Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0161 BETH LANE - Health
161 Beth Lin. 272-165 Hyannis I� c o n a 9 COMMONWEALTH OF MASSACHUSETTS DMSION OF PROFESSIONAL LICENSURE OFFICE OF INVESTIGATIONS Application for Complaint 617-727-7406 www.mass.gov/reg Date Received(stamp): Entered into the Database(Date): / / Docket Acknowledgement letter sent(Date): / / Signature: -------------------------------------------------------------------------------------------------------------------------------- Please complete this form as fully as possible.(PLEASE DO NOT WRITE ABOVE LINE.)Please type or print legibly in ink. SUBMITTED BY: Name: Desmarais Donald R Last Name First Name M.I. Address: 200 Main Street 508-862-4740 Number Street Daytime Phone Hyannis MA 02601 City State Zip Code Evening Phone Best way to reach you: ❑Evening Phone ❑°Daytime Phone X E-mail: donald.de sma.rai s @ town.barns table. LICENSEE SEEKING COMPLAINT AGAINST(use separate form for each licensed individual): ma.us Name: DaS i lva Viviane A, Last Name First Name M.I. _ Address: Number Street Daytime Phone Hyannis MA 02601 9069081 City State Zip Code License Number/Type Class Brazil Real Estate Business Name Business Address Daytime Phone Hyannis MA 02601 City State Zip Code _. Business License#/Type Class Please check the trade or profession that this application for complaint pertains to Accountant Funeral Director Optometrist Aesthetician Gas Fitter Physical Therapist Architect Hair Salon - - Physical Therapist Assistant Athletic Trainer Hair Stylist Plumber Audiologist/Speech Language Health Officer Podiatrist Pathologist Hearing Aid/Instrument Psychologist Barber Home Inspector Radio/TV Tech. Barber Shop x_ Real Estate Agent/ ' Chiropractor Land Surveyor P Broker/Salesperson /N Dietitianutritionist Landscape Architect Real Estate Appraiser Dispensing Optician Manicure Salon Rehab.Counselor Drinking Water Manicurist Sanitarian Ed. Psychologist Marriage&Family Therapist Social Worker Electrician Mental Health Counselor Veterinarian Electrologist Occupational Therapist Engineer _ Occupational Therapist Fire or Burglar Alarm Assistant Page 1 of 2 Description of the incident(s): Briefly describe the incident(s) that led to your application for complaint and note the times and dates that events occurred.List the names of all individuals involved.Please attach additional pages if needed. I am a health inspector working for the Barnstable Public Health Department. On 5/19/2006 @ 11 AM I responded to an overcrowd i nq comn1 A i nt T cl i d noi- an into h home but- T called Vivian DaSilva of Brazil RE who had a for sale si n on the front lawn. I did not identify myself as a health inspector but simply asked how many bedrooms are in the property. She responded "it has 3 legal bedrooms but you could—put up a waT 1 in the di ni ncx room to aet a fourth" _ ~ This house at 161 Beth Lane, Hyannis, MA is in a Zone II water protection area and is limited to 3 bedrooms As a sole source aquifer down here on the cape we must protect our qr-aundwater and I heed ` o be abl , to trust the' hi crs of the Realtors. My card is enclosed with furthur contact info. (Please use a separate sheet if necessary.Do not write in the margins.) Additional information or materials attached ❑Yes &No To speed up the application for complaint process,submit legible copies(not the originals)of all relative documents supporting your application(e.g.contracts,medical records,cancelled checks,etc.).You will receive an acknowledgement letter notifying you if a complaint is issued based on your application.If a complaint is not issued, you will receive information on additional resources that may available to you. AUTHORIZATION FOR RELEASE OF RECORDS AND FORM REFERRAL My signature to this form,or a photocopy thereof,authorizes the Division of Professional Licensure to: (1)receive copies of all medical,dental and mental health records relating to my application for complaint,and(2)to refer my application for complaint to other appropriate law enforcement authorities to investigate and/or prosecute. Please note that all applications for complaints are examined to determine their factual basis. The act of filing an application'for complaint does not assure or imply that disciplinary action will be taken against the licensee. I attest that the information provided is true,correct and complete to the best of my knowledge. 5/22/2006 Signature Date Mail this form to: Division of Professional Licensure,Office of Investigations 239 Causeway St.,Suite 400 Boston,MA 02114 Page 2 of 2 r ' ell, C� - 2 73 "7h (,L;6" &A;d) t IG � • ` TOWN OF BARN.;TABLE ®/ I:C�ATION �i SEWAGE erck < � - K-I V'IL'a:AGE 17 V G i'V V�!t_l , SSESSOR'S MAP & L0�� INSTALLER'S NAME&PHONE NO.O> C`��PCL`�/��. a� SEPTIC TANK CAPACITY <-'��Z;-do v.j -,o&e,-a zwef. LEACHING FACILITY: (type) NO. OF BEDROOMS BUILDER OR OWNER. PERMITDATE: �`'� �`" O COMPLIANCE DATE: Separation Dis°Lance Between the: Maximum Adjusted Groundwater Table to the Bottom;;f 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. d � - C- Q Mo f\ C ry � � V � No. Fee Od THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION.- TOWN OF BARNSTABLE., MASSACHUSETTS Application for Digpogar *pgtem CCongtruction Permit Application for a Permit to Construct( . )Repair( )Upgrade( /Abandon( ) O Complete System 0 Individual Components Location Address or Lot No.