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Home My WebLink About0205 BETH LANE - Health 205 BLTH LANE, HYANNIS A-272-136 I i No................�.. ... ; e". F�$..ad............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF........... ld _24 ..... , ppliratiou for Dispoiial War s Tomitrurtiun 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal 9 S st....at_... ._........ .... .... .., . ram. --------------------•---------• /� ' sP Own ddress 1.4 •••. ...� ... ._. . ---------------------------- -- ..:......: �.jPS _ /S f . Installer �" Address Type of Building Size Lot Sq. feet ---................... Dwelling—No. of Bedrooms____________3___________________'_______Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other ffxtu es __.___ ---------------------- - - W Design Flow___________ ________________ ___ gallons per person per day. Total dail oflow........3._�.._�--�_______._.____.___galloons. WSeptic Tank—Liquid capacity�_��__gallons Length_____ _________ Width__. _ `-_____ Diameter---------------- Depth_____._.. x Disposal Trench—No_ ____________________ Width__ jf__._.___ Total Length_____._.__�___._._ Total leaching area_.._;_ __ ___�_ sq. ft. Seepage Pit No........I.._..___-__ Diameter_._��__�_.__ Depth below inle ........... Total leaching area_ _.sq. ft. Z Other Distribution box (� Dosing tan ( ) ��/U �� '~1_4 Percolation Test Result Performed by.___�_:_ _...,5 � ._____r.�_✓_________________ Date..________.____________/_______.___ 1.. Test Pit No- 1-__ .. minutes per inch Depth of Test Pit._..../9._ Depth to ground water__&� fs, Test Pit No. 2... -__minutes per inch Depth of Test Pit.____.�.__._____ Depth to ground water-----11...___t.j__---- O Description of Soil.._!J= ... 11�/-•l ----� y ��i .�G!��- .....�-.-��-.------ x417 U ------- ----------------•---•---•-----•---------------------------- 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 I i I p 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-issued by the board of health. Sigd----- ---- ----------) -----•-•-------------- •--/ Date Alication Approved B c_ ' -•----.. tE-- ____________________ ...___-jam- - _�—! PP PP Y 7 _ Date -----fi----•-------------------------------------------•-------------- -------•---- Application Disapproved for the following reasons___________________ _ ---•-----.----------------------------------------------------------------------------------------•-•._....-----------------------------•----..------------------------..__....-------------------------- Date PermitNo......................................................... Issued-.... \- ...-----•--------------- Dat- --- e (7 No......... .. Fps it ................ THE COMMONWEALTH OF MASSACHUSETTS OARD O T Appliratiun for Dhgpvii al fur Tun rurtiun 1hrmit Application is hereby made for a Permit;to Construct ( = ) or Repair ( .) an Individual Sewage Disposal system { ...... ................ ----- -----.- +! _._. ... .......................................................... (/ res ....... �' .--- . . -------------------------------------- ` Installer Address Type of Building Size Lot...�.......................Sq. feet U 3 Dwelling—No. of Bedrooms................................ _Expansion Attic ( ) Garbage Grinder ( ) ._.._____... No. of ersons____________________________ Showers — Cafeteria pa,, Other—Type of Building ................ p ( ) ( ) P4 Other fixtures ------•-----------------------•- - d :. Design Flow....._._._ gallons per person per day. Total dail flow______.._... W i •-•••-•-----•--- ..g P P P y 0................gallons. Di�osal Trench—q No. ..P. __:_. 4 .49gallons Length____ .... Width.... ......... Diameter..._.._........_ Depth..�f-_-. i tic Tank nc Liquid ..capacity Width ............_._.. Total Length------ '._..... Total leaching area...................sq. ft. P / Seepage Pit No........I-_-______- Diameter ---- Depth below inlet......