HomeMy WebLinkAbout0095 BETH LANE - Health 95 BETH LANE, RYANNIS
A=272-170 LOT 43
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Town of Barns fable
Departiment of Regulatory Services
Public Health Division Date -Olt e!
' �Ara39• �+� 200 Main Street,Hyannis MA 02601 S'
rEb Nlh'i A H i t+
Date Scheduled r Tune Fee P
d.
. W
Soil Suitability :Assessment fogDis o al
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rm
Perfoed Ay: I ) yyitnessed By: d �+
LOCATION& GENERAL,INFORMATION
Location.Address Owner's Name /p"GZX Ia✓fj
Address
r .. Assessor's Map/Parcel:
Engineer's Name ,
NEW CONSTRUCTION. REPAAt. Telephone
Land Use •Slopes(%)
Surface Stones .
Distances from: Open Water Body ft Possible Wet Area
ft Drinking Water Well ft
Drainage Way ft Property Line -- —ft Other
ft �
SKICTCII:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes) -
1"
Parent material(geologic)
Depth to Bedrock
Depth to Orouudwatec Standing Water in Hole:
t Weeping from Pit Face
Estimated Seasonal High Oroundwater
]D]ETERIV WATION FOR SEASONAL-TUG
II WATER TABLE
Method.Used:
Depth Observed standing In ob..hole: lb, Depth Itl soil tnUttles:
Depth to weeping from side of obs:hole: In,
Index Well 0 Reading Date: Index Woll leYol III, Groundwater Adjustment g•
- Adj.factor _ A .OrOundwtiter Level A
Observation PERCOLATION VEST Date_ 1jrhua
Hole# 1 Time at 9"
Depth of Pere 1J - i _
Start Pre-soak Time @
Time(9"-6")
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back---------;
***If percolation test is to be conducted witbin 100' of wetland
Barnstable Conselrvation Division at least one(1) week prior to beginning.ut first notify the
P
Q:1S EPTICIPERCFORM.DOC
DEEP.OBSERVATION ROLE LOG Hole#
Depth from Soil Horizon Soil Texture Sdil Color Soil Other
— Surface(in.) (USDA) (Munsell) Mottling
(Structure,Stones;Boulders.
orisi tency %'Gravel)
tl At
t
A♦ •
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in-) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
on istenGravel)
71-1
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%t3
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consi to
Flood Insurance Rate Maps /
Above 500 year flood boundary No s
' Within 500 year boundary No_ yros
Within 100 year flood boundary No.� Yes r_�
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in a l areas observed throughout the
area proposed for the soil absorption system? l '
If not,what is the depth of turally occurring pe ious material?
Certifiication
I certify that on L� (date)I have passed the soil evaluator examination approved by the
above analysis was performed b me consistent with .
Department of Enviro mental Protection and that the a y p y
P
the re uired training,exp a exp r'ence described in 10 CMR 15.01'
'j of
Signature Date v
Q:\SEPTIC\PERCPORM.DOC
MW
TOWN OF BARNSTABLE
LOCATION SEWAGE#
..VILLAGE 4 k,4,411VIV ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.Qlj�W
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Ccii�`���� (size)
NO.OF BEDROOMS 3
OWNER f!5A0ZZ 4,00,,0
PERMIT DATE: 6—J,'�� COMPLIANCE DATE:
Separation Distance Between the: ^- - O
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility API 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 'J� -".77 `E/
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e
Vp " a
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rs
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No. 0 1� 'Z( 1 Fee (�.7b
THE COMMONWEALTH OF MASSACHUSETTS Entered in comp tee r: �
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
21pplitation for Disposal 6pstrm Construction permit
Application for a Permit to Construct( ) Repair(A,-*U,'pgrade( ) Abandon( ) ❑Complete System Pln'dividual Components
Location Address or Lot No.q s`�G`e;7,- ]✓ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel pZ — /�� �/�
Installer's Name,Address,and Tel.No. Deesiigneerr's Name,,Address,and Tel.No.
Tf,cCJ Gr'�'+ ��
07
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building .4-InAlp No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided mil' gpd
Plan Date o 00� Number of sheets Revision Date
Title
Size of Septic Tank -y;i,9'TIi✓� OiJO `Type of S.A.S. 2 2VC4-,1(1_ r _borb ?
Description of Soil '
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of 11,aoh. q
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. y l b a / Date Issued
7, No. � _ � � ! ` �� Fee
THE COMMONWEALTH, MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION;- TOWN-0 BARNSTABLE, MASSACHUSETTS es
Rpplication for Mi4.0!5aY 4pstem Construction permit
Application for a Permit to Construct( ) Repair(06-10u,pgrade(') Abandon( ) ❑Complete System adividual Components
Location Address or Lot No. c�'c�T� ,�Jv Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel ;1 2,4 — ";74:7
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building: ' 1
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building loo e�_p No.of Persons Showers( ) Cafeteria( )
Other Fixtures /
Design Flow(min.required) %3 gpd Design flow provided �y�' gpd
Plan Date O c;21000' 00'� Number of sheets Revision Date
Title w" /
Size of Septic Tank XT/I✓�r /DOO 6Fype of S.A.S. 2—
Description of Soil ���" �L�/✓� �o G
Nature of Repairs or Alterations(Answer when applicable)
,x
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He4h.Signed Q��( `� Date 6 �`q
6'
Application Approved by Date ( — /L
Application Disapproved by Date
for the following reasons
Permit No. a 6 7 /u Date Issued 46
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired('All Upgraded( )
Abandoned( )by�J JT! ��" -(/, tfG��T�C (Pike
at 9 s_ 1w has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 m/(, -2 t 'Hated f, 1 ( - /S
Installer (7JJ� ��"�OU�" Designer 40,' 01Z
#bedrooms Approved design flow gpd
The issuance of"this permit shall not be construed as a guarantee that the system will fu ion ahesigned.
