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0088 BISHOPS TERRACE - Health
88 Bishops Terrace Hyannis F/R A = 251 211 Ir I� i ;TOWN OF BARNSTABLE r�J WCATION '� I-SETS-7,8 IQ ICACC-SEWAGE# 2-0 p 3-5 VILLAGE ASSESSOR'S MAP&PARCEL )-� - .21 I INSTALLER'S NAME&PHONE NO. T�2�j e�f~ S e✓� SEPTIC TANK CAPACITY G (' LEACHING FACILITY.(type) - boa GI-Jnanb oze) /a,SA ;L5 NO.OF BEDROOMS 3 - OWNER v o ✓I A a � h4A PERMIT DATE: a C MPLIANCE DATE: o L 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 � w � e r �u Q cz CIO ON No.�U 3�r Fee V / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ; PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es ltl4tat10YY f0CI tlDBRY 6- pstPtn Construction Prittlt Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. Y 6,5h p&S tq jo,> Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel A§7 d e i•1 e✓/4 Installer's Name,Address,and Tel.No. Desi er's Name,Acidress,and Tel.No. Type of Bu' ing: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) _s 3 r) gpd Design flow provided 3y2 0 ,�$� gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank loop Type of S.A.S. Z 02D _572W 6& Z-22y/MMIS Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Health. Signe Date ID—7-=/6 Application Approved by Date 1 U- 7 - /6 Application Disapproved by Date for the following reasons Permit No. 3,S6 Date Issued 16 ` 7- (6 r py_ I No. . . A >� Fee �V i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es ftpliLatlon for Disposal 6pstetn Construction i3erlttlt ; Application for a Permit to Construct( ) Repair.Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. j3�Sh piS '1 t�ap,� Owner's Name,Address,and Tel.No. e Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,A ess,and Tel.No. Y''tQ Le k Type of Bu' ing: 2 `� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ! Other Fixtures i Design Flow(min.required) S j Q gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title I Size of Septic Tank Q UD Type of S.A.S. ,Z 07D SQd a4V�Ifs Description of Soil Nature of Repairs or Alterations(Answer when applicable) /_CGJ Date last inspected: ' Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Health. ,/J r Sign( .. - r[ ---yam Date Application Approved by i F ,"ill y Date U- 7 - /(, Application Disapproved by 1` m� i Date for the following reasons 4 VI) n , Permit No. 4-V L j.�(� Date Issued 16 7- /6 � V ---------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that th .On-site Sewage Disposal system Constructed( ) Repaired((,Upgraded( ) Abandoned( )by o WilG )tiZ2 t at �g /jai S has been constructed in accordance with the provisio s/of Title 5 an the for Disposal System Construction Permit No. �,0/6- .� dated /u- %-/4 Installer '0o nicM f e2 Designer 171,-Ye.1 •4- �xr►s T;VC #bedrooms Approved des ow 39 Q w- gpd The issuance of is pe it shall not be construed as a guarantee that the system wily .mum ion as design Date 3 Inspector - - - _ --------------------- ---------------•------------------------------------------------ No. 2 a I - Fee /O U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem/Construction pertnit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) I System located at � /s l�ole and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:ConstructiP n must be completed within three years of the date of this permit. Date j o / 7/�(O Approved by �'1✓ f Town of Barnstable .BIKE o Regulatory Services Richard V. Scali,Interim Director * EASNsiAB1z 9�A M6 9 � Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form -Date—- 13 -"_ Sewage Permit#-ZO i(o%3S - —Assessor's Map\Parcel Designer: L, Installer: ✓!e J'� Address: Address: %yy /V�1' S� On -Q— 7- 16 ,� _was issued a permit to install a (date) bb� �,(iinpstaller) septic system at CJ �S�1 v r S J'(J U&(It- based on a design drawn by (address) Sews' I hC, ' dated '(designer �Y� I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than lOF�lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the sy tern referenced above was construct e with the terms of the IAA approva etters (if applicable) Installers Signature) e igner's Signature) (Affix Designer amp Here) PLEASE RETURN TO B TABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT.•CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc I i Town of Barnstable P# Department of Regulatory Services Public Health Division Date MAM 16 y. ems$ 200 Main Street;Hyannis MA 02601 3 ArfD NI►t I r Date Scheduled Time— Fee Pd. 1 oil Suitability Assesshieni fbrS, e Disposal m Performed B < CA"V& M emWitnessed By: ✓� �• ��T i CATION & GENERAL INFORMA ON kQ Location Address �S Owner's Name �)/1/j�—J'( � I Address TW Assessor's Ma /P rcel: 2_40 /��. ] Engineer's Name NEW CONS1RUt1 I ION REPAIR Telephone# +�0 3�j0" 1) Land Use ] ►J �j' Slopes(40); Surface Stones Distances from: Open Water Body?_ _ft Possible Wet Area�ft, Drinking Water Well ft brainage Way � �_ft Property Line �'ld ft Other ft SKETCH:(Street name,'dimensiods'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) fA.►� I ��-y d�•1 e.A' �I�jlb . Parent material(gedlogic) I Depth to Bedrock Depth to Groundwa(er. Stan ing Water in Hole: Weeping from Pit Face.,_.T Estimated Seasonal Nigh Groundwater Dlt: �j`TION FOR SEASONAL fIIGH WATER TADL� Method Used: ! Depth Ob ery standing in obs.hole: In. Depth to salt moUlus; P t><. Depth to weeping from side of obs.hole: in, Groundwater AdjuetMent � � Ac�.�faetor.,,,._,�.. Act.CmundwaterLevel,,,,e, index Well# __— Reading Date Index Well level PERCOLATION TEST . Date— TIme Observation I Time lit 9" N Hole# Time at G' ....._..--- Depth of Perc 11me(9"•6") t Start Pre-soak Time"@ 1613 End Pre-soak Rate MinJlnch — � Site Failed; j Additional Testing Needed(Y/N) Site Suitability Assessment: Site Passed�_ I • original:.Public Holth Division Observation Hole Data To Be Completed on Back------ ***If percola#6n test is to be conducted within 100' of wetland,y ou must first notify the Barnstable C40servation Division at least one(1) we6k prior to beginning. I ,L DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.4b Gravel O n tl I A !b 4 y: 3S Z�I GOIL6 DEEP OBSERVATION HOLE LOG Hole#_Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) l Z`1 : LMa dn 9 Tf 154" CL DEEP OBSERVATION HOLE LOG Hole# A Depth from Soil Horizon Soil Texture Soil Color Soil Other . Surface(in.) (USDA) (Munsell) Mottling, (Structure,Stones,Boulders. Consistency, o Gravel DEEP OBSERVATION HOLE LOG Hole# N Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency, ra I Flood Insurance Rate Map: ,/ Above 500 year flood boundary No_ Yes _y Within 500 year boundary No V Yes, Within 100 year flood boundary No V Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pe vious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviro mental Protection and that the above analysis was performed by me consistent with the required tr, ' g,pertise and experience described in 3,10 CMR 15.017. Signature Date �b Q:\SEPTIC\PERCFORM.DOC Certified Mail#70062150000210421023 �°ptHE rower Town of Barnstable Regulatory Services y y n"RN�-CA81E' � MASS. Thomas F. Geiler,Director 9 O° 039• AIEaMA�"' Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 15,2008 Benjamin and Ana Damasceno 88 Bishops Terrace Hyannis,MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 88 Bishops Terrace,Hyannis was inspected on 08/7/2008 by Jamie Cabot,Health Inspector for the Town of Barnstable due to a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.300—Sanitary Drainage System Septic System accommodates three bedrooms 105 CMR 410.482—Carbon Monoxide Detectors No Carbon Monoxide Detectors for upstairs bedroom You are directed to correct the violations listed above within 24 hours by: installing Carbon Monoxide Detector for upstairs bedroom. You are directed to correct the violations listed above within 30 days by: removing the fourth bedroom by creating a five foot cased opening in the doorway. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10)days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection.. Zf ORDER OF T E BOARD OF HEALTH nas A. McKean,R.S., CHO Q:\Order letters\Housing violations\Rental ordinance\Address.doc �oF try r�� Town of Barnstable o� Regulatory Services BARNS-TABLE, Thomas F. Geiler,Director y MASS. 1639. Public Health Division ArEO MA'I A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 11, 2008 Attn: Hyannis Fire Health Inspector Jaime A. Cabot conducted a housing inspection in response to a complaint. In accordance with the State Sanitary Code, 105 CMR 410.482, the Health p rY Department is required to notify the Fire Department if there is a smoke detector violation, or possible smoke detector violation. The following property had possible smoke detector(and\or CO detector) violation(s): 88 Bishops Terrace. Hyannis, Assessors Mau-Parcel: (251-211): - CO, Carbon Monoxide detectors not provided for Bedrooms ime A. Cabot-Health Inspector Q:\Order letters\Ilousing violations\Rental ordinanceUire ViolationsTIRE TEMPLATE.doc Health Master Detail Page 1 of 1 Well Fuel Tank Parcel: 251-211 Location: 88 BISHOPS TERRACE, HYANNIS Owner: DAMASCENO, BENJAMIN P &ANA Business name: y Business phone: Rental property: r Deed restricted: r Number of bedrooms : 3� Contaminant released: F . Fuel storage tank permit: (— Save Parcel Changes eturn to Lookup Parcel Info Parcel ID: 251-211 Developer lot: LOT 34 Location:88 BISHOPS TERRACE Primary frontage: 141 Secondary road: KITSY LANE Secondary frontage:91 Village: HYANNIS Fire district: HYANNIS Sewer acct: Road index:0126 Asbuilt Septic Scan: 251211 1 Interactive map: '•' }° Town zone of contribution:GP (Groun \ater Protectio Overlay State zone of contribution:IN District) Owner Info Owner: DAMASCEN BEN3AMI P &ANA Co-Owner: Streetl:337 OCEAN T - APT 7 Street2: City: HYANNIS State: MA USA Zip: 02601 Cow Deed date: 1/10/2005 Deed reference:C175612 Land Info Acres: 0.42 Use: Singl F MDL-01 Zoning: RC-1 Neighborhood: 0 Topography: Level Road: Paved Utilities: Public Water,Gas, eptic Location: Construction Info Building NoYear Built Effective Area Bedrooms Bathrooms 1 1972 1542 3 Bedrooms2 Full Buildings value:$121,400.00 Extra features http://issql/intranet/healthMaster/HealthMasterDetail.aspx?ID=251211 8/7/2008 ' TM THE COMMONWEALTH OF MASSACHUSETTS FORM 30 C&W HOBBS 8 WARREN BOARD OF HEALTH &a►.-> S-ra fSLe CITY/TOWN = W (tA(--t✓ 0 'Zoo KI/VV DEPARTMENT ADDRESS Lr_ko 0 M qq TELEPHONE Address 83 11 '—C RAC. ��Occupant . Floor Apartment o. No. of Occupants No. of Habitable Rooms_No.Sleeping Rooms 3_ No.dwelling or rooming units No.Stories �— ►� Name an ddressofowner u _ y�,►�` d w�•► ¢�- ��V"�►�� t A M A--�C - — Rema ks e9 Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ECI Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: Irg 69-0 c TLCI S lfD BASEMENT Gen.Sanitation: Iv K-Co E w LA P Vr, t rl I �►. Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: CZ 6--C 'cu 2 Obst'n.: f? S Tay / Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys- Central V� ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Su ply Line: ❑ MS ❑ ST Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICV Panels, Meters,Cir.: C�110 ❑ Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks N Kitchen A c 2 ® GL[ c. 2 Bathroom Pantry Den Living Room Bedroom 1 — O C4A 10 G I-7&n- Bedroom 2 5 Bedroom 3 Bedroom 4 / Hot Water Facil. Su Stacks, Flues,Vents,Safet s: Kitchen Facilities Sink Stove Bathing,Toilet Facil. um anit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPO IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES PERJURY INSPECTOR G '+ TITLE DATE 7 TIME GI P.M. A.M. THE NEXT SCHEDULED REINSPECTION -�'V,g A P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or pe-sons occupying the premises. This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within-his category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water'sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 10E CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.6CO3 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Contrcl, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-bu-ning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintair such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns,shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner _ to remedy said condition within the time so ordered by the Board of Health. l_ TOWN OF BARNSTABLE V-)CATION PrG� - SEWAGE VILLAGE ASSESSOR'S MAP & LOT —Z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY V MA all / f LEACHING FACILITY: (type) Ce (size) LcL 2� NO. OF BEDROOMS_,, BUILDER OR OWNER �— PERMTTDATE: 1 l A COMPLIANCE DATE: IS OS^ Separation Distance Between the: + Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility an wells exist PP Y g t}' (R Y 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 � fT 6 TOWN OF BARNSTABLE LOCATION SEWAGE# � — Z VILLAGE ASSESSOR'S MAP &LOT�; �"' /� INSTALLER'S NAME&PHONE NO. "7? SS / 3 3-- SEPTIC TANK CARkITY x S T f �Jr�A ro 2 s � ) size lax `7 LEACHING FACILITY: (type) �"� (size) NO.OF BEDROOMS BUILDER OR OWNER -5 vC �fATiQ L S / PERMITDATE: COMPLIANCE DATE: �` 1 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by be W� � �� .n a - � �, � � � � ` � i � � �� i ! `� � �; � � � '� _..� � �� - ���� No. r9- COS ©d� Fee ®o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for 30iopooar Opztem Cougtrurtton Permit Application for a Permit to Construct( )Repair(X Upgrade( )Abandon( ) O Complete System individual Components Location Address or Lot No. yi tp5 'TeAvo t._ 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. _+9Cao Type of Building: Dwelling No.of Bedrooms Lot Size JTCcO sq.ft. Garbage Grinder Other 'Type of Building��� No.of Persons ra Showers( dj t Cafe"eria( y) Other Fixtures Jyc.�n Design Flow. gallons per day. Calculated daily flow SbA . ®ri gallons. Plan Date \ \ O 1!3' Number of sheets \ Revision Date '-- Title � Size of Septic Tank TIAC6�-- Type of S.A.S. y aq%"—`T -JT_€ V4 Description of Soil �p 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 provision of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu b this Board It Si tied Date Application Approved b Date Application Disapproved for the following reasons Permit No. QLOO c:; — 00 7 Date Issued 0 No. Fee r�0 ,♦ q,,,lk•.. 74- r; �1 THE COMMONWEALTH OF MASSACHUSETTS Entered in compute PUBLIC HE=ALTR'1DIVISION T WN OF BARNSTABLES MASSACHUSETTS ! 2pplication for ;Digpogaf *pgtem. Congtruction 1permit Application for a Permit to Construct( )Repair(X Upgrade( )Abandon( ) ❑Complete System ;SZMdividual Components Location Address or Lot No. 'ob 't3 jj! V jb p5 - -ex>.c Owner's Name,Address and Tel.No. Assessor's Map/Parcel a S I I 1 Installer's Name,Address,and Tel.No. Designer'4,Name,Address and Tel.No. Cat_' f3-5 -+9uo Type of Building: Dwelling No.of Bedrooms Lot Size I L" sq.ft. Garbage Grinder Other Type of Building�6rJ F_ No. of Persons Showers( P1 Cafeteria( ) Other Fixtures -k 4tvz� �,rc� lr c st1Cc�a, J � r � . Design.Flow gallons per day. Calculated daily flow �1 �� gallons. Plan Date \ \ Number of sheets 1 Revision Date Title Size of Septic Tank �'x -_4- c c�\_ Tf 1vif Type of S.A.S. f k04;-�L Description of Soil ---, Nature of Repairs or Alterations(Answer when applicable) �k , A7) o\Gc� Date last inspected: r Agreement: The undersigned agrees to ensure the construction and maintenance'of the afore described on-site sewage disposal system in accordance with.the provisio m of Title 5 of the Environetal`', ode and�nor to�place the system in operation until a Certifr- . cate of Compliance has been issue by't=&7 lth. `• .. O Si ned Date Application Approved by, Date Application Disapproved for the following reasons Permit No. !Z)4DQ c, - C}O 7 Date Issued O --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,,MMASSACHUSETTS Certif irate of (Compliance THIS IS TO CE I KM the On-site ewage Disposal System.Constructed( ) Repaired ( )Upgraded( �) Abandoned( )b _ _ at / 5 has been constructed i accordance with the provisi ns of it 5 d th Disposal System Constru tion Permit No. 2aa S_`-Uo7 dated u Installer Designer The issuance of this pe t shall not be construed as a guarantee that the sys em w`ill tutiction as designed Date 1� I(�C Inspector J, 0 W....Y. No. �Co s --QQ / - - ��— . Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migogaf *pgtem Con$trurtiott permit Permission is hereby granted to Construc ( )Repair, )Upgrade(�)Abandon( ) System located at _ _ and as described in the above Application for Disposal gystern Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the da ie—of this erm"t. Date: 05 Approve TOWN OF BARNSTABLE r, LOCATION SEWAGE # VII,LAGE_. ��`' ASSESSOR'S MAP &LOT INSTALLER'S NAME&.PHONE N0. SEPTIC-TANK(CAPACITY ` J �! .. LEACHING FACILITY: (tyPe) c �-- 0-V (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:--- 1 COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells.exist Feet " on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by A-it o4/V t �jaa7laa7 Town of Barnstable , E Regulatory Services I Thomas F. Geiler, Director 39: Public Health Division Thomas McKean, Director 200'tVtain Street,Hyannis,NiA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: ( o!5 Cis Designer: .�. - Installer: Address: 0. RLK e1 v1.� Address: Agn 0 AA C�A&b(. � On 1 5s ' was issued a permit to install a date) (installer) - -- septic stem at P y based on a design drawn by (address) 6 '5,�G�, dated p 4� designer) X 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 majanges (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; I zN >•xus, �I (In 'a er ignature) �� C;ARME SHAY No. 1151 Qwv�'� �a Designer's Signature) / (Affix De a�.. ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVI CERTIFICATE OF COMPLIANCE WILL NOT. BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Acalth/Sepric/Designer Certificiiion Form JAN-5-2005 WED 02:04PM ID: PAGE: 1 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION %P FAILED INSPECTION ARCEL Z' Oar TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION a Property Address: 88 Bishops Terrace -- Hyannis, MA 02601 j Owner's Name: Bill Meagher = + .: Owner's.Address: Date of Inspection: November 23, 2004 � = ` Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford ' Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: December 1. 2004 . The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Meakher Date of Inspection: November 23, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 88 Bishops Terrace Hyannis:MA Owner: Bill Meagher Date of Inspection: November 23, 2004 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. p PP .Y 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: 3 Page 4 of 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Mearzher Date of Inspection: November 23, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 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 (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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No ' the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Meagher Date of Inspection: November 23, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all,system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the 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. ✓ _ 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)J. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Meagher Date of Inspection: November 23, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2004-96.750 jzals.;2003- 153.000 als. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Pumped 3 years ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ 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: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Meajzher Date of Inspection: November 23, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ 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: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring 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.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Meagher Date of Inspection: November 23, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (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.): r 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Meagher Date of Inspection: November 23, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gaL) 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.): The pit was full. Liquid was up to the cover. The pit was in hydraulic failure. The cover was 16"below grade. CESSPOOLS: None (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): Conunents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Meagher Date of Inspection: November 23, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. a 3 0 laaa8 f 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 88 Bishops Terrace Hyannis, MA Owner: Bill Meagher Date of Inspection: November 23, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35+/- 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: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 35'+1-to ground water at this site. Usin the he Cape Cod Commission technical bulletin, the high around water adjustment for this site(AIW 247, Zone C, 10104)was 6.1'. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. I 11 I -\ COMMO:^IWEAL,rH OF MASSACHUSE7rs EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE S OI -ICIA.L INS PECTi ?N FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBS'(-'PFACE SEWAGE DISPOSAL, SYSTEM FORM PART .A 11__x:R"TIFI TION Property Address: _ � ��'fJ• �x� C� Owner's Name: _ Owner's Address: >C/na v /yr ,R Date of Inspection,: Name of Inspector: (please priLt) HENRY J . LEARY Company Name: SUPERIOR_-TOME: INSPECTIONS Mailing Address: p ,O . BOX 44 CARVER , TEA.. n2 0 Telephone Number: gOA_44'E :iV11 CERTIFICATION STATE, 11`,NT l certify that I have personally insp•_ci,d'the sewage disposal system at this address and that the information reported below is n"ue, accurate and complctc iS of the time of the inspection. The inspection was performed based on my training and�:xperience'in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved sy<tem inspector pursue,it to Section 15.340 of Title 5(310 CMR 15.000). The system: 'Passes I Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails i Inspector's Signature: k/ - 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:his inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and tt.e :ystem owner shall submit the report to the appropriate regional office of the DEP. The original should be sent tj ti.e system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This rel.—ort only describes co�d`itions at, the time of inspection and under the conditions of use at that time. This inspection does not address hoer cbe system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000,: page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Roc Owner: Date of Inspection: Inspection Summary: Check A,B,' ,D it E/ALWAYS complete all of SecGo❑ D A. System Passes: I haw-not found any information wF ich irAicate;s that any of the failure criteria described in 310 CMR 15.303 or L; 31(' CA;R 15.304 exist. A :y iriltve.crit.;;riZ not e ai.:ated 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-"determined" please explain. The septa:;tank is metal and cv,,.,r"0 years old* or the septic tank(whether metal or not) is structurally unsound,exhibis substantial infiltrat.c'.; or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is�eplzced with a compl.y4j.g septic tank as approved by the Board of Health. `A metal septic aank will pass inspecti.oii if it is saucturally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20.dears old is available. ND explain: observation of sewage backap or break w or high static w7aff ievei is the disn-waion box aux to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass mspectwo if(with approval of Board of Health): broken pipe(s)=replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping rnorc.than.4 tomes a year dw,to broken or obstructed pipe(s).The system will pass inspection if(with approval of th. L':o.;_d of Health): b-o;,e.i pipe(s)are replaced obsu rction is u.-moved ND explain: 2 Page 3 of I 1 f OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY AS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIF.ICCATION(continued) Property Address: G1 ,z /vomit Q=� Owner: Date of Inspection: o 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, safet,/ )r the environment. 1. System will pass unless Board of Heald., determines in accordance with 310 CM.R 15.303(1)(b) that the system N�s mit functioning in. a.manner which tvia p:-otr;ct public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within M feet of a bo dering vegetated wetland or a salt marsh 2. System will fail unless the Itoard•of Health(and Public Water Supplier,if any)determines that the system is functioning in a mange,=that protects the public health,safety and environment: _ The system has a septic !.an.;and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tribu:cry o a surface water supply. "1-he system has a septic Gwik and SAS and the SAS is within a Zone 1 of a public water supply. the system has a septic ma' and SAS and the SAS is mithin 50 feet of a private water supply well. _ nt:system has a septic rartk 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..iiStance **This system passes if the well-water analysis. performed at a DEP certified laboratory, for coliform bacteria and volatile organic cowpounds _4.dic:..teS 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: 3 F • Page 4 of 1 I OFFICLAL. INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFfCATION(co;nfi ied) Property Address: Owner: _ Date of Inspection: or- D. System Failure Criteria applicable all systems: You must indicate"yes"or"no" to ea h of the following for all, inspections: Yes No Na Backup of sewage into faui1it/or system component due to overloaded or clogged SAS or cesspool _ 2 Disuiiarge or ponding of eriu,ent to the,surface of the ground or.,,--a-face waters due to an overloaded or ciogt;ed SAS -.�r cesspool /o Static liquid level in the distribution box above.outiet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is:less than 6"below invert or available volume is less than %day flow —�lo Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped No Any portion of the SAS, cesspool or privy is below high ground water elevation. A o Any portion of cesspool cr 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. AD Any portion of a cesspool or privy is within 50 feet of a private water supply well. &Q Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet tom a private water supply well.with no accep:at le water quality analysis. [This system passes fftbe Tacit grater auafysis, performed at a DEP certifit-.laboratory,for coliform bacteria and volatile organic compounds indicates that the well is ^'ree moan pollution from that facility and the presence of ammonia nitrogen and nitrate nitrog4-:m 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 hav determined that one or more of tine above failure criteria exist as dcsc,-ibed in 310 Cv1R 15.3(.3,therefore the system fails. The system owner should contact the Board of Heal,: to determine what will be necesaty v.)come dx failure. E. Large Systems: To be considered a large system the system must serve a facility witha design ilowvf 10,000 gpd to 1U00 gpd• You must indicate either`yes" or"no"to eactr'ofthe kjota7& (The following criteria apply to large systems in additim to dir- Gera afro) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet:of 3 tributary to a surface di-biking water supply the systern is located in a nits oger. sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone 1, of a public water suphi;- well If you have answ�.red "yes"to any qur,S.W n in Section E the system is considered a significant threat, or answered "yes"in Section 0 above the large syst.c,,has :failed. Fh<s owner or operator -.;any large system considered a significant Threat�inde:r Section E or faih:d and:,•Sc;ction D shall upgrade the system in accordance with 310 ClvfR 15.304. The system owner should contact the appr,upiiate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION"FORMM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: — .c.c..Q �Owner: Date ' Date of Inspection: �' o Check if the following have been dor_. ou must indicate"yes" or"no" as to each of the following: `¢es No ` 5 Pumping information .vas Ir.r vided by the o ner occupant, or Board of Health _ tq q Were any of the system cornNnents ptunped out in the previous two weeks ? ' Has the system received normal flows in the previous two week period? fNoo Have large volumes of water been introduced to the system recently or as part of this inspection? N/f} Were as built plans of the system obtained and examined? (If they were not available note as N/A) YC5 _ Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out ? YCS _ Were all system compone�its excluding the SAS, located on site ? �ES _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of conrtruc6on, dimensions, depth of liquid, depth of sludge and depth of scum? jC S Vla:.,the facility owner(ants (ccupants if different from owner) provided with information on the proper maintenance of subsurface sewage dispr sal 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. �E3 _ 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)] /C OCfYr� �j wJ ;,O U6-- HT7Vlr 7�L i Z GT6v Co�!G/L Page 6 of I i OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: ,F - > - 0 / FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 I.:umber of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15..201 (for example: 1 10 gpd x # of bedrooms): 30 6- p Number of currew residents:3 Does residen.:e nave a garbage grinder 1',, s or iio): ,vo Is laundry ou a separate sewage syst�m (/es or no):wo [if yes separate inspection required] Laundry system; inspected(yes or no): _ Seasonal use: (yes or no):,,V0 Water meter readings, if available(last;' year.;usage Sump pump(yes or no):pjQ Last date of occupancy: C.u/Z.2E/✓; COMMERCIAL/WDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft;etc.): Grease trap present(yes or no): — Industrial waste holding tank:preser.!(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): GFHERAL INFORMATION Pumping Reco,ds Source of information: V-,'as system;,w:lpec! as part of the inspe ti n(yes or no;7: :; T rr_Z.s 4.��C�L r�n2 k/G-�9/zc If yes, volume p_rnped: ___gallo�L,.-- How w.s rlusrxtity pu�::l ed detrri fined? 1:._/etiA.✓L.f Reason for pumping: ���,,, TYPE OF SYSTEM f�eptic tank,distdhutia ox, soil absorption system _Single cesspool Overflow cesspool _-Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Altemative technolot , Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy o`t,e DE,P approval Other(describe): �A proxunate age;of all components, Jd.t? tnstallea (if known)and source of information: .'i.-Co -SE7 !Py%'_....:= L IB. Were sewage odors detected when arriviag at the site (yes or no):{Vp Page 7 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DIISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �u� Date of Inspection: BUILDING SEWER(locate on site plLn) Depth below grade: 8' Materials of construction:_cast iron 40 PVC—other/(explain): Distance from private water supply well or. :;uction line: /�1!/- Comments (on condition of joints, ver.cin,:,evidence of leakage,etc..): SEPTIC TAN K:CG 5(locate on site pkul) Depth below grace: _ Material of construction: t,<oncrete -_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: 6 x qx,: _ Sludge depth:�,2 -_3�� Distance from top of sludge to bottor.n of outlet tee of Scum thickness: Distance from top of scum to top of outl�t tee or do) ) Distance from bottom of scum to bottc m of outlet tee oi affl -�q How were dimensions determined:,d jE6. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of'.eakrge, etc.): CO"r=�,y I'e: A f�2'--) i��i ' 5- c _ST2[1G?�Uk;-R .Ly. So_ ��✓��;;,;����iJ� uVG�— �Jd/+L ��� n yTG1:J .2-NVG 2�% GREASE TRA:''::4•%(loc;atc on site;)!.La) 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 bot,..,m of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendrtions, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of le:-,kage, etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM --NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE`4AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: / Date of Inspection: TIGHT or HOLDING TANK&,j (taak must be pumped at time of inspectionxlocate on site plan) Depth below grade: Material of construction: concrete_ _ _rr etal__fiberglass __—Polyethylene other(explain): Dimensions: — - — — -- Capacity: ---aligns Design Flow: ga.ior . day Alarm present(yes or no): Alarm level: Alarm in workiiil;order(yt:s r,)r r.;o): Date of last pum�)ing,: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX:N f., (if present must be o ened local p )( eon site plan) Depth of liquid level above outlet invert: Comments(note if box is level and di:Aribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): PUMP CHAMBER:Z �(locate on site plan Pumps in work;-,g order(yes or no): Alarrr:s u,workL:g order(yes or no): Comments(note condition of pump ch nibe-is 6:�0[S[.l.n&'�-n of Ps ad aMuruuaaces, eta.): I 8 Page 9 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW'iGE DISPOSAL SYSTEM =_ISPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: - o/ SOIL ABSORPTION SYSTEM (SAS)': 7[:S(locate on site plan, excavation not required) If.�AS not located explain why: / b77-1,,n F- 4-S ` 20.•. G �G' T�leachnng pits, number: leaching chambers,number: leaching galleries,number: leaching tr nc!',es,number, lengdt,: 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.): ,40 Aih V To los o1. �- S,a,e,:� y 6-tZA v L%L ti o HYy �?� l�r 3' i3Ec o c✓._._T �R—r �niU��c Z D2y 6-1 , t CESSPOOLS: (cesspool must b,: 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 scuin layer: Dimensions of cesspool: Materials of.�onstruc.ion: indication of'groundwater inflow(yes o- no): _ Comments(note condition of soil, sign of hydra�ili: fauure, level of pondirrb,condition of vegetation, etc.): PRIVY:j�k(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of.hydrauhc failure, level of ponding, condition of vegetation, etc.): 9 i Page 10 of 1 1 OFFICIAL INSPECTION FORM-Nar Fo"OLZJZV'i`ARV ASSESSMEtYTS SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM fNTORMLATION(condmood) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage dispc-sal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells wit} 00 feel. Locate where public water supply enters the building. 3 S t:.D iL I( Eck 1-7 28 In Page 1 l of 1 l OFFICIAL, INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWi,.GE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corainued) Property Address: Owner: Date of Inspection: jE: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water/< � feet Please indicate(check)all methods used to determine the high ground water elevation: ' Obtained from system design pi m. gn;,record-If checked, date of design plan reviewed: Observed site(abutting propertylo?).ervation hole within 150 feet of SAS) Checked with local Board of Heal:;r-explain: Checke;d with local excavators, installers-(attach documentation) 1�Accessed USGS database-explain: US t_S rc�i You must describe how you established the high ground water elevation: Eg? fdoLL /LeA2 oC 2� ` r2 o. "=T , — TO 3 U/--AeJL- 8077-;# oG' C529J itro Z4 D S G S �=7 o.v c02 4.) _ I I Il � � � � � � 1A � u � r �; p� ,� : � j � A. � 0 c � �� �I �, � � � � w �, w �� \ _ - �. j �� *� � � F� <,� i x � T No -•.......-- Fly$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �11 _... .. OF...............:vrkl, I (�ZI��L.... .. .................................... Applira$inn for Ditiposal annstrnr#inn Vautit Application is hereby made for a P&mit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem at: gT :..L�. s...�,�.. .,�......�. �..�.Y*ita.........................................••••........................................ '2 oca' ress, or Lot No. ..... a..�..1:1.�. ... ..... Add :�e.... . ............... ........................................ ........................•--•......................... O . . .. wner Address ...:.(W A).K......LL N /A,4 C�..-F................................. ............................................. ................................................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- W Design Flow..........SA........................gallons per person per day. Total daily flow...........2.0___....................gallons. WSeptic Tank—Liquid capacity./Q00gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ................ Width.................... Total Length.................... Total leaching area....................sq. ft. /.�� Seepage Pit No.. Df�_ _&�ia eter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water______________._-_..___. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ...................................--- O Description of Soil---- / .T.__ tl.<1.................................••---•••.-----•----.--•-•-•-•-••---- ---••••--------••-.-••------••••-•-•---•------- W V -----•••---••-•-•--••-••---•---•••-•••-••-•••--•-------••••--••.........-•••••......-•---- ...............................••-•----•-•--•--•-----•-•---••---•••••--••-•-•-•----•------•......-•-•--..... W Z ----------------------------------------------------------------------- ------------------------•-•--....-----------..__...-----------------------------------------•---------------------............•. V 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 Article XI of the State Sanita ode—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha bee issued by th rd of alth. Signe�•- •..............1.�'l.: ............................ ............ ............)/ ..... Date ApplicationApproved By......................................................................... -----_-----_------- --------------------------------------- Date Application Disapproved for the following reasons:................................................................................................................ ••----------------------•.....•-•..........----------•--••-•---•-•-•••-•-•---••-•--........--••--•••••--••••-•--•••----••--.....................-•------ ............................................. Date PermitNo......................................................... Issued......................................................... Date r- elT ............................ _ - THE COMMONWEALTH oF MAssAm*usErre 8����& /�K� ���� HEALTH ����^ ^^ ^�� ��" C1eW p---'-��4^� _�x� .................. ___ � ��������'��° ��~ ���.� �� � ������ - '����-- -- --- - ��---- ----~- ~~--~-~~��~~- nr �~°° Application is hereby ozudc for x Permit to Construct ( ) or Repair ( ) an Individual So"xgc Disposal - ^1 �~~~���� , -�'�^�� -~_------------_------------_----------_---- ° = L* m" ___J_!0________ ..................................__.......................................................... Owner= , Address | Installer x�m ------------------------- Type of Building � Size Lot......._--_--_-'8m. fee � --No. of .'----__-- Attic / ) Gr�ulor� ( ) Other-Type of Building ............................ No of persons............................ Showers ( ) -- Cafeteria ( ) ~~ Other fixtures ............................................................................................................................................... -� Design _mm � Z Other uisroon000 onxT / Dosing tank L � ~� Percolation Test Rcuobo Performed by........................................................................ Date......................-.............. � Test Pit No. l_---'-miootoyperinch Depth of Test Pit_.................. I)entb to ground water....................... (14 Test Pit No. per inch Depth of Test Pit..................... Depth to ground water-----.----� -'---.---'' ......................................................... 0 Description nfSo�'- x+4 .....................................................- ..........---'-_....... ' _-_--_-'_�-' .......................................... ..........................................------................................ ........................... ............. ----'-'-'-'-----'--.----'-----.__-'''---.'------- ------ ------.-.----.--'-_-__- �� Nature of oc �1�rab000--Auawcr when -------.-- ................... ............. -..........--..................................................................... ---------------------------------- ..........._'-._--.-_---............... � '�,-_-__- The undersigned agrees minstall the alforedescribed Individual Sewage Dim� S��� �n ��� `� ^ � the provisions of Article XI of the State 5 agrees not to place the system in | operation until a Certificate of Compliance has h=� ia,uc6 by `^`», � Signed......... ..............___.__ __ . . ...~� Date ApplicationApproved Bv...................................... .....................................................- ............................. Date Application Disapproved for the following reasons:................................................................................................ .............. ............................................- .........................--............................................... .-------- ................................................ � Date PermitNo......................................................... Issued........... .......................................... Date THE oommomm/suLrH OF MASsACHussrrs BOARD OF HEALTH � ....V. ....OF-' ----- � Ta4»firate of T^wutpl«at»a THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired has been installed in accordance with the provisl06s of Article XI of The State Sanitary �Xe as escribed in the application for Disposal Works Construction Permit No....... ----------- dated------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE �ONSTRUED AS AcuARAWTEE TH'A'...T...T...HE SYSTEM WILL FUNCTION SATISFACTORY. | / � DATE.-........................................................................... ---_______.___.__._____________________. � THE COMMONWEALTH Or MxasACMussrrs BOARD OF HEALT H ~ �---'��F-^���� ------ ~� y_-' �-- -----------'--- FEE �! -..........- � R apuOu1 to Construct ( ) or Repair an Individual Sewage Disposal System at Nn....+J14.....^��.���*��^�� --- ___ Sfrect � s�o �� � \��yQ���� ���d �o���.�� D�-_2�'���� ^^ ^ / -_ .......................................--------.................................... - Board ofucalth DATE--'------ ............... ................................... rpnm 1255 xoonS w wmpnsw INC.. u�u�*cn" ' . ' �' . t LEGEND - HYANNIS PROPOSED CONTOUR LOCUS J ® PROPOSED SPOT GRADE WEQUAQUET _ LAKE a EXISTING CONTOUR p W + 96.52 EXISTING SPOT GRADE s' ~ W �' cu m —W— EXISTING WATER SERVICE F 'S s a 128.51' y TEST PIT I � � � ¢ �\ -- -- -- Q�\�� J /f SCALE: 1"=20' 6 g f C) 69 DRIVEWAY /— LOCUS MAP I I LOCUS INFORMATION I I I II PLAN REF. 25306-8 TITLE REF. C175612 I i --------`----- 1 (,�} PARCEL ID: MAP 251 PAR. 211 IN STATE ZONE II G I PAVED DRIVEWAY 11 % 1 � o-}. .T-W- -- — -—wt- `, SEPTIC SYSTEM z i I , 6 REPAIR PLAN o _ LOCATED AT: I > m 1 v, W Q I I r� a l o I , o I TP-t � 88 BISHOPS TERRACE o i ,` ' x „ HYANNIS, MA ' J � PREPARED FORf - 0 Q0zz z BENJAMIN DAMAS C ENO 0 EXIST. 1!000� SEPTIC N TP_ SEPTEMBER 28, 2016 36G� j Of Mqs D R / 1 i E R 0. 1 L_O T 3 4 sgro I TAR�a� n \ 69 AREA = 18424 sf+- {� i \ LAND COURT PLAN 25306-B ASSR MAP251 PCL 211 MEYER & SONS, INC. 6a 125.61' P.O. BOX 981 PLAN BENCH MARK EAST SANDWICH, MA. 02537 SCALE: 1 in = 20 ft * PH: (508)360-3311 PAINT SPOT ON 0 20 40 BULKHEAD CORNER FAX: (774)413-9468 70.33 meyerandsonstitle50gmail.com O 10 20 40 USGS DATUM ASSUMED SHEET 1 OF 2 J 1808 i I ELEV. TOP FOUNDATION MOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (68.5) 'VENT = 71.09 � F.G.EL: 69.50 F.G.EL: 69.0 F.G. EL: 68.7 - a� � MAINTAIN 2% MIN SLOPE OVER LEACHING AREA 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2" F.G.EL: 68.38 STONE OR FILTER FABRIC DOUBLE WASHED STONE ,. 77 V 4" SCH 40 PV sw C r 10"I ®®®®®®®®®®® 14H 6" © S= 1% (MIN.) A TEE'S ARE TO BE INV.65:70 FTWE ®®®®®®®®®® 4" SCH 4o PVC 2 E F. DEPTH ®E3aEM ®woo INV.67.25 :....a... ( INV.65.50 2 X 8.5' 4 PROPOSED DB ' GAS -3 EXIsnNc OUTLET BAFFLE , = INV. 67.35 - DISTRIBUTION BOX EFFECTIVE LENGTH 25' (H-20) INV. ELEV.= 62.42 EXISTING 1,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON ���� OF MAssq�y BREAKOUT OUTLET TEE AS MANUFACTURED BY o D E4 M ELEV.= 63.4 TUF-TITE, ZABEL, OR EQUAL TOP CONC. ELEV.= 63.4 NOTES: 1 CONTRACTOR SHALL VERIFY ALL EXISTING N 4 INV. ELEV.= 62.42 11W 10® ®®® . PIPE INVERTS PRIOR TO CONSTRUCTION ®® 2) D-BOX SHALL BE SET LEVEL AND TRUE TOG/STE��O ®®® GRADE ON A MECHANICALLY COMPACTED SIX SANITAR � �� BOTTOM EL.= 60.42 ®®® INCH CRUSHED STONE BASE, AS SPECIFIED IN 3. T. 3.75' 310 CMR 15.221(2) EFFECTIVE WIDTH = 12.5' 3) REPLACE EXISTINGING1 1,000 GALLON SEPTIC TANK SEPARATION 5.00 FT. WITH 1500 GALLON SEPTIC TANK IF FAILED, SEPTIC SYSTEM PROFILE DAMAGED, NOT H2O LOADING, OR UNDERSIZED. BOTTOM OF TESTHOLE EL: 55.42 SOIL ABSORPTION SYSTEM (SECTION) 4) INSTALL INLET & OUTLET TEES W/ GAS BAFFLE AS REQUIRED (500 GALLON H-20 LEACH CHAMBER) GENERAL NOTES: SOIL LOGS P#:151511 DESIGN CRITERIA 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. NUMBER OF BEDROOMS: 3 BEDROOOM 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: SEPTEMBER 14, 2016 SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE SOIL EVALUATOR: DARREN MEYER, R.S., CSE 1 DESIGN PERCOLATION RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: # 614 DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D. - 310 CMR 15.405 (1) (e): WITNESS: DAVE STANTON, BARNSTABLE HEALTH 1) A 2.10 Fr. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING GARBAGE GRINDER: NO (not designed for garbage grinder) TO BE 5.10 Fr (MAX) BELOW GRADE VS REQ'D 3 FT. (H20/VENT PROVIDED) 6 TP-1 Depth Elev. SEPTIC TANK: 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE eACKFlt.LEO PRIOR EIev, TP-2 Depth 330 gpd x 200% = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK .TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 0" 0" A � A (330) = 445.94 S.F. DESIGN ENGINEER. 68.79 68.42 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING LOAMY SAND LOAMY SAND LEACHING AREA REQUIRED: FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 10YR 4/1 1OYR 4/1 •74 ENGINEER BEFORE CONSTRUCTION CONTINUES. 67.97 B 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. LOAMY SAND 10" 67.42 B LOAMY SAND 12" USE TWO (2) 500 GALLON H-20 PRECAST LEACH CHAMBERS W/ 4' 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 10YR 6/6 10YR 6/6 STONE ON ENDS & 3.75' STONE ON SIDES: 25' L X 12.5' W x 2'D THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 65.87 C1 FINE- 35" 68.09 C1 FINE- 32" BOTTOM AREA: 25 x 12.5= 312.5 SF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. MEDIUM MEDIUM (`4 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. perk ® el. 64.0 SAND SAND SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 2.5Y 6/4 2.5Y 6/4 TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 62.79 72" 62.42 72" TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D j 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE C2 C2 DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING MEDIUM- f MEDIUM- 10. EXISTING CLEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 2'5Y 6/6 �TION. D } 2.5Y SAN/6 PROPOSED SEPTIC SYSTEM UPGRADE P LA N 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 55.79 156" 55.42 156" 88 BISHOPS TERRACE, HYAN N I S, MA 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY <2MIIN/INCH IN;"C" SOILS AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY NO GROUNDWATER OBSERVED Prepared for: Damasceno 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 14. NO WETLANDS WITHIN 100. OF PROPOSED LEACHING. Engineering and Survey by: SCALE DRAWN 15. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED) • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 MEYER&SONS,INC. N.T.S. DMM to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX 981 requirements of 310 CMR 15,017. 1 further certify that I have passed the Soil EvaL Exam in October, 1999. EASTSANDWICH•MA02537 DATE CHECKED SHEET NO. 508-382--2922 09/28/16 DMM 2 Of 2 *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE �® Least 24 inches tall) SECTION A -A 1nNT14e,PteiL� _ Schedule 4 PVC w/Charcoal Odor Filter 10' min. from I'ROF_ILE VIEW' OF ADDITION TO LEACHING SYSTEM oSTRIBUTIONPBOX s°i THE Existing Foundation E house to septic tank _ _ D-BOX cover must be 1 Wash d Peastone SET LEVEL FOR AT LEAST 2 FT. _ 12 � CONCRETE COVER < Septic tank covers must be 3' of 8" 1 " e TOP OF FOUNDATION = ELEV. 100.00 (Assumed) within 6 in. of finished grade within 6 in, of finished grade / - /2 r I --3/4" to 1 1 2 " Washed Crushed Stone 1 >. 2 -Grade over Septic Tank - 98.00 Grade over D-Box - 9B.00 -Dade over SAS - 98.00 / r I 3 - 5' OUTLET KNOCKOUTSA\ XZ1 ' 4- PVC (CAPPED) INSPECTION PORT TO BE - S e 0.02 INSTALLED AND TO BE WTHIN 6' OF GRADE OUTLET i 12` INLET 3 HOLE H-10 Top Loud - Ekv. =95.00Lr) 6! 8 „e:iisnoa:"rer . 5=0.01 DIST. BOX 3' Maximum Cover .. •� - - Top OF System- Elev. s94.50 t6• Exist. or Greater EXIST, PIPE 0 1,000 GAL. - LID i 50 - S- O.Ot' per foot i -15.5'- 4" - SCH. 40 Te `! tia` 4i FROM EXIST. FOUNDATI N 0) SEPTIC TANK N --10" Effective Depth 1 75' II H-10 oa sir.. 2ao 5 Units @ 6.25' = 30 � PLAN SECTION CROSS-SECTION CONCRETE FULL FOUNDATro w _ - II Uri t� 3 3' a) a 0.83' (10 inches) _ SYSTEM PROFILE 6 �'at 3/4"-"/2" °' " if - 37,25' 3 HOLE H-10 DISTRIBUTION BOX Compacted stone ° NOT TO SCALE5psw, !.Not to Scale c ° ° m II rn Effective Length Wm a 4' - --1 4' SOIL ABSORPTION SYSTEM (SAS) o ea allWxps Cf Vg ;O'V4 NAvTE. i f 2.5� > _ - 6 in.of 3/4'-1 1/2" 10' 6 INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN GENERAL NOTES compacted stone Effective Vidth (OR EQUIVALENT) . Not to Scale NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE w o 1. Contractor is responsible for Digsafe notification w Bottom of rest Ode 1 Elev.144 00 m NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" EFFECTIVE HEIGHT IS 10" and Na Groundwater Observed o 144' / protection of all underground utilities and pipes. - - - 2. The septic tank and distribution box shall be set level on 6" of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay Environmental Services, Inc. 5. The contractor shall install this system in accordance PERCOLATION TEST with Title V of the Massachusetts state code, the approved plan and Local Regulations. 6. If, during installation the contractor encounters any Date of Percolation Test: DEC. 30, 2004 soil conditions or site conditions that are different Test Performed By. CARMEN ( SHAY, R.S., C.S.E. from those shown on the soil to or in our design Results Witnessed By. WAIVER per Barnstable B.O.H.) g g EXCAVATOR: Shay Environmental Services, Inc, installation must halt & immediate notification be Percolation Rate: Less Than 2 MPI 0 42" _ made to Carmen E. Shay - Environmental Services, Inc. 7. No vehicle or heavy machinery shall drive over the l 145.03' - septic system unless noted as H-20 septic components. 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. --- 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Test Hole 10. All solidpiping, tees & fittings shall be 4" diameter 9 No. 1 SHED 28.6' Schedule 40 NSF PVC pipes with water tight joints. DEPTH SOILS ELEV. 11. Municipal Water is Connected to ALL OF The Residence and Abutting j 0 9&00 Loamy 16'- '--------- ---------------- --------------------------- -------- 98 Properties Within 150 Feet. Sand Failed THE PROPERTY LINES ARE APPROXIMATE AND 10 nR 3/2 Leach Plt - COMPILED FROM THE SURVEY PLAN GENERATED BY 0"-4" A 97.75 4" P VC f0 THOMAS E. KELLEY SURVEYING CO., ENTITLED '' PLAN OF LAND IN HYANNIS, MA" PLAN # 25306-B SHEET 3 Loamy //VETJT .: ., lF.< ttj Sand DATED DATED APRIL 10, 1970, 10 vR 5/6 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN 4"-42' B. 94.50 ,/� D-Box 1T SHOULD BE USED FOR NO PURPOSE OTHER THAN Medium / THE SEPTIC SYSTEM INSTALLATION. TEST HOLE #1 20' Q Sand I ( ko EL_EV.= 98,00 z.s Y 7/4 i C6 DECK O EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE OR 32"-144 C, 186.00� I F ---------1 t t t REMOVED TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION I I � NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE I - 1 I f FROM THE EXISTING LEACH PIT TO BE DISPOSED 1 OF AS PER BOARD F HEALTH SPECIFICATIONS. P ECIF CATIONS. -IROJE ,T BENCH ,MARK= - TOP OF .FOUNDATION - ----- Nc`) -wETLANfrS-A€ZE-PREsrNT waF-tiN 200 aF THE -PROPERTY,-- ..t 3 BEDROOM - ELEV. 100.00 (Assumed) ( HOUSE ASSESSORS MAP 251 PARCEL 211 I t 1 8 LEGEND jASPHALTi # 8 - � t Perc #1 �\ iDRIVEWAI� Depth to Pere: 42" to 60" �� DENOTES PROPOSED Perc Rate= Less Than 2 MPI L 704X1 -_ I L I i SPOT GRADE Groundwater Not Observed _i d No Observed ESHWT i �- - Eic I I DENOTES EXISTING ADJUSTED H2O Elev. = None �`\ 4 _ -----i----- ------------------------------------------- ------- 98 X 104.46 LOT II{34 SPOT GRADE �, I' �'-♦---� i ' GRAVEL 18,560 Square Feet +/- PL PROPERTY LINE ' DRIVEWAY f { - - 96P PROPOSED CONTOUR t C 96------- --- ---;/-------------ll------+-_ :il ----------- ------------------------- -------- 96 - - - - _ -97 EXISTING CONTOUR ------ --- ' 145.00' p - L - DEEP TEST HOLE & 2-18" otnM. ACCESS MANHOLES i r1 PERCOLATION TEST LOCATION --- --------------------- 6 FOOT STOCKADE FENCE ---- -- - INLET _ 1_J 1r 1 _ �J l 1 A_J ���� �! OLI ET LOT(40 FOOT RIGHT OF WAY) P PLAN THE ACCESS COVERS FOR THE SEPTIC TANK, l: DSET DEEPER THAN 6 ISTRIBUTION BOX AND LEACHING COMPONENT INCHES FINISHED OF PROPOSED SEPTIC SYSTEM UPGRADE y c. .. GRADE SHALLBE RAISED TO WITHIN 6" OF STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. PREPARED FOR PLAN VIEW INSTALL TtiF-TITE CAS BAFFLES OR EQUALS W( L�I A M M EA G H E R 3-24' REMOVABLE COVERS� AT #88 BISHOPS TERRACE 3" min•dearance B n. inlet to outlet 6.mM t3' ttxET'Y U�ld lei I OUTLET - INLET mi -F12 H YA N N I S , M A s' -r -- t 5' -7' Design Calculations E e 1 � 4'-0"min. PREPARED BY: b9 °iB"'" Lig,d depth Number of Bedrooms:3 ' Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) u/� o Garbage Grinder: No A M tiG rAE it L l ► A llL1 Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) `Pc�, . Septic Tank - 2 x 330 Gal./Day = 660 USE EXIST 1,000 GAL. Septic Tank. VIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 0 20 40 5 CROSS SECTION END-SECTION Bottom Area: 0.74 gal/sq. ft. x 376 sq. ft. = 273.8 gallons I I o P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons Fs rEFF EAST FALMOUTH MA 02536 Providing: = 331.80 gallons SgNITA0' , TYPICAL 1000 GALLON SEPTIC TANK Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' {t TEL�FAX 508-539-7966 NOT TO SCALE 0 INCHES) EFFECTIVE DEPTH, SCALE: 1 '=2O TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1 "=20' DRAWN BY: CES DATE: JANUAR 4, 2005 ON THE ENDS. No STONE UNDER. PROJECT#SD675 FILENAME: SD675PP.DWG SHEET 1 OF 1