HomeMy WebLinkAbout0343 BEARSE'S WAY - Health 343 Bearse's Way
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 343 Bearses way-Hyannis,Mass.
Owner's Name:_Deutsche Bank National Trust Co.
Owner's Address: 3 Park Plaza 16th Floor Irving Cal.92614
i
Date of Inspection:_9/28/08 G
Name of Inspector:(please print)_Eric Stevens I ✓�aA
Company Name:_E.Stevens Construction,Inc.
Mailing Address: P.O.Boz 71 Marstons Mills,Ma.02648
Telephone Number:_(508)776-9054
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection.The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310
CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 13G
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of CZ.,
Health or DEP)within 30 days of completing this inspection.If the system is a shared system orPs a = w
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 cggi4 s sent toi
the buyer,if applicable,and the approving authority. o co
J �•
Notes and Comments System was upgraded in 2004.In good working order o —v
ti
****This report only describes conditions at the time of inspection and under the conditions f use at
that time.This inspection does not address how the system will perform in the future under t e same
or different conditions of use.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
V
Property Address: 343 Bearses way
Owner:_deutsche_Bank
Date of Inspection:_9/28/08
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_ I have not found any information which indicates that any of the failure criteria described in 310
CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: Everything is in good working order.S.A.S.was dry at time of inspection
due to house vacancy.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced
or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,
will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will
pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 343 Bearses way
Owner:_Deutsche Bank
Date of Inspection:_9/28/08
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)
that the system is not functioning in a manner which will protect public health,safety and the
environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines
that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100•feet
of a surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply
well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more
from a private water supply well**.Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to
this form.
3. Other:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_343 Bearses way
Owner: Deutsche Bank
Date of Inspection:_9/28/08
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_x_ Backup of sewage into facility or system component due to overloaded or clogged SAS or
cesspool
i _ 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 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 ground water elevation.
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
x_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_x_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. [This system passes if the well
water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist
as described in 310 CMR 15.303,therefore the system fails.The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant
threat,or answered"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.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 343 Bearses way
Owner:_Deutsche Bank
Date of Inspection:_9/28/08
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
x Pumping information was provided by the owner,occupant,or Board of Health
x Were any of the system components pumped out in the previous two weeks?
x Has the system received normal flows in the previous two week period?
_x Have large volumes of water been introduced to the system recently or as part of this inspection
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?
x _ Were all system components,excluding the SAS,located on site?
i _x_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and
depth of scum?
_ _x_ Was the facility owner(and occupants if different from owner)provided with information on
the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined
based on:
Yes no
x _ Existing information.For example,a plan at the Board of Health.As-built card
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 343 Bearses way
Owner:_Deutsche Bank
Date of Inspection: 9/28/08
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3_ Number of bedrooms(actual):_3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330
Number of current residents:_0
Does residence have a garbage grinder(yes or no):_no_
Is laundry on a separate sewage system(yes or no): no_ [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):—no-vacant
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): no_
Last date of occupancy:_2007
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgtetc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
I
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:
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,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)
_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 was
installed in 2004
Were sewage odors detected when arriving at the site(yes or no):—no—
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_343 Bearses way
Owner:_Deutsche Bank
Date of Inspection:_9/28/08
BUILDING SEWER(locate on site plan)
Depth below grade:_26"
Materials of construction:_cast iron _x_40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):_Sewer line is true and no sign of
leaks in basement.
SEPTIC TANK:_X(2)_(locate on site plan)two 1000 gal.h10 tanks in a row.
Depth below grade:_16"
Material of construction: X_concrete metal_fiberglass polyethylene—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a
copy of certificate)
Dimensions:_(2)_1000 gal.h10 tanks side by side.
Sludge depth:Tank(1)_18"
Distance from top of sludge to bottom of outlet tee or baffle: 26"
Scum thickness:_7"
Distance from top of scum to top of outlet tee or baffle:_6"
Distance from bottom of scum to bottom of outlet tee or baffle: 6"
How were dimensions determined:_mearsured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.): Both tanks are sound with T's and gas
baffle's in place.2nd tank had no solid carryover.Just full of effulent.