Date Inspector i V
No. ) d 1 b —2 t�- Fee U�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
;Disposat �&pstem Construction hermit
Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( )
System located atT �'
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construc-ion usst be completed within three years of the date of this permit. ��o /� ('
Date ' ( Approved by UIN `(-,,/
From: 06/24/2016 07:38 #081 P.001/001
s
Town of Barnstable
Regulatory Services
Richard V.Scali,Interim Director
LIARNSTABLE.
Public Health Division
Thomas McKean,Director
t 200 Main Street,Hyannis,MA 02601
Office: 508-862-4 44 Fax: 508-790-6304
Installer&Designer Certification Form
Date: Sewage Permit# Assessor's MapTarcel " -170
Designer: Installer: --P � ;IJF"
Address: f�o1( A-1 Address:
On_ o �l _was issued a permit to install a
(date) (installer)
septic system at based on a design drawn by
(add ess
1Q,1 c�kk1 dated
(designer)
i certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
_ 1 certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State& Local.Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in �Fjj
n)iance with the termsof the IAA approval letters(if applicable) �Q ,ys�
/,
DAVIL1 \�
( .nstaller's ature)
NIASOPI
p No.1066�a
'
(Desi er's Signature) (Affix Desi rs- p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\.Septic\Designer Certification Fonn Rev 8-14-13.doc
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IRosa,Amy ';L-o
95 Beth Lane
CONTRACT Customer Name Customer Signature _
r Hyannis,MA 02601 bb� Sales Re —
r SKETCH Contract Date 508-292-8198 presentative Signature
ATTACHMENT Customer Phone contract Price__
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NOTES' 'Each;box equals one fool unless otherwise noted.This sketch Is a good faith
representation of the work to be done,it is understood that all dimensions
derived from this sketch are approximate,and that all locations of outlets,fight
fixtures,plugs,jacks and/or switches are subject to change If necessary.
Rosa,Airny F
CONTRACT 95 Beth Lane ,,
Customer Name � Customer Signature
Hyannis,MA 02601
SKETCH Contract Date 508-292-8198 � Sales Representative Signature
ATTACHMENT Customer Phone Contract Price 11:.
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NOTES' Each box equals one foot unless otherwise noted.This sketch is a good faith
representation of the work to be done,It is understood that all dimensions
derived from this sketch are approximate,and that all locations of outlets,light
fixtures,plugs,jacks and/or switches are subject to change frnecessary.
i
o�S HaE Tay, ,
Town of.Barnstable Barnstable
Regulatory Services Department A`"'"e`caM
BARNSTABLF-
MASS
,� Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1520 0000 1968 9675
June 20, 2016
James W. Holland
95 Beth.Lane`
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The.septic system located at 95 Beth Lane Hyannis, MA was inspected on 05/26/2016
by David B. Mason; certified Title V.Septic Inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 1.5.00) due to the following:
• Leaching pit or cesspool with high liquid level, <12" below inlet(per Town
Code 360-9.1).
You are ordered to repair or replace the septic system within Two (2)years from the date you receive this notification.
Failure to repair/replace the septic system within the,deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF'HEALTH
as cKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\95 Beth Lane,Hyannis.doc
r
Town .of Barnstable
RARNMBLE
MAM
,.� Regulatory. Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862 4644 Richard Scali,Director
FAX: 568,190-6304 Thomas A.McKean,CHO
fi Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"X"marked in the❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA -
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool. -
ONE (1)-YEAR DEADLINE.CRITERIA
❑ Static liquid level in the distribution box above•outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation t
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any.portion of,a cesspool within 510 feet of a private water supply well with no '
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).' -
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any."conditionally passed-systems"(broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
eaching pit or cesspool with high liquid level, <12"below inlet(per Town Code
v`§360-9.1)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
y ❑
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Parcel Detail Page 1 of 2
rnw �.:
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BARN5TAl LE:. 1
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Logged In As: Pa rice I Detail Monday,June 20 2016
Parcel Lookup
Parcel Info —
Parcel ID 272-170
Developer Lot LOT 43
Location 95 BETH LANE F I Pri Frontage 1125 I
Sec Road I Sec Frontage I l
Village HyanhiS f fire District HYANNIS I
Town sewer exists at this address NO r �T ) ` Road Index f0119
... �
Asbuilt Septic Scan' �t_
L
Interactive , {
272170_1 Map
-•Owner Info
Owner HOLLAND,JAMES W •- •.-.I Co-owner
Streetl 95 BETH LN f Streetz
City FHYANNIS _',I State MA zip 02601 Country
Land Info -
Acres 0.35 I use Single Fam MDL-01 I zoning RC-1 ' Nghbd 10105 I '
Topography Level ` Road Faved I
utilities Public Water,Gas,Septic " Location
Construction info.
