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore,the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E)Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"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.
4
I
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5,2004
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
N Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
n/a _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y _ Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
including
Y _ Were all system components,exeluding the SAS. located on site?
Y _ Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal systems please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
N Existing information.For example,Plan at the Board of Health.
Y _ 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)]
5
i
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept.
Number of current residents 0
Does the residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection requiredl
Laundry system inspected (yes or no): n/a
Seasonal use(yes or no): no
Water meter readings,if available(last two year's usage(gpd): 84 gpd
Sump Pump(yes or no): no
Last date of occupancy: October 2003
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203):: gpd
Basis of design flow(seats/persons/sgft/etc.):
Grease trap present: (yes or no)_
Industrial waste holding tank present: (yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no).
Water meter readings,if available:
Last date of occupancy/use:-
OTHER: (Describe):
GENERAL INFORMATION
PUMPING RECORDS
Source of information: System not pumped in recent past(Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
X Septic tank,distfibutiembox, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection records,if any)
Innovative/Alternate 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:
System is assumed to have been installed at time of dwelling's construction in 1974—no records at Health Dept
Were sewage odors detected when arriving at the site: (yes or no) no
6
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5, 2004
BUILDING SEWER_(Locate on site plan)
Depth below grade: 1.5 ft
Material of construction:_cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting, evidence of leakage,etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_
SEPTIC TANK:Yes (locate on site plan)
Depth below grade: 8 inches
Material of construction: X concrete_metal_fiberglass_polyethylene
other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 alg lon)
Sludge depth: 6 in
Distance from top of sludge to bottom of outlet tee or baffle` 28 in
Scum thickness: 0 in
Distance from top of scum to top of outlet tee or baffle: 10 in
Distance from bottom of scum to bottom of outlet tee or baffle: 14 in
How dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Pumping is not required at this time,but maintenance pumping is recommended eve!y 2 years. Liquid level at
outlet invert.Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out
GREASE TRAP: none (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:_
Date of last pumping:
Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5,2004
TIGHT OR HOLDING TANK: none (Tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal _fiberglass_polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow:_gallons/day
Alarm present(yes or no):_
Alarm level: _ Alarm in working order(yes or no):_
pumping:Date of last
Comments:(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: none (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.)
PUMP CHAMBER: none (locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order: (yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5, 2004
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required)
If SAS not located, explain why:
Type:
X leaching pits,number 1
_leaching chambers,number
_leaching galleries,number
_leaching trenches,number,length
_leaching fields,number,dimensions
_overflow cesspool,number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
Soils above leaching pit appeared unsaturated.No evidence of surface ponding breakout,lush vegetation or
other evidence of hydraulic failure was observed. Leach pit was dry.
CESSPOOLS: none (cesspool must be pumped at time of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
PRIVY: none (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5 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'(Locate where public water supply enters the building)
�LE
PITH LOCATIONS
S
A B
1 22 ft 25 ft
2 25.5 ft 28 ft
2 3 32.5 ft 33 ft
SEPTIC
TAANN a
K o
I
A 8
EXISTING
DWELLING
# 233
W
Z
J
W
W
H
3
I
M E G A N ROAD NOT TO SCALE
10
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 233 Megan Road
Hyannis
Owner: George Armstrong
Date of Inspection: March 5, 2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to ground water: 25 feet
Please indicate(check)all methods used to determine high ground water elevation:
Obtained from system design plans on record-If checked. date of design plan reviewed .
Observed Site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of health-explain:
Checked local excavators,installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Barnstable Geographical Information System Department mapping records indicate that the property is
25 feet above the groundwater table.
11
-_Location:Lot #2C Megan-Road-- Sew-..-Permit .#_3.18 _
-Villa.ge: --Hyannis --
Installer: Frank J. Linhares
- -- -- --- -p.0. Box 6-61- --l�tatt-apoisett-,- Mass0 -- ------- ---
Builder: William E. Dacey Jr.Date Permit Issued: - /25- — --i -- —
Date-_Compliance-_Issued-a _-- -
t`
12+4
................
THE COMMONWEALTH OF MA,$!�ACHUSETTS
BOARD OF H
I Lj-------OF/,� ------------------------------------
Appliration -for Uiiivoiial park T_ �'trurfion Vrrnift
Application is her0 made for a Permit to Construct ( or Repair an Individual Sewage Disposal
System at:
..................--------- ......... ........ ----------------------------------------------------------------------------
Lo tion- or Lot No.
........ ........ . ........................ -------------- .. .................. .................................................................................................
r Address
Lra
.... .. .........
nstal I er Address
Type of Building Size Lot............................Sq. feet
U -----------------------------Expansion Attic Garbage Grinder ( )
Dwelling—No. of Bedrooms.............
