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Home My WebLink About0041 BACON ROAD - Health 41 Bacon Road Hyannis A= 309-151 �� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments JJ ;fit Property Ad//d7�r�esss//�' �W &V )/ T°a / / J/ ON ner QN ner'S Nam le 4 1 information is e page.required for every frown e!2 — � State Zip Code Date of Inspection =n Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checidist at the end of the form. Irnpooutf ms""'�" A. General Information 61* aq filing out for on the computer, use only the tab 1. Inspector key to move your cursor-do not use the nAum Name of inspectorkey- cDnWy►time ,?L7 �U h company Address a-�--� clyrro n I state j XIP Code Telephone Number Lrcense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system Inspector pursuant to Section 15.340 of Tide (310 CM 15.000). The system: 2(3 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Y-b� hs to s Signaffire 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 share 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 hiture.under the.same or different conditions of use. lyre•3!13 Title 5 Of6aial Ire petition Form Subst rteoe Se.Ve oisposd S lebm•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �l� ef2 Property Address V 01g;e1 w ON ner Ow ner's Name /info p� ,Q /�� information is f��f �' l�`l Yfil�� _V r F J `L requiredforevery VW� page. City/Town State Zip Code We of hspectim B. Certification (conw 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'yfes", "no"or"not determined"(Y, N. N.D)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 efittration 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): tins•313 Title 5 OtSdal Impec5m Form Subsurface Se wage Disposal System-Page 2of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 1,?Az&t/ Property Address 050 p� >� Ow ner Ow na's tame ;Lay � Q inforrrefion s - — State r _ A 1� ;L �7O required for every (} '�° / page. Gty/Tawn to Zip Code Dateof Inspection B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): y�` ❑ 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 O s-3F13 Tide 5 Offidal bs pecdon Form Subsurface Sewage Disposal S)sWm•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner ON ner's Nacre information for ev page. Cityfrcwn --/•1'O / ` ,/�J ,Q ,+ ) State Zip Code Date of Inspection B. Certification (cord.) 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 ❑ [UJ 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 dogged SAS or cesspool ❑ G Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Y/ Liquid depth in cesspool is less than 6°below invert or available volume is less than day flow t9rs•3H 3 Title 50ficial i spectlon Far¢suw0am seyge Dispesel S ystem•Pape 4oi 17 eL Commonwealth of Massachusetts Title 5 Official Inspection Form UVSubsurface Sewage Disposal System Form -Not for Voluntary Assessments 4h /3, 60V) ®Z� Property Address H �}��/ A Ow ner Ow ne's Name V lO /�' /l r�y� A A / �j inforrnation is required for every X�nxgd" /Y`I 4 Nk 4V 0a l ✓ 70�Y page. City/Town State Zip Code Date of Inspection B. Certification (coat.) Yes No ❑ �/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ lY 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. ❑ l� 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 analysts,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 ftLI_S I have determined that one or more of the above failure criteria exist as described in 310 CM 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. 1 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 ❑ 0 the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone it 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. One•3113 riite5Oficial Inspeclon Form Subsurface SexageDisposal System-Page 5of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G11i9za�U l2� Property Address Irb R K A Ow ner Ow rws Name )?�� requ edf revery ST/9"-Z> !i '-eA L1 ��6 l-jq- ��I' page. Qyfrown 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 ❑ W/ Pumping information was provided by the owner, occupant,or Board of Health ❑ ICY Were any of the system components pumped out in the previous two weeks? 12/ ❑ Has the system received normal flows in the previous two week period? ❑ p/ Have large volumes of water been introduced to the system recently or as part of this inspection? 2r ❑ Were as built plans of the system obtained and examined?