Building 1 of 1
Year 1980 Roof ""� Ext
Built )Struct Gable/Hip ) wall Wood Shingle I
7
Living IRoof AC
Area1152 i—N-one I —2a qtoyer I Type
ps
Style Ranch I wali Drywall I Rooms 2 Bedrooms ( 28 Bps
2. BMT 2
Model Residential I Floor Pine%Soft W d I R oa„s 1 Full-0 Half I 24
t
Grade Average I TYPe Hot Water I'Rooms`5 Rooms )
Heat und-
Stories 1 Story I Fuel OIII Foation' Poured Conc.�I
Gross 2I
Area856
Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
5/1/1987 Addition IB30728 1$15,000 11/15/1989 12:00:00 AM HY ADD'N
! http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=20809 6/20/2016
Parcel Detail Page 2 of 2
Visit History '
Date Who Purpose
1/17/2001 12:00:00 AM Paul Talbot Meas/Listed-Interior Access
11/15/1 990 1 2:00:00 AM ML Meas/Listed-Interior Access
Sales History
Line Sale Date Owner Book/Page Sale Price
1 6/15/2000 HOLLAND,JAMES W 13073/248 $140,000,
2 8/15/1980 CZARNECKI,DAVID R&JANE P 3138/302 $0
Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parcel Value
1 2016 $94,800 $41,500 $0 $108,700 $245,000
2 2015 $89,300 $39,500 $0 $105,400 $234,200
3 2014 $89,300 $39,500 $0 $105,400 $234,200
4 2013 $89,300 $39,50-3 $0 $105,400 $234,200
5 2012 $89,300 $38,503 $0 $105,400 $233,200
6 2011 $126,100 $1,100 $1,600 $105,400 $234,200
7 2010 $126,000 $1,100 $1,700 $105,400 $234,200
8 2009 $120,500 $1,100 $800 $142,100 $264,500
9 2008 $147,400 $1,1c0 $800 $148,100 $297,400
11 2007 $146,800 $1,100 $800 $148,100 $296,800
12 2006 $128,600 $1,100 $800 $149,800 $280,300
13 2005 $121,500 $1,100 $800 $135,700 $259,100
14 2004 $98,600 $1,100 $800 $135,700 $236,200
15 2003 $88,400 $1,100 $900 $41,400 $131,800
16 2002 $88,400 $1,100 $900 $41,400 $131,800
17 2001 $88,400 $1,100 $900 $41,400 $131,800
18 2000 $66,700 $0 $0 $27,200 $93,900
19 1999 $66,700 $01 $0 $27,200 $93,900
20 1998 $66,700 $0 $0 $27,200 $93,900
21 1997 $64,100 $0 $0 $27,200 $91,300
22 1996 $64,100 $0 $0 $27,200 $91,300
23 1995 $64,100 $0 $0 $27,200 $91,300
24 1994 $62,300 $0 1 $0 $30,600 $92,900
25 1993 $62,300 $0 $0 $30,600 $92,900
26 1992 $71,000 $0 -$0 $34,000 $105,000
27 1991 $81,800 $0 $0 $47,500 $129,300
28 1990 $77,800 $01 $0 $47,500 $125,300
29 1989 $77,800 $0 $0 $47,500 $125,300
30 1988 $44,900 $0 $0 $20,700 $65,600
31 1987 $44,900 $0 $0 $20,700 $65,600
11 32 1986 $44,900 $0 $0 $20,700 $65,600
Photos
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=20809 6/20/2016
Commonwealth of Massachusetts ��a �/
. . � goo
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
95 Beth Lane
,M Property Address
James W. Ho
lland
Owner Owner's Name
information is -0,
required for every Hyannis MA 02601 May 26, 2016
page. City/Town State Zip Code Date of Inspection
n+
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information (^
filling out forms �/� W3 k
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David B. Mason
use the return Name of Inspector
key.
David Mason
r� Company
Name
4 Glacier Path
Company Address
East Sandwich MA 02537
City/Town State Zip Code
508-367-1617 S1287
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further-Evaluation by the Local Approving Authority
May 26, 2016
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
I
�n4 ' VS
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Beth Lane
M
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
95 Beth Lane _
Property Address
James W. Holland
Owner Owner's Name
information is H annis MA 02601 May
required for every y y 26, 2016
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
` safety and the environment:
❑ Cesspool or privy is within 50 feet.of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May required for every _Y y 26, 2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y y
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Beth Lane
M
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y _ Y
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
nM
95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every Y Y
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Yes
9 ( Y 9 (gpd))�
Detail:
2014; 80,250 ag Ilons and 2015; 64,500 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y Y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Board of Health
Was system pumped as part of the inspection? ❑ Yes ® No
If volume pumped:
yes gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Y
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May required for every � y 26, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Tank dbox and original pit installed in 1980 and 2nd pit installed in 1991
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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: 10+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 8 inches
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 Typical
Sludge depth:
' 8"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is required for every Hyannis MA 02601 May 26, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 32
6„
Scum thickness
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Scour Stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Effluent level with outlet invert. Tank is 8 inches below grade. Septic tank is in need of maintenance
pumping. portions of tank observed, specifically manhole access and tees appear in good condition.
PVC tees in place.
Grease Trap (locate on-site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: -
gallons
Design Flow:
gallons per day
Alarm present: ,❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,
;M 95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Effluent level with 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.):
Box is level. Evidence of solids carryover. Evidence of decay of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May required for every Y y 26, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2-6 foot pits with 2' stone. Effluent up above effective leaching with staining to top of leaching pit.
leach pit is 36" below grade. There is a riser within 8" of grade. No indication of break out.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
requiredfo is Hyannis MA 02601 May 26, 2016
required for every Y _ Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y �
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20
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:
Groundwater Contour Map
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Groundwater Contour Map. Test hole logs indicating no ground water to a depth of 12'for 72 Beth
Lane.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 95 Beth Lane
Property Address
James W. Holland
Owner Owner's Name
information is Hyannis MA 02601 May 26, 2016
required for every y y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE
LOCATION `.SC SEWAGE#
VILLAGEI t� S 4) i
-- t �<<� ASSESSOR'S MAP&LOT
INSTALLER'S NAME 6t PHONE NO(_ ' lc � - V77-��33'�
SEPTIC TANK CAPACITY
3 1
LEACHING FACILITY:(type) L— . j- (size) 10;
NO.OF BEDROOMS ,3 PRIVATE WELL OR PUBLIC WATBRf/ _
BUILDER OR OWNER CC;F- a At-3ce_C_ki S
DATE PERMIT ISSUED: y� e
DATE COMPLIANCE ISSUED-
VARIANCE GRANTED: Yes No
a'
a�+a 3a
qa
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=272170&seq=1 6/2/2016
8 ba
` towNOFg�N '?oOV
COMMONWEALTH OF MASACHUSETTS '® �aT'9
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS — :
'DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
w
_Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner DAVID CZARNECKI
Address of Owner: '96 BETH LANE HYANNIS,MA'02601
Date of Inspection: 3/17100
Name of inspector. JOHN GRACI '
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(31.O CMR 15.000)
x a .