�/ Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �O gallons per day. Calculated daily flow o gallons. Plan Date "J�o 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) Date last inspected:. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued' is B d f Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 2 0 Date Issued f & ti No. 0 s Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ? PUBLIC HEALTH,,DIVISION.,-TOWN OF BARNSTABLE1 MASSACHUSETTS ficati0n for Oigogar *pgtem CCon5truction Permit d. 5 Application for a Permit to Construct( )Repair( )Upgrade(v)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No, L' y Ownerr''s�Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms -� Lot Size sq.ft. Garbage Grinder( ) Other' Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 7 0 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 w. Nature of Repairs or Alterations(Answer when applicable) E Date last inspected: Agrpleement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the.provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued )lis B. d f Health. ,. Signed Date Applic t on Approved by :' ;. Date 6~ Application Disapproved'for the following reasons Permit No. 2 00S= 3W't:. Date Issued --?cf'—u5 ———— ————— . —————————————————————— ——— ,�` 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 ��� ���,,� d �y has been constructed in accordance with the provi ions of Title 5 and the for Disposal System Construction Permit No. 2Cl°5'"39) dated Installer LJ�hi �G��G'GG/` Designer 094,4'/A I A5?. The issuance of this permit s all not/be construed as a guarantee that the stem`vi fu tin aj�degbe-dam Date �� 1. Inspector- --- -- 1 ——————— --- ——————— �., ...v .,.. No. THE COMMONWEALTH OF MASSACHUSETTS Fee fiU— PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS *p!5tem Con.5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(Y)Abandon( ) System located at 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 mut be completed within three years of the date oft ili s p� i . Date: � _ Approved by 4,/ - r Town Of Barnstable l •. �: Regulatory Services b�P Thomas F. Geiler,Director ASS- Public Health Division FEoAa. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: U 12 Z.b Designer: 6• y"lk� Installer: Address: .',�.I 6UV-,t� 'P4� Address: �, ��-•l Jw iG� �� I�ZS� w�s� On : -`�' GA*4was issued a permit to install a (date) (installer) septic system at ��- _ ogsed on a design drawn by (address) M Ns o� dated 116 06- (designer) - l�I certify that-the septic system referenced above was installed substantially according to the design,'which may include minor approved changes such as�{lateral relocation of the -distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. `Ins ler's Signature) 31 . k ° ? �. yt3 si er's Signature} (Af x Designer's Stiamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTU THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE P LIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form UaitniUa xUn 1,:0-1 rAA 1U64a244*0 xopery n. Uur w. WJ . uuc 5/25/O1 K. Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the ei ngi nerd plan signed by ate dated 1`� concerning the property located at 1� LA4. ts gQ of the following criteria: This failed system is connected to a residential dwelling only..There arc no commercial or business uses associated with the dwelling. e The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. o There is no increase in flow and/or change in use proposed • There are no variances requested or needed. o The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the gfoundwater table using the Primptor method when applicable] Please complete the followings I A) Top of Ground Surface Elevation(using GIS information) I B) G.W.-Elevation 3�-.V+adjustment for high G.W.2 DIl~•FERENCE BETWEEN A and B SIGNED• DATE- NOTICE Based upon the above information,a repair permit wilt be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. 2A* ILIDM. go VD qc beft foldar.pereikmP t a r TOWN OF BARNSTABLE VILLAGE ASSESSOR'S MAP 9 Tic) fn �uFe� 'S NAME&PHONE NO. e%��y SEPTIC TANK CAPACITY �G✓ LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER Z5,491i-21e- PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I/J� 7. 0 o � W I� all �, r r— COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION sy� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A a .a CERTIFICATION5 MAN Property Address: 161 8,e—A 1,4,1�C � 01NO Owner's Name: isiarnou,�ra(:� ® Owner's Address: f(r 6e,-,zA 4,4. ,e —..> Date of Inspection: c�i'islo y Name of Inspector: (please print) Company Name• Mailing Address• 06 156 A- 14,61 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the informationsreported 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: r, Passes Conditionally Passes I Needs Further Evaluation by the Local Approving Authority Fails ze�' Inspector's Signature: �- Date: (.?a. 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 systemowner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /,6/ be-!A ,L.hr?-e Owner: g/Azeze 61,—Va -L Date of Inspection: 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 19:303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: ' B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. 