(If they were not available note as WA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS,.located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soa Absorption System(SAS)on the site has been determined based on: Ila' ❑ 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 Residendal Flow Conditions: Number of bedrooms(design): -- Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 for example: 110 T3 0 ( p gpd x#of bedrooms): tuns•3113 Title 50fbdal lnspecOon F am Subsiufece Semae Dispose System-Pape 6of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Properly Address Owner e 4-411 ,/� Owner's Name informations � requiredforevery 14 ,9�- ) U page- City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes [2 No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes (� No information in this report.) Laundry system inspected? ❑ Yes Lam' No Seasonal use? VYes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: q0 6 Pb Sump pump? ❑ Yes No Last date of occupancy: cuy7n ZAe Date Commercial/Industrial Flow Conditions: Type of Establishment: S Design flow(based on 310 CMR 15.203): Gaflons 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: tiros•M 3 Title 5 OF6dal Inspection Form Subsurface Sewage Oispwd Swtem•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Properly Address isc))\'i1 . ( -) M� Owner Owner's Nary e�) /� 7 n 9�'� /� ) / informationrequired for every !�"U�1(.!u' Y LA L� :14`�°I t�X ALS /* Cd 246 G q y G y147 �Y page. aly/rown State Zip Code. Date of hspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General lnformatton Pumping Records: Source of information: Was systempumped as Nrt of the inspection? Yes No If yes, volume pumped: gakm How was quantity pumped determined? Reason for pumping: `'� � dJ r� �L✓ Type of System: Ind' 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/Altemative 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 VA system by system operator under contract ❑ Tight tank. Attach.a copy of the DEP approval. ❑ Other(describe): Ors•3/13 Two Mic$IrepecOon Form Subsurface sexege 0ispwA Sim.Rgge 80f 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l Is4av A0 Property AddressVO H AMU P�4 A Ow ner Owner's NUam�e/ ,p/��/� }(�(�l /�� information equire fo is V/1z ✓ /`'G(JC1 ` /Y [�yrN✓v `o V��, om required for every _ page. Cdyfrown State Z' Code 1P Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: I�-76A-&bLT O-LaS Were sewage odors detected when arriving at the site? ❑ Yes S No Building Sewer(locate on site plan): Depth below grade: ! -� feet Material of construction ❑ cast iron CI 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet ,Material of construction: L�7 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: yearn Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 150D CAL- of Sludge depth: 0 t5ns•&13 Title 5 offidd Im pecdon Form Subsurface Se wageDispasef Slstem•Page 9of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `mil 13/V&W Property Address V6 H Nab ON ner ON ner's Na/mneinformation is e 7 / required for every �!� page. City/Town State Zip Code hate of Inspection D. System Information (coat.) Septic Tank(cont.) ail Distance from top of sludge to bottom of outlet tee or baffle -74 Scum.ttckness Distance from top of scum to top of outlet tee or baffle L? Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? � � /)W r) LTY�IAII ZV Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): fi/I Za1/< eZAMP 1 A) 69-) 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 Sns•Y13 Title 5offiaal Ins Pection Fame Subsurface Sewage Dlaposal S stem•Page 10 of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface jSeewage Disposal System jFForm -Not for Voluntary Assessments b�d Properly Address JJ/Q Owner Owner's Name��Q )OM i�7�I A° requInforired r d for is /�, /j1 ��1 d��i GHQ q'A ImI t 4 � �9✓ 0 J, required for every. i R, ✓"`� �ala(�� v (� page. Cdy/rown State Zip Code Date of hspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, I liquid levels as related to outlet invert, eHdence of leakage, etc.): S Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth glow grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: 9alk Design Flow: 9aWs per daV Alarm present: ❑ Yes ❑ No Alarm level: Alarm in wortdng older: ❑ 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 t5re•31 3 Title 50fbdal lne pection Famr Subadace Se wge Oispasa9 System•Page 11 or 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 1 eiw) Y�o Property Address D Ow ner Ow ner's Name equ reedffoorevery raAi,21U MAe - G9`(i9�V AM z7 14-6" Ov)l page- City/Town State Zip Code Date of Inspection D. System Information (corn.) 