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HomeMy WebLinkAbout0083 BETH LANE - Health 71 BETH LANE, HYANNIS A=272-171 i i L Commonwealth of Massachusetts ,i; Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Beth Lane(laundry system) ' Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020,� page. Cityrrown State Zip Code Date of Inspection r � 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. Inspector Information 6/'Or- 141008 on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane IC=V Company Address Centerville Ma 02632 Cityrrown State Zip Code �e 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails - 8/11/2020 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ip, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ........... / 71 Beth Lane (laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The property located at 71 Beth Ln Hyannis is served by 2 Title V septic systems. This report represents the laundry system consisting of a 1000 gallon septic tank, distribution box and 4 Infiltrators. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is Hyannis Ma 02601 8/11/2020 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts 1= , . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is Hyannis Ma 02601 8/11/2020 required for every H y - page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 aseptic 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ., � 71 Beth Lane (laundry system) Property Address Jane Cutler Owner Owner's Name information i e required for every Hyannis Ma 02601 8/11/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone,1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts . Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 71 Beth Lane (laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 f Commonwealth of Massachusetts . Title 5 Official Inspection Form (- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes [D No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ® Yes ❑ No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 I Commonwealth of Massachusetts ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Beth Lane (laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every y H annis Ma 02601 8/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 1E f Commonwealth of Massachusetts ,g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �n ............, 71 Beth Lane (laundry system) Property Address Jane Cutler Owner Owner's Name information is H required for every yannis Ma 02601 8/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: system installed 3/13/1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 THIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w � 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons 5" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2„ Distance from top of scum to top of outlet tee or baffle 7 Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f Commonwealth of Massachusetts +n . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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): M Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts 1- g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. 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.): Distribution box was video inspected and found level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp-doc•rev-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y ........... „ J 71 Beth Lane (laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: 4 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8111/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s was not located, no lush vegetation, no signs of past overloading. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts !� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments +M Ji 71 Beth Lane (laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 3S or a9' a91 y� 3s ( i ;3E rn L A,.E t5msp.doc•rev.72621118 Title 5 Official Utspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 71 Beth Lane(laundry system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: _ Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Beth Lane(laundry system) Property Address Jane Cutler, Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 't t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts ta7-7d--1 �- �� ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments t c 71 Beth Lane( main system) ; Property Address Jane Cutler A g° Owner Owner's Nam t information is ? required for every Hyannis Ma 02601 8/11/2020 page. Citylrown 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. Inspector Information 5/# Ig901 on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name _ key. 74 Beldan Lane Company Address Centerville Ma 02632 Cityrrown State Zip Code Ion 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection 1 have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authon 4. ❑ Fails 8/11/2020 Inspector's Signature Date The system inspector shall It a Xcopy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .1y e 71 Beth Lane(main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The property located at 71 Beth Lane Hyannis is served by two Title V septic systems. This report represents the main system consisting of a 2500 gallon 2 compartment septic tank, distribution box and 3 precast leaching chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) 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 es no"or"not determined Y, N, ND for the following statements. If"not Y ( ) 9 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 g1pd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is y required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes E No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ® Yes ❑ No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No. Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is H required for every y annis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: system installed 4/6/2009 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 71 Beth Lane ( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): t Depth below grade: 2feet Material of construction: ® concrete ❑ metal El 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: 2500 gallons 2 compartment Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" 7" Distance from top of scum to top of outlet tee or baffle Distance from bottom of-scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is a 2500 gallon 2 compartment h-20 tank in driveway with steel covers to grade. Tank was strucurally sound and not leaking. Tank has 2 inlets both from house and from RV drain access in driveway. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form (� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, Inlet and outlet tee or baffle condition, structural Integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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): i Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): oilDepth 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. Steel cover to grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Beth Lane( main system) Property Address ' Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71-Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. City town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 3 precast leaching chambers in a 42'x13'x2'trench. Leaching facility was dry at time of inspection with no signs of past hydraulic overloading. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts in Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 ANT JA RI v i SyrTi�i►► s s F epV',ZS ;r t5insp.doc•rev.7/262018 THIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts i� Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every y H annis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 71 Beth Lane( main system) Property Address Jane Cutler Owner Owner's Name information is required for every Hyannis Ma 02601 8/11/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. i ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: i 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t 0 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 }= TOWN OF BARNSTABLE ` 1_0,"'ATION SEWAGE# VILLAGE/�J'��'��� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY � roo ,�-zeCr�� (�)c®dr�/c�Ti�C�s"� /o oo LEACHING FACILITY.(type) TOe (size) 00�1 S`aX eZ NO.OF BEDROOMS -� �II 6UV0 p0V1JV1T tt zb OWNER ���o�r✓7 PERMIT DATE: 3 —�s—off 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 JA elfAA' o sT �,r v 7' INI 7y,��� 0 od 10, OAI 'P J . r No. 20 — bS3 j� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for �Di5po5al 6p5tem Con.0truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) LA.(omplete System ❑Individual Components Location Address or Lot No. oo� Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel Z? �7sT Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 ► �`L�t Stze sq.ft. Garbage Grinder Other Type of Building Q 2"..� , No.of Persons Showers( ) Cafeteria( ) Other Fixtures �'Zr Design Flow(min.required) �9� gpd Desi�flow pfov1 ed Plan Date .� C O 9 Number of sheets / Revision Date r n n d-�— Title Size of Septic Tank �� o —3�"bo�'t GoiAD�� 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_g the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issuen bythhisa f Health. dSige p Date Application Approved by Date (2 Application Disapproved by: Date for the following reasons Permit No. 00 Date Issued o '� - b 53 Fee i Entered in computer: THE�COMMONWEALTH OF MAS�SA�CH`USETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for �i!5po!gal 6pgtern Con0truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) [;�Complete System ❑Individual Components Location Address or Lot No. i7/ /"�{% ��+. /�k Owner's Name,Address,and Tel.No. Assessor's Map/Parcel :� ',T �7a1 Vf 1 o�QJ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i Type of Building: s T Ms ovAk, 9q. Dwelling No.of Bedrooms "lze ft. Garbage Grinder Other Type of Building T'. No.of Persons Showers( ) Cafeteria( ) Other Fixtures h qqCC „� Design'Flow(min.required) �_'� gpd�Design/flow pi'ovi'ed Plan Date .7, -- Number of sheets I Revision Date Jel- r) Title Size of Septic Tank ti-? o —�r"`� G o_1yW_4 ype of S.A.S. Description of Soil IR 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 o the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B r of Health. Signed Date 'S _'/��� Application Approved by _ Date — /2 d Cl ' Application Disapproved by: Dated for the following reasons Permit No. 200� 053 Date Issued 3 / THE COMMONWEALTH OF MASSACHUSETTS -BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal,System Constructed ( Repaired ( ) Upgraded ( ) .• Abandoned( )by at �/ E3�t�'/Ti'at G'/•e. . ,off/��A/1i/�✓/f' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. X o O`( — 053 dated Installer - -i �`d/C Designer U/,CJ •6%//:bli4'•IO���'C .r. J��` ' #bedrooms J� Approved design flow d ���� I The issuance of this a it sha 1 n`ot construed as a guarantee that the system wi u ion as I p Date �?/ 7 Inspector L' // ; 1 =--_------__--------_ _ — \---/----.