44 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 enfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or &scted pipe(s)or due to a broken settled or uneven distribution box. System will ass inspection if with � Y P sP ( � approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will ass inspection if(with;approval of the Board of Health): „ broken pipe(s)are replaced obstruction is removed ND explain: - i Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:a-1 Be/-! 4Ast�p— Owner: ili.,zc�l ✓a��,/s Date of Inspection• /plc,rr C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system . is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of'a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORME—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /&4/ 2.4.,le- Owner: � io� Date of Inspection: D. System Failure Criteria applicable to all systems. You must indicate"yes"or"no"to each of the following for all inspections: Yes No k Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool k _ 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 _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 1 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. _X_ 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,coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: /d/k To be considered a large system thesystem must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following; (The following criteria apply to large systems,in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner-or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. I • Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:Wit;/ AesFheQ. ,S�An'7"-5 M4 , Owner: 'fs�rzC �d cc� a(S Date of Inspection: < /o�e 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 theOcaner,,dccupant.,or Board of Health F _ Were any of the system components pumped out in the previous two weeks? j _,.Has the system received normal flows in the previous two week period? JL 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: Yes no Existing information.For example,a plan.at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION G Property Address: Owner: i�/.g�rL2 'alcy�r„Ij Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): -3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example:410 gpd x#of bedrooms): 356 Number of current residents: Does residence have a garbage grinder(yes or no):Aw Is laundry on a separate sewage system(yes or no):_0 [if yes separate inspection required] Laundry system inspected(yes or no): ZV Seasonal use: (yes or no):n10 Water meter readings,if available(last 2 years usage(gpd)):(9aoi)T Sump Pump(yes or no):A�V Last date of occupancy: &ZU Np-t COMMERCIAL/INDUSTRIAL /V/f Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of.design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5"system(yes or no):_ Water meter readings,if available: - Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: O'WA 4-- Was system pumped as part of the inspection(yes or no): AV If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 13,40 Rage 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1,6/ Owner: li ir, G d w/x-t i Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 22" Materials of construction:_cast iron M 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): 44�7 yr e6en cr a /Pf�t SEPTIC TANK: //(locate on site plan) Depth below grade: /3 " Material of construction:_e concrete metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 'C'4/ ';� Sludge depth: y`E Distance from top of sludge to bottom of outlet tee or baffle: r/,9 h Scum thickness: `e Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: r�, How were dimensions determined: M,--ASclre— f t Fr.e Int Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc.): Q 4 U1,VS A'C ,n 014C�r��n%- °s���c l vss}//,fir sa.Lm d, &..te lk zyk le lt"l At1it• Nei 't/a. P:RC� Md f ,rk2kk GREASE TRAP: (locate on site plan) Depth below grade:— Material of construction:_concrete metal— fiberglass—polyethylene—other (explain). Dimensions- Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1,61 -e- /Icy Owner: g-VAnL 0Edz&1W l;S Date of Inspection: F, TIGHT or HOLDING TANK:110 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition.of.alarm and float switches,etc.):. h DISTRIBUTION BOX: ✓ if resent must be o ned locate on site plan) ( P Pe )( P ) Depth of liggid level above outlet invert:J_4 ` 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.): ��fia-s.�iv•�iess\ `�f33C PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): w ;Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 161 1,Af7 Owner: E&,u- Cd a.1,%rd1 s Date of Inspection: X15/a!5/ SOIL ABSORPTION SYSTEM(SAS): v*" (locate on site plan,excavation not required) If SAS not located explain why: Type k leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): E"--5 :ItU4 Aft b 9se,3L M-L a� 'Pa / JLin F/006e -,,P-bat OL&R•r /n 1ie'ri' � CESSPOOLS:4(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction- Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ��� e PRIVY:'1 (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.): 3 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: %e,f A e A I-AA � Owner: Date of Inspection: 6 L5,& f SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. �Alwn 1 b 3H' . 