GREASE TRAP:_(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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 343 Bearses way
Owner:_Deutsche Bank
Date of Inspection:_9/28/08
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.): D-box is level and working correctly.No sign of
solid carryover.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 343 Bearses way
Owner:_Deutsche Bank
Date of Inspection:_9/28/08
SOIL ABSORPTION SYSTEM(SAS):_X pocate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
X leaching chambers,number:_(5)3050 Infiltrators_
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.): S.A.S was dry at time of inspection.Checked with inspection port located in
middle of field.House has been vacant the better part of a year.
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 343 Bearses way
Owner:_Deutsche Bank
Date of Inspection:_9/28/08
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks
or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_343 Bearses way
Owner:_Duetsche Bank
Date of Inspection:_9/28/08
SITE EXAM
Slope X
Surface water X
Check cellar X
Shallow wells
Estimated depth to ground water 2168" feet
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If checked,date of design plan reviewed: 2004
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: Perc test from system design
showed no ground water at
168"
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Town of Barnstable P# 7 7
Department of Regulatory Services L -
• Public Health Division Date
MAJ.xnNae�►etB g
:
, �& 200 Main Street,Hyannis MA 02601 prFD MP't
Date Scheduled v / P 7 Time Fee Pd. a O
Soil Suitability Assessment for Sew a Disposal
Performed By: Witnessed By: �
LOCATION & GENERAL INFORMATION
Location Address 3 Y3 664,rse r � Owner's Name Ct;, rn
Address 315. Z?J ZR�� l�
Assessor's Map/Parcel: `�/ a�—l��@ Engineer's Name 10. . c4d/ )4< / S
NEW CONSTRUCTION REPAIR Telephone# 6o 77 —hh9700
Land Use �f�Z4J/lJ Slopes('Yo) Q I� Surface Stones
Distances from: Open Water Body ND ft Possible'Wet Area /UU ft 'Drinking Water Well
Drainage Way NO ft Property'Une 8 It Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
�353 .�
Parent material(geologic) -sj" �� *"" Atpo_d to Bedrock y/
Depth to Groundwater. Standing Water in Hole: I Weeping from Pit Face r/
Estimated Seasonal High Groundwater
23 (I.3RS6d vpd u Tw.v mov j
DETERMINATION FO SEASONAL H�GI3 WATER TALE
Method Used: ��/
Depth Observed standing in obs.hole: in. Depth t soll mottles: ln.
Depth to weeping from side of obs.hole: id. Groundwater Adjustment _.. ft.
Index Well# Reading Date: Index Well level Adl.factor,,,,,_ Adj.Oroundwater level A
PERCOLATION TEST taste 8 ° '1lYme
Observation .J
Hole# 1 Time at 9" .._
at 6"
Depth of Perc7411 Time
Start Pre-soak Time @ Time(9"-6")
End Pre-soak
Rate MinJlnch L2
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) 4)
Original: Public Health Division Observation Hole Data To Be Completed on Back----------
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTICVERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole# 1
Depth from Soil Horizon Soil Texture Soil.Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistent %Gravel
aL
0�/6Bii �2 Med.S1+,, l 2,5y 6/4
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
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
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Sol] Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. I
Flood Insurance Rate May:
Above 500 year flood boundary No— Yes
Within 500 year boundary No,/✓ Yes
Within 100 year flood boundary No V 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 �B(l.���-3(date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required tr ' xpertise and experience des 'bed in 310 CMR 15.017.
Signature Date— g
Q:\SEPTICVERCFORM.DOC
COMMONWEALTH OF MASSACHUSETTS
Ch EXECUTIVE OFFICE OF ENVIRONMENTAL M
DEPARTMENT OF ENVIRONMENTAL PR TECT
JUFAILED INSPECTIONTOWN HE
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP
Property Address: 343 Bearses Way
P
Hyannis ARCEL
Owner's Name: Wersilley Castro LOT
•
Owner's Address:
Date of Inspection: 6/3/2004
Name of Inspector: (please print) Patrick T. Sullivan
Company Name: Ready Rooter
Mailing Address: P.O.Box 371
Sandwich,MA 02563
Telephone Number: (508)888-6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
,,,O"'Fails
Inspector's Signature: ^�(�---� Date: c,
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
' Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
Inspection Summary: Check A,B,C,D or E/ Xaluated
f S tion D
C. System Passes:
I have not found any information which iailure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failuree indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be placed or
repaired.The system,upon completion of the replacement or repair,as approved by the Board Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the for the following stateme . If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(w er metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is' ' ent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, t leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or 'gh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or un en distribution box. System will pass inspection if(with
approval of Board of Health):
broke/n pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required p mg more than 4 times a year due to broken or obstructed pipe(s). The system will .