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636
Telephone Number: 608-564-6813 FAX 608-664-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes d #
" Conditionally Passes
_
Needs Further Evaluatio the Local Approving Authority
Fails
Inspector's Signature: Date:3117/00
The System Inspector shall su it a copy of this inspection report to the Approving Authority.(Board of Health or DEP)wlthin thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
"The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of-inspection..My
` inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." .
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM FOR MAINTENANCE EVERY TWO YEARS.
r
revised 9/2196 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 95 BETH.LANE HY_ANNIS$ MA 02601 M272 P170 L43
Name of Owner DAVID CZARNECKI
Date of Inspection: 3/17/00 +
INSPECTION SUMMARY: Check A, B, C,or D: ,
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure"conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
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
w replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
The septic tank Is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance,
attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,
whether or not metal,Is cracked,structurally unsound,shows substantial Infiltration or exfiltration,or tank failure is imminent.The
system will pass Inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health.
.= Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s)or due
to a broken,settled or uneven distribution box.The system will pass inspection If(with approval of the Board of Health).
_broken pipe(s)are replaced
obstruction is removed
_distribution box is levelled or replaced
Y nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection If.
(with approval of the Board of Health):
_broken pipe(s)are replaced
obstruction Is removed
revised 9%2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION(continued)
Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner DAVID CZARNECKI
Date of Inspection: 3/17/00
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: r
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM.IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
_ Cesspool or privy is within 50 feet of-a bordering vegetated wetland or a salt marsh.
•I
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT,.THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS Is within 100 feet of a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well.
_ The system has a septic tank and.soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a 3
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less
than 5 ppm,Method used to determine distance n&(approximation not valid).
Y 5
3) OTHER
n/a
revised 912/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner DAVID CZARNECKI
Date of Inspection: 3/17/00
D. SYSTEM FAILS:
You must indicate either"Yee or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15,303.The basis for this determination is
Identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. -
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level In the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
Required pumping o
_ X eq ed p p ng more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Q. ..
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
_ X Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply.
X 'Any portion of.a cesspool or privy is within a Zone I of a public well. '
X ` Any portion of a cesspool or privy is within 50 feet of a private water supply well,
_ X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,
ammonia nitrogen and nitrate nitrogen. ;
E. LARGE SYSTEM FAILS: ry
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:, "
The system serves a facility with a design flowof 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply -
X the system is within 200 feet of a tributary to"a surface drinking water supply
X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the.
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 95 BETH LANE HYANNIS,.MA 02601 M272 P170 L43
Name of Owner: DAVID CZARNECKI
Date of Inspection: 3/17/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health.
X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.
Large volumes of water have not been introduced into the system recently or as part of this Inspection.
X As built plans have been obtained and examined..Note if they are not available with N/A. ,
X _ The facility or dwelling was inspected for signs of sewage back-up:
x � n
X _ The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X - All system components,excluding the Soil Absorption System,have been located on the site.
X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of
construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been
determined based on:
X. _ Existing Information,For example,Plan at B4O,H, ..
X _ Determined In the field(if any of the failure criteria related to Part C Is at Issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X . _ The facility owner(and occupants,if different from owner)were provided with Information on the proper maintenance of SubSurface Disposal
Systems.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner DAVID CZARNECKI
Date of Inspection: 3/17100 ,
FLOW CONDITIONS
RFCInFN*iA1; .
Design(low: 110 g.p.d./bedroom ..
Number of bedrooms(design): 2 . Number of bedrooms(actual):
Total DESIGN flow: 220 gpd
Number of current residents:2
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate Inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or noj: NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO ,
Last date of occupancy: n/a
COMMERCIAL'/INDUSTRIAL a
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding.Tank present:(yes or no): NO
Non-sanitary waste discharged to the Title 5 system:'(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:n/a
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
1998 SYSTEM WAS LAST PUMPED
System pumped as part of inspection:(yes or no):NO "
If yes,volume pumped n/a gallons
Reason for pumping:n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
_ Single cesspool
Overflow cesspool
- Privy
Shared systern(yes or no)(if yes.attach previous Inspection records,if any)
_ 1/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information: ;
1980
Sewage odors detected when arriving at the site:(yes or no): NO
revised 9/2/98 Page 6 of 11
R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner DAVID CZARNECKI
Date of Inspection: 3/17100
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 12"
Material of construction:. _ cast iron X 40 Pvc other(explain)
Distance from private water supply well or suction line: n/a
Diameter: 4" w,
Comments: (condition of joints,venting,evidence of leakage,etc.)
THERE IS TOWN WATER .
SEPTIC TANK: X r ..
(locate on site plan)
Depth below grade: 6"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 1000G L 8'6"H 6'7"W 4'10""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33" }
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
Comments: _.
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
.SYSTEM'S USEFULL LIFE. y
GREASE TRAP: _
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass Polyethylene_other'
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments: `
(recommendation for pumping,condition of inlet and,outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n1a
revised 9098 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner DAVID CZARNECKI
Date of Inspection: 3117100
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: n/a
Material of construction: _'concrete - metal_Fiberglass _Polyethylene._other
Explain: n/a
Dimensions: Na.
Capacity: n/a gallons
Design flow: Na gallons/day
Alarm present: NO
Alarm level:N/A Alarm in working order:NO
Date of previouspumping: n/a
P
., Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage Into or out of box,etc.)