1� , o b� 3y.6" \ U Pax r � J Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: &9j,%j Date of Inspection: SITE EXAM Slope f'144 Surface water Nra,-V- Check cellar 540-s Shallow wells WO Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan_reviewed: 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) t Accessed USGS database-explain: ld 5 E 5 o&42rve-f,&% eatW 044-A (I,V i tjA_ ,S y eqV &d &ffrIft You must describe how you established the high ground water elevation: 40,Ltl /-I I w- .W 4,&.4, l4.oailtz lya-1 ern AftA AJ,71- ju 9fu,F I dA ,%O Pu ZjVAA—X Ctrs, d4rd d"O'D F ` SKETCHIAREA TABLE ADDENDUM ' c�tmc -,Bryant J. and Melaine J. Edwards p 161 Beth Late -a-Y, ciw Hyannis C0ww Barnstable safe MA zipcoae 02601 North American Mortga a Com any 12. 0 BATH A D 10 MASTER T BEDROOM BEDROOM H G ICI TCHEN cv C C fry c LI VI NG AREA " BEDR OM O C ROOM C 14. DG. O 40. 0 * DIMENSIONS ARE APPROXt MATE *ROOMS ARE NOT TO SC SCAB: 1 kA 442 fed AREA NAME OF AREA Sq. Ft. TOTALS Gross Living Area Calculatlorls F GIAI UVING AREA 1320.00 1320.00 20.00 X 14.00 280.00 . YOR SCREEN FORCE 120.00 120.00 26.00 X 40.00 1040.00 GAR Iwo-CAI!GARAGE sn oc 572.00 LL , . � v Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One winter Street Boston Ma. 02108 John Grad ' D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 161 Beth Ln.Hyannis MO Address of Owner: Date of Inspection: 1/26/98 (if different) Name of Inspector: John Graci Ed Bogle I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 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 This Inspection Is based on criteria defined In Tftle V Conditional) P s5e5 code 310 CMR 16.303.My findings are of how the system is Y performing at the time of the inspection.W inspection does — Needs rth Evaluation By the Local Approving Authority notimptyanywarrantyorguaranteeofthelongevityofthe Fails septic system and any of Its components useful life. Inspector's Signature: Date: 1126198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x 1 have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. 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 CoMpllance(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 conforming septic tank as approved by the Board of Health. (rerised 04f27137) One Winter Street • Boston,Massachusetts 021108 • FAX(617)556-1049 a Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 161 Beth Ln.Hyannis Owner: Ed Bogle Date of Inspection:1126199 _ Sew.aae backup or.breakout or hicih.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —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 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined 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 Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 04r17)97) f _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 101 Beth Ln.Hyannis Owner: Ed Bogle Date of Inspection:1126199 D]SYSTEM FAILS(continued) 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. — — Any portion of a 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. 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: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 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 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 it of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consuls the local regional office of the Department for further information. (revlsed 04127)9T) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 161 Beth Ln.Hyannis Owner: Ed Bogle Date of Inspection:1126199 Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of.the system components have been pumped for at least two weeks and the 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 NIA. x _ The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — 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. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)] (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 161 Beth Ln.Hyannis Owner: Ed Bogle Date of Inspection:1126198 FLOW CONDITIONS RESIDENTIAL: Design flow: 2" 9•P•d./bedroom for S.A.S. Number of bedrooms: z Number of current residents: 6 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: Seasonal use(yes or no): No - Water,meter readings,if available:(last two(2)year usage(gpd): NO Sump Pump(yes or no): No Last date of occupancy: We COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:o gallons/day 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: nra Last date of occupancy: nfa OTHER:(Describe) rya Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped 3 years ago. System pumped as part of inspection: (yes or no)Yes If yes;volume pumped: 1000 gallons Reason for pumping: nla TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date Installed(if known)and source Information: 1978 with new pit Installed In 1994 by ABCO permit 196.1631 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 151 Beth Ln.Hyannis Owner: Ed Bogle Date of Inspection:1126199 SEPTIC TANK: x (locate on site plan) Depth below grade: t' Material of construction:x concreate_metal_FRP_Polyethylene—other(explain) if tank is metal,list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: LTVH57"W'10" Sludge depth:2" Distance from top of sludge to bottom of outlet tee or,baffle: 25" Scum