pass inspection if(with appro of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
' Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaXvegetated
e Board of H in order to determine if the system
is failing to protect public.health,safety or the en
1. System will pass unless Board of Health in cordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner wect public health,safety and the environment:
_Cesspool or privy is within 50 feet of , ter
Cesspool or privy is within 50 feet of vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)dete nes that the
system is functioning in a manner that protects the public health,safety and environme .
_The system has a septic tank and soil absorption system(SAS)and the SAS i 'thin 100 feet of arfa suce water supply or tributary to a surface water supply.
_The system has a septic tank and SAS and the SAS is within a Zon of a public water supply.
_The system has a septic tank and SAS and the SAS is within feet of a private water supply well.
The system has a septic tank and SAS and the SAS is le than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine ce
**This system passes if the well water analysis,perf ed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates tha a well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitro n is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analy s must be attached to this form.
3. Other:
' Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or
cesspool
/�A Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
_,['Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
-,z-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 50 feet of a private water supply well.
_.Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
S (Yes/No)The system fails. I have determined that one or more of the above 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 flo 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 abov
yes no
_the system is within 400 feet of a surface drinking water ply
the system is within 200 feet of a tributary to a surfa drinking water supply
the system is located in a nitrogen sensitive ar (Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered`des"to any question in S 'on E the system is considered a significant threat,or answered
"yes"in Section D above the large system h ailed.The owner or operator of any large system considered a
significant threat under Section E or fail der Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should con the appropriate regional office of the Department.
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
" Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_,Z'Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or
cesspool
0 Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
_t./-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.
-,.z-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 50 feet of a private water supply well.
_.�,Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
S (Yes/No)The system fails. I have determined that one or more of the above 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 flo 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 abov
yes no
the system is within 400 feet of a surface drinking water ply
_the system is within 200 feet of a tributary to a surfa drinking water supply
_the system is located in a nitrogen sensitive (Interim Wellhead Protection Area—IWPA)or a mapped
Zone H of a public water supply well
If you have answered"yes"to any question in S 'on E the system is considered a significant threat,or answered
"yes"in Section D above the large system h ailed.The owner or operator of any large system considered a
significant threat under Section E or fail der Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should con the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
Check if the following have been done. You must indicate`yes"or"no"as to each of the following:
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
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 bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Iz- Was the facility owner(and occupants if,different than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
Existing information.For example,a plan at the Board of Health.
✓ _.'Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ��C'Yjz .
Number of current residents: 17
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):r, o[if yes separate inspection required]
Laundry system inspected(yes or no): —
Seasonal use: (yes or no):Aj cz�,
Water meter readings,if available(last 2 years usage(gpd)):
Sump Pump(yes or no):L9
Last date of occupancy: c-,:j t r�
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgtetc.):
Grease trap present(yes or no):
Industrial waste holding tank present or no): _
Non-sanitary waste discharged to the ifle 5 system(yes or no):
Water meter readings,if availabl
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: n, �z
Was system pumped as part of the inspection(yes or no):.�
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
SeptF SYSTEM
ic tank,disWbo6ex-box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):,tr�j
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC_other(e lain):
Distance from.private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:Zo&cate on site plan)
Depth below grade: ( '"
Material of construction: vc ncrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: -0 x
Sludge depth:
Distance from the top of sludge to bottom of outlet tee or baffle: Z) it
Scum thickness: i "
Distance from top of scum to top of outlet tee or baffle: 4 °
Distance from bottom of scum to bottom of outlet tee or baffle: 1
How were dimensions determined: --e sA
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
�i i�iw� � "��S'L7'C��a'b V� �ti� �r,.l►''� w..� O V�2./- D���t��
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fibergl _polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top o/ge,
Me:
Distance from bottom of scum to be or baffle:
Date of last pumping:
Comments(on pumping recommet
d outlet tee or bade condition,structural integrity,liquid levels
as related to outlet invert,evidenc :
Page 8 of 11
I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
TIGHT or HOLDING TANK: (tank must be pumpedZtimespection)(locate on site plan)
Depth below grade:
Material of construction: concrete_metal fiberglassene_other(explain):
Dimensions:
Capacity: gallons
Design Flow: !al
lons/day
Alarm present(yes or no):
Alarm level: Alarm in working er(yes or no):
Date of last pumping:
Comments(condition of alarm an oat switches,etc.).