THE DISTRIBUTION BOX IS STRUCTURALLY SOUND.,
PUMP CHAMBER: =
(locate on site plan)
r,
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
Na
revised 9/2198, Page 8 of,11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner. DAVID CZARNECKI
Date of Inspection: 3/17/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(2)1000 GAL li X 5
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
,
leaching trenches,number,length: (n/a)n/a
teaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number:. (n/a)n/a
Aftemative system: Na `
Name of Technology: n/a
Comments: r
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PITS APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.ONE PIT HAD 1 OF WATER[NIT AT THE
TIME OF THE INSPECTION.DID NOT EXPOSE THE SECOND PIT.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool n/a '
Materials of construction: n/a _
Indication of groundwater: n/a.' inflow(cesspool must be pumped as part of inspection)NO
Comments:' -a
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Na
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition'of vegetation,etc.)
n/a
a
revised 9/2/98 Page 9 of 11 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART G
SYSTEM INFORMATION(continued)
Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner , DAVID CZARNECKI
Date of Inspection: 3/17/00
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
• V
CO
PC tl2
Page 10 of 11
revised 912198
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 95 BETH LANE HYANNIS, MA 02601 M272 P170 L43
Name of Owner DAVID CZARNECKI
Date of Inspection: 3/17100
NRCS Report name: n/a
Soil Type: Na
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet n/a
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans,on record -
_ Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
Checked local excavators,installers
X -Used USGS Data ,
{
Describe,how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-12+FEET
r
revised 9/2/98 Page 11 of 11
TOWN OF BARNSTABLE
LOCATI(75N � i� { (.�('� i�t �. SEWAGE # "CIS
V.
i� 4)-A��
VILLAGE � �`�C(Vv ; d ASSESSOR'S MAP & LOT ,tomI?P-
11 �-7 7- _
h INSTALLER'S NAME & PHONE NO :i
I) SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) G— ! , "{ (size)
NO. OF BEDROOMS —3 PRIVATE WELL OR_PUBLIC K&TFRL:�
BUILDER OR OWNER - a tQ e-c Ki 8 e
DATE PERMIT ISSUED: "` / '
DATE COMPLIANCE ISSUED: �
VARIANCE GRANTED: Yes No _ `
I
� t
4
h
V-
Y`
No...., f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
TOWN OF BARNSTABLE `
Applira#ion.for Uiipnsal nxki- Tnnitrurtinn jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair X� an Individual Sewage Disposal
System at• n
t--,V....................... ...... .... ` -----------------•-------.--•------------..--------.-------------
Loca ion-Address o5 Lot No.
\ ner ,�•,, / A r
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling of Bedrooms.............................. ._...Ex Expansion Attic�-+ g—-No. --------- p ( ) Garbage Grinder ( )
aOther—Type of Building ............................. No. of persons............................ Showers ( ) = Cafeteria ( )
Other fixtures .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.'
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..............:---sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by........................................................................... Date.......................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water•-_---__________--_---
fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-
Description of Soil...... . �...?.J-----.._•
V .....----••--•-•--•--•--•----•-••-•--••---•--•••----•••-•-•-•••--------------•--•----••-------•-•------...--•--•----••-•--------•••-•-----•-----•--•--•••-•--..................•-----...-•--
----------------------------------------------------------------------------------------- ----------------------------------------------.. ..........................
U
................. ............................
• --I gip---c� ---Le=•`- 4?............ v =---------------------- . S '"^......--------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environm. tal Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compli ce has bee issued by the bo rd of health.
Signed .............. �.--TC 1& d -_'
Daze
Application Approved BY --------------------------------------------------------------- -... .......
Dace
Application Disapproved for the following reasons- ---- ----------------------------------------- --------------- ---------------------------------------- - ------------
-- -------------------------------------- -- ---------- ---- ---- ------------- --------------------------- ------------- . .......-------- --.................... --- ---------:...--------------
Dace
Permit No. .. ------- - 1--..------ 5............... Issued Y------ t. ----- 9.......
Daze
THE COMMONWEALTH OF MASSACHUSETTS !
BOARD OF HEALTH
` TOWN OF BARNSTABLE
Appliration for lispuaal Works Tonstrurtinn Vamit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at„...
• Location Address ((�� o//r Lot No. •-••-
•wner Ads
`�
Installer Address
dType of Building Size Lot----------------------------Sq. feet
U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( )U
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures -------------------------------•------•--•-•--
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No--------------------- Diameter..............•..... Depth below inlet.................... Total leaching area..................sq. ft.
Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water----------:_------__---
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-_-.------------_-_.
P+
O Description of Soil.......�---�- ---. -. . �.....:......:.. r
----------------------•----•----•-----------------
w
UNature of Repairs or Alterations—Answer when applicable.......—r- ,__M._I�_., - ------------------- ..................
............ ...
Agreement: i
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compli nc has been issued b(ry�\the
'board of health.
Signed..... t-�' .. .----4 � ................ "- 7 4 1
`....
Dace
Application Approved BY --- ----- V-----�-------------------------------------------------------------------------------------------------------�.`..�..���.....9�......'�
Application Disapproved for the following reasons:
----- -------------------- ---- ------------------------------------------------------------ --------------------------------------------------------------------------------------------------------- ........................................
/ Date
Permit No. ........ ... - Issued .... .. te
THE COMMONWEALTH OF MASSACHUSETTS ` 3
BOARD OF HEALTH \..,
TOWN OF BARNSTABLE
w Certificate of Tontylianric
THIS IS 0 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ', )
S
bY-------------------- ... Z < ..-.......� �(LS; '
- O � sta ler
at .. ..... ...... ---.. ....... tom.'
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...... .- .�-...�... dated ....j�7..................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT COBI�SY iDJAS A GU RANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. ", ..."....... "�.1 6._.......... Inspector Q�� ------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF��H'OALT�H,�
TOWN OF BARNSTABLE
No .: .3.. , ` . FEE
.,cxra........
Btavos�W331orks Tons#rnrtion Vamit
Permission is hereby granted? '_ '�T_.. <... .. .... ,, _.�_r..:. C ........................
to Construct ( ) or Repai ) an Individual Sewage Disposal System
at No .......q.�'--•-----•-- =' y �®• �s;:s�: Street
Street
as shown on the application for Disposal Works,Construction Permit No?l/��._0___. Dated.` ...... 7.....5--/...........