thickness:4" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle:14" I 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.) System and all components are structurally sound and runctioning property.Recommend pumping every one to two years. GREASE TRAP: (locate on site plan) Depth below grade: nra ( lain _other lene Pol eth exp Material of construction: concrete_metal_FRP_Polyethylene ) Dimensions: nra Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:nra Distance from bottom of scum to bottom of outlet tee or baffle: nra Date of last pumping; 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.) nfa BUILDING SEWER: (Locate on site plan) Depth below grade: t�v Material of construction:_cast iron x 40 PVC_other(explain) Distance from private water supply well or suction linetown Diameter: 4 Qmments: (conditions of joints,venting,evidence of leakage, etc.) (revlaed 04r17)87i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 161 Beth Ln.Hyannis Owner: Ed Bogle Date of Inspection:1126198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade:rda Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: n1a Capacity: rda gallons Design flow: rda gallons/day Alarm level:_nra Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) rda - DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments:- (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)Ho Alarms in working order(yes or no)_Yea Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) rda (revleed 04127ST) E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 161 Beth Ln.Hyannis Owner: Ed Bogle . Date of Inspection:1126fga SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rya Type: leaching pits,number: 2tAOD gallon leach plt leaching chambers,number:rda leaching galleries,number: nia leaching trenches,number,length: nia leaching fields, number, dimensions:We overflow cesspool,number:n1a Alternate system: rda Name of Technology:_ry Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Systems are structurally sound and functioning property.The new pit D has 3'of water In It. - CESSPOOLS: I� (locate on site plan) Number and configuration: rda Depth-top of liquid to inlet invert: n1a Depth of solids layer: rda Depth of scum layer: n1a Dimensions of cesspool: rda Materials of construction: n1a Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Iva ' PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: We Depth of solids: n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) rda (revised M71H7) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 161 Beth Ln.Hyannis Ed Bogle 1126198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references,landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) OT AI � P C L100 � 00 k' �p 3y (revlaed0427197) Page ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) c _ 161 Beth Ln.Hyannis Ed Bogle 1l26198 Depth of groundwater 9 12+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Describe,in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS maps and charts (revisedG4)27197) tripe 10 of 10 } � TOWN OF T3AR1,2"TABLE LOO'; T10N_� SEWAGE # — VILLAGE N ASSESSOR'S MAP & LOiAll P-` INSTALLER'S NAME PHONE NO.C' (,k\-ow Y nAs,,&,,- 177-0349 SEPTIC TANK CAPACITY 1 000 LEACHING FACILITY:(type) �, Q °�._ (size)f®Xv 18 0 c- , NO. OF BEDROOMS PRIVATE WELL OR PUBLIC,WATER BUILDER OR OWNER r e. DATE PERMIT ISSUED: Lq DATE COMPLIANCE ISSUED VARIANCE GRANTED: Yes No ,� ,c- ♦A v j W, A V rz O w 1^ �a THE COMMONW0 1 OF MASSACHHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratinn for Diti-Vi ial Work,i Tnnitrurt"inn Urrntit Application is hereby made for a Permit to Construct ( ) or Repair (<) an Individual Sewage Disposal System at Cam\ _ Local -: ddress - .1........................... 1�_ __m�_l\_1rv____•••_ Ad' 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 ( ) d Other fixtures --------------•--------------..----------------------- w Design Flow--------------------------------------------gallons per person per day. Total daily flow....---__-__-__.......................------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth---------------- x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No.........:......... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-.-.__._. ----_._.. Depth to ground water_-.-_.._-.-.- .__.-. (4 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water.......--_--___._.___--. P4 •---....-•---••-------------•-------............'-"'-•--'-•----....----...............•-""'--•-"-'•-•--•".__..."--'-"'•""'._.._-'-'-"-...-'-''"--- 0 Description of Soil___.... ...__ w U Nature of Repairs or Alterations(� sorer when ap licable._.--.--__._V :&At% .\-.......__L.-- �.s.J.._._...(ra `o:___.__... ............................S -----•---�._.._�__� :_......... ' ���A-_--�U----�I �..._ S1!?.._ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of4TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ce has been issu d by the boar f health. 0 l @ p ined - ------------------------ ........................................r' ..5 ----- - - ---- I)ace C� .r Application.Approved By ----- - -- -- ---------------------------------- ... .------ -- --- --- -------- ....----- - .-.�- . ..-_�.. .."..`�5. Dare Application.Disapproved for the following rearonf. ------------------------------------------------------------------------- ---------------------------------- -------------- -------- ------------------- -- --- --- - .."