—. . No. D Dol 6 53 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS +1 Mi.5ponl *p!5tem Congtruction Permit Permission is hereby granted to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) System located at 9/ �Ei°�' �- , /yJr.�w.e.�✓° 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 must be completed within three years of the date of this permit. Date ?, Approved by �^ r 1 Tow, n-Qf Barnstable �•�� HE Teti Regulatory Services o " -Thomas F.Geiler,Director • �NS1'ABEE. ' . a Public Health Division lFo.►4+a a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: ZOl) � Designer: %'�yl� �. ' 1 r1I Installer• a , CI6L Address 5*T Address: 1444 MWI-67JAG[_�6M62 on (�Vas issued a permit to install a (date) (installer) septic system at 1HVA based on a design drawn by (address) dated Z � (designer) ' v,ertify that the septic system referenced above was installed substautiall y'accordin to . . g a design, which may include minor approved-changes such as later'a .relocation of the distribution box and/or septic tank- . . k . . , I cer.W,that the septic system referenced above was installed vsnth''malor,changes. 0'e greater thin 10' lateral relocation-of the SAS or any vertical eloaafican o£any component of the septa ;system)but in accordance with State &Local Regulations. Plan revision or,` certified as-butt*designer t6 follow. S u a . �K OFbMgs"9 2kDAVID. cG . (Installers attire) �• VIASON - •A 4�• No tfl66 � ' S s (D er s Signature} (Affix' gner's Staii�p Here) PLEASE RETURN TO BARI�TSTABLE PYJBLIC-HEALTH.DIVISION. C RTII+'I.0 TE Ole'.. COMP3LIANCE WtI.)L..°1rIO'I':MEN. SSUEU BOTH°-'3"-EJ[&-JFORM ` . 'AS_ BUILT CARD ARE RECEIVED]B'�I_THE B . STALE PUBLIC DSION THANK YOU. . a: Q:Health/Septic/Designer Certification Fora Town of Barnstable �,t+r P# Department of Regulatory Services I4� ' Public STABS Health Division oa 200 Main Street,Hyannis MA 02601 Date Date Scheduled Ttme Fee Pd. Soil Suitabilio Assessment for Sew e Das osal M Performed By: f ( to Witnessed By: ,00) t / LOCATION-&'GENERAL�©RM4TION Location Address 7� ��,�j - 'Owner's Name.`. Address Z/f pe�P';e e,-. y/ Assessor's Mip-Marcefi -7 _'J i Engineer's Name sxf NEWCONSTRUC17ON REPAIR 4�__ D Telephone# Land Use `. Slopes(%) •� � Surface Stones /(/ Distances from: Open Water Bod' y ft ` Possible Wet Area' t ' i J ft Drinking Water Weyer ft t Drainage Way R i Property Line ��__.ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pe;c tests,locate wetlandsn proximity to holes) • use Co a Z I Parent material(geologic) . O / Depth to Bedrock Depth to Groundwater. Standing Water in Hole: ''•• ''''^^ Weeping from Pit Race Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE - t Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in. Depth to Boll mottles: In, Index Well.# Readin =-ln Groundwater Adjustment ft. g Date: Index Well level Adl,factor, �� AdJ.arouttdwaterLevel, . PERCOLATION TEST bate Observation m xYtlta Hole# I Time at 9" -- Depth of Perc � -- ,-t Time at 6" Start Pre-soak Time @ � Time(9"-6") End Pre-soak, — RateMinJlnch '`� . Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed.(Y/N) 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 ConIserva I tion Division at least one(1),week'prior to beginning.. Q:ISEPTICIPERCFORM.DOC , DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture w Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Ca i tenc % ravel T210 Z— U�7 0 5 f rat 3 . DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% ray 00 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (.USDA) (Munsell) Mottling (Structure,Stones,Boulders. ConsistencL%Gravel) i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. Consi ten d. Flood Insurance Rate Map: Above 500 year flood boundary No Yes V__ Within 500 year boundary No"' Yes Within L00 year flood boundary No - Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio terial exist in 11 areas observed throughout the area proposed for the soil absorption system. If not,what is the depth of naturally occurring per ious material? Certification + I certify that on `� (date)I have passed the soil evaluator examination approved by the Department of Enviro mental Protection and that the above analysis was performed by me consistent with . the required training,exp 'sea a ri ce described in 3 10 CMR 15.017. Signature I i Date ZOU Q:\SBPT1C�PERCFORM.DOC Hazardous Materials Inventory Sheet Checklist � Ate ysical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts-(ie.gas being used to fuel machines,thinner to clean brushes all count as hazardous materials) __.6::�8forage Information-location,of storage,how long is storage for? If none,note that. /6isposal Information-where and who?If none,note that. pplicant Signature-understand what is listed and noted jKStaff Initial-any questions,know who to ask Vehicle Washing/kinsing? -provide a vehicle washing policy and _ plain it-note that it was given Attach the Business Certificate with your sign off and comments -"The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. YOU.WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which You must.do by M:G.L.-it does not give you permission•to operate.]- Business Certificates are avai[ab[e at the Town Clerk's Office, to n [which Main Street;,Hyannis, MA.02GO1 (Town Hall) tma p;• "* Fill in ploaso! ?�3,�r gin:.a._.•_• �;i� 1 " YOUR NAME: APPLIGANT'S � ./h C`� Z w BUSINI=SS YOUR HOME ADDRESS; / ��/ �✓ . f�y� j� ���,��o s-7 21, TELEPHONE # Nome Telephone Numbee�S`o 77 NAME OF!