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HomeMy WebLinkAbout0083 BLACKBERRY LANE - Health S31''acicberry Lane Hyais, TYIA 02601 A= 249,0'8f ; � i TTOWN OF BA1 RNSTABLE LOCATION SEWAGE # XILL'AGE ASSESSOR'S MAP ,3 10Tm"V?" 011 INSTALLER'S NAME&PHONE NO.'" SEPTIC TANK CAPACITY - LEACHING FACILITY:.(type) 3 CE SS2?952 L`5_ (siie) a x NO. OF BEDROOMS BUILDER OR OWNER Ali'DATE: bS COMPLIANCE DATE: ? Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet r Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i _. �s '.� � , ' � � � 'i . re � . ` �, TOWN OF BARNSTABLE LOCATIOANAME&PHONENO. SEWAGE# .1POS- VILLAGE ASSESSOR'S M�AP&PARCEL INSTALLE W I J-U A4- t f J ik)Co SEPTIC TANK CAPACITY %� O LEACHING FACILITY:(type) NO.OF BEDRO MS OWNER Mh PERMIT DATE: O� COMPLIANCE DATE: O 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 A� - a2 B2av, r A 3 -ai B3 5J qY -y2 Q9-�,s �-3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name -n information is required for every Hyannis Ma 02601 10/17/17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information ( filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Q Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/17/17 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how.the system will perform in the future under the same or different conditions of use. t5ins,3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every �H annis Ma 02601 10/17/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 gallon septic tank. As well as a concrete distribution box and 21 H2O 16" biodiffusers B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved'by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): I ❑ 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 } l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: i **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. I ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a.DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the, system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. CityrFown 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 ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information-in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 187 Gpd 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 'a .e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Tank size Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspectio,n of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of-Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w °y 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis annis Ma 02601 10/17/17 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: 12/8/08 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): . 2 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.): Septic Tank (locate on site plan): Depth below grade: 1.5feet Material of construction: I ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 241 Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site.plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i I 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (Iodate 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 I Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form '- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/1.7/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments µ 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. Cityrrown State, Zip Code Date of Inspection D. System Information (cont.) Type: .❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 12'x33'x16" ❑ 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.): NA Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �= F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17. page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis annis Ma 02601 10/17/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately r t5ins-3/13 . Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 150" NGE feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12/8/08 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this-inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 117 10/17/2017 Assessing As-Built Cards TOWN OF BARNSTABLE ✓ LOCATION &4CCRERRY JAU EWAGE# 009_Sd 4 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER' NAME&PHONE NO. W SEPTIC TANK CAPACITY ..V O C� LEACHING FACILITY:(type) RIQZ(si,.) 0 7 NO.OF BEDROQMS OWNER K �p - PERMITDATE: L�� COMPLIANCE DATE: O 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 L-aching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY ki A� E�Z 4t Ajyly�_ 134 40 i http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=249081&seq=2 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 83 Blackberry Lane Property Address TSUKERNIK, VLADIMIR & LIYA Owner Owner's Name information is required for every Hyannis Ma 02601 10/17/17 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Certified Mail#7006 0810 0000 3525 0199 OFIKE l Town of Barnstable Regulatory Services • rm wirnstie. ► Thomas F. Geiler, Director NAM .6�9. Public Health Division RFD MA'S A Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 July 6, 20d7 Leandro De Jesus Paizao 83 Blackberry Lane Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.000 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND THE TOWN OF BARNSTABLE CODE. The property owned by you located at'83 Blackberry Lane, Hyannis was inspected on June 14, 2007 because of a complaint. The following is a violation of the State Environmental.Code: 310 CMR 15.214: Nitrogen Loading Limitations: 6 "bedrooms" were observed at said location, which is located within a Zone 2, Wellhead Protection Area with less than one acre of land. The following is a violation of the Town of Barnstable Code: J1§ 70_4: Rental units not registered: The units are not currently registered with the Town of Barnstable Health Division. You are directed to correct the violation listed above within Fourteen (14) days of your receipt of this notice by pulling a building permit to eliminate the illegal bedroom in the basement so that a total of only five bedrooms are present at said location.'The Town of Barnstable Health Department has a policy to eliminate the privacy of being considered a bedroom by installing a minimum five (5) foot cased opening with no doors, and no beds\ people sleeping are allowed.in the room, and by registering your rental units with the Town of Barnstable Health Division. 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 and\or a criminal complaint being filed against you in Barnstable District Court. Each day's failure to comply with an order shall constitute a separate violation. QAOrder letters%ousing violations\83 Blackberry Lane.doc PER ORDER OF T BOARD OF HEALTH T as A. McKean, R.S. Director of Public Health i i QAOrder letters\housing violations\83 Blackberry Lane.doc ;• COMI MONWEAL'I`H OF MASSACHUSETTS 1 P," 7 `7eP: >' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS / DEPARTMENT OF ENVIRONMENTAL P Ii.OTE CTION V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A t CERTIFICATION Property Address: $3 �lac ioLolt Owner's Name: Wr OI �6 �3 Owner's Address: m 6D! Date of Inspection: Q i Name of Inspector.-( leasq prin tcka.-,( lede 7 Company Name: I r0Y1 n,5 pec. (oit s Mailing Address: l eA-i- 6V Telephone Number: ,�� _.�f jT'— 6 08 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: X Passes Conditionally Passes r .: Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: p 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. 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 I i i Page 2 of 1 I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address Owner: P( Date of Inspection: p O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: Q� 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"secti need to be replaced or repaired The system,upon completion of the replacement or repair,as approv the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the foll g statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or enfiltra *on tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic as approved by the Board of Health. *A metal septic tank will pass inspection[fit is ctwally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years of available. ND explain: Observation of sewage bac or break ow or Ingh sWk water level in the distribution box due to broken or obstructed pipe(s)or due to a bro n,settled or uneven distribution box.System will pass inspection if(with. approval of Board of Health): broken pipe(,)alas placed obstructiaas ics.0 moved distnl u ion box is leveled or replaced ND explain: The sy em required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspe ' n if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i Page 3 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 8 L&CL a�`t niS Owner: �( Date off nspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in der to determine if the system is failing to protect public health,safety or the environment. I. System will pass unless Board of Health determines in accordan with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect publ' 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 ve- ted wetland or a salt marsh 2- System will fail unless the Board of Healt and Public Water Supplier,if any)determines that the system is functioning in a manner that prot the public health,safety and environment: _ The system has a septic tank and it absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a ace water supply. The system has a septic d SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a se c tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply we **.Method used to determine distance **This system pass if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and vola"e organic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteri a triggered.A copy of the analysis must be attached to this form. 3. Ot r: 3 Page 4 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS T: SUBSURFACE SEWAGE 'SYSTEM INSPECTION FORM PART.A.- CERTIFICATION'(continued) Property Address: * 1GL6.1/Ag p Owner: f Date of Inspection: js tS D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No -4- 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''/z 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.