Other—Type of Building ------ --------------------- No. of persons______--__-__------_---__._- Showers Cafeteria ( )
Otherres --------------------_-------- --------------------------------------- ----------------------------------------------------------------------
Design Flow__________ _-------------------gallons per person per day. Total daily ow___-_-____.-P_--.__-.-..--.-_gallons.
9 Septic Tank—Liquid cap *��_-eallons Len Width Diameter---------------- Depth----------------
ac,Disposal Trench—No..��, . �id ............. Total leach*
---------; i_ I ai - leaching area----- f I.
-----------
ri5me't. ........... ------ -----------ST It.
Seepage Pit No_________________-- 1 me -------------------- Depth below inlet____-_-_-____-_-___- Total leaching
Other Distribution box Dosing tank
Percolation Test Results Performed by_.,..................................................................... Date...................................
Test Pit No. I----------------minutes per inch . Depth of Test Pit-.- _______-._._-_. Depth to ground water.-----------------------
1:14 Test Pit No. 2--------_-----minutes per inch Depth of Test Pit.__.._._' --------- Depth to ground water--.-__--_______-_-_._..
...... ....j•
............. ....5..r
--------------I---------------------------- - ------------------------------------------------------------------------------
0 Description of Soil----------------- J.......... ......................... -------------------------------------------------------------------------------
........................................................................... ........... ------------------
U ------------------------------------------------- ..................................... ......... .
------------------------- ------ --------------------------------------------- ------------------------------------------ ------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable._................................................................ ........_------- ---------
--------------------------------------------------------------------------------------------------------------------Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code T e under ' further
yped fur ier agrees not to place the s em in is
operation until a Certificate of Compliance has been is he& the b/arA of health.
--- -- --------------- --
Signed... ............ ... ............. ---------------------------------- ------411 Date
ApplicationApproved By-------------------------------------------------------------------------------------------------- -----------------------I-------------
Date
Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------------------
............................................................................................................................................................
ate --------
PermitNo......................................................... Issued.......
,/�------------------ ----
1pate
—-—------------------------------------------------------- ---------------------------------
i
1
r ,
f
1
............. .. ................
THE COMMONWEALTH OF MA ACHUSETTS
M�
BOAR F H
O
.. ........ ------------------...........................
Appliration -for Di-qVviial Works istrurtion Prrmit
Application is he, by made,fora, Permit to Construct or Repair an Individual Sewage Disposal
System at:
.......... ...... ---------- --- ........ .1. ........... .. ... .. .....................................................................
Location-A es or Lot No.
.................. ..........................4----- ---............. ...........................................7------------------------------------------------------
' r 00f Address
. ..... . .........
"Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. 'of Bedrooms... _._... ---------------------_---__Expansion Attic Garbage Grinder
.-I -
a.1 Other—Type of Building ............................ No. of.persons.--_____.-.-________--_-_-__ Showers Cafeteria
PA Other res ..... -------_------------------I-----------------------------
--------------------------------------------------------------------------------------
ow.......... ................gallons.
Design Flow_____ ----------------------------------gallons.per person per day. Total daily 4;.r-------------
04 Septic Tank—Liquid capa allon- LeneOr--—--------- Widtli/.—je---- Diameter---------------- Depth...._____.......
i I pn
7 1 .............
t
Disposal Trench NO. #0.......... -------------- Total leaching area.--- --------- :sq. f t.
_&pt below'jolo�inlet__._._._-_...___._.� . Total leaching area_----------------sq. it.
Seepage Pit No---------------- tam i.............
Z Other Distribution,bo,x, Dosing tank
Percolation Test, Results Performed by........ ............................I ................................... Date-a -,-------------------------------------
Test Pit No. I................minutes per inch Depth of Test Pit..................._ Depth to ground water-..._..-.--------.--_
!� Test Pit No. 2................minutes per inch Depth of Test Pit.._... ......... Depth to ground water--.---_-___-__--_-----.
----------- --- 0 ... ....
. . ..... .... ....
------------------------------------------------------
0 Description of Soil------
----------------------------------------------- ............................A;��............................................................................................................
---------------------------------- --------------------------------------------------------------------------------------------I-------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.-.-__-........... ........................................................__---------_-----
--------------------------------------------------- ------------------------------------------------------------------------------------------------I-------------------------I......................
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 e undepqned.further agrees not to place the em in;
T
operation until a Certificate of Compliance has been i L T'y the Xalq of health.