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan))
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chain r,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
SOIL ABSORPTION SYSTEM(SAS): -.jf!f"0ocate on site plan,excavation not required)
If SAS not located explain why:
Type
_,�eaching pits,number:
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.):
CESSPOOLS: (cesspool must be pumped as part o tion)(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 infio (yes or no):
Comments.(note condition of oil, 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, sign/oydraulic failure,level of ponding,condition of vegetation,etc.):
• Page 10 of 11
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Bearses Way
Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
u
. Q
5 � I
O O O = 30` 6 /1
,6 = Q LC
i
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Bearses Way
i Hyannis
Owner: Wersilley Castro
Date of Inspection: 6/3/2004
SITE EXAM
Slope
Surface water
Check cellar f
Shallow wells
Estimated depth to ground water>0 feet
Please indicate(check)all methods used to determine the high ground water elevation:
(Obtained from system design plans on record—If checked,date of design plan reviewed: q
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with the local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain: v-,„v, c, ; r, vs6.5,
You must describe how you elished the high ground water elevation:
,r-
--
TOWN OF BARNSTABLE
\ L. CATIC. M-(�� SEWAGE #
ViLLAGE �&AO !S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE N
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
k.-;O.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
CA P
Dq,(
- a
i
i TOWN OF BARNSTABLE
LOCHATION; 3 e4/"$j- ' 1/1i4 Y SEWAGE # i!d
VILi:AGE H. AIV I 1 S ASSESSOR'S MAP& LOT v2
INSTFLLER'S NAME&PHONE NO. A!'e& C C 7 A,' 0 iC
SEPTIC.TANK CAPACITY �bl
CACHING FACILITY: (type) h -70 To (size)
NO.OF BEDROOMS
5UILDER OR OWNER W4 ,T GL C 5
PERMITDATE: l I71U `{ COMPLIANCE DATE:
,Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) _ Feet
Edge of Wetland and Leaching Facility (If any wetlands exist `J
within 300 feet of leaching facility) Feet
FurnisheAby
'34-
A C- 3 �.
A F
� 3 a
Fee
No. �
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Z[p prtcation for 30igozar 6potem Con5tructton Permit
Application for a Permit to Constntc )�Repair ) rade( )Abandon( ) ❑Complete System ❑Individual Components
Location Addre/A or Lot No. /'/ �1 Owner's Na►ge,Address and Tel.No.
y� vCFl2S,6..5 (:�gY l ylJi✓.✓i S WE/2 57f/// 6A5-7e d
"Assessor's Map/Parcel
;Z ZZ ®;L ep 3,e/7 t(54C ajt s t?s W/a Y
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
/32C-lJ dooc/ST �10 CA)AOI
Type of Building:
Dwelling No.of Bedrooms t3 Lot'Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily,flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Cc s'i /oo 2o Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y this Board of Heallb. 01 /
Signe o oA. Date !'<
Application Approved by Date
Application Disapproved for the following reason
Permit No. Date Issued
--------------------------- --_-- ------- ----- -
fy
i.. -No. 1 -----�. Fee
1
THE COMMONWEALTH OF MASSACHUSETTS �- t Enteredn Coniputer:f f
Yes
.PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS "
01pphratton for �Dtgogar *pgtem Comaruetiou'Vermdtt
Application for a Permit to Construct°( )Repair(A)Up rade( )Abandon( ) ElComplete System El Individual Components
Location Address,or Lot No. Owner's Name,Address and Tel.No.
J 513 Uc- 2Sc S Ge,-f) 5 66�E 4, 5'1 //y ens z n d
Assessor's Map/Parcel _1/ 0h�+l
02 z oZ v w tt4 ..
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
S�v < 7 > > 3 2 5- oF - -25 577 D
Type.of Building: -3�y
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow rJ s6 gallons per day. Calculated daily flow � � gallons.