\iEW.BU1dVES l✓Ty l'l` TYPE OF BU YE SW[=SS:s ��o i-•� is THIS A HOME occUPATIbN? S. Np.. ADD RE55 OF BUSINESS Sle 3_zS ' Y�l • dilly TNIAP/PARCEL-NUMBER When starting a new business there are several things you must do in order-to be in compliance with the rules and regulations'of the Town of Barnstable. This form is intended to assist you-in-obtaining the information you may need. You MUST GO.TO 200 Mann St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses-required to Legally operate your business in this town. 1. BUILDING COM�1AL55 ER'S OFFICE This ind.ivid al has b ir�fa e of pormit require nts that pertain to,this type of business. Aut prized Sign t e COMMENTS: 2. BOARD OF HEALTH This individual has lb forme f th per t r@quire, ents that pertain to this type of business. Authorized Si ture** COMMENTS: . 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature.** COMMENTS: Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: �Q'� Jr��'�c�' C p" "iry G®�' ��c?ice` Cc+. BUSINESS LOCATION:, .� � �'��i l�v��/ tee. �Y ��/. INVENTORY MAILING ADDRESS: 22 jdf4�t`�rSi Z.4;1G` y ./��•r. TOTAL AMOUNT: i TELEPHONE NUMBER: ';77 S`' o Z2:z CONTACT PERSON: S77`277v - EMERGENCY CONTACT TELEPHONE NUMBER: Acl,-:� O!r t"7 7 -1 MSDS ON SITE? TYPE OF BUSINESS: �'�� �0�.•�.q OG ell;i oa P INFORMATION/RECOMMENDATIONS: - Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. O Werved/Maximum Obppserved/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, r Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers � . i (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS LK CERTIFICATE OF ANALYSIS Page: 1 Barnstable County Health ]Laboratory ysr^�HUs�,�j Report Dated: 4/13/2006 Report Prepared For: Jim Leboeuf Order No.: G0635019 Septic Service 71 Beth Lane i Hyannis, MA 02601-2225 Laboratory ID#: 0635019-01 Description: Water-I)Tinkin�a Sample#: _-- Samplin canon Collected by: J.LeBoeuf , 71 Beth Ln.Hyannis,M' ! Collected: 4/12/2006 Received: 4/12/2006 Routine ITEM RESULT UNITS RL MCL Method# LAB: Inorganics Tested Nitrate as Nitrogen 0.40 mg/L 0.10 10 EPA 300.0 4/12/2006 LAB: Metals Copper BRL ing/L 0.10 1.3 SM 3111 B 4/12/2006 Iron . ! BRL mg/L 0.10 0.3 SM 311113 4/12/2006 Sodium 20 mg/L 1.0 20 SM 31 1 1 B 4/12/2006 LAB: Microbiology Total Coliform Absent P/A 0 0 309 4/12/2006 LAB: Physical Chemistry Conductance 140 umohs/cm 2.0 EPA 120.1 4/12/2006 PH 7.3 pH-units 0 EPA 150.1 4/12/2006 Sodium level is at the maximum contaminant level. Those on"a low sodium diet may wish to consult a physician. Approved By: (Lab ector) lZ j t Z f RL = Reporting Limit ;` <•Q MCL=Maximum Contaminant Level Q0 Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 MASSACHUSETTS DEP/DIVISION OF WATER SUPPLY IOC INORGANICS REPORT(FORM#1A.3) I. PWS INFORMATION 1. PWS ID#: 20004 2. City/Town: Hyannis, MA 3. PWS Name: Hyannis Water System 4. PWS Class (bold) COM, NTNC, NC 5. DEP Source Co e o 6. Sample Location 7. Date Collected 8. Collected By 4020004/ 71 Beth Lane HWS #99J4/25/06 Client 9. Is the Source Treated? Yes 10. Was the Sample Collected after Treatment? No 11. Manifolded: If applicable, list the connected sources: 12. Routine: ® Special: F1 (explain below) Notes: Lab Name: Premier Laboratory, LLC. Lab Cert.#: M-CT008 Subcontracted? (Y,N) N Lab Sample ID#:E604C73-1 (use symbols to relate each analyte to a specific Lab) Sub. Lab Name: Cert. #: Lab Symbol: Composite If applicable, list the composited sources (DEP Source Code/Sample Location) Notes: Compound Lab Result MCL Detection Analytical Date Lab (regulated) Sample ID# mg/L mg/L Limit mg/L Method Analyzed Symbol Arsenic Barium r4 Cadmium i r- Chromium Fluoride*Mercury** .> Selenium Sodium E604C73-1 27 none 1.0 200.7 05/102/06 Antimony Beryllium Nickel Thallium Cyanide Compound Lab Result MCL Detection Analytical I Date Lab (unregulated) I Sample ID# mg/L mg/L Limit mg/L Method Analyzed Symbol Sulfate II. LABORATORY ANALYTICAL INFORMATION: * There is also a secondary MCL for fluoride which is 2.0 mg/L. **Please note that if method 245.1 is used for mercury,only method revision 3.0 will be accepted by DEP. Laboratory Director-Signature and Date: _ 5/3/2a006 Attention:Mail TWO copies of this report to your DEP Regional Office within 30 days of receipt of results and no later than 10 days after the end of the reporting period. FOR DEP/DWS USE ONLY:PLEASE MAIL&DATE AS COMPLETED Accepted: Disapproved: Data Entered into WQTS: Comments DEPARTMENT OF ENVIRONMENTAL PROTECTION g BACTERIOLOGICAL ANALYSIS REPORT-CONTAMINANT ID#3100- PWSID# PUBLIC WATER SYSTEM NAME TOWN/CITY: LABORATORY NAME&ID#' 4020004 Hyannis Water S stem H annis MA Premier Laboratory,LLC. M-CT008 DEP APPROVED SAMPLE SITE SAMP LAB. COLLECTION COLLECTION ANALYSIS TCM TOT COLIFORM/ FC/ECM FECAL-E.COLI/ CHLOR.RES. TYPE SAMP ID# CODE# LOCATION DATE TIME DATE CODE 100 ml— CODE# 100 ml" OR HPC/ml SAMPLE COLLECTED BY: RS E604C351 031 Citizen's Bank(Airport Rotary) 04/25/06 08:15 04/25/06 303. 0 0.18 Jeremy Cadrin RS E604C352 014 Cape Cod Medical Center 04/25/06 08:34 04/25/06 303 0 0.050 Jeremy Cadrin RS E604C353 005 Hyannis Post Office 04/25/06 08:24 04/25/06 303 0 0.43 Jeremy Cadrin RS E604C354 032 Sheraton 4 Points Resort 04/25/06 09:10 04/25/06 303 0 0.069 Jeremy Cadrin RS E604C355 004 Hyannis Yacht Club 04/25/06 08:46 04/25/06 303 0 0.28 Jeremy Cadrin RS E604C356 003 Hyannisport Post Office 04/25/06 08:56 04/25/06 303 0 0.050 Jeremy Cadrin RS E604C357 016 West Hyannisport Post Office 04/25/06 09:19 04/25/06 303 0 0.050 Jeremy Cadrin RS E604C358 002 Barnstable High School 04/25/06 09:29 04/25/06 303 0 0.050 Jeremy Cadrin RS E604C359 033 D.P.W.New Offices 04/25/06 10:03 04/25/06 303 0 0.053 Jeremy Cadrin RS E604C3510 030 Cape Codder Resort -04/25/06 10:18 04/25/06 303 0 0.38 Jeremy Cadrin RS E604C3511 025 HS Maintenance Bldg. 04/25/06 09:46 04/25/06 303 0 0.050 Jeremy Cadrin SAMPLE