Signed-A.... -- - -------------------....... .... ..... ...- ------------ -
Date
ApplicationApproved By.................................................................................................. -----------------------------------------
Date
Application Disapproved for the following reasons:....................I............................................................................................
......................................................................................................... ----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSA 9HUSETTS
BOARD'1 F HEA1.
1
..........................................0 F..�............ . ..............................................................................
Qwrtiffrate of
THIS IS T TI hat Indi ual Sewage Disposal System constructed or Repaired ( )
by-------------_-----
............... .............. .................. ..... ................ ..............................................................
Installer-----------
................ .............. ..............................................................
at.................... ------------ ------ ----- ..................
__,-isio--s --i_p Article XI of The State Sanitary Code as described in the
has been installed in accordance with the DrOViSiO S 0i
application for Disposal Works Construction Permit No..----------------------------------------- dated...._.__...__._..._............._..__...........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........... Inspector
.......................................................................................................................................................
E COMMONWEALTH OF MASS HUSE 5
BOARD/flP HE
.. . ...........................OF..... :.. ....... ..........................................................
.. ..... ....
No......................... FEE
...................
Bi_r1:Vo.6aL orks TonOurttbon Vrrmit
Permission i Kereby granted--- ..... ........... ........ ............................................................................
#to Construct ) or P epair J./) an Individual Sewage Di sal S tem
N at 'No.
....
.................r------------------- ------------------------------------- -----------------
Street
as shown on the application for Disposal Works Construction Permit No--------------------- Dated......._......._._....._..._._............
.........................................................*-------------- -----------------------------
Board of Health
DATE..................... ..........................................................
FORM 1255 HOE38S & WARREN. INC.. PUBLISHERS
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Installerc Frank „r , I
. �in��a.res
a P.Co Box 661 Trattapoisettp T}.ass°i � lliam � .
E. Da.ce 112 West Main St Jr.Jr
,. H�%an-1 i s, Ta S s
Oa.te Permit issued : / / i
Date Compliance Issueds
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5
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS
NAME in town (which you must do by M.G.L.- it does.not give you permission to operate.) You must first obtain the necessary
signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, Vt FL., 367 Main Street,
Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law.
Fill in please: DaterJg
Q
$4 APPLICANT'S NAME: (J D L Z
Y UR HOME ADDRESS:
USINESS TELEPHONE # HOME TEALELPHONE #:
NAME OF. CORPORATION: AS FE
NAME OF NEW BUSINESS n:S P.[!L'.i JCL i7 i�i'1411 e3 TYPE OF BUSINESS 1196W I,P&.
IS THIS A-HOME OCCUPATION? YES NO .
ADDRESS OF BUSINESS 3 M�t`s 12C�'-sue .* 14P N► .S MAP/PARCEL NUMBERo��� (Assessing)
When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of
Barnstable. This form is to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth Rd.
& Main Street) to make sure you have the appropriate permits and licenses required.to legally operate your business in town.
,1. BUILDING CO ONER'S OFFICE
This individ al ' en�f d - L-------7>
any permit requirements hat pertain to this type �I 8UIVIPLY WITH HOME OCCUPATION
u orized Sin re COMPLY MAY RESULT IN FINES.COMM NTS: i
2. BOARD OF HEALTH
This individual has bee nformed o e requirements that pertain to this type of business.
G-
Auth r' ed Signature**
COMMENTS: HAZARDOUS MATERIALS REGULATIONS
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature"
�t COMMENTS:
.1
;t .
HX1X.
Materials Inventory Sheet Checklist
e
� ysical Street Address-Check database to ensure it exists
Working Phone Number
Actual Amounts—(i.e.gas being used to fuel machines,thinner to
clean brushes all count as hazardous materials)
torage Information—location of storage,how long is storage for?
If none,note that.
isposal Information—where and who? If none,note that.
pplicant Signature—understand what is listed and noted.
^^Staff Initial—any questions,know who to ask.
(1Vehicle Washing/Rinsing?—provide a vehicle washing policy and
explain it—note that it was given. '
Attach the Business Certificate with your sign-off and comments.
"The Inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what You discussed with them
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: ASP -cr & 1 17 1�l rZ
BUSINESS LOCATION: - �o�'�'t — INVENTORY
MAILING ADDRESS: �r/''�(f Uto C%Z,9 TOTAL AMOUNT:
TELEPHONE NUMBER: 12-Y( Y_j P-0
CONTACT PERSON: Fe-9-0 O M CjZ_U-
EMERGENCY CONTACT TELEPHONE NUMBER: qb bI as MSDS ON SITE?