---------------------------------
DATE.1•^----_....7--------....11....----------•------••-•--••--
FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS
L O C AT 1 SEWAGE PE RNIT p0.
Mi1LLAf; E
INST-A L L EAti NAME 0 ADDRESS
JOHN A. AALTO BACKHOE SERVICt
369welnut Street
West LBarnstable, Mass. 02669
0 U I L D E R OR OWNER
DATE PERMIT ISSUED
DATE C 0 M P L I A N C E ISSUED
1
�O
� � 1
h r
�1 a
No.............. •. FEs (.......�.........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
{ _.......... �!.(i!..!V_.....OF..........
...............................
Appliration for Dhipaasal Warkii Towitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System t Za /�3
.. . :. � ................................... •• ...........--.•--.-- ............
Loc n- d s or Lot No.
....................... ------ 1 -PCB.__. ✓��?`r.
• caner --Address
W � _. ....- .a .................................... .. � /6�-Y`.�.--•• r .........
a
tl
Installer Address �����
Q Type of Building Size Lot.. ........................Sq. feet
V Dwelling—No. of Bedrooms.... Expansion Attic j ) Garbage Grinder ( )
Other—T e of Building ..... No. of persons............................ Showers — Cafeteria
a
� Other fixtures --------------------------------------------------------------------------------------- -------------------------------------------------------------
Design Flow..._....... ...................:.gallons per person pe day. Total daily}flow..........3. _ ...................
WSeptic Tank—Liquid capacity_AM.gallons Length----- �-___ Width......`7���__ Diameter_............. Depth...!f!...-.
x Disposal Trench—No. .................... Widt//h.. ........ Total Length...... ..f.._. Total leaching area--------------------sq. ft.
Seepage Pit No....... . Diameter_..M._V..... Depth below inlet___..._...._.._. Total leaching area..................sq. ft.
Z Other Distribution box ) Dosing tank )
aPercolation Test Result Performed by._._... ._._ �..., �.................... Dateo/"_71 !--.-__....._
a Test Pit No. 1 --•-minutes per inch Depth of Test Pit Depth to ground water_.®kl
(i Test Pit No. 2.._L_z.....minutes per inch Depth of Test Pit__. __ -----_•__- Depth to ground water--_r`__________________
Ix -•---
O Description of Soil r �( � � � - --
U ---�4 _
ey
W
UNature of Repairs or Alterations—Answer when applicable._________________________________________________________________________________.•-•----_---__.
...-•----------------------•-------------•---------------------------------------------.---•-_-----------•-----------------------------------._--.-----------------------------------..........---•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar healt ,�-
Sign ..... . .. ..... ...�:_--- ---- �•-•------------•---•-••
Date
Application Approved By........ �t - -:..... ,1 -�D ��'
Application Disapproved for the following reasons-........................
•...................••---------•-•----------------------------------------•-•-----------------------•-----•------••----•----•-•-•---•-••---•---------------------------------------
Date
-Permit No------=-------•--...----.........•--__-...-•----•--_.... Issued.... __ _". .
Date
F
Y° M
No............ .�'�.. lip
," ...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® 50F. I-iEA T
.... . P TIIN.... ..OF.:.... �1:(i' .................•
Applirtation for Bigpnaal Works Zonstratrtinn Vrrmit
Application is hereby made for a Permit to Cgfistruct (ap ) or Repair ( ) an Individual Sewage Disposal
system
...........rim......!...........................................A .................... ....... ...........
H' a -dress
Installer Address
Type of Building Size Lot............................Sq. feet
.-� Dwelling—No. of Bedrooms.........„ ..........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfi es --••-•--•------•-------------•--••--••--------••-•-------------•-••-----------------------•-.........
W Design Flow..... ...._.._--F _gallons per person p i y Pday. Total da �iow........ �.................01jons.
WSeptic Tank—Liquid capacity. gallons Length................ Width-------:........ Diameter-_.--__---______ Depth... ..__..
x Disposal Trench—No..................... Widt i� ....... Total Length-__-----�- e.... Total leaching area....................sq. ft.
Seepage Pit No______________ ___ Diameter..__.......:...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing to )
`-' Percolation Test Result Performed by....... !__ ._. Date »
a
Test Pit No. 1..... ____.minutes per Inch Depth of Test Pit....
Depth to ground water
} �r_..
fs, Test Pit No. 2................minutes per inch Depth of Test Pit........ ........... Depth to ground water....._---_----_---_----.
a0 t r
x Description of Soil .....J _T `: rt jl .....�� .
-----------------
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
�., .
W
UNature of Repairs or Alterations—Answer when applicable:---__-_.......................................:................................................
.......-••-••••--••-••--------•---....----•----------••--•------•--••-------•-•--------•-•--•---•-•--••••--_•••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of"T'T._.E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee 's ued by th' boar healt `
Sign ----• --. ..••... ••...----+.�./... �`
• Date
Application Approved BY ,y�" _ � ---------------------- ......../-'� "••S`"'7. .
--•-----•--...-•---•.......................................................................................Date
Application Disapproved for the following reasons:_...
---------------•--••-------------------- ...........................................---------------------------------•---••••••---
Date
PermitNo. .----•-----------------•------------ Issued..............................................=..........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
I �rdifiratr of Toutplianrr
THIS IS TO CERTIF.,•Y, That the Irkdividual Sewage Disposal System constructed ( ) or Repaired ( )
by------------_----------- ..b- . ......A.A.4 .0---------_- ------------------------------------------------------------------------------------------------------
ns aller
at �.... .WJLL.......... ot..........�' --- �-� �------ `I—Aw -..-----•----•-------------------
has been installed in accordance with the provisions of T� 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. 9..a_____.__. dated__..1.. _""_ _:�_t __ '_�...........
1�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL UNCTION SATISFACTORY.