-IThis system passes if the well water..analysis, performed at a DEP certified laboratory;for cotilbrin bacteria and volatile organic_compomds 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 S ppm,provided that no othe=.failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CUR 1.5303,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: Q To be considered a large system the system most serve a facili 'th a design flaw of 10,000 gpd to 15,000 gpd. 6 You must indicate either"yes"or"no"to each of the foil g: (The following criteria apply to large systems in addi ' to the criteria above) yes no _ — the system is within 400 feet of a e drinking water supply the system is within 200 fe of a tributary to a surface drinking water supply _ — the system is located' a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public r supply well If you have answered"y 'to any question in Section E the system is considered a significant threat,or answered "yes"in Section D abo a the large system has failed.The owner or operator of any large system considered a. significant threat un Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syst 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: l efo LA-4 Owner: Date of Inspection: 0 D 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 0t 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? N/J 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 oflthe 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 Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 1 I OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: -f-1 A� /' �1,�•C . �ec=5 Owner:. 10. Date of Inspection: p FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): yYf7 Number of current residents: Does residence have a garbage grinder(yes or no): /W Is laundry on a separate sewage system(yes or no): AIo [if yes separate inspection required] Laundry system inspected(yes or no): IW Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): /JD p� Last date of occupancy: G� COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq c.): Grease trap present(yes or no): Industrial waste holding tank p ent(yes or no):— Non-sanitary waste dischar to the Title 5 system(yes or no):— Water meter readings,if ilable: Last date of occupanc use: OTHER(descn ): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): AID 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 oC 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 ob_tained 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: ,T6 H�r�> Were sewage odors detected when arriving at the site(yes or no): 1� 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address u(,�� �er Owner: AI Date of Inspection:_6 1 0 BUILDING SEWER(locate on site plan) . Depth below grade: y8� Materials of construction: X 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: Material of construction:_concrete_metal_ rglass__polyethylene —other(explain) . If tank is metal list age:— Is age confirmed a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to botto of outlet tee or baffle: Scum thickness: Distance from top of scum to to of outlet tee or baffle: Distance from bottom of sc to bottom of outlet tee or baffle: How were dimensions det ined: Comments(on pumpin ommendatioas,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet' ert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal erglass_polyethylene_other (explain): Dimensions: Scum thickness. Distance from top of scum to top o utlet tee or baffle: Distance from bottom of scum ttom of outlet tee or baffle: Date of last pumping: Comments(on pumping r otnmendations,in and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet inv evidence of leakage;etc.): 7 i Page 8 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: nnr5 Owner: �ion:Fn_- Date of Insp p 71GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass_polyethylene other(explain): Dimensions: Capacity: -gallo Design Flow: ons/day Alarm present(yes or no)- Alarm level: Al m working order(yes or no): Date of last pumping: Comments(conditio of alarm and float switches,etc.): DISTRIBUTION BOX: (if present t be openedxlocate on site plan) Depth of liquid level above outl vert: Comments(note if box is le and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of bo etc.): C PUMP CHAMBER: (locate on site plan) Pumps in working order(ye no):. Alarms in working order es or no): Comments(note con or; on of pump chamber,condition of pumps and appurtenances,etc.): - 8 i ' Page 9 of I I OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I&Jc'�Q//tf 1'0-_' Owner: e Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): L (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): // � �/ lzu S a �' (G D - a'd�1 CESSPOOLS:__Y (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: i Depth—top of liquid to inlet invert: Depth of solids layer: a (1 Depth of scum layer: of Dimensions of cesspool: Materials of constructiow Ckj wetk �— Indication of groundwater inflow( es or no):M Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of ve etati n,etc.): 1 X 51 � 40 oc l- 11 t d UVCI PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note conditi of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART C SYSTEM INFORMATION(continued) Property Address: F.,hQ[ Owner: (` Date of Inspection: 6 o SKETCH O .