TYPE KEY TOTAL COLIFORM FECAL COLIFORM/ REMARKS: RS-ROUTINE SAMPLE METHOD(TCM) E.COLI METHOD RO-ORIGINAL SITE REPEAT CODE# FC/ECM CODE# UR-UPSTREAM REPEAT MF 3 0 3 ' EC 4 0 0 DR-DOWNSTREAM REPEAT MTF 3 0 5 SWTR-MFC 4 0 1 SUBCONTRACTED LAB PJ J��1BLE): AR-ADD.REPEAT(DIST SYSTEM) P-A 3 0 7 raw water U/O� RW-RAW WATER ONPG 3 0 9 MMO-MUG 4 0 6 ANALYZED BY DATE 4127/2006 SS-SPECIAL 3 1 1 EC-MUG 4 0 8 (LAB USE) PT-PLANT TAP'SAMPLE NA-MUG 4 1 0 AUTHORIZED BY: DATE:4/27/2006 LAB ID#ASSIGNED BY STATE CERTIFICATION PROGRAM (LAB USE) "CAN BE EXPRESSED AS#/100ML,PRESENT(P),ABSENT(A),OR TOO NUMEROUS TO COUNT(TNTC) COLISURE METHOD-THIS CAN DO TOTAL COLIFORM and E.COLI SIMULTANEOUSLY,HOWEVER THE SAMPLE MUST BE INCUBATED 28 TO PAGE 1 OF 1 48 HOURS COPYt:COPY TO DEP REGIONAL OFFICE;COPY2:OWNER COPY;COPY3:LAB COPY 5C2E935D Gam' DEPARTMENT OF ENVIRONMENTAL PROTECTION B BACTERIOLOGICAL ANALYSIS REPORT-CONTAMINANT ID#3100 PWSID# PUBLIC WATER SYSTEM NAME TOWN/CITY LABORATORY NAME&ID#' 4020004 Hyannis Water S stem Hyannis,MA Premier Laboratory,LLC. M-CT008 DEP APPROVED SAMPLE SITE SAMP LAB. COLLECTION COLLECTION ANALYSIS TCM TOT COLIFORMI FC/ECM FECAL-E.COLI/ CHLOR.RES. PE SAMP ID# CODE# LOCATION DATE TIME DATE CODE 100 ml" CODE# 100 ml— OR HPC/ml SAMPLE COLLECTED BY: RS E6048401 031 Citizen's Bank(Airport Rotary) 04/18/06 10:14 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048402 014 Cape Cod Medical Center 04/18/06 10:31 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048403 005 Hyannis Post Office 04/18/06 10:22 04/18/06 303 0 0.054 Jeremy Cadrin RS E6048404 032 Sheraton 4 Points Resort 04/18/06 10:43 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048405 004 Hyannis Yacht Club 04/18/06 10:53 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048406 003 Hyannisport Post Office 04/18/06 08:15 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048407 016 West Hyannisport Post Office 04/18/06 08:27 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048408 002 Barnstable High School 04/18/06 08:37 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048409 033 D.P.W.New Offices 04/18/06 09:26 04/18/06 303 0 0.050 Jeremy Cadrin RS E60484010 030 Cape Codder Resort 04/18/06 09:34 04/18/06 303 0 0.050 Jeremy Cadrin RS E60484011 025 HS Maintenance Bldg. 04/18/06 08:55 04/18/06 303 0 0.050 Jeremy Cadrin RS E60484012 HS Small Tank 04/18/06 09:56 04/18/06 303 0 Jeremy Cadrin RS E60484013 HS Large Tank 04/18/06 09:56 04/18/06 303 0 Jeremy Cadrin SAMPLE TYPE KEY TOTAL COLIFORM FECAL COLIFORM/ REMARKS: RS-ROUTINE SAMPLE METHOD(TCM) E.COLI METHOD RO-ORIGINAL SITE REPEAT CODE# FC/ECM CODE# UR-UPSTREAM REPEAT aMF30 3 EC 4 0 0 DR-DOWNSTREAM REPEAT 0 5 SWTR-MFC 4 0 1 SUBCONTRACTED LAB IFAR-ADD.REPEAT(DIST SYSTEM) 0 7 raw water RW-RAW WATER 0 9 MMO-MUG 4 0 6 ANALYZED BY DATE:4/25/2006 SS-SPECIAL 1 1 EC-MUG —A--—8 (LAB USE) 1 PT-PLANT TAP SAMPLE NA-MUG 4 1 0 AUTHO RIZED BY. DATE:4/25/2006 'LAB ID#ASSIGNED BY STATE CERTIFICATION PROGRAM (LAB USE) CAN BE EXPRESSED AS#/100ML,PRESENT(P),ABSENT(A),OR TOO NUMEROUS TO COUNT(TNTC) —COLISURE.METHOD-THIS CAN DO TOTAL COLIFORM and E.COLI SIMULTANEOUSLY,HOWEVER THE SAMPLE MUST BE INCUBATED 28 TO 48 HOURS PAGE 1 OF 1 COPY1:COPY TO DEP REGIONAL OFFICE;COPY2:OWNER COPY;COPY3:LAB COPY 9]M850 S, DEPARTMENT OF ENVIRONMENTAL PROTECTION B BACTERIOLOGICAL ANALYSIS REPORT-CONTAMINANT ID#3100 PWSID# PUBLIC WATER SYSTEM NAME TOWN/CITY LABORATORY NAME&ID#" 4020004 Hyannis Water System Hyannis,MA Premier Laboratory,LLC. M-CT008 DEP APPROVED SAMPLE SITE SAMP LAB. COLLECTION COLLECTION ANALYSIS TCM TOT COLIFORM/ FC/ECM FECAL-E.COLI/ CHLOR.RES. TYPE SAMP ID# CODE# LOCATION DATE TIME DATE CODE 100 ml`" CODE# 100 ml"" OR HPC/ml SAMPLE COLLECTED BY: PT E6051711 027 Maher TP RAW Manifold 05/02/06 06:25 05/02/06 303 0 Jeff Ingram RS E6051712 027 Maher TP Treated Manifold 05/02/06 06:27 05/02/06 303 0 Jeff Ingram PT E6051713 009 Mary Dunn#1 RAW 05/02/06 08:22 05/02/06 303 0 Jeff Ingram RS E6051714 009 Mary Dunn#1 Treated 05/02/06 08:26 05/02/06 303 0 Jeff Ingram PT E6051715 010 Mary Dunn#2 RAW 05/02/06 08:25 05/02/06 303 0 Jeff Ingram RS E6051716 009 Mary Dunn#2 Treated 05/02/06 08:30 05/02/06 303 0 Jeff Ingram PT E6051717 011 Mary Dunn#3 RAW 05/02/06 06:46 05/02/06 303 0 Jeff Ingram RS E6051718 011 Mary Dunn#3 Treated 05/02/06 06:56 05/02/06 - 303 0 Jeff Ingram SAMPLE TYPE KEY TOTAL COLIFORM FECAL COLIFORM/ REMARKS: RS-ROUTINE SAMPLE METHOD(TCM) E.COLI METHOD RO-ORIGINAL SITE REPEAT CODE# FC/ECM CODE# UR-UPSTREAM REPEAT MF 3 0 3 EC 4 0 0 DR-DOWNSTREAM REPEAT MTF 3 0 5 SWTR-MFC 4 0 1 SUBCONTRACTED LAB ff IF ggqpppP 1&A,��E AR-ADD.REPEAT(DIST SYSTEM) -TA 3 0 7 raw water "llf RW-RAW WATER: ONPG 3 0 9 MMO-MUG 4 0 6 ANALYZED BY DATE 5/4/2006 SS-SPECIAL 3 1 1 EC-MUG 4 0 8 (LAB USE) PT-PLANT TAP SAMPLE NA-MUG 4 1 0 AUTHORIZED BY: DATE:5/4/2006 LAB ID#ASSIGNED BY STATE CERTIFICATION PROGRAM (LAB USE) CAN BE EXPRESSED AS#/t00ML,PRESENT(P),ABSENT(A),OR TOO NUMEROUS TO COUNT(TNTC) COLISURE METHOD-THIS CAN DO TOTAL COLIFORM and E.COLI SIMULTANEOUSLY,HOWEVER THE SAMPLE MUST BE INCUBATED 28 TO PAGE 1 OF 1 48 HOURS COPY1:COPY TO DEP REGIONAL OFFICE;COPY2:OWNER COPY;COPY3:LAB COPY 93BF350 DEPARTMENT OF ENVIRONMENTAL PROTECTION B BACTERIOLOGICAL ANALYSIS REPORT-CONTAMINANT ID#3100 PWSID# . PUBLIC WATER SYSTEM NAME TOWN/CITY LABORATORY NAME&ID#• 4020004 Hyannis Water System Hyannis,MA Premier Laboratory,LLC. M-CT008 DEP APPROVED SAMPLE SITE SAMP LAB. COLLECTION COLLECTION ANALYSIS TCM TOT COLIFORM/ FC/ECM FECAL-E.COLI/ CHLOR.RES. PE SAMP ID# CODE# LOCATION DATE TIME DATE CODE 100 ml— CODE# 100 ml" OR HPC/ml SAMPLE COLLECTED BY: RS E6048401 031 Citizen's Bank(Airport Rotary) 04/18/06 10:14 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048402 014 Cape Cod Medical Center. 