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located,explain why: t5m 313 Tide 50ftldd Impaction Form SubsLafaceSe wage DispoeW Syatem-Page 12 of 17 I - Commonwealth of Massachusetts HIM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not fir Voluntary Assessments Property Address 'V 6 �vd ,A ON ref 14 till AD Ow ner's Name , information is required for every M19TI96lifS " %y 41 IUAI;& A` page. City/Town State Zip Code Date of Inspectbri D. System Information(cont) Type: ❑ leaching pits number. •�., lld' leaching chambers. number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system T e/n yp ame of technology: Comments (note condition of soil;signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Nofilm Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): O 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 t5tis•3H3 TitleMfidelInspec6mFormSubswfaceSe eD' osal�B �P S)stam•Page 13 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Qv ner iequiretion is �n�� /.e �I rt/ � /i �`�G67✓ c`pId required for every /l� �� .��/ y 7 page. City/Town State Zip Code Date of inspection D. System information (corn.) 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.): tl Mns•313 TileSofidal lnspectlon Fa t Subsurface Sewage DisposEd Syebm•Page 14 of 17 Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4?If& Properly Address � 1/[s o✓b U P Z'A Ow ner Ow ner's Name information is c/ 4 /� h required for every 9/J yj�tI,�T�d `j L i�l� 14X page. atyltown State Zip Code Mete of InspectionD. System Information (corrt.) 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 �IdJJI t7 rJ ' 7 �. r(3 ) 60 19ns•3/13 Ti6e5oF4dd InspecknFomc Supser(ooe S9vageDisposd Syem•Pape 15 d 17 ^ _C\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments zJ/ Property Address owner _V 0 )4;/U )V to l�/Q inforrviation is ow ner s Name required for every �'�<y'a Lr� " y i Z/I W-S page. Cdylrown State Zip Code We of hspection D. System Information (corn.) ,S,ite Exam: it Ll Check Slope Lg' Surface water 0 Check cellar ❑ Shallow wells Estimated depth to high ground water. 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: 5 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: 13 Before filing this Inspection Report, please see Report Completeness Checklist on next page. Sm. 3/13 riile5Official his peeUmFam SUW erece Se a Disposal S�g �P ystem•Page 16af 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property A ires's 77 , & A Ow ner Ow ner's Name information is .717 — �rl/Z 4k�J,L required for every ,/D Ua �'1 Z'Y v� ✓d� C/�tJ( � _ ` `' .` V�� r page. Cfty 6wn State Zip Code Date of inspection E. Report Completeness Checklist inspection Summary:A, B, C, D, or E checked g?Inspection Summary D(System Failure Criteria Applicable to All Systems)completed L�System Information—Estimated depth to high groundwater EvSketch of Sewage Disposal System either drawn on page 15 or attached in separate file MIS-3/13 Title 5Of6da11mpectan Fw m Subsurface savage Disposal SWWm•page 17 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return key. B & B Excavation,lnc. Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number „s B. Certification 3 ,1 I certify that I have personally inspected the sewage disposal system at this address and thafthe 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 toiSection'1.5.340,gf Title 5(310 CMR 15.000).The system: I ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2/22/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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•11/10 Title 5 Official InspectionTFubsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is y required for every Hyannis MA 02601 2/122/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have riot 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): h t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 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/z day flow 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. Cityrrown 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- 10,000g pd. ❑ ® 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 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 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-11l10 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 M 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 d n/a 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date 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 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. CityrFown State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source of information: upgraded in 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20 feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection, building sewer appeared to be in good condition with no evidence of leakage. Septic Tank(locate on site plan): Depth below grade: 6-1feet 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: 68"x 68"x 10'6" Sludge depth: 2" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. Cityrrown 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 36" Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection, septic tank appears to be stucturally sound with no evidence of Ieakage.Tee's present. 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): j *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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is MA 02601 2/22/12 required for every Hyannis page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good condition with no evidence of carryover or leakage. 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 Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ❑ 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.): At time of inspection leaching appreared to be in good condition with no signs of hydraulic failure.Water level was 1'6" below invert. 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 ,M 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 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.): r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. Citylfown 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 ' a t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 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: >10feet 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: 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 l • Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Bacon Road Property Address Steve Santos Owner Owner's Name information is required for every Hyannis MA 02601 2/22/12 page. City/Town 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 k 15ins•11,10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 0/ CdA 14'`QD SEWAGE# ®()57— / VILLAGE S ASSESSOR'S MAP&LOT J INSTALLER'S NAME&PHONE NO. �,I/[5 /VCO -7r-,2 t SEPTIC TANK CAPACITY 'LEACHING FACILITY:(type "7 (A ek(size) d s X �X NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: —.51nO—Q- Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching,Facility (If any wells exist on site`:or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands,exist within 300 feet of leaching facility) Feet Furnished byk �U �1`� \ �_ � .. � / , /` •�I � �`� V /� �•.� 4� �� G a` — V �'�� I � �: r lNo. r w Fee d�/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zi pplication for 0iqu al 6pgtem Con,5truction Permit Application for a Permit to Construct( )Repair(grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �p n Owner (''ss Name(, �� ddress and Tel.No. Assessor's Map/Parcel �/ 30 9 -- �s 1 Installer's Name, aR4%N 0 Designer's Name,Address and Tel.No. 350 Main Street fijetve f— 67 '1ZW. Yarmoutti, MA 02673 3 _ a Type of Building: Dwelling No.of Bedrooms o;� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 0, U gallons per day. Calculated daily flow :?.45_3 gallons. Plan Date /- Number of sheets 1 Revision Date /V IA? Title Se(-.,aS'L Size of Septic Tank AS0Z) Type of S.A.S. 5_04 4/1 V Description of Soil �!r P 64-A Nature of Repairs or Alterations(Answer when applicable) P,r pl,,� 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 de and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of H al Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No Fee p 7 s !? THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprication for loioaar 6rar u - Con.5truction Permit Application for a Permit to Construct( )Repair( -,--upgrade( )Abandon( ) El Complete System D Individual Components '"Location Address or Lot No. ( / CO�l �� Owner's Name, ddress and Tel.No. 'Assessor's Map/Parcel 30 ,l� / 5AII Ue_ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: _ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building `'No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow U gallons per day. Calculated daily flow 3.53 gallons. Plan Date S'3�- S Number of sheets Revision Date Nllq Title M Size of Septic Tank Type of S.A.S. J: Soo IS W / Jfct-rA Description of Soil Pe r P Nature f Repairs or Alterations(Answer when applicable) P,f ` Date last inspected: w Agreement: The undersigned agrees to ensurdthe construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental de and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of H al .- Signed Date g " Application Approved by Date 9 3 Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Qfompliauce THIS IS TO CERTIFY,tha the On-site Sewage Disposal System Constructed( ) Repaired ( graded( ) Abandoned( )J)N K "4—)- )J<O at 1// / �^.17� i ,s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Noc9100 5'9114 dated 3 5 Installer (,r'ti 7< o Designer Y�Ys The issuance of this permit sh 11 noo construed as a guarantee that e syste 1 c ias designed. Date ,J Inspector No. � � -----------,—'--------- Fee /UU THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wi$poga[ *pgtem Cou!5tructiou Permit Permission is hereby granted to Construct( )Repair( UpgrJa/de( )Abandon( ) System located at ��t'i<e/I ;� / �A"I✓t S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construe ion mus be completed within three years of the dQofis eDate: 3 3 �✓ A rove Approved y p.....-. _ .^+w..^..�w.. ..wa.a...axt+"^r^ .^—.•„ 1e.^.+w+a.ar. _ met*.=. t 9/16/03 Notice: This Form Is To Be Used For the Repair.Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, (�IQ,Qyt Q,u�!hereby certify that the engineered plan signed by me dated �[ 05- concerning the property located at 6W' J (oAIO meets all of the. following criteria: • This failed system is connected to a residential dwelling only. There.are no commercial or business uses associated with the dwelling. • The soil is.classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information). N0 Gw�n B) G.W.Elevation 1 - �+adjustment for high G.W. DIFFERENCE BETWEEN A and B SIGNED : DATE: J 3 NOTICE Based upon the above information;a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic sy stem 8m plans. q ASeptic\percexemp.doc Town of Barnstable E+e,�w. Regulatory Services ' y�P ' Thomas F.Geiler,Director BARN LE. 'Yqj i639• `0� Public Health Division arFo ;�a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-8624644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: � ' l � CJ� Installer: [1j CAN(-6 Address: I ' �x 6� t Address:. �?j� � c T, i E. SA-1�O VJ I C4 A* 02G37 1N a'12 MA l 02G73 On was issued a permit to install a (date) I (� (installer)er septic system at ACD�J 1'le'"kO based on a design drawn by (address) dated (designer) 1-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 Plan revision or certified as-built by designer to follow. r w��I�A cr' r; DP r: { 14 i (Installer's ignatur �F e G/STEa Sg)V17AR\�� esigner's Signature} (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form I - 1 r ,fir vN ASSESSORS MAP : NOTES: 3 TEST HOLE LOGS M ELM ?e r PARCEL: 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH 9� CHESTNUT ST �� +. A a SOIL EVALUATOR: T).. 0- ?-6 CSE THIS PLAN,, 1995 MASSACHUSETTS TITLE , V & TOWN OF an ti H FLOOD ZONE q00 }a2 �o Eas M� ST WITNESS : �OT 'R�Vt�Q �, 12/JST��Gh BOARD OF HEALTH REGULATIONS. Ro ��r� C ES REFERENCE. DATE ✓}�� 2 U 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, ASTORIA tSJ" PERCOLAT 1 ON RATE:' L M t N !N + SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO GR INSTALLATION. T3 sr s O eutt ,t 90 l j I: TH- I C—L. 0,50 TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION �� F � ��( WN N `� tF,?ASSET� Ems, . (� 4 ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE ovM g� Iq� I l,o R 3 Ht c TZ. I�l r ��{{ (DPI �y DETERMINATION. r SANfl j g y ¢ LOpF.M 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "t FOOT. (UNLESS SPECIFIED OTHERWISE) 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A LOCAT ION MAP (Wr,S) I rjt vm 6 GARBAGE DISPOSAL. {�D n^ �J 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) (20 A4_ezl s MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON Cy s A BASE OF 6"OF CRUSHED STONE. 2•SY l _�X1�it1N G�55Poat,s � (3C PvN►�°Eb, C1�uStt��D 132 T �-- �wv PA TiTI,E V. -- • -NO_V4\J I VA-Tr,- WI✓L b� Wl1 nl /5U O F- heOp. >✓1LA-rv175 W !N ✓� o F �p lhG}h nl SEPTIC SYSTEM DESIGN �° (N p v �i l�or� TL� �- r,C- � -t� o o D FLOW EST I MATE A-)'V-V G BEDROOMS AT 110 GAL/DAY/BEDROOM - 33O GAL/DAY 3 �3�- 'D U P N01 '^J SEPTIC :TANK 1 _ lK-TU kL- Exit !'l RO PE Z � '730GAf_/DAY x 2 DAYS - GAL �x�snNy USE L.��2 GALa,LONSEPTIC TANK NEIA) T JAOIr 7) SOIL ABSORPTION SYSTEM (� 1= 1,500 15 eLl,-0#4 P6 CST I-C-A-Q4, C04M> SoNr,- ON At,(-SI126S LZ5,Lx I3Iwx2tfl ! X.J4h S;DE AREA: �(ZS) Z + 2jx2 X 0.7f IIZ S 1 B6TTOM,AREA! 7-5 x 13-x O ¢ = Zoo.�-o 363 GPr, SEPT I C SYSTEM SECTION > 330 GPn req eT o tv 1 EX/S TING pF \I �m-� WELLING � "� c1 G. 4C_S� 7 'm Z C G43.68�N \ \ rJ Vkk CO UGIC S "W/1 A 9 4, \ G 1 y4>0 n , 1" �- �0 0 �nr5ti rgc(e 9 MTN 1 Hof _ T o _ \ �r�Q� n ,r �/ /7" �0 1 g • _ �Z> 1 -1 0 1nst�ll 1 d vv e e EL 40 zn ri cm�i «.�J` / �\ (�q� Fla ffh t 7 = rJ 0 1� r u >; 4�:42 �. Co''S�vYre G 'Stw►c 93 E ,� fl TJ o -ro> �y j/ OCR GAL o D-B1O�X 3S. -1-rt� ��• �a�lLsf" 3 n SEPTIC TANK /41r- try �Uvhl e �l' >a EDGE OF PAVEMENT � � Q mA lufvt> W Sl7 ed Stow Sv BACON ROAD a ; f SITE AND SEWAGE PLAN LOCATION : q'( 5prwt4 � tN Of RA � �02 p Eyq PREPARED FOR l�t�C�/� V o �3 CAWS 0 ER 1 U L i $ No. 1140 � O C � r_ a SANiTAR�� DARREN M. MEYER, R.S. s ALE --30 1 JA P.O. Box 981 DATE: 31 t)S t EAST SANDWICH, MA 02537 DATE HEALTH AGENT Ph: (508) 362-2922