--------- Total leaching area. ._sq. ft. Z Other Distribution box Dosing tank aPercolation Test Result Performed by... _,_ 1..__r _-....... ................. Date.... "1Q.' ........ Test Pit No. I .. ._ minutes per inch Depth of Test �.�.__ Depth to ground water. pul� (s, Test Pit'No. 2... _ ..minutes per inch Depth of Test Pit......Aa?.._... Depth to ground water.-__;#......!_-...___. a0 ------------ .._..� - f -------..... - ----- .................... Description of Soil... 1 - ....•---- � ,� � � - ��- .��.�-j._.•� =��---•----- W � . - - ---------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable---------------------------------------......................................................... ---•--•--------------------------------------------------•------------------------•---•---••-----•-----------------------•-----------------------------.._..---•-----•-------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TT T E 5 of the State Sanitary.:Code—Tfie,undersigned further agrees not to place the system in operation.until a Certificate of Compliance has been issued by the board-bf he Si r n d --• ...... �r' r ..................•... --- ........................... D to Application Approved By. r= T ... 106 3�. Application Disapproved for the following reasons--------------------------------------------------------------------------------------------Date._....:--•---- --•---•---•-. •-------•••---•-_.... ............................................... PermitNo------------------- •---•----------------------- Issued_......�f--.........-- .................... Date Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........r.0.WAJ...........OF..... .... .t .. .:!. . :............................................ �f� Y. rr�ifirtt�r ,af Bunt li�nrr . THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1-1-or Repaired ( ) by----------- D --------------A L �------- •-•-•-------••----•------- Installer has been installed in accordance with the provisions of r of The State Sanitary Code as,described in the application for Disposal, .__:Works Construction Permit No _________ .............. dated__../*"__j--_~7 y.............. THE ISSUANCE OF .THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ;�. :.:. DATE.. Inspector.. ---------------•-----........---- .a...... �' •----- _..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No ...:. /-' L.N.............OF...-........ STAbLh.................................... FEE._ ~�.. Elifipwi al Vork.5 TuniArtulivat Vanfit Pe'rmissi i --,-s hereby granted------------ 0- .AJ.----•-A-A-L -•-------------------...:_..............------------...............-- to Construct _) or Repair ( ) an Individual SewageDisposal..System at No.----•4-0- ...._�............15E ...�1v.................K--. / !VA Street as shown on the application for Disposal Works Construction P it No.:. .:.........:::.. Dated....j�Z.. ........41 9 - -.•--------•--•.--•-- Board of Health DATE........1��= �l .................................................. FORM- 1255 HOBBS & WARREN, INC., PUBLISHERS .,�•ta h / ' a LOCATION 4 / SEWAGE PERMIT NO. VILLAGE /✓ , INSTA LLER'S NAME 8 ADDRESS JOHN A. AALTO B.ACKHOE SERVICE West Barnstable, Mass. 026.68 BUILDER OR OWNER �j 'e- ,9"X A/-, o A? DATE PERMIT ISSUED �'- 79 DATE COMPLIANCE ISSUED C �' jo ce No. ' e. Fee THE COMMON ' EALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for loioogaf *pgtem Comaruction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Individual Components Location Address or Lot No.�d��K Owner's Name,Address and Tel.No. Assessor'sMap/Pazcel a_� 3 � '�` t--Y��• 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 3 3 O gallons per day. Calculated daily flow � ( gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ?_ ST X600 Type of S.A.S. Ck t P Description of Soil \QL_ Nature of Repairs or Alterations(Answer when applicable) Gt.�'T1�1(` �/�2L� is fL S (a.