TYPE OF BUSINESS: Y 41 Y1!�v
INFO ATION/RE,COMM NDATIONS: Fire District:
y G v, !c
Waste Transportation: Last shipment of hazardous.waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
III Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint & varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor & furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
.. e • II � v
A.M. t HYANNIS
291/219 ti i
A.M.
291/243 4
t Rom• 2$ BF
9�
s
------- _ LOT 20 S8136'30,,E r ��
A.M. ! LOCUS z
291/244 / 170•25 I N
AREA=13,473f S.F.
8 64' 1 o
00 '� I UPOLE N v�
O I lnsp Ports , TBM=46.48 II e$
COR. CONC. 1
T H 1 1 yr•---------— 1
A.M. i f ---- ! _ `N FAWCETTS
291/220 Q i --- ! �-'. ---- _ I POND
/% - ---, G _ r ASP !
\'12"0 -2 �' / --------- _ _ G HALT DRIVE ---� LOCUS MAP
5 ----
N _ " o _-- LOCUS INFORMATION
W W - b G ! PLAN REF: LCP# 27099-B (SH.3)
\ t O TITLE REF: CTF#181674
PARCEL ID: MAP 291 PAR. 244
`� ` \ i #2 3 3 i ! ZONING: "RF"
FLOOD ZONE: "C"
TOF=48.00 COMMUNITY PANEL: 250001-0005—C DATED:08/19/85
10"0 46 — W SEPTIC SYSTEM
43.0 !�
43.M I. N f z REPAIR PLAN
EXIST. 1,000G ,
� LOCATED AT:
.. ,
\ SEPTIC TANK � � Q i
- ,,,,,, z 233 MEGAN ROAD
s8136'300PE - Lv HYANNIS, MA.
----- ------------�------ 45
j PREPARED FOR
166.59 MIRIAM & FERNANDO
A.M. / C R U Z
291/245 APRIL 18, 2013
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OF Algs�q�
z D#RamM 9�
Yd0. 114
GENERAL NOTES:
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 'GIST
BOARD OF HEALTH AND THE DESIGN ENGINEER. LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO STARTING WORK. S4NITA?\
r 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE V.
Z
LOCAL RULES AND REGULATIONS- 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR I 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLYTO LA' AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
DESIGN ENGINEER.
0 APPROVAL BY THE BOARD OF HEALTH AND THE 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING fi SCALE: 1"=20� MEYER & SONS, INC.
4 FANY ROM CONDITIONS
HOSE ENCOUNTERED
UNTEREDHEREON DURING CONSTRUCTION
0 DESIGN CD O DIFFERING
ERIN 14. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC. ) LEGEND
15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW P.O. B O�//� 9 81
ENGINEER BEFORE CONSTRUCTION CONTINUES. FOR THE USE OF A GARBAGE GRINDER t
5. ALL ELEVATIONS BASED ON ASSUMED DATUM. PROPOSED CONTOUR
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 16. NO WETLANDS WITHIN 150 Fr. OF PROPOSED LEACHING EAST SANDWICH, M A. 02537
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 17. BONUS ROOMS IN BASEMENT ARE NOT TO BE USED FOR SLEEPING PURPOSES. ® PROPOSED SPOT GRADE
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. EXISTING KITCHEN IN BASEMENT TO BE REMOVED BEFORE ISSUANCE OF CERTIFICATE OF
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. COMPLIANCE OR IT WILL BE REPORTED TO THE ZONING ENFORCEMENT OFFICER. EXISTING CONTOUR (5 0 8)3 6 2—2 9 2 2
8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED + 96.52 EXISTING SPOT GRADE
TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR.
W— EXISTING WATER SERVICE
{ TEST PIT SHEET 1 OF 2 J 1530
�.
y ,
NOTE: TO PREVENT BREAKOUT, THE PROPOSED ,
NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:42.66
FOR A DISTANCE OF 15' AROUND THE
PERIMETER OF THE S.A.S.
SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. {
T.O.F. EL.=48.00 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER 14"
OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. INSTALLED
F.G. EL.=46.50t LENGTH OF
.. /- �F.G. EL.=46.Of F.G. EL: 45.Ot F.G. EL: 45.5(MAX.)
/ 9.45'
9" MIN COVER/ 77 yEk
36" MAX COVER ' L = 25 L = 10'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) f237" No. 1140
® S=1% (MIN.) EL. = 45.20 0 S=1% (MIN.) ® S=1% (MIN.)