/��� �.- -...- Permit No. � �... .. .............. Issued -----.-- 1 0 ^9s ----------------------------------------------Date -..-.. Dace 165 0 THE COMMONWEAL TH OF MAS�SACHUSETTS w '-; BOAR® OF HEALTH . TOWN OF BARNSTABLE _ AVV irati it•for Di-tipwial 3Vnrkii C omitr acttaQn rruttt Application is hereby made for a Permit to Cortsfruct ( ) or Repai ()<) an Individual Sewage Disposal System at• �'• ,. r ------------- � .m. �` ` � -N�---------- ........................� Locatig(, 4idress or Lot No p ........... W O vncr ...__ _A�drtssr........ _. .. Y`f y, Installer ' Address d Type of BuildingJam " ` t Sq. feet U ? }J �„,• S>z, Lot............-............... Dwelling—No. of Bedrooms.__._._.___J_________________________._-__E xaris>on Attie''( ) �' Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of pers"ons._.__.�_____=/______�- Showers ( ) —.Cafeteria ( ) d Other fixtures --------------------=�-/,'": -- t -----------------•--------- 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 ( ) a Percolation Test Results Performed by-------------------------------------------------------------------------- Date-------................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water---------------------_- 4 (S. Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-....................... Description of S oil____._.___ t� ------------------ ------••-----•-------•-•....•---•••--•--••------••--•----•-••---•---•-------••----•••---••------•- W g U Nature of Repairs or Alterations—,An wer when a licable_______________ ;.a 1. _____...___._.9e] -,� --••••--(, 0...... Agreement, TI The undersigned a'g:rees,to install the aforedescribed Individual Sewage Disposal System in accordance with tkp . ions of I ITLE of-the'State Environmental Code—The undersigned further agrees not to place the system in operation until a Cerctfica'0t of�Complia c has been issu d by the board of health. .M p Signed - // �/ J ` Dare p Application.Approved By ......� ©.. .. .. .... �t .... / ' ----9 _. Application Uisapproved for the foll6wipg1easons; - - A 1 Dace .,, Permit No. t Issued ---------> .."'. ----------------- Dare 1 THE COMMONWEALTH OF MASSACHUSETTS 61 BOARD OF HEALTH TOWN OF BARNSTABLE 11 erti t ate of TDitiplian e TIIIS IS70 CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by - ..�r- •.a ., .......�_O.,5 -- � - ate >....... -�---- --------- ------ ------ ----- has been installed ini'accordai ce-wit-h the provisions of TITLE of The State Environmental Code as described in the application fo&bisposal Works ConstfVction Permit No. W5_ .��— -- dated T�HEJS,SUANCE OF THIS CERTIFICATE SHALL NOT 9E CONSTRUED AS A GUARANTEE THAT THE SYSTEM'WILL FUNCTION SATISFACTORY. 16- �- — ---- Inspec r _.. ;t yY, THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH TOWN OF BARNSTABLE No. V •--•------i.... FEE.30:0_0.. Movaa ttt Workii Tomitrurtuatt "Permit Permission is hereby granted---_ _C.S "'.!---- \ ............................................................ to Construct, ( ) oD epair :a n Sewage rspos. ystem - ............... ----•---------_•-•__'-_.... Stree ...- as shown on the application for Disposal Works Constructio Permit No. ----- ___- __ Da"ted_.� ___^_150_" /i')----•. p •........ ............ B of Healt ......... h L DATE. _1 FORM 36508 HOBBS R WARREN.INC.,PUBLISHERS 4 tf lam. Jkt ��`hy i� .. ,a.per «i� - - r•..yd '+ Y.,i. y n ji JAN r?"O" ; r 1 c '° �..... .. ....r�-:7�\/. fr�r� ��1•✓'� '� . ai � ��� - �,,•.:...r,,v,,.// r iVS l/i t yr t l �.. i`Gb tx s3ei q I i 41'.ds' r ... RN II`J i I mS P E C T O R K, N17 � ........... �r ...�....... /./ ...... .... .�... ....1. C ',,i+1s pssiL s ri.y' .. .... ....... .... .. ..... ..'`.....C... �, ..r ... ....................`` ............................ I ...� .. �?... ................19.7.7 -.w.:s..axxT+ ���'�i4. '�kTAr+.�-ri.i.d✓�.Y �S a',.itt.:�� , 1..: I. G�nrrF. .,{ti+ya.� .:.: ..- .. .* .,'F'.. ..,,.vw.-..• .?-,wr: o-r•^t]ar:..: ..:'ice+ ...... cord. to the"following information: . $•:''4.3t:*.,�' ,.r k! '3ry` -! P. .y .� ..�f^'•.f..J.�a .............1.:.1.�1.•�..1....... ................... ........................... ....... .............................................................................................. .............. Fire.District ... ......... ... ......... 1P '..... Address s,.`. ... r-,.. of. .... . ....... .Address .... . . .......... ...Address .......... ... ........... . . ................. ............ t?oundation .......... ....�.� ......�. .......... ....... 1 �i"Tyr z 1 c Interior ................................. i i t Plumbing d }t.r r;1� .1 r{ .. .... � . .. .... .Approxtmate'Cost .. +r..,+:n,iti e P-e `,..a� �x(.:' '..�. i :f r r g 'hoard - ------ ----------------19-------- . Area .....�.7� ...... ........ V;ht,t !-iii en ions Fee .......0....... ....................... u•}rf. . .tip'., i:-80 -R,�',.) OF' HEALTH E ' e i ' I i 1 '•_��_. i I 'h�• ,Rules and:Regylations'o he Town of Barnstable r arding t e above trip r 5?V It-:�: ' f �2 Name........... ....... ......... ....... ... . ... . TOWN OF BARNSTABLE LOCATION kAbJe • SEWAGE #?S—/,f3 I VILLAGE ASSESSOR'S MAP & LOT ° INSTALLER'S NAME & PHONE NO.C2±�\-ow SEPTIC TANK CAPACITY 000 oO LEACHING FACILITYAtype) �, , r °� (size) wog c. NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER . DATE PERMIT ISSUED: . ' DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Ub s - .13 - �' 7' l 0 tA T IO S-E W A G E P.f R M PVT N 0. VILLAGE INSTA LLER'S NAME & ADDRESS BUIIDER . :--'OR, OWNER DA T E P ER.MI:T. ISS_U E D - z �- 71 DATE C OMPL. 1 A NCE-i ISSUED r �, �� �. � � .