/ Plan Date Number of sheets Revision Date
/
Title
r Size of Septic Tank e ' ' ' �"� Type of S.A.S.
Description of Soil
4- All
Nature of Repairs or Alterations(Answer when applicable)
a
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health-
Signed, C Date
Application Approved by - �U ' � �! / Date �� f
ti
Application Disapproved for the following reaso
Permit No. .. c `i Date Issued
041
THE COMMONWEALTH OF MASSACHUSETTS
7 BARNSTABLE, MASSACHUSETTS
I jo W N)r►^S In 6'semo 7 1 Certificate of Compitance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (Upgraded( )
Abandoned( )by f �` e /� /�,�
3-1/3 (5rp2s �=s lli✓� %
at � hajs;by�constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. en
Installer Designer
The issuance 11syp l't s_liall not be construed as a guarantee that the st m w f�unctio as-des'
Date ►I ' Inspector
t
No.;TNT
/1 --------- --- --
� Fee
i/ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
'Woogal *pgtem Congfrurtton Vermtt
Permission is hereby granted to Construct( )Repair Upgrade( )Abandon( )
System located at
I/ly
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:Construction st be co l�ted within three years of the date of this- e" rmit�
��/ v
Date: Approved by
TOWN OF BARNSTABLE
LOCATION Y SEWAGE# )00 — L/6
VILLAGE AIL/f1B y 5 ASSESSOR'S MAP& LOT_,;Z
INSTALLER'S NAME&PHONE NO. C 8 7
SEPTIC.TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS .
BUILDER OR OWNER W e�
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:.._.._..
° Maximum Adjusted Groundwater Table . d 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
Furnishe by
00
I
p .2,y t
� 6 .
A F ® SO
r
Town of Barnstable
• �, `"� o Regulatory Services .
Thomas F.Geiler,Director
MAM• .a,�v�rRsrt, •
g Public Health Division '
i639. �g
t .r. Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Forth
Date: lzq (2)4-
Designer: J t L. Installer: Arc 000,51• Co
Address: 2_5A Address: 9/`/
On was issued a permit to install a
(date) (installer) .
septic system at 3 43 BC-Ai-5 t;.s W N LJU a,,n&ased on a design drawn by
(address)
f310�4-
•J ,CA D(L(ALi 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 relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical.relocation of any component
of the septic system)but in accordance with State&Local Regulations. Plan revision or
certified as-built by designer to follow.
��,,H OF 444,8
RONALD sG
JAMES
CADILLAC
`'(Instillees Signature) 9 #1060�a
S"NI TAP\P
(Designer's S ature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC H]kALTH DPASION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTIN THIS FORM"AND AS-
BUILT.CARD ARE RECEIVED By THE BARNSTABLE P LIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Demper Certification Form
SEP-13-04 02 :24 PM R. J. CADILLAC. PLS. RS 508 775 9700 P. 01
3-4
ci-1-5* r(co �i�
Z
�\l o Beirooms in boiSemeoT
��. TOWN OF BARNSTABLE•
w.t
i.�.iCATTJiV �/3 Bncai25f5 GcJlac% SEWAGE #
VILLAGE ASSESSOR'S MAP d LOT
INSTALLER'S NAME PHONE NO.77P MACOMGr l r So 1.,
SEPTIC TANK CAPACITY /00 p
&ACHING FACILITY:(type)—P,4' (size) 1000
_;NO. OF 'BEDROOMS PRIVATE WELL OR PUBLIC WATER
ftft&OR OWNER .
DATE PERMIT ISSUED: ,m
DATE COMPLIANCE ISSUED: �
VARIANCE GRANTED: Yes No
�J
I
rice-
i
}
No. -7.. Fxs....$....30...��.
r bleConsov D8p8 m8M HE COMMONWEALTH OF MASSACHUSETTS
mvewz OARD OF HEALTH
iDnet! Date TOWN OF BARNSTABLE
Allp iratiun for Ui_ripwial Wurlai Towitrurtiun rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair kX) an Individual Sewage Disposal
System at:
343 Bearses Wa Hyannis
....................••••---••..••....•d
------------•--.............----•- --••-•------------•----------•-----•----------••-•-••-------------•-•-----.....---•••......••-----
Location-Address or Lot No.