DATE............. ` -'"" '��.................................... Inspector... ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
0(7)
N .7� ... ................ t!W ............OF..... 1 .............................. FEE.
�i��r�a��1 nr � �nn��rttriilan .ernti� ,.
Permission > hereb ranted....... �_. ._.:_. .....
Y g .., .4 f`�---------------------------------------- ------............
Ito Constriuct or Repair ( ) n Individual Sewaf Di osal stem {�
eet �
as shown on the application for Disposal Works Constructi "`�
•-------------------------------------------------- ----------- ........................................
Q Board of Health
DATE..............
...........................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TYPICAL SYSTEM PROFILE
AREA PLAN FINISH GRADE=-S T T A 4
r FDN TOP N 0 0 SC L - I
v�L� -52.00 r FINISH ?
SCALE . I FINISH GRADE OVER TANK- . , � .
GRADE > OVER PIT=
LOT 4 � BETH S LANE
! ( PVC OR P O O ::. • • • • o e e . o
' g ,
C. is TEES . • • �: e o O
0 0 <v.o �.... o ....o..... �.. a... o e o • • • • o 0 0
I
:i3SMT
r e •
GAL. 4 o e o 0
FLR ., _ •,
BO.T REINFORCED I X o o t
,, D S e • • • o e o 0
CONCRETE ,
o e e • • • e o u e
... :. . .. ; :. TO BE INSTALLED ON
:;. :.. ..o.... .. . . .... .. . .. ......: ;....::. e
a . A e o • e o
o-.. LEVEL STABLE BASE • e o o e
;w :: e e 'o • � e c
•
. .. �.. SEPTIC , TANK
... ,..� O BE INSTALLED ON 'A e ' • e e e
a
LEVEL STABLE - BASE .r_ . • ,
f
• o • • ` 1 ee
t
S
f •
-a- 2 { 8 2 _WASHED PEAT A
_• a e • • • e o e o e
, , k � / _ 1/ PEAS TONE ALL ►.
rr
...,.,.., "�: BRICK a.,.MORTAR COURSES AS • • • • • _ • o o .a e
I
AROUND FREE`OF IRONS .FINES
D REQUIRED TO'BRING 'COVER - A
Y., ,, TO GRADE
AND D T PLACE
.,. � _ U S I N
HI LEAC NG. . PIT
. .
-25 65JD ) 24 C.I.MANHOLE COVER 3/4 -:TO I 12 WASH ED,CRUSHED
_
T A A F BASE TO BE; V
FRAME SEE `DETAIL STONE ALL ROUND FREE OF LEVEL
� . a IRONS FINES AND DUSTIN
ORE QD.
.� �f'� ,,.. -PLACE
Tam x/ -... r. .., :.' ..
C� ,3 r_, . F F A . . ;
/ovo G' .� OR IN GRADE
DE ..
' C�
S��'rc ,, �, SC Y T M PR F .
�.,,_ h E S S E 0 ILE
�t `�,,
..,
�. �. _ _ SOIL , AND PERCOLATION
T _
. r /�` may+ '1 .i.r
rya
I y � r 4 „ .
t� r ,,
a 5�,c 8 , --.-� P M INr .
_ r.a. � � x • . n .. ._... :.. . . ... . . ERC: RATE . �' .�. IN
4�j Jq
q ;.. .., ..
f
Q s.• o F
.,..�F,;r,, � .,•, 4 R I N V. E L E V SEE
�r t �,
_. u . _,_t. � N, _ , C. D SPOHR ,
k a ;
: ,. ; .. TAKEN 8Y .
,. . . ... r...n � INLET _ t o , SYSTEM PROFILE ,, �� ,
/ ! y LINE o o , �y
,,.`..., .... ,.:., ,:.._:„...: •. a.,.__ .�� ,.. n �sp Pam^''. t� •�^.�/r
o �� ` WITNESSED: BY.
OPC
N N G S W/4.1 8 . ; , _,...., ,
OUTER DIA,. & 1 -3 4 0 o DATE.
ie�' e ,; /
0
, , ; INSIDE DIA. o -_ _ ,. TEST,PIT GND`ELEV. ,5 2
S�t� : 6
bra � .� ~., _ ;: 'TOTAL
' AREA
o G>:
._,,
0 P m.
t • O ,., OR /
., .... l
w",
2- 1 _ _
�,
:max C c "3 S, /Al2)
B
? „ J ! OT. PERC. HOLE
, : :; � EFFECTIVE DIA.
A i
- "17 �. , .: •. , DOWN
y � r, ,.,
���' � THAT TN P � �� t� ,. .. ." ;
LEACHING PIT SECTION
.T1-IOWAI DAt T�1,$ t� � C ��r� � �`� - G SEC / � �� � 1.2
rOW & No SCALE DESIGN DATA .
REAR r1a�I5;
, NOTE:
0 E DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM ' " �.
c—/_5rr�y o N0. OF BEDROOMS a
I : I,
DISPOSAL;
27 �'�:
, LEACHING PIT . :.:NOTES.
. EST. TOTAL DAILY °'EFFLUENT GALS.
PT
I ; CONC.TO BE 4000 P.S.I a 28 DAYS . SEPTIC TANK 1.{2 '� GAL.
2. REINF W 6 - x 6 _ 6 GA W. W. M.
3. 2 AND 4 SECTIONS ARE AVAILABLE FOR
GENERAL NOTES
GREATER DEPTH REQUIREMENTS
I . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN
t
NOTE: ACCORDANCE WITH TITLE5 OF THESTATE SANITARY CODE
EXCAVATE TO ELEVR LOWER AS DATED 9 ANY LOCAL APPLICABLE.� JULY I,I 77 a OC L RULES I
REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING
2. ANY CHANGE TO THIS PLAN MUST BE APPR D. 1N j
,� MATERIAL BENEATH'PIT. REPLACE EXCAVATED MATERIAL
OWNERS 4 BU I L. DER WRITING BY MR. CHARLES D. SPOHR.