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. t 5a a i Page I I of 1 I OFFICIAL.INSPECTION, FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IDISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: CtcL � Owner Date of Inspection: Q SITE EXAM Slope y QS Surface water Y� 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 plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you establish d the high ground ater eyevation: U 5 Gs �.� ��► d6 JAevr ou ov �S I1 i Commonwealth of Massachusetts Title 5 Qfficial. Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form o���ytI °AOFWILLIAMy� Inspection results must be submitted on this form or on the official 5 Inoectlo rm dated 611512060.'Inspection forms may not be attend in any way. NARVEY .A. Certification important. i N S? When 6tk v out 1. Prppe fc, atio •forms on the computer,use V 14 c /� � �2/Z� �'�el .only the tab key Property to curssoredo of 4 use the return �s-No y key. C' �14 j cJ Ovyn dress / ,AA . /r`A J Cityyrrci n Stale Zip Code (� Date of inspection: ��� Date 2. Ins cto Ne e f lnspWor 1 `q r�dt tJc 2, city awn _C'�F . stale Zip Code — Telephone Number I Certification Statement: 1 certify that I have personalty 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 Me 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally-Passes XFalls jNd�sMr Ev a n a Local Approving Authority �Signature Date The system Inspector shall submit a dof 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 gmeathr,the Inspector and the system owner shall submit the report to the appropriate regional office of the DER The.original should be sent to the system owner and copies sent to the buyer,ff 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. 151nsp.doc•11/2004 Titre 5 oetciat bfspecSon Form:Subsurface Sewage pfsposal System Page 1 of 16 Lo I I .2 - r f - Commonwealth of Massachusetts.. Title 5 Official Inspection, Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cons IQ- I-I j Zip Code ...nw-ra Name Date of lrupedton I -- Inspection Summary:Check A,B,C,D or E!always complete all of Section D A) System Passes: /J ,* t ❑ I ha of found any information which indicates that any of the failure criteria described in 310 C 5.303 or In 310 CMR 15.304 exist,Any failure criteria not evaluated are indicated below. Comments: e) stem Conditionally.Passes: ❑ One more system components,as described in the To.ndttidnal Pass"section need to be repla r repaired,The system,upon completion of the replacement or repair,as approved by the Board ealth,will pass. Answer yes,.no or no termined (Y, N. ND)In the❑for the following statements. if'not determined,"please expl ❑ The septic tank Is metal and r 20 years old*or the.septic tank(whether metal or not)is structurally unsound,exhibits sub ntial infiltration or exfittration or tank failure is Imminent will pass inspection if the exis ' tank Is re aced with a complying approved by the Board of Health. cow ying septic tank as A metal septic tank will pass inspection if it is rally sound,not leaking and if a Certlficate Of Compliance indicating that the'tank is less than 20 did is available. ND Explain: Nl GMP-doc•11/2004 Title 5 O(ticiaf Inspection Form:Subsurface Sewage Da!system- Page 2 of 16 .Commonwealth of Massachusetts Title 5 Official Iris ection Form Not for Voluntary Assessments; Subsurface Sewage Disposal System Form A. Certif c do {rnt) KEQ Property 9ress �— - ��S(� /' AIL, state ��Zlp ow T�IIn )c B) Sys el!m Conditlonaily isasses(!cost:): ❑ Observation of sewage backup o:r break out or high static water level in the distribution box due to broken or obstructed pipes)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 lion is removed ❑ distribution box is leveled or replaced ND Explain �f— : -1w. � Q o� ( ❑ The system required pumping more than 4 times a year due to broken or obstructed pipes).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes)are replaced ❑ obstruction is removed ND Explain: 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. I. System will pass unless Boar d..of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is n'ot 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 pmry Is within'50 feet of a bordering vegetated wetland or a salt marsh tssp.doc•1112004 Title 5.0friclal Inspection Form:Subswface Sewage Disposal System Page 3 of 16 i Commonwealth of Massachusetts Title 5 Official: insp.ection Form Not for Voluntary Assessments Subsurface Sewage Disposal,System Form A. Certification ( nt.) j sate coca S -c nfe���� ©� o T-zc,. ��/ •C Date or lns C) Further Evaluation Is Required by the Board of Health(cont.): 2. Syste will fail unless the Board of Health(and Public Water Supplier, if any) determin at the system is functioning in a manner that protects the public health, safety and a vironment: ❑ The s has a septic tank and soil WtIon system(SAS)and the SAS is within 100 feet o surtace water s or to a surface water supply. ❑ The system has a s c tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank an AS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS;and th AS 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 ed laboratory,for coliform bacteria and volatile organic compounds indicates that ttte wet!