04/18/06 10:31 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048403 005 Hyannis Post Office 04/18/06 10:22 04/18/06 303 0 0.054 Jeremy Cadrin RS E6048404 032 Sheraton 4 Points Resort 04/18/06 10:43 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048405 004 Hyannis Yacht Club 04/18/06 10:53 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048406 003 Hyannisport Post Office 04/18/06 08:15 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048407 016 West Hyannisport Post Office 04/18/66 08:27 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048408 002 Barnstable High School 64/18/06 08:37 04/18/06 303 0 0.050 Jeremy Cadrin RS E6048409 033 D.P.W.New Offices 04/18/06 09:26 04/18/06 303 0 0.050 Jeremy Cadrin RS E60484010 030 Cape Codder Resort 04/18/06 09:34 04/18/06 303 0 0.050 Jeremy Cadrin RS E60484011 025 HS Maintenanc e Bldg. 04/18/O6 9 08:55 04/1 8/06 303 0 0.050 Jeremy Cadrin RS E60484012 HS Small Tank 04/18/06 09:56 04/18/06 303 0 Jeremy Cadrin RS E60484013 HS Large Tank 04/18/06 09:56 04/18/06 303 0 Jeremy Cadrin SAMPLE TYPE KEY' TOTAL COLIFORM FECAL COLIFORM/ REMARKS: RS-ROUTINE SAMPLE METHOD(TCM) E.COLI METHOD RO-ORIGINAL SITE REPEAT CODE# FC/ECM CODE# UR-UPSTREAM REPEAT MF 3R07 EC 4 0 0 DR-DOWNSTREAM REPEAT MTF 3 SWTR-MFC 4 0 1 SUBCONTRACTED LAB IF PI�A<3LE)_ AR-ADD.REPEAT(DIST SYSTEM) P-A 3 raw water RW-RAW WATER. ONPG 3 MMO-MUG 4 0 6 ANALYZED BY DATE 4/25/2006 SS-SPECIAL 3 EC-MUG 4 0 8 (LAB USE) PT-PLANT TAP SAMPLE NA-MUG 4 1 0 AUTHORIZED BY: DATE:4/25/2006 LAB ID#ASSIGNED BY STATE CERTIFICATION PROGRAM (LAB USE) "CAN BE EXPRESSED AS#/100ML,PRESENT(P),ABSENT(A),OR TOO NUMEROUS TO COUNT(TNTC) —COLISURE METHOD-THIS CAN DO TOTAL COLIFORM and E.COLI SIMULTANEOUSLY,HOWEVER THE SAMPLE MUST BE INCUBATED 28 TO PAGE 1 OF 1 48 HOURS COPY7:COPY TO DEP REGIONAL OFFICE;COPY2:OWNER COPY;COPY3:LAB COPY 93AAM +, TOWN OF B ARNSTABLE LOCATION ; �/ 9,9 i/-/ SEWAGE # c7 S f VIIIAGE /7 ��y'S ASSESSOR'S MAP & LOT,1-7� i 7 Z k. I' !NSTALLER'S NAME&PHONE NO. 6,, -Or SEPTIC TANK CAPACITY /00-0 111A`1a.y 6c X s T� LEACHING FACILITY: (type)9 /A/.)Er 1r1-147-0/2 f (size)3,:z.X to X� NO.OF BEDROOMS 3 _ BUILDER OR OWNER 4.1 PERMITDATE: 3 /.Z. COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ® V t A w n Q � Z Li v� No. /� f< 7,R ` /' O� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for -Migogat *pgtem Congtructton Permit Application for a Permit to Construct( )Repair( Upgrade Abandon( ) ❑Complete System ❑Individual Components LocatiSS��nn Address or Lot No. Owner's Name,Address and Tel.No. 7/(}�r/W �A.✓E �i`Yr�„✓,v�J �iYvt1E LFL�Dt/& Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �AY�✓� L9/d Cf/Ar�+�3F ACC �1- 7 7.3 13G 2 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /9" v 514-5 Tv FJt �sr� .- /000 7-stNsr- �,v.0 �TQ,gro2r � �.57'C��c� �2o�w� 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 Co e and not to place the system in operation until a Certifi- cate of Compliance has been issue t ' �ad o Signed Dated r Application Approved by Date — ) 2-- 7 ee Application Disapproved for the Mowing reasons Permit No. Date Issued No. 7,R Ot Fee THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for ;Dtg;po!5al *p!5tem (Con!5truction permit Application for a Permit to Construct Repair y Upgrade Abandon El Complete System El Individual Components Locaty* Address or Lot No. Owner's Name,Address and Tel.No. C Assessor's Map/Parcel .Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No., 4., 3 9 Z- Type of Building: Dwelling No.of Bedrooms —3 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 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 4,0 � 'Eyt_sr,, �.f _/00D 7,i^-vc- X1�r,Q,*r 15;e o w 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 A— Title 5 of the Environmental Co e and not to place the system in operation until a Certifi- cate of Compliance has been issue t * -aard o i — Signed Date Application Approved by a. n Date � - ) I - Applicati Application Disapproved for the UOW4 reasons Permit No. Date Issued —————---———————————---————---———————————--- -- - - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired Upgraded Abandoned by -, 6AeI4 17- at has been constructed in accordance with the provisions of Title 5 and the for Disposal Syst erns- dateduction Permit No. Installer i / Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 7)LI Inspector ----————————————— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS liqossal *p5tem Cong4ruction 3permit 7 Permission is hereby granted to Construct Repair Upgrade Abandon system located at ;� -d� _ 01 10 end 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 must be completed within three years of the date of this permit. Date: Approved by V 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT,(WITHOUT ENGINEERED PLANS) I��y,��.�llu��►.a► ac.9v/J;hereby certify that the application for disposal works 17 construction permit signed by me dated / /�� , concerning the property located at 71 i3cT1,7` meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed " • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: / A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) b B)Observed Groundwater Table Elevation(according to Health Division well map) 3a SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert i -� 2ATp2S L �l �y o Z— f s� TOWN OF BARNSTABLE LQCATION ��'9r'/,/ GA �+/ SEWAGE # GE /T y��y'S ASSESSOR'S MAP&LOT Z7� ,/ 7 2. :'":INSTALLER'S NAME&PHONE NO. y S>✓PTIC TANK CAPACITY ��O o G'i4//O y 6c X,s r� ,IrACHING FACIUN: (type)y /•t/F,�r4�oTv/1`s" (size) NO`OF BEDROOMS 3 UILDER OR OWNER 3•�rh LcL Z%7 c>a F p PERMTTDATE:3/ /a �5 COMPLIANCE DATE: e3 §eOaration Distance Between the: : .Iu[aximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet ti Private Water Supply Well and Leaching Facility (If any wells exist oii site or within 200 feet of leaching facility) Feet Edge of.Wedand and Leaching Facility(If any'wetlands exist <w_ithin 300 feet of leaching facility) Feet Furbished by JNw a SI✓ - '.. 