,. WITH CI.EAN,CLAY FREE GRAVEL, MECHANICALLY
3. WHEN CONSTRUCTION IS COMPLETED,`PRIOR TO BACKFILLING
- COMPACTED IN PLACE.:- _,
- " NOTIFY THE ENGIN€ER AND BOARD OF.HEALTH FOR INSPECTION.
SIDE` A EA = / .- N
Cl 41Pe Ff_ Y4_1A,1 I'U/ , per` R _S F ��S.F.F /GAL GALS
4. FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED.
I�'tl+/ � r� C BOTTOM A EA= .F.�_ �
�� . R � S S F/GAL �.. GALS 1
5. THESE ELEVS. MUST NOT BE CHANGED WITHOUT WRITTEN
Al- 0� � '.a.S" , TOTAL AREA =- S. F TOTAL ,51 GALS l
APPROVAL BY CHARLES D. SPOHR.
LEGEND 6. FOUNDATION INSPECTION REQD. WHEN EXCAVATED.
e + 50..0 EXIST.` GROUND ELEV.
B. M. NOTE :
50.0 FINISH GROUND ELEV. UNDERLINED ,
1
R P
*" PIPE EV DATE DESCRI TION
��.� ;r� lea, � C�� ;��r��`"•�' •A , � �`" 4 7 5 0 t E INVERT. ELEV.
E V. -
e
� l - L v, oo/..,�� . .,.� � � � +C�. 0 TEST PIT LOCATION ATI O N
SEWAGE DISPOSAL SYSTEM
FOR
o SEPTIC TANK
PL. N LA 4
_
� R � FL�'NN BU I LD -R
- [1 DISTRIBUTION BOX
! / rlel(
N T r ° f f p � f� FROG , ..— 4C, i . PIPENL:
�JLUT
,ocr A 4BIT. FIBER PIP TI T I N .11-ttttt-t-1- E GH J0 NTS 1� S�t��3 � �
r�.
n
• ,v DESIGNED. GD.SPOHR DATE30 r,�C?;° 7 DRAWING N 0
-- — PROPERTY LINE �� =f ;'
,o l37r av /
O i i � F F. ,
'. S
l.c�. �" O� � 55l�,�, DRAWN SCALE:AS SHOWN , .
,
MIN. CODE DISTANCE1, 0 SIA
MA EC P GL LOT HOUSE TQ MIN P S a �CNECK ED. C. 'D. S .
-
ASSESSORS MAP : Z7�
___-- --__ __.------ TEST HOLE LOGS
PARCEL : 17Q
_ _. _ 1 The installation shall corn pt wtth Title V aus�
L" p j" SO L EVALUATOR: I l� 0 M �.�. ) r �l � 1 'fotvn of 9"AD10(ird of
FLOOD ZONE: U�� . (7 I lealth Regulations.
WITNESS
I 2) The installer shall verify the location of utililies, sewer inverts and septic
REFERENCE: i IG. �' `
cC c3� c30_ DATE:
t _ components prior to installation and setting base elevations.
PERCOLATION RA f E: L. Yl/�I 2 � 3) All bravity septic piping to be 4 inch Sch 40 1 VC at I/8 per foot. 'The lust
two feet out of the d-box to the leaching shall be level.
ETY ve TH- I TH-2 4) his plan is not to be utilized for property line determination nor any other
_ _._------ .__.-_-__ _. __. __-_-- purpose other than the proposed system installation.
A ° 5) All septic components must meet Title V specifications.
6) Parking shall not be constructed over I I10 septic components.
IV)
"l
�y, b t1 o
b" 7) The property is bounded by property corners and property lines.
3/1 �, �� 8) The property owner shall review design considerations to approve of total
LOCATION MAP I j 1 design flow and number of bedrooms to be considered for design. Receipt
`01
� of payment for the plan and installation based on the plan shall be deemed
, , approval of the design flow by the owner..
9) The existing leaching or cesspools shall be urn ed and Tilled with m
G 6yq/U /t g g P p p material
V per Title V abandonment procedures. Those within the proposed SAS shall
be removed along with contaminated soil and replaced with clean sand per
` I
Title V specs.
10)System components to be 10 feet from water line. Sewer lines crossing the
water line shall be sleeved with 4 inch SCII 40 PVC with ends grouted if
applicable. The proposed SAS is being installed below the water service
line. The line is to be sleeved as aforementioned and maintained in place.
SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line il'such
exists.
_-------�" 3 BEDROOMS AT GAL/DAY/BEDROOM - MGALIDAY 13)Tne installer shall verify the location, quantity and elevation of the sewer
lines exiting the dwelling"rior to the installation.
SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting
/ r Title V requirements.
GAL/DAY x 2 DAYS - t 10L/ GAL 1
' - i USE I GALLON SEPTIC TANK
V15-0 �
r OIL A SORPTION SYS7Et� -
o 1
10OF
SIDE AREA X2,X ► % 111, 97 ' � DAgVID
BOTTOM AREA: Z � , , Z�7�� I � MASON
No.1066
-IS-EP-T+Q, SYSTEM SECTION
Avg Vr�xwwl
f\j N ` _L(t�'`�, _ _.V✓ _'""-_` v h.l to ---�. /67,
I IL 10
b �
/ '� 5�r�j aell .
GAL ��c� ff_ ter ' n
SEPTIC TAN - I i w
1W _ ,
--�. ----y_y 7 Z
':6DTfDM Or- /(i�HDL4Ah8
'Y' 1' p SITE AND SEWAGE P
LAN
L OCAT I 0 N :
_ s
A _
PREPARED FOR : JI (,
0
o SCALE:
F
DAV I D B . MASON R!�) DATE: Cv ZI
DBC ENV I RONMENIfAL DESIGNS
s
EAST SANDWICH . MA
W DATE HEALTH AGENT
( 508 ) 833- 2177
W
Z
i
1