� y � �. G l , � `� 1 `� �� III . ,� A No._ .. Fizz....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... ...... ...........OF......................................................................................... ApplirFatiun -fur 11upuual Workii Towitraurtivaa Vautit A plication is hereby'made for a Permi to Construct (X, or Repair ( } an Individual Sewage Disposal Syst t• + . � =-------- -------------- p�-- ----- Lo n• dress Y�� Lot N .................... . ........ -----•------------•----•-....--.-•- - - ® ---- ....•- ..... ... ---•---- O ddress a ... d-�----- •.---...---....................................................... ......------••. .....................---------•- Installer Address �' Type of Building Size Lot_._l�-� ?---------Sq. feet U Dwelling—No. of Bedrooms------ -----------------•. -_-_---_-_Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building ._ '' _ .'.� p aN� (Y) ( ) �_____________ No. of ersons__ _.._ _.._.._ .._._._. Showers — Cafeteria P t Other fixtures ------------------------------------- - W Design Flow....................................`......_gallons per person per day. Total daily flow-_______-_.�"ai-o_...______..........ga WSeptic Tank—Liquid capacity/P.®Rgallons Length---------------- Width................ Diameter................ Depth_A---------- x a Disposal Trench—No..................... Width__..........._..__. Total Length---.-_-----_-_._-_-- Total leaching area.-------------.-----sq. ft. 3 Seepage Pit No-----I------------- Diameter.......4-,X-Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box (4) Dosing tank ( ) Percolation Test Results Performed by .. Date -� f��� minutes per inch Depth o' Test Pit-------------------- Depth to ground water-..- _.------ ,� Test Pit No. 1...___Z_____ ri Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water----fJ,Erff Ile n: ----------- �P ------- •--- O _ Description of Soil LC� ------ �° .......-------------------------------------- --------------------------------- - Ux f ` `41.541 -- --•-- -------•-------------•--------------••--......---------------•------------------- ------------ W U Nature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------........... . o -----------------------------------------------------------------------------------------------•---------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed DV the board of health. Signed.--�'`'- --- -E'�-¢�---------=-------------------------------------- -------------------------------- A Application Approved B L ---- PP PP Y .... '..a)-9." Date Application Disapproved for the ollowing reasons.•----------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------•-----------------------------------------•--•---------------------------------------------------------------------•------ Date Permit No. �� Issued............ '._ '.�7 .----------- Date JV7 No----- FRI&...........:�._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----...........OF..........--...-...-...... ---------------------------------------- -for Diti anal Works Tonstrurtion Vrrmit tion is hereby'made for a Per t to Construct or Repair an Individual Sewage DisposalS s #4 ..6--------------R-------------------------------- -- ---------------- ................... 7 Lot N ------------ --- ---------------------------------- ....................... ----- .. . ................ ....... Adres Loi!!��ddress .... .. ................... ------------------------------------------- ---------------------------------------------- - ---------------------------------------------- I..�a er Address ' I. (,Dor Type of Building Size Lot - j U .....Sq. feet Dwelling—No. of Bedrooms-----9--------------------------------Expansion Attic Garbage 'Grinder gal Other—Type of Building _ _fW9------------ No. of persoii,54� Showers Cafeteria Otherfixtures ----------------------------------------------------------;------------------ --------------------3-3 0----------------------------------- Design Flow_________________________________ gallons per per-son per day. Total daily flow............................................S a3jons. 9 Septic Tmik—Liquid capacity -gallons Length---------------- Width______-______-_ Diameter_._._---.______ Del)......o_.......... Disposal Trench—No--_-- _____________ Width__________________-- Total Length____________________ Total leaching area--------------------sq. ft. Seepage Pit No-----/............. Diameter......41T Depth below inlet-----•.............. Total leaching area--------------_--sq. f I. z Other Distribution box (4,) Dosing tank ..IV--- 7 Percolation Test Results Performed by---------- - Ak .6-&-------------- - ----------------- Test Pit No. I......*21------minutes per inch Depth o Test Pit____________________ -round water---......... Depth to --VAOV 6 ---------------- (L4 Test Pit No. 2................minutes per inch Depth of Test Pit-___________________ Depth to ground water.... ------------------------------------- . ........a--- ---------------------------------------- 77_�`11�---------------- ---------- ---------------------------------------------------------------------------------- U ----------------------- ------ ------------------------------------------------------------------------------ 0 Description of Soil ----- - ---------------------------1=1 --------_---_-- ------------- ............ ............... ----------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alee��ations—Answer when applicable-----------------_--------------------------------------------------------- ---------------- ry a�-------------- ---------------------------------------------- ------------------------------------------------------------------------- ----------------- -------- - ----------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ------------------------------------------------------ -------------------------------- DaAt ,,. Application Approved By--------- --- ---- ....................................................................... ------------1 6.1 -------------------- Application Disapproved for the following reasons:--------------------------------------------------------------------------------------------Date-e-----------_ ..........................................................................................-------------------------------------------------------------------------------------------------------------- Date 4 Permit No.----.. Issued------------7, N, 77 -7------------------------------------- .................................... Date T E COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.......... ............. .................. ................... ...........(9rdifirate of Tomptiaurr THIS IS TO CERTIFY, That the.,Indiv.idual Sewage Disposal System constructed or Repaired y by..... ......... Ia e ----------------------------------------------------------------- 04 o" t .......;------ ------ ----------- r ------------------------ ---- -------------------------- a ........ ........................................ XI cl f The State Sanitary Code as described in the has been installed in accordance, with the provisions of o 0 0 C application for Disposal Works CT Ii struction .............--------------------- dated------ T 5 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. OAdso 44 ......... ...7_7........................................... Inspector_------------*6vo 44f. .........../&........................ .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .,,HEALTH ................... ........ 7 ............. OF..... ................................... No------------------------- FEE--- .............. Permission is hereby granted.......... ...............4<3AF................... -----------------................................................ to Construct or Repair an Individual Sewage: Disposal Sys ern rl...........at . .... . . ........... ---------------------------No................. Street .................................................... Dated________7. ,4 7 . as shown on the application for Disposal Works Construction,,�P ---- No------_47�1 ----------------------------- .............................. ------------------ ................................................... Board of:Health DATE_ -------------------................ --- - ------ FORM HOE38S & WARREN. INC.. PUBLISHERS k, i } ASSESSORS MAP: Z --- TEST HOLE LOGS /3 PARCEL: 1 _ C NOTES: l FLOOD ZONE: S" � 1G SO I L EVALUATOR: 1 ' CN ---- ___ _—_ .----- _ _ . _.._.__ WITNESS : REFERENCE _.l D I « G DATE: 1) The installation shall comply with Title V and Town of Barnstable Board of PERCOLATION RATE-' ./-77Mjq111W1 Health Regulations. 2) The installer shall verifythe location of utilities sewer invert _ components prior to inst s and installation. septic 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. . • - � '.�� --- 6 Parkin shall not be con _) g constructed over H10 septic components. LOCAT I ON MAP (�F5) 4 — mot— 7 The property y is bounded by property Ycomers and property Ylines as depicted. y, 8) The property owner shall review design considerations to approve of total design flow to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow. �L 5, 9) The existing leach pit(s)shall be pumped and filled with material per Title V ,,,,, , - , • iL, abandonment procedures. Those within the proposed SAS shall be removed + �✓ along with contaminated soil and replaced with clean washed sand.per Title V specs. 10)System components to be 10 feet from water line. 11) If a garbage grinder exists it is to be removed. SEPTIC SYSTEM DESIGN I l / o o FLOW EST I MATE Igo BEDROOMS AT GAL/DAY/BEDROOM GAL/DAY � - SEPT I C TANK ?MGAL/DAY x 2 DAYS 6400 GAL USE 1 GALLON SEPTIC TANKrflllbl' X SOIL A1330RPT I ON SYSTEM - -= x n_ �/ � ��► � ' '( $ y oar W /7 1� SIDE AREA: 2 )J' X 'x a►T1 f 'i�5Z - 't - \ I OTTOM AREA: 0 s IY SEPT I C SYSTEM SECTION . ,�,, I� �\ o — JI Q I -' ..ss"d� ="'�'_";,i,i :_!; �..e.. .. `. '' �� _' ,..a.,.:. sS3it5 y •a! ..a'^r.*rae-:r`:1'�dCv,ereti�,:?� •�� r N - 1000 GAL (� 0 ( D+D II l 1 I l I ,SEPTIC '✓T K ►17 3 SITE ND SEWAGE PLAN LOCAT I ON : HqAkAV-116 , MA P PREPARED FORHy: 1 1 a h 1' i - SCALE• I��Z W DAV I D B . MASON R� DATE: ( 1 0 DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA W ( 508 ) 833- 2177