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 r t%Mp.doc•11/2004 Title 5 OMGW Inspection Form:Sub=face Sewage Disposal System Page 4 of 15 Commonwealth of Massachusetts 'Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certificatio ( . nit.) (< Z,4 A) � s PropeqAWren y�� � s � �/ � e c. -j se. t6�1° /)v y /-0d S me Date of inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage Into facility or system component due to overloaded or ❑ dogged 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 ilquid level in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool �( Uquid depth In cesspool Is less than 6"below invert or available volume is less ❑ than%day Clow ❑ Required pumping more than 4 times in the last year NOT due to dogged or obstructed p4*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 quardy 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 6 ppm,provided that'no other fallure criteria are triggered.A copy of the analysis must'be attached to this form.] Yes No ❑ The system falls.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. t5insp.doc•1112004 Tide e 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 5 of 16 �.Commonweafth of Massachusetts Title 5 Official Inspection Form 15, Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification ( nt.) 7,C_ ` 4 4 T�M 6 le ms ' 0,26G ?2:r' � — - ��' � �smte 8� �d f,�� o+Nne, me / We of Inspection 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 syste ,you must indicate er'yes 'or'no*to each of the following,In addition to the questions in Secti D. YES No �� -° ❑ ❑ the sys is within 400 feet of a surface drinking water supply ❑ ❑ the system is wi 200 feet of a tributary to a surface drinking water.suppiy ❑ ❑ the system is located in n sensitive area(interim Wellhead Protection . Area—IWPA)or a mapped 11 of a public water supply well . If you have answered'yes'to any,question In Section E the tem is considered a significant threat. or answered'yes"in Section D above the large system has fail owner or operator of any large system considered a significant threat under Section E or failed u n D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should tact the appropriate regional office of the Department. t51nsp.doc•11r2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Pogs a of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Che ll t 13/,-)c-.K/ ev� n PM� [� 00240 c.M se s�reU�.d Zip code - e ti / R C Date of Inspeclton Che 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 ❑ 7�— Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flaws 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 WA) �, ❑ 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. Determhed 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(3xb)] t5msp.doc•I Ia004 Tide 5 Oflidal Inspection Form:Subsurrace sewage Disposal system Page 7 of it .Pommonweafth of MassachuseM Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Syste atinn 7C"tl C srata zip code s Marne , Date of ktispec Lion aesldential Flow Conditions: Number of bedrooms(actual): Number of bedrooms(design): ( ) DESIGN flow based on 310 CMR 15203(for example:110.gpd x#of bedrooms): �,0,j 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ( No Is laundry on a separate sewage system?'fif yes separate Inspection required] ❑ Yes No Laundry system inspected? Yes ❑ No Seasonal use? ❑ Yes No —e Water meter readings,If available(last 2 years usage(gpd)): Sump pump? Yes No Last date of occupancy: Data Commercial industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203). Gdom per day(ice) Basis of design flow(seats/persons*.ft.,etc.): Grease trap present? - ❑ Yes ❑ No 14 Industrial waste holding tank present? _ ❑ Yes ❑ No Non-sanitsry waste discharged to the Title 5 system?, ❑ Yes ❑ No Water meter readings,if available: Last date of occupancy/use: D Other(describe): Lgnsp.doc•11/2OD4 Title 5 Offldal Inspection Form Subsurface Sewage Dispo System- Page 8 of 16 Commonwealth of Massachusetts Title-5 Official Inspection Form Not for.Voluntary Assessments Subsurface Sewage Disposal'System Forma C. Syst In on (con grew • �a (0 c P ",IV,, 7,P—APcode .0 Name L, C Date of impecr3on General Information Pumping:Records: Source of information: Was system.pumped as part of the inspe ' n? . ❑ Yes ❑ No If yes,volume pumped: ,8 i How was quantity pumped determined? Reason for pumping: Type of System: , ❑ Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ ply ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/Altemattve 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. 1�— 0ther(d ''be Appro)d age of all cornponen. to Installed(if known)and source of information: Were sewage odors detected when arriving at the site? Yes ❑ No MW.doc•1 MOM TMe 5 OfCrdal Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 i Commonwealth of Massachusetts Title 5 Official. Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Sys of ation r-5 0 77")C- / coen �� pr�A Pt C-1;;. c smte Zip Code vv Owrorg 1N^a`n e / Date of inspection �LY V �/� Budding Sewer p e on site plan): Depth below grade: h lost Material of construction: IF ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or n fine: feet Comments(on condition of joints,venting,evidence kage,etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction. ❑concrete ❑m ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Complia (attach a rs copy of certificate) ❑ Yes ❑ No Dimensions: . Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness _4 Distance from top of scum to top of outlet-tee or baffle -Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? t5insp.aoc-I IrZO04 TWe 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of.Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form . C. Sys N lnf ation (cunt pia f} 0� `�®l cityrr slate �Code Owners Name Qrc'l , Dale of kispectkm Commen (of�pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid leve as related to outlet Invert,evidence of leakage,etc.): . Grease Trap(locate o ite plan): • Yv Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fibe ❑polyethylene ❑other(explain): Dimensio - Y Scum thi s I Distance from top. scum to top of outie tee or baffle Distance from bottom of to bottom of outlet tee or,baffle Date of last pumping: Data Comments(on pumping recommendations, t and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence ge,etc.): Tight or Holding Ta tank must be pumped at 1� of Inspection)(locate on site pier): Depth below grade: � �O Material of construction: 0 concrete []metal ❑fiber ss ❑polyethylene ❑ other(explain): t5hispAft•I M2004 Title 5 Official Inspection Form:Subsuftm Sewage Disposal System Page 11 of 10 Commonwealth of Massachusetts lopTitle. 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Sys m of ationCAY co le 'Q f 1� � 1� 23p Code Owner's Na Date of ftPectbn Tight or olding Tank(cost.) ' Dimensions: Capacity: gallons Design Flow: gaAons Per day Alarm present: ❑ Yes ❑ No Alarm level: in working order. ❑ Yes❑ No Date of last pumping: D Comments(condition of alarm and float swltches,.etc.): Distribution Box('d present must opened)(locate a plan): Depth of liquid level above outlet invert Comments(note If box Is level and distn'bution outlets equal,any evidence of solids carryover,any evidence of leakage Into or out of box,etc.): Pump Chamber Qocate on site plan): Pumps in working order. /J _ ❑ Yes ❑ No Alarms In working order. ❑ Yes ❑ No MIGP.doo•11R004 Title 5 0f6d81 I nsPection Form:Subsurfaoe Sewage Disposal system. Pape 12 of 10 -Commonwealth of Massachusetts Title 5. Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C.*bystefor ti n (co t ( � JQ we State Zip Code ov /� Owners Name C / Date of Inspection Comments(note co itior ' mp chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate ite plan,excavation not required): If SAS not located, expl 'n why: Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innova ve/altemative system Type/name _ technology: q Comments(note condition of soil, sign hydraulic failure; level of ponding,damp soil, condition of vegetation, etc.): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal . wag System Page 13 of 16 I • Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Sys em 1r70 ation nt.) P ddress --I -2 S .�-C L6 State p Code Owner's Name C`tZJ Dale of Inspection Cesspools(cesspool must be pumped as part of Inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet Invert `mil �/l! Depth of solids layer Depth of scum layer f Dimensions of cesspool (p Materials of construction j A c.(� Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): C U�_A� Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil,signs of hydraulic failure, le I of ponding,condition of vegetation, etc.): ISirtsp-doc•11/2004 TWO 5 official Inspection Form:Subsurface Sewage DisPosaj system. Page 14 of 16 i Commonwoun of Massachusetts Title 5-Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. S 1 ti r aon nt.). �� ii ( A) Owners Name DaW of Impec Lion `\,11 Irj u 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 eaters the building.. 01 4e i L%up.doc•11/2004 Title 5 OR9cial Inspection Form:Subsurface sewage Disposal System- Page 15 of 16 . ''Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System lnj ationfront.) •o C �Y .�t __7 R-2 J—'-s Prop Y ddressl Ci rf State Zip Code 'C_ M 0 c) / Owner's NarDe 'J, / Date ol Inspection Site Exam: Slope Surface water Check cellar Shallow wells ) 2 Estimated depth to ground water. / 7 r-1 Please indicate all methods used to determine the.high ground water elevation: Obtained from.system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health­Je *n: C 5 ❑ Checked with local excavators,, installers-(attach documentation) ❑ Accessed USGS database-explain: You m st,describe how you established the high ground wat r eleva�tlo ' ..i P l5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 - e � ZOO 8 ,SOS .► . `�C-�J No. Z Fee /Of7 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes O'"plication for i�tl0 Y �pgterrY �ottgtruction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No.g� J� Owner's Name;Address;and Tel.No. Assessor's Map/Parcel 9, p,� 'r C x tiS L IKox�G �.s� Installer's Name Address,and Tel No.W!/��"�N'/���v 6 y Designer's Name ddress and Tel.No./� g( �t � 09' S,—D - 0 F °l-- Type of Building: Dwelling No.of Bedrooms Lot Size 0 sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) V gpd Design flow provided d gP Plan Date Number of sheets Revision Date Title L I Size of Septic Tank „w) �Q Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �f�j�(,(J �1 � ➢L /�a./ Q M/1/ Date last inspected: i 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 ofliealth. Signed i Date OCR Application Approved by e_ Date 1 L Application Disapproved by: Date for the following reasons Permit No. Zd Off— ,rU Date Issued I Z 0 C, a8 '+a�+s»' �7F-r8+'..TF"'z.