�\ tC! S jy-e n a, S l V ne r C, �C A_9C �0(_ Date Iasi 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 y eat . Signed o Date ol" Application Approved by Date Application Disapproved for the fo owing reasons _ Permit No. Date Issued _-No. �' �. Fee THE COMMON EALTH OF MASSACHUSETTS —Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS zY, 01ppfication for ;Dt.5pogaf *pgtem Congtruction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Individual Components k a Location Address or Lot No.�� `��G, Owner's Name,Address and Tel.No. Assessor's Map/Parcel �� _ `3 CS '` Installer's"Name,Address,and Tel.No.. Designer's Name,Address and Tel.No. v�c \z'—C.(n(Z12 S-e Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) rs Other. Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 U gallons per day. Calculated daily flow �4n gallons. —Plan Date Number ofAsheets Revision Date Title Size of Septic Tank N000 Type of S.A.S. r Description of Soil Nature of Repairs or Alterations(Answer when applicable) �wS`�(�( >y�- tC�n C c✓>! 73c'u--/f Lam.v c`c c�I S [.� �A� stiore n w S i n-�t 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 _eeti--issu`edrby f1Yl. � f-Flealth: t� Signed o. Date Application Approved by J 'I Date Application Disapproved for th fo lowing reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(V Abandoned( )by r —L 1�1 QF_ S F t at ha -e n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of thi `e 'it s�ha Rl not b construed as a guarantee that the syster u j !'o us d r ned. 'l Date Inspector l 1 S � No. Fee,,' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpozar 6potem Construction permit Permission is hereby granted to Construct( )Repair( )Upgrader�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. r Provided:Cons ' ct on must be completed within three years of the date of t s7t. ( (IDate: Approved by l7 "/ vv _ 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, Q ��✓ , hereby certify that the application for disposal works construction permit signed by me dated �.�c �� , concerning the property located at ;)-o meets all of the following criteria.- The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. " The soil is classified as CLASS I and the percolation rate is less than ore equal to 5 minutes per inch. q There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed Xnere are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surfact Elevation(using GIS information) �~ B) G.W.Elevation the MAX.High G.W. AdjustmentU = I J DIFFERENCE BETWEEN A and B ® d SIGNED : DATE: [Sketch proposed p an of system on back]. q:health folder:cert r �T r1� ` - -� ec� TOWN OF BARNSTABLE .. •. t LOCATION SEWAGE # . . VILLAq_,, GIL LOTw a INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITYoxf LEACHING FAcmrrY: (type) Cf.OG-tom z ) � lC N0.OF BEDROOMS. a, BUILDER OR OWNS1.4 PERMITDATE: 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 � w n 0?7 ?- 136 Commonwealth of Massachusetts .� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessment / �Oo / ,M 205 Beth Lane Property AddressW Brenda Bromley Owner Owner's Name information is T required for every Hyannis MA 02601 6/27/2017 ;;i; page. City/Town State Zip Code Date of Inspection �r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms �'= ( aqa 3 on the computer, use only the tab 1. Inspector: key to move your A,. cursor-do not David B. Mason use the return Name of Inspector key. �V Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-833-2177 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 ZLX�Z-u4j;� June 29, 2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The information and observations contained in this report represent the condition of the system only on June 27, 2017 at 1 PM and does not represent the operating condition of the system from this point forward. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. Cityrrown 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.doc-rev.6/16 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 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins.doc•rev.6/16 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 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. City/Town 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.doc-rev.6/16 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 M 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. CityTTown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gp ))� Detail: 2015; 26,250 gallons and 2106; 34,500 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.doc-rev.6/16 Title 5 Official'Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. City/Town 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 yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 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 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is Hyannis MA 02601 6/27/2017 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 4/30/1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 7"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: Typical 1000 gallon Sludge depth: 211 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 205 Beth Lane N Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 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 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" 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 is level with outlet tee. No evidence of leakage. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. Cityfrown 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 Level with outlet inverts 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.): some roots growing into outlet pipe, but not impacting box. Dbox is 15" below grade. No evidence of solids carry-over. 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.doc-rev.6/16 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 GSM 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators with stone around. ❑ 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.): Took pictures of inside of chamber. There is no standing effluent in the units. Top of units are 25 inches below grade. No indication of staining in units. 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.doc•rev.6/16 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 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 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.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Beth Lane M Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 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: Ground water contour map ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Utilized groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 205 Beth Lane Property Address Brenda Bromley Owner Owner's Name information is required for every Hyannis MA 02601 6/27/2017 page. Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE `\ ee tt� H � �CLOCATION VILLAGE N-`/u ww f S ASSESSOR'S MAP&LOT. INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACrrY t `r c LEACHING FACILrrY:(type)Ar"I�CO4i cw 1 z) �`cc NO.OF BEDROOMS_ BUILDER OR O 6(i I,. PERMITDATE: COMPLIANCE DATE: r 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 cY z 4 l?o 0 13L 3 y 3 133' I- http://www.townof bamstable.us/Assessing/HMdisplay.asp?mappar=27213 6&seq=1 6/29/2017 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ELF/ ct w'v( S ` ASSESSOR'S MAP& LOTrt�,1c :— INSTALLER'S NAME&PHONE NO. ► •� �O—�H�-Scf� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) g(A C I z ) -NO. OF BEDROOMS BUILDER OR OWNER/ C7f i r• PERMITDATE: q COMPLIANCE DATE: 11 n Separation Distance Between the: i 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 . v -� ly Q>° i f i F � `' oe - TYPICAL SYSTEM PROFILE AREA PLAN FDN TOP FINISH GRADE= 2 Va NOT TO SCALE SCALE : I �' ' ' FINISH � ' . r�;, FINISH GRADE OVER TANK= 5-= `^` ,.. GRADE OVER PIT=-==` rl 9 � L T 8 BETH S LANE — PVC 0 R �] / O 0 . • . e o O �C. I . TEES g9.33 • • e . • o BSMT '`f �" �9:�c `• n.o o . o.- a.: o • • o • • • • e o 0 00, GAL. 4",q. o .'.a e e e e • • • o e e e REINFORCED DST. BOX — • e a • ! • o 0 o e e `' CONCRETE 8 '.: ,e e • • o • • . • o o e j TO BE INSTALLED ON I A LEVEL STABLE BASE • e 10 • 1 • a o e • e SEPTIC TANK TO BE INSTALLED ON A • • e • • e LEVEL STABLE BASE - 2"-1/8"- 1/2 "WASHED PEASTONE ALL ' ' • • ' ' ' ' e � I •. i r` BRICK a MORTAR COURSES AS • e . • . e • • o e o e AROUND FREE OF IRONS, FINES � REQUIRED TO BRING COVER TO GRADE AND DUST IN PLACE + _ LEACHING PIT � f' 24 C.I. MANHOLE COVER a - 3/4 TO 1 -112 WASHED CRUSHED I FRAME — SEE DETAIL STONE ALL AROUND FREE OF BASE TO BE LEVEL IRONS, FINES AND DUST IN —--.5 7T �W '' � PLACE FOR FIN. GRADE l\ �a ,Wf -%' C-9 SEE SYSTEM PROFILE - SOIL AND PERCOLATION DATA f0, pH. N. ` INV. ELEV SEE i4 - FOR -- .- -- --__ '---•ioT `^ i a INLET SYSTEM PROFILE TAKEN BY : C.- D. SPOHR �� IO' LINE 0 - —t-6 ' WITNESSED BY: — --- -t ° D OPENINGS W/4 1/8 0 i • � OUTER DIA. a 1 -3/4 _ o•• ' '�' � � DATE . /G OGT" 1� � ' J o INSIDE DIA . o _- try 74 j 7 ° ° D TEST PIT-GND ELEV. 07-*67 6 TOTAL ° D ; AREA v 2 B CAP i4 I e A/O ll o 0 0 0 o a o ` ° 10IQ W4`/'t T�'�e /OOa 'C v t (All e ? VF- 4- fj .� f 2 6 - 6 D IA. 2 L/19 ? E ley" OIL-:, I�hS+" BOX �� 7- � � .� -- ►� —- ---- - t5;K7 n_' /O ' 6 '' EFFECTIVE DIA. ' BOT. PERC. HOLE G x8 PPEG45T t Q a -- ----- AAJi� ca�AY,6-4- �,•�s1CH�t/4 � DOWN 4ti'a; II LEACHING PIT - SECTION M ` No SCALE DESIGN DATA : ,� NOTE: DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM NO. OF BEDROOMS -G o� / Z CERT iFv TEAT 7-,�ir P,eOP0S� �- Ha'E 5-How ,! C OMFokI45 To T� DISPOSAL LEACHING PIT NOTES: �: TtWAI O &A&AlS7�6ei4F ZO-k//AI& EST. TOTAL DAILY EFFLUENT GALS. I . CONC. TO BE 4000 P.S.I a 28 DAYS . SEPTIC TANK f L'Ll GAL. 2. REINF W 6 % 6 " 06 GA- W. W. M. r / _ - 3. 2 'AND 4 ' SECTIONS ARE AVAILABLE FOR GENERAL NOTES GREATER DEPTH REQUIREMENTS I . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN NOTE : � �} '''�`O�OR LOWER AS ACCORDANCE WITH TlTLE5OF THE STATE SANITARY CODE EXCAVATE TO ELEV.' v .S DATED JULY 1,1977 81 ANY LOCAL RULES APPLICABLE. REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING ' S MATERIAL BENEATH PIT. REPLACE EXCAVATED MATERIAL 2 ANY CHANGE TO THIS PLAN MUST BE AFPRD. IN 07- WITH CLEAN,CLAY FREE GRAVEL, MECHANICALLY WRITING BY MR. CHARLES D. SPOHR. COMPACTED IN PLACE. 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING, -SIDE AREA �S. F.��S. F./GAL GALS NOTIFY THE ENGINEER AND BONKL) OF HEyLTH FOR INSPECTION. rU'L,. •l:J1G` �:,�= .�� _ = `y �'=� , 'r•�=I/c'�`;f _` 'R /�� /.�T�t,`f' Uf ys -1 / i 4. FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED. n�N'VER ,� `s �U I LDER BOTTOM AREA r ` S. F. —S. F/GAL GALS 5. THESE ELEVS. MUST NOT BE CHANGED WITHOUT WRITTEN f-�IVA bps 271 ,,G6. ; ....t.•-,,�..-...�, �.,...,.. -•R ,, TOTAL AREA =. w. TOTAL ' '°' GALS S. F. APPROVAL BY CHARLES D. SPOHR. CL_.1:),2k' ,!� /-LYA/Al 4:3U, LEGEND 6 FOUNDATION INSPECTION READ. WHEN EXCAVATED. Q1� COA1 FlUe" kOAD /-/y klCS 'i i' -/ A /AZ'Z + 50.0' EXIST. GROUND ELEV. n� 50.0' FINISH GROUND ELEV "UNCERLINEC "Iti�• NGTE• 4750] PIPE INVERT. ELEV. REV. DATE I DESCRIPTION 14ZL ELi-_"V� , HASE0 0 PA Adf+K1r Ems" Q TEST PIT LOCATION SEWAGE DISPOSAL SYSTEM FOR [ SEPTIC TANK� CLARK F L_Yf�\a N BUILDERS D E R � RLA PLAf'J�' _ L S r ❑ DISTRIBUTION BOX LOT }� L N f 4 � " � C. I . PIPE 79 8� CAF��E' 4 SL�I�t/ ' �'� -rtHtrtt+- 4��BIT. FIBER PIPE - TIGHT JOINTS t SPt;xR (P I T C H E RS WAY), HYAN N I S No 74Sd _ 1 \I ` p F� �� ,'/ DESIGNED: C.D.SPOHR DATE30 OCT. 7'-'j' D R A W I N G NO. 7-0W&I W,47 �.� - -- - PROPERTY LINE �p9 - 3;z /.3 .. :. ,. c f£� �I — I/ DRAWN: C J SCALE:ASSHOWN MAP SEC PCL LOT HOUSE MIN. CODE DISTANCE , {{,� � ` r 3 0 10 9 • J�. "A CHECKED: C. D. S .