4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC
to• In-
140r", E �
ta" 6 10.75" TO NITAR��`�
\INV.-
INV.=44.10 4ec£vEilO 43.85 INV.= 42 2 RT a COUPLER DETAIL 13
GAS BAFFLE PROPOSED
D-BOX INV.=42.80 3 ROWS OF 6 UNITS ® 5'/UNIT + 1 COUPLERS ® 1.16'/UNIT = 31.16'/ROW
INV.=43.0 SOIL ABSORPTION SYSTEM (PROFILE)
EXISTING 1.000 GALLON SEPTIC TANK
EXISTING SEWER OUTLET RESTORE VEGETATIVE COVER
BACKFILL WITH CLEAN PERC SAND
TO TOP OF CHAMBERS 60"
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING
PIPE INVERTS PRIOR TO CONSTRUCTION BREAKOUT=TOP ELEV.=42.66
2) D-BOX SHALL BE SET LEVEL AND TRUE TO INV. ELEV.= 42.20
GRADE ON A MECHANICALLY COMPACTED SIX
INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 41.37 -•- EXISTING SUITABLE
310 CMR 15.221(2) 2.88' MATERIAL
3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK 5' MIN. ABOVE BOTTOM OF B WITH 1500 GALLON SEPTIC TANK IF FAILED, T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 3 x 2.88'
DAMAGED, NOT H2O LOADING, OR UNDERSIZED. (7.07' PROVIDED) USE 3 ROWS OF16-ADS ARC 36HC
4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL.=34.30 - (H20) UNITS - NO STONE W/ 1 COUPLERS
IN EACH ROW
GAS BAFFLE AS REQUIRED
I
SEPTIC SYSTEM PROFILE TYPICAL SECTION
N.T.S. wT.s., 16"
SOIL LOG P#:13920
DESIGN CRITERIA DATE: ' APRIL 11, 2013
SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE #1614 SECTION
NUMBER OF BEDROOMS: 3 BEDROOM DWELLING INVERT
WITNESS: DONALD DESMARAIS, BARNSTABLE BOH HE70HT END CAP
SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN
DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 330 G.P.D. Elev. TP-1 Depth e Elev. TP-2 Depth ADS - ARC 36HC CHAMBER (H20 LOAD)
GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) A LOAMY SAND 45.30 0" ' 45.30 A LOAMY SAND 0"
SEPTIC TANK: 330 gp 1OYR 3/2 1OYR 3/2 MODEL ARC 36HC
gpd x 200% = 660 d USE EXISTING 1,000 GALLON SEPTIC TANK 44.67 8"� 44.67 8"
LOAMY SAND 1 B LOAMY SAND LENGTH 63" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT
LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. 42.21 37"i 42.21 37"10YR 6/8 1OYR 6/8 EFFECTIVE LENGTH 60" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY
DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE.
DISTRIBUTION BOX: 3 OUTLETS (MINIMUM) C MEDIUM SAND C MEDIUM SAND SIDE WALL HEIGHT 10.75"
PERC TEST 2.5Y 6/4 2.5Y 6/4
® 4oso I OVERALL HEIGHT 16"
PRIMARY S.A.S. OVERALL .WIDTH 34.5" 4640 TRUEMAN BLED
USE 3 ROWS OF 6 - ADS ARCHC 3616 H2O UNITS-NO STONE HILLIARD, OHIO 43026
AND EXTENDED 1.16' WZ COUPLER IN EACH ROW 37.80 C2 90" 37.80 C2 90" CAPACITY 10.7 CF e
FINE-MEDIUM , FINE-MEDIUM CAPACITY G&I ADVANCED DRAINAGE SYSTEMS INC.
BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF CHAMBER) 2.5Y AN j2 � 2.sY�7/2 PROPOSED SEPTIC SYSTEM SITE PLAN
(CHAMBERS: 6/ROW)18 UNITS x 5.0 LF x 4.80 SF/LF = 432.00 SF 34.30 132" 34.30 132 233 MEGAN ROAD, HYANNIS, MA
(COUPLER: 1/ROW) 3 UNITS x 1.16 LF x 4.80 SF/LF = 16.70 SF
i
TOTAL AREA = 448.70 SF PERC RATE <2 MIN/IN. IN (*Cl" HORIZON) Prepared for: Dedecko/Cruz
DESIGN FLOW PROVIDED: 0.74GPD/SF(448.70SF) = 332.03 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN DATE:
Meyer&Sons,Inc. macBougan su+vev NITS D.M.M. 04/18/13
I, Darren M. Meyer. R.S.. CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 p0B0X9Bf (508) 419-1086
to conduct soil evaluations and that the above analysis has been performed by me consistent with the EAST SANDWICH,MA02537 REV. DATE: CHECKED SHEET NO.
requirements of 310 CMR 15.017. 1 further certify that V have passed the Soil Evol. Exam in October, 1999. 50"622922 D.M.M. 2 Of 2