� r- L&��w,�,'1%•,n..d+n,..'�+k�.n��-r.9tir+'��h:�4.;ti,.`,,," Y.'"y,,,.r"�`If*"'e�^:�"'".,(rtI No. CaC7 U� �a 'I✓ ? y� f', Fee �QO ` Entered in computer: .TH�CO "�ONWEALTH OF MASSACHUSETTS .Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZlppYication for ;h5pozat- *p�tem Conotruction Permit i Application for a Permit io Construct( ) "'Repair/upgrade O Abandon O ❑Complete System ❑Individual Components Location Address or Lot No. fi y..../V Owner's Name,Address;and Tel.No. Assessor's Map/Pamel Installer's Name Address,and Tel.No.w/9/A ����6 � Designer s Name,Address and Tel.No c�( �T�/�C 1-- t Type of Building:Dwelling No.of Bedrooms _ Lot,Size J—t-�-�-= sq.ft. Garbage Grinder(' ) Other Type of.Building No.ofPersons' Showers( ) Cafeteria Other Fixtures I Design Flow.,-(min.required),,,.,. gpd Design flow provided gpd r x `:Plan Date Num er of sheets Revision Date Title / `,• r� -'{ ', �'I Il, t i Size of Septic Tank X) T§Pe of S s S. Description of Soil { Nature of�R-eepairJs or Alterations(Answer when applicable) �p y I Date last inspected: I Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the,provisions of Title 5 of the Environmental Code and not to place the system.in operation until a Certificate of - Compliance has been issued by this Board of Health. Signed Date . Application Approved by Date Application Disapproved by: " Date for,the following reasons Permit No. Date Issued I Z f.ri c-I Gj h ——-——'————————————— ——————— ——_-—————————-- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (v) Upgraded ( ) Abandoned( )by s at — has been constructed in accordance .7 'with the provisions of Title 5 and fer Dis osal Sy tem Construction Permit No.ZCc�. - �O c�3 dated ►Z Installer ' Designer v -P io . ,#bedrooms Approved&nflow G ��O / gpd W_ LO The issuance of this per it�all tbec s 2ias a guarantee that the syste asdesignedLAI Date Inspectorr�/ '� No. ®! Fee AD o THE COMMONWEALTH OF MASSACHUSETTS r PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS i Wigpozat �&P!5tem Cori.5truction Permit -,Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at Ri .4-rr- F'')i /' -( A �, slr► and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date C)0 v Approved by !i , N® coc U > �� 4 , Torn of Barnstable °pTME Regulatory Services Thomas F. Geiler, Director AARNH'fAHLE. Public Health Division 1639. ,0 pTFoy° Thomas McKean, Director 200 Main Street, Hyannis,NIA 02601 Office: 503-362-4644 Fax: 503-790-6304 Installer & Designer Certification Form J Date: lO109 Sewage Permit# Assessor's ivlap\ParcelE2�-6�j Designer: l 1 M. y"`e Q,fr Installer: Address: 0 • Address: V . SArowLSE N 0253_� l On (date) (installer) was issued a permit to install a 2 septic system at based on a design drawn by (address) dated los (designer) I certify that the septic system referenced above was installed substantially accordin(2 to the design, which may include minor approved changes such as lateral relocation orth=. distribution box andlor septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or am: 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. c ,DAR . (Installer's Sig ature) V �. No: 1140OA� 'SEC/S1E� SANITAII�P� �'Lelo (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNS ABLE 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: Health/Septicl)esigner Certification Form 3-264'doc THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA i i I i ✓' Sip �g 'T1 444S0=1= , l At S�r�ad!o- �as • r�ry{•S II '1 i V t "T C:/a z �L�Cx--------------- ST i S fi la0 VL alai rJ: . 1 I , j i j I K eK 1 i Le i j h i i es4i 1 i I , {r LEGEND � �. '� �' ;� �; �,.. •_ -_ , kit both den -- ('� NO TE 18) ! — _ g PROPOSED CONTOUR PROPOSED SPOT GRADE `- t Jam" -4. din. liv. l �� < �j —— 98 —— EXISTING CONTOUR _Fr room _ room Fq T /! EXISTING SPOT GRADE j. sc�rzs°dIB � ` i 7 r W— EXISTING WATER SERVICE FIRST FLOOR / T � l / / n y � • 30 .� TEST PIT i (� ;�h� bed both bed1,�, room room o i / h Iti _ .. N,LE I (� LOCUS MAP N.T.S. bed bed room room _ I GENERAL NOTES: - i 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SECOND FLOOR 1 % I BOARD OF HEALTH AND THE DESIGN ENGINEER. \ �0- / 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: \ \\ - 310 CMR 15.405 (1) (A): _ ! \ t• L� 1) UP TO A 0.75 FT. VARIANCE FROM 310 CMR 15.211 TO ALLOW �r 50 ! \� \•\ �� LEACHING TO BE UP TO 3.75 FT BELOW GRADE VS REQ'D 3 FT. (H20/VENT PROVIDED °O ft 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR % TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE ` ! Q \•S2 / �� DESIGN ENGINEER. 1-\ (� \ ��' /( 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION,DIFFERING i tz O � \.\/ FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN <- 4 `/ 'A / ���/ ENGINEER BEFORE CONSTRUCTION CONTINUES. i� \\ 0 \< -1 / P\/ 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. /� n �j� , 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF / -� / THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF g�-'--— HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. / 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY �� // 0 ,/ / \ THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. \�— //� / \ 10. EXISTING PITS/CESSPOOLS TO BE PUMPED, REMOVED & FILLED WITