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HomeMy WebLinkAbout0072 BLACKBERRY LANE - Health 72 BLAV:I<BERRY LANE OYANNIS 1 o , ° ° ° i ° • •E �f TOWN OF BARNSTABLE LOCATION- � �i V�`�Ir SEWAGEZX1, 00V VILLAGE �G��%tea ASSES & LOT D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING,FACILITY: (type (size) NO. OF BEDROOMS BUILDER OR O R PERMITDATE: D COMPLIANCE DATE: t 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 J r 1 r © d . II I' an 20 14 09:28a p.1 Commonweal of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owner's Name information is required for every Hyannis MA 02601 1-17-14 page. Cilyrrowo State Zip Code Date of Impaction 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. (mng out forms n A. General Information ```�,,,,,,�lluu,�,,,,'' ' filling Out forms on the computer, ` tNOFNgssC.y'i use only the tab 1. Inspector. � � •9 key to move your cursor-do not ' • JAMES ,' James D.Sears =�: use the return Name of Inspector tce� Capewid Eerprises,LLC o o .•� Company Name 153 commercial Street � /5rIINrSPG�\```\\ Company Address Mashpee MA 02649 City/rown state Tip Code 50"77-8877 S 1623 Telephone Nurrlber license Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that theme information reported below is true; accurate and complete as of the time of therinspection.The inspection was performed based on my training and experience in the proper function andmaintenancVrof oW Re sewage disposal systems. I am a DEP approved system inspector pursuant to'Section 4.6.340xof Title 5(310 CMR 15.000).The system: 3- cap ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority zlz Qi 1-18-14 w6wie_s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This Inspection does not address how the system will perform In the future under the same or different conditions of use. t5h •3A3 Title 5 Official Inspection Forth Subwrfeoe sewage Disposal system-Page 1 of 17 I Jan 2014 09:28a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner owners Name information is required for every Hyannis MA 02601 1-17-14 page. Cityrrorm state Zip Code Date of Inspection B. Certification (cunt.) 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: i r 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 oompletion 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 efitrration or tank failure is imminent System will pass inspection if the existing tank is replayed 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): • t?bw:3/13 Title 5 ORldal Inspeam Form:S~ace Selvage Disposal System•Page 2 of 17 j Jan 2014 09:29a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Bevy Lane Property Address Nancy Schaefer Owner Owner's fame requk for a Hyannis MA 02601 1-17-14 required torevery page. City/Town state Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumpsialarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cant): ❑ 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 t5na-3/t3 T'fe 5Offidal tnspeclian Fate SLft u law Semp Disposal System•Page 3 of/7 r r Jan 20 14 09:29a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 72 Black Berry Lane Property Address Nancy Schaefer Owner Owner's Name Information is requIred for every Hyannis MA 02601 1-17-14 requir page. Cltyfrown state Zip Code Date of Inspection B. Certification (cunt.) 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 watersupply 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 dogged 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 eilampog is less than 6°below invert or available volume is less than day flow L F -�Iel l ti C ISlns-3M3 TftW5 Official lne peetlon Form:SuDaurfeoa Sewage prtppyal System•papa 4 of 17 an 20 14 09:45a p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Black Bevy Lane Property Address Nancy Schaefer Owner Owner's Name information is required for every Hyannis MA 02601 1-17-14 page. Cityr 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 N 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 S 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 11 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. M s 3113 Title 5 Official Irmpectlon Farm Slbaafece Sewage Disposal System•page 5 of W 5 Jan 20 14 09:45a . p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owner's Name infortnafion is required for every Hyannis MA 02601 1-17-14 page. Cityrrown 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? El ® 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 NIA) ® ❑ 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 facture criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design). 6 Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 15ins-3N 3 Me 5 Offidal Inspection Form SuDsiafaoe Sewage Disposal system-Page B of 17 i Jan 20 1409:46a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry lane Property Address Nancy Schaefer Owner Owner's Name information is Hyannis MA 02601 1-17-14 required for every H y , page, Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. tank D.Box and eight high cap chambers. Number of current residents: 0 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 ID No Water meter readings, if available(last 2 years usage(gpd)): 2012-79,000Gals 2013-80,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA 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: 15hs'-3r13 Title 5 Offidel Inspec9on Few..Suburfaae Sewage Olsposel Syslem-Pape 7 of 17 e•, Jan 20 14 09:46a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Qwner. Owners Name information is require for every Hyannis MA 02601 1-17-14 d page, Cityrrown, State Zip Code Date of Inspection D. System Information(cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 10-7-10 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) ❑ Innovahve/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 15irt!-3/13 ` Tdle 5 ORbPJ hspecfion Fom><Subsurtace Selvage Dlspaeal System-Papa 8 of 17 t Jan 20 14 09:46a p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry lane Property Address Nancy Schaefer Owner Owner's Name Infor requir etion is requir Hyannis MA 02601 1-17-14 ed for every . 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: 2001 Permit # 2001 -020 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 20" Depth below grade: 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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): •Depth below grade: 10"feet Material of construction: ` ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No ' Dimensions: 1500 Gal- Precast. •Sludge depth: 3" t51ns•3113 Title 5 Of dal Inspaflon Form Subsurface Sewage OLVasal System-Pape 9 of 17 Jan 2014 09:47a p,g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owners Name Information is required for every Hyannis a MA 02601 1-17-14 page. Cityrrown state Zip Code Date of Inspection- D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 2T Scum thickness 1" all Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17" i. How were dimensions determined? Asbuilt Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at wonting level. Tank and cover's at 10"belolw grade. In and outlet tee's. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: teat 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 tsi"s.3113 Title 5 Olfldal Inspection Form Subsurface Sergipe DlWosal System•Pegs I of 17 Jan 20 1409:47a p.7 Commonwealth of MassachuseHs Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owner's Name information is required for every �H annis MA 02601 . 1-17-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cons.) 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 t5tns 3113 Tttla 5 otricbt wpectlon Form SLdmffete Sewage OWpoW System•Page 11 of 17 Jan 20 14 09:47a p.8 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owner's Name information is required for every Hyannis MA 02601 1-17-14 page,: Cdyrrown State Zip Code Date of Inspection D. System Information (corn.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-21" below grade. Box is clean and solid wRwo line's out. No sign of over loading or solid 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: t5lns-'3113 Tdle 5 oflldel. ktspei9an Fomc SLftuafaee Sewage Oisrwsm System•Pepe 12 of 17 Jan 20 14 09:48a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner owner's Name information is required for every Hyannis MA 02601 1-17-14 page. City/Town State Zip Code Date of Inspedion D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number. 8 ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativelaltemative system Typefname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is eight high cap chamber's 58'x11'x2'. Ck D Box and camera out to chambers. No sign of over loading or solid cant'over. No sign of holding water. i 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 3113 TrUe 5 ofrldal Uapedion Form:Subsurface Sewage Disposal System•Page 13 d 17 ry.' Jan 20 14 09:48a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owners Name Informarequir-ed foon r Hyannis MA 02601 1-17-14 required for every page. cityrrown 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.): i 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.): . _ 15ins-U13 TWe 5 Of cW h9pedon Forme Subsiataoe Se wage Disposal System•Page 14 of 17 b ' Jan 2014 09:48a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owner's Name information is required for every Hyannis MA 02601 1-17-14 page. Ci yflrawn 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 A / - 3; 13 13 a 3 /PCA -3 = 3� " 13 -3 _ �� ❑3 d� f t5his4.3/13 Title 5 ofBdal hspe®on For c SuhsuQaae Sewage Oisposal System•Page 15 or 17 Jan 20 14 09:49a p.12 a . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owner's Name information is required for every Hyannis MA 02601 1-17-14 page., Cityrrown State Zip Code Date of Inspection D. System Information (cons.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 48' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Jf 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: GIS ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Per paper work and GIS on file at BARN. B.O.N. G.W.at 50.9' 2.7 ADJ. =48'. Bottom of leaching at 4'below grade. Bottom of leaching at 44'+above G_W.. Before filing this Inspection:Report, please see Report Completeness Checklist on next page. 15ins 3113 Mile SOflboalIn spection Pam:Subsilaes Sewsp Disposal System•Pape 16 of 17 Jan 2014 09:49a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 72 Black Berry Lane Property Address Nancy Schaefer Owner Owner's Name information is required for every Hyannis MA 02601 1-17-14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary.A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t51ns•3113 Title 5 Orridal taspedlon Fom[SLbsufec+e sewage Disposal System-Page 17 of 17 ' TOWN OF BARNSTABLE . i . LOCATION SEWAGE #dAa—_00p { VII.LAGEyG v l C ASSErSSa & LOT 0 INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY Z--. t� , I !J , LEACHING FACILITY: (type) (size) � � NO. OF BEDROOMS BUILDER OR OWNFR SD F J / PERMITDATE: COMPLIANCE DATE: / Separation Distance Between the: j Maximum Adjusted Groundwater Table to the Bottom of Leach ' 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 arithin 300 feet of leaching facility) Feet .1., . Furnished by, YY 1 1 £ 1 i� �.� U 0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZtppYtcatton for Mtgozar 6potem construction vermtt Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) 04Complete System ❑Individual Components Location Address or Lot No. 7a� U_ Owner's Name,Address and Tel.No. Assessor's Map/Parcel PC"0FA9d to Ins! is e,Address,and 1.No. Designer's Name,Address and Tel.No. Vnj Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow gallons per day. Calculated daily flow 662 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. L Description of Soil Nature of Repairs or Alter tions(Answer when applicable �L.�7 jai S. J [J'"��}� fl Date last inspected: �`i I X Z� 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 if-- .cate of Compliance ha issue y d Signed _ Date Application Approved by t, Date Application Disapproved for the following reasons Permit No. Date Issued -g ~r T , reties , No. '�/!) 1 �:. V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:.. Yes <,PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS s Application for Migpogai *pgtem Congtructi-o-n Permit Application foc a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) XComplete System O Individual Components , Location Address or Lot No. � �/� � L � Owner's/Name,Address and Tel.No. Assessor'sMap/Parcel �Vl.~� Insta er's Name,Address,and ki.No. Designer's Name,Address and Tel.No. to i Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures /Design Flow (o gallons per day. Calculated daily flow 667 7 gallons. Plan Date Number of sheets Revision Date Title r _. Size.of Septic Tank 1 Type of S.A.S. G c' (., Description of Soil" Nature of Repairs or Alterations(Answer when applicable) 01!'� / (� J' i c-, c I .S r ,Date last inspected: t 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 aLC�e>;tif- cate of Compliance has bee' ' n issued-b'y this-B• d o al�th, Signed Date / CJ Application Approved by G 1," ' _ .., Date Application Disapproved for the following reasons x ' w t Permit No. Date Issued _._4.. ---------------------------------�f�CA �- �,. THE COMMONW_" ALTH OF MASSACHUSETTS r� ' 4 BARNSTA E, MASSACHUSETTS Certificate of Compliance C THIS IS T90 9-ER111HY, that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded ( �) Abandoned( )by �� ✓ at #( /&)A.g has be n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No` — dated Installer Designer ! c� The issuance of this permit shall not b�iy construed as a guarantee that the syste w ll function as�design�e Date fi� InspectorI ! �111� �C-- V No.e%w/^ 7,Q--------�--------"----------Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogal *pgtem Congtruction Permit Permission is hereby granted to.Construct )ReEair `Upgrade )Abandon( ) System located at i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructi n must be completed within three years of the date of Date:�Z/�� Approved b M �4 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 Pf, MIT_(WITHOUT DESIGNED PLANS I �4s, hereb certi that t e y fy h application for disposal works construction permit signed by me dated 1-14 o f , concerning the property located at �� �(�►, �,�.? meets all of the following criteria: V. This failed t o system is connected to a residential dwelling,only. There are no commercial or business uses associated with the dwelling. . ZThe soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. here 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 • There 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 pplicable] 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, I Please complete the following: A) Top of Ground Surface Elevation(using GIS information) OI B) G.W. Elevation h-V +the MAX. High G.W. Adjustment.pC r-_ `" 2r 7 DIFFERENCE BETWEEN A and B SIGNED : DATE: [Please Sketch proposed p n of system on back:]. I NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert O Ol ..� C� ,, TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM Mail To: NAME OF BUSINESS: Board of Health MAILING ADDRESS: - 6za �M" own of Barnstable TELEPHONE NUMBER: 7�.5 ` �Z a�6°� P.O. Box 534 Hyannis, MA 02601 CONTACT PERSON: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for your own use, in quantities totaling, at any time, more than 50 gallons liquid volume or 25 pounds dry weight? YES NO This form must be returned.to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous characteristics and must be registered wken-stari dttn quaht-ties-t Ni%ymGi:e.;,harp-°0 "a ons Ir41'd3mmo vol e o;r 25 no xdtp wwz Please put a check beside each product that you store: Antifreeze (for gasoline or coolant systems) Drain cleaners Automatic transmission fluid Toilet cleaners Engine and radiator flushes Cesspool cleaners Hydraulic fluid,(including brake fluid) Disinfectants Motor oils/waste oils Road Salt (Halite) Gasoline, Jet fuel Refrigerants Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides, Other petroleum products: grease, lubricants rodenticides) Degreasers for engines and metal Photochemicals (fixers and developers) Degreasers for driveways & garages Printing ink Battery acid (electrolyte) Wood preservatives (creosote) IRustproofers Swimming pool chlorine Car wash detergents Lye or caustic soda Car waxes and polishes Jewelry cleaners Asphalt & roofing tar Leather dyes Paints, varnishes, stains, dyes Fertilizers (if stored outdoors) Paint & lacquer thinners PCB's Paint & varnish removers, deglossers Other chlorinated hydrocarbons, Paint brush cleaners (inc. carbon tetrachloride) Floor & furniture strippers Any other products with "Poison" labels Metal polishes (including chloroform, formaldehyde, Laundry soil & stain removers hydrochloric acid, other acids) (including bleach) Other products not listed which you feel may Spot removers & cleaning fluids be toxic or hazardous (please list): (dry cleaners) Other cleaning solvents Bug and tar removers Household cleansers, oven cleaners White Copy-Health Department/ Canary Copy-Business