4 L 0 C A T I N t, . SEWAGE PERMIT NO. VILLAGE e 1N.STA LLE S N &MIE A ADDRESS 9---UIL,DER OR OWNER r DAT E PERMIT 1S'SU E D y 7-�-d WAT` E COMP'l1A;NCE ISSUED 'V_ �_� '�',�, � � } C� ��_ L �� � __ No kle.fi FEs.. . ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1,�C%/1 ........O F........ 9/I�. , �.� '.............. Allp iratiaau. for %spviial Warkfi 6witrurthatt lirrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at* .... ••-•--••- 1,., .... 22 ...._ . ..-----••-------•--•--- --•---...------•............. .. ....... ocatio Ad Tess or t o. Installer Address �x� Q Type of Building Size Lot___/_____ .......Sq. feet U Dwelling—No. of Bedrooms.......... ______________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria aOther fixtures --------------------------------------------------------------------------------------------------•--•-•----•-•-••--•--•-•-•--•-••-•--•••-......•---- d W Design Flow.....................�.....SS ___..gallons per person per day. Total daily flow....................a;3_o............gallons. W Septic Tank—Liquid capacity__0_ _g g p f _ d p allons Len th................ �'��idth__�.!...._ Diameter__..___..._._._. Depth __._.... x Disposal Trench—No. .................... Width.._............_._ Total Length.................... Total leaching area___. ----------- ft. i Seepage Pit No......I------------- Diameter_____I©_-6-__- Depth below inlet..... _...______. Total leaching area.- -e. ...sq. ft. Z Other Distribution box ( X) Dosing tank r Percolation Test Results Performed by.--C.z.S9.t....+' est ............... Date - 7 a .......... Depth to ground water-_'h<�- ..._.. Test Pit No. 2.......11......minutes per inch Depth of Test Pit......)_..._.__.__. Depth to ground water-------V.............. 0 Description of Soil -" •. .-•-••--------- •- - v W ---------------------_-_ -------••------••---•••----•--------------------------------•----•-••-•••---••-----••---------•------...........-----------•-•-•-•-•--••......••--•-----•----•.............. VNature of Repairs or Alterations—Answer when applicable.-.-_---------------------------------------•-_---_____-____-_-__-.-___-__•-_______•-•-•---•-__. .............................................................-..........................................................................................................-.............................. Agreement: _ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:T p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' u d by the boar o i- lth. ................. ............ ................ Date �) Application Approved By 44tl•-• - -• .-- -- ��Y ........................ _.... . ems...._.... Date Application Disapproved for the following reasons_______________ ______________________________________________________________________________________ ______ .._...•-•---••••-•--...:_...--•-•-•---•-•••-•-•-•-•----•-•--•.....---•-•-•-•--••-•----------••--••....•-•-------------------•-•-------•---••------....------------------------------------------------- Date Permit No......................................................... Issued---- 1__ /. -• Date No.NYAIKel FRj; . ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... ..............................OF......... .......................... Appliration for Uhipoiial Works TOmtrurtion Vautit Application is hereby made fora Permit to Construct 616 or Repair an Individual Sewage Disposal System at: r-7 Z ......./ ........................................ .................................................................................................. Address —A Lot 0 ZI ........... oc ---------- ......V1 __Z . .....Z. . .................................... .... ...... -------- Installer Address Type of Building Size Lot-_-- V..........Sq. feet U Dwelling—No. of Bedrooms---- ....... ..............................Expansion Attic Garbage Grinder P4 Other—Type of Building ............................ No. of persons---------------------------- Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design Flow......................ffi......5�5-------gallons per person per day. Total daily flow....................-j:�a 4.............gallons. 1:4 Septic Tank—Liquid capacity.1 fl;Pf�2gallons Length...... __1--- Width.2K/.�...... Diameter................ Depth_.__4........ Disposal Trench—No I.................... Width_...._......._...... Total Length......._............ Total leaching area....................sq. ft. Seepage Pit No-----1----_-----_ Diameter-____ Depth below inlet... ........ Total leaching area-2.R.57..sq. ft. Z Other Distribution box Dosing tank I - Percolation"test Results Performed by---_Z...... ­Ak-��:.""qc'.I!,ne............................... Date...................................... Test Pit No. I... ...minutesperinch Depth of Test Pit---1 ........... Depth to ground water.. ` __. Test Pit No. 2................minutes per inch Depth of Test Pit.-.__gi............ Depth to ground water....._.11.............. --------------------­-----­--z..,A........?;.... ... . .................................................................. -ch- - ...t�.,.......... ...... j 0 Description of Soil........... . ......7 .......... ............................ .................................... .7------- ......... ........ .................................................. ............... ...... U W ..................................................... ............................. ---------------------- ......................................... ................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been, u�ed by the b -r :f h* y LL1�_ D1.7 M Sn, ..... .. .................. .......... . .......................... ............ . ............ Da Application Approved By.... 4.4.. ... ............................ ........... ... 7 - Date Application Disapproved for the following reasons:.-. ........... ....................................................------------------------------------------ ----------------------------------------------------------------........................................................................................................................................ Date PermitNo......................................................... Issued.................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ..............OF... ........... ................ (9rdifiratr of Tomplia' Urr All- IS TO CAR or Repaired That the Individual Sewage Disposal System constructed 7----------------------------------------------------------------- JO...Woe- - --------------------- -­ ---- ----- ................................................ '77 nstall Vr- 44194441 s been installed in accordance with the provisions of f) o Th State Sanitary Co e as described in the �'application for Disposal Works Construction Perinit0 ------------------------------------ a ---------- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL.F75TIOK SATISFACTORY. I�- 'do-/ DATE................................................................................. Inspector------. P ? ---- ...............................I.......W....... THE COMMONWEALTH OF MASSACHUSETTS Y BOARD Ojq HEALTH ............�`�. ..........OF.---.......13-04 W. ............................................ N FEE.....--.. .------. D ispos orkg Va" Permission is hereby granted..... ......... .............. ... ................... to ConsirQ or Repai �n Individual e,,a .e D* pos S tem -7 ................................................. at No.... 4_.! . ........ . ...A-S.- e 0. as shown on the application for Disposal Works Construction Per Dated 41V R__9 e ----------------- I Board of Heal DATE ........................... /4/:- ...................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ASSESSORS MAP :_ _-'�Z Z2 TEST HOL_._ _ _ . _._ . . _E LOGS v� PARCEL : /7Z NOTES: ---_� Z FLOOD ZONE: ,<,/c�% 4 PFL/<f ,q 13 L, SOIL EVALUATOR; _._._ WITNESS : I I b REFERENCE: -� 1) The installation shall comply with Title V and Town of Barnstable Boar o DATE: r 1 Cif, PERCOLATION R ATE: Z— M I l v, , Health Regulations. 2) The installer shall verifythe location of utilities, sewer inverts and septic components prior to installation and setting base elevations. TH- I TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first W two feet out of the d-box to the leaching shall be level. Q VG � 1 4) This plan is not to be utilized for property line determination nor any other f V purpose other than the proposed system installation. t C) A;Q lb I 5) All septic components must meet Title V specifications. LOCATION MAP (�'> n �j / 6) Parking shall not be constructed over H 10 septic components. �r-s--/ �, �� 1 CI6 ;7 7) The property is bounded by property corners and property lines. - �0 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt 1 � of payment for the plan and installation based on the plan shall be deemed I b�(LI� approval of the design flow by the owner. ZONING: RC-1 FRONT: 30' 9) The existing leaching or cesspools shall be pumped and filled with material SIDE AND REAR: 15' �j,D _ �p Gj per Title V abandonment procedures. Those within the proposed SAS shall (,.�N9, yea w be removed along with contaminated soil and replaced with clean sand per GP DISTRICT �ek- Title V specs. — . _ 12p 00, , ,�.,( ----- �---�-��--�---------- �� 10)System components to be 10 feet from water line. Sewer lines Grassing the I , water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DESIGN applicable. The proposed SAS is being installed below the water service �i line. The line is to be sleeved as aforementioned and maintained in place. N FLOW ESTIMATE a er exists rt is o e removed and is the responsibility o hem owner to ensure such. 3g 3 BEDROOMS AT 10 GAL/DAY/BEDROOM -J GAL/DAY _ 12)T e • er is o to a caution in excavation around the gas line. I13)The installer shall verify the location, quantity and elevation of the sewer o CONC. o EXIST. SEPTIC TANK lines exiting the dwelling prior to the installation. PATIO DWELL. ��O GAL/DAY x 2 DAYS - GAL USR%Z� LOT 45 GALLON SEPTIC TANK(X *16RD rot -- 15000 SF f i/ -- / } `� w' -7 Q r SOIL ABSORPTION SYSTEM - - / Win,,`n � -� N,� l.•f�- � 1�2c� �00��. ������ Wt1'�f �{ y��� 8' - 50 0/1 \/ SIDE AREA: 2-X ��,��+ 12'83'. XZ � ' BOTTOM AREA: 0 _o / Io ' 12 NOTE: SEPTIC LOCATION FROM SEPTIC SYSTEM SECTION AS BUILT PLAN OBTAINED FROM TOWN BOARD OF HEALTH DATED I 3/13/98 BY ARCH CONST. or fbUW Q11 0 6e 0 ILI qto 25D GAL SEPTIC TANK o _._, L:1 '4 ' 1 _i_. bD kkZ, WOE> ale N OFA �, ! ,D DAVID 9�y a MASON '' SITE AND SEWAGE PLAN o IC{ 6�g� / : Zd �` �,; , LOCATION : _All o PREPARED FOR : "--1")jt SCALE: DAVID B . MASON DATE: DBC ENVIRONMENT L DESIGNS EAST SANDWICH . 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