He 1_e n---..i s..e l Y..............••-----•--•------------------------•--...._....._
W J.P .Macomber Jr . Owner Address
Installer Address
UType of Building Size Lot............................Sq. feet
�. Dwelling X No. of Bedrooms---------------------
-----------------------Expansion Attic ( ) Garbage Grinder ( )
CL4 Other—Type of Building ............................ No. of persons-----------2............... Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length............... Width..............-. Diameter.....--......... Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet---................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed b Date........................................
.a Test Pit No. 1................minutes per inch Depth of Test Pit.--................. Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ...............
--------------------
•-----------------------
•--------------------
•-------------------
------... ...................
--------------_-----
0 Description of Soil---------------------------------------------------------------------------------------------------------------------------------------------------------- --------
U ---•-----•••....-------••-•--------•--....Banc-•_& Gravel
W
x -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-----••-------------•_..
U Nature of Repairs or Alterations—Answer when applicable.............................omit---ce.ssnooi_s-.,.._.-install
1--•1000...gallon_-tk an __.1_-._-di-s_tr1bution._box__ 1-1-0-00___gal-lon__ l e ach...pit packed___in stone
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complian e has ben 'ssued by the b and f health.
Signed ... ,.Y(J/.'f'� ... .4/2.0%9.4.......:......
dC / Dare
Application Approved By ............� ---
.�..a. e .`I.�
Application Disapproved for the following reasons: ........................................................................................................................................
................................................................................................................................................................................................................ ........................................
Dace
PermitNo. �� yi3 ............................ Issued ....................................................................
Dare
30.00
No...............�.� �' FIms.............................
THE COMMONWEALTH OF MASSACHUSETTS
4•BOARD OF HEALTH TOWN OF BARNSTABLE
.c ppliratiou for Bi-tip 1 ial Workii Towitrnrttitn Permit
Application is hereby .made for a Permit to Construct ( ) or Repair (KX) an Individual Sewage Disposal
System at:
s
343 Bearses Way Hyannis
Location-Address or Lot No.
Helen Nissely
W J.P.Ma a ombe r Jr. Owner - Address
•--•-----•---••----•----•--••--------------•--------------------------------------------•--•_...._ ........................................................
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling X No. of Bedrooms__________________--____-_---_-__-_-_.-_._-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons...._..__......_..._........ Showers ( ") — Cafeteria ( )
a' Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid'capacity--_-_-.---_.gallons Length................ Width................ Diameter................ Depth.__._._.__......
x Disposal Trench,`No. .................... Width.................... Total Length................_--- Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
fZq Test Pit No. 2................minutes per-inch Depth of Test Pit.................... Depth to ground water........................
n+ -••••••-•••••-•--------•-••••-
O Description of Soil____________________
V -•-••-......_..-••••-••••••-----!••••••...Sand & Gravel
- -- ---
W
U Nature of Repairs or Alterations—Answer when applicable-----------------------------omit-••c esspool-s_.-,-•-install
1-I000--Gallon- tank 1---di•s-t-ribution box 1-1000_--gallon leach pit �pcked in stone
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been-issued by the board f health.
Signed ...� tl�/..... .... 412.0t9.4.......:......
Application Approved By ............ � //
...................................................................................
Dare
Application Disapproved for the following reasons: ........................................................... .................................................... ..................
.......................................................................................................................................................................::...................................... ........................................
Date
PermitNo. ............................ Issued ............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fEltifirate of V((..��amplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXXVX
J P.Macomber Jr.
by ....................................................................... ............................................................................................................................................................................
Installer
at .....34.3....Bearses...Way....Hyannis............................ ............................................
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -.'-�6N!
_..`... ...�.......... dated ...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT TRU�EA AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
........
DATE..../.. ......--... ?................/.................... Inspector.:... ? ......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH - ,
TOWN.OF BARNSTABLE-
� FEE...... ...
'Btspnsal Works Tunstrnrtion permit
J P Macomber Jr.
Permissionis hereby granted•.-----�---.'-------------------------•-----------•••------._...--•-•••----••--•--•-••------:..............................................
to Construct ( ) or Repair (XX} an Individual Sewage Disposal System
343 Bearses Way..Hyannis
at No.... •.-------•••=----••--
street as shown on the application for Disposal Works Construction Permit No:Yt)'J�_57
Dated_-____.
.....................:.......... -------------•-•-
Board of Health
DATE ('�-a-- ---- -- ��___--•----------•-----------------•-
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
ALWAYS DIG SAFE PRIOR TO CONSTRUCTION--UTILITY LOCATIONS SHOWN INCOMPLETE. JOB NO. B04-15
CAUTION: THIS IS A SITE PLAN NOTES Costro.dwg R'►E 2_8--
SURVEY, AND NOT A PROPERTY 1. LOCUS IS A.M. 292, PARCEL 20.
LINE SURVEY BY THIS OFFICE. 2. ELEVATIONS SHOWN ARE TOWN GIS f0.4'.
LOT LINES SHOWN ARE APPROX- 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED AUGUST 19, 1985.
4. ALL PIPES TO BE 4" SCH 40, AND PITCHED AT 1/4" PER FOOT. (UNLESS NOTED)
0 IMATE. NO PLAN EXISTS FOR 5. MUNICIPAL WATER IS AVAILABLE. LOTS WITHIN 100' ARE ON TOWN WATER.
6. COMPONENTS TO BE AASHTO H-10 UNLESS NOTED. Gen. Patton
LOCUS. PLAN CITED IN DEED „ ' „ Dr.
c� x 49 7. INLET TEE TO PROJECT DOWN 13 , OUTLET TEE DOWN 14 . o
ABUTTS LOCUS. 8. IF TWO OR MORE LINES, WATER TEST D-BOX FOR EQUAL FLOW
'n D-BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET.
N 9. DEPTH OF COMPONENTS NOT TO EXCEED 3', OR VENTING MUST BE PROVIDED. NOT TO
06 COVERS: BUILD UP COVERS TO 6" BELOW GRADE--1 ON D-BOX, 1 ON LEACHING SCALE
01 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 TO 1/2„ PEA STONE ON TOP. LOCATION MAP
4910 11. IF UNSUITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUND,
a4n920 CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC.
12. IF AN OVERDIG IS CALLED FOR BELOW, FILL MATERIAL FOR 5' AROUND AND UNDER LEACHING
IS TO BE CLEAN GRANULAR SAND MEETING SPECIFICATIONS OF 310 CMR 15.255(3). TEST HOLE 1 (P10,777)
4 ,1 13. PUMP AND FILL ANY EXISTING CESSPOOLS. REMOVE ANY CLOGGED SOIL, BLOCK, AND STONE IN
49 LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT. DEPTH (inches) ELEV.(feet)
14. ALL CONSTRUCTION TO MEET TITLE 5 AND LOCAL REGULATIONS. 0 47.9
/ m TEST HOLE DATE: August 9, 2004
PERFORMED BY: Ron Cadillac, Soil Evaluator
/ 8 6 fill
WITNESSED BY. David Stanton, RS
33 PERC RATE: <2'-00"/inch (C layer)8 48, NO GRADE CHANGES 49.1 SOIL SURVEY(1993): Eastchop loamy fine sand „
4& ' ARE PROPOSED Top Found. GEOLOGIC MAP(1986): Barnstable plain deposits 60 42.9
/ ' Q C1 layer 2.5y 5/6
rn / 4�e4 6 48 3 Invert 46.57t 74„a loamy med. coarse
/ Invert 45.27 Invert 44.95
N/F �/� ' r Exist. Cast Iron Use Gas Baffle Use Gas Baffle , sand
Existing Proposed Invert 44.20 5 INFILTRATOR 3050 S 90„ 40.4
CHASE 48,6 =rn / O / �� Proposed 44.2
•� � - - - - -1 - C2 layer 2.5y 6/4
4 G�� // �/ / / NE
\ 48 fl2 Existing Proposed S=1"/ft TOP PEA4"T�nspection
48 2 48 6 ��/ 48, I 1000 Gal. I P S=5/8 /ft Port medium sand
�P Invert 45.52 Septic Tank 1000 Gal. -----� _
Existing L- - - - - Septic Tank
�,1' / g.6 �G'/ x 48, 24" 168„ no water 33.9
�! 4 /GO x Invert 45.20 T
48.5 / Proposed
::'..48 48.7 Invert 44.37 Invert 43.70 41.7
BENCH MARK--TOP OF WOOD 4 ,9 /� ::..� / x 6 Stone or compact Proposed Proposed I 7.8 Bottom
STAKE=47.94 (TOWN GISt0.4') TH 48.3 1 I t IV 1 ,-I
x ,
(10'-10. OFF HOUSE CORNER) \,8 /4 4H 6 I W 1( r-7 1 I_ I 1 a CD Bottom TH1=33.9
<
tioTti� DESIGN DATA
47, 47.94 6: ,9 qS
BEDROOMS: 5
BENCH MARK--S.W. CORNER OF LA .47 B '�>o S� 48, GARBAGE GRINDER: No
CONC. BULKHEAD=4&61 v �I �$ CAUTION: PUMP EXISTING SEPTIC ` _. _._ _ __. _ ._i LEACH-`AREA
t( 47.5 REQUIRED CAPACITY 550 GPD
(TOWN GISt0.4) 47 •-•: TANK PRIOR TO DOING OVERDIG.
' tv 47, k EXIST. & PROP. SEPTIC TANKS: 2000 GAL. USE 5 INFILTRATOR 3050'S WITH APPROX.
BOTTOM LEACHING AREA: 528 SF 4' OF STONE ALL AROUND TO MAKE A
x 47. , k [(44 X 12')] 44' X 12' X 2' DEEP LEACH AREA.
47.5 _ `L1 N/F SIDE LEACHING AREA: 224 SF 5, REMOVAL
47,0 ' [2(12'+ 44') X 2' DEEP)]
C) DIXON , TO LOAMY M
.::..:: . "�. 47.1 co/ 46,9 - X DESIGN CAPACITY: 556 GPD L DO COARSE F AND.
/ `�::•:;:' .,� IV/ [(528 SF + 224 SF) X .74 GPD/SF] DOWN 5
:: 07,0
:.:.....
46.9
nc. .417159 ....... BOARD OF HEALTH REQUIRES R.J. CADILLAC
Bound �,• ,�o x , : t : : ::.� TO INSPECT SEPTIC SYSTEM:
7;
Found :::::::...
''::
ems::. : 47,0 1 . CALL R.J. CADILLAC OR HEALTH AGENT TO
...:: 2,
INSPECT REMOVAL HOLE PRIOR TO PLACING
NEW MATERIAL.
47.0 2. CALL BOTH R.J. CADILLAC AND HEALTH
8 o 7,5 AGENT FOR FINAL' INSPECTION.
N/F , SITE PLAN
MONTIERO 47,o FOR
THIS PLAN IS A VALID COPY ONLY IF IT BEARS
Conc. AN ORIGINAL RED STAMP AND SIGNATURE. WERSILLEY C. & SELMA CASTRO
c�±cA'n Bound
LEGEND Found
� f 343 BEARSES WAY HYANNIS MA
TH 1 TEST HOLE LOCATION, NUMBER N/F 9
4✓ WATER LINE MARKINGS ENNES '` RONAI RoNP4LD s"
E OVERHEAD ELECTRIC WIRES (IF SHOWN) n� 3 ,, �� AP AUGUST 23, 2004 SCALE: 1 =20
G GAS LINE MARKINGS #1-I our /` r>m U 05'�
x 9.5 X$,7 EXISTING & PROPOSED ELEVATIONS ('X' MARKS POINT)
A0
6-- EXISTING CONTOUR
� °suRv��° " RONALD J. CADILLAC, PLS, RS
8- PROPOSED CONTOUR '� '_�� ' ` �e����'��
0 UTILITY POLE (IF SHOWN) v ;' PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN
® EXISTING DRAINAGE CATCH BASIN P.O. BOX 258
x - FENCE (IF SHOWN, NOT ALL SHOWN) WEST YARMOUTH, MA 02673
TREE (IF SHOWN, NOT ALL SHOWN) HEALTH AGENT APPROVAL DATE PAGE 1 OF 1
(508) 775-9700
REV. 9/13/04--TANK SIZE REVISED TO MEET 1995 CODE (PRIOR PLAN MET 1978 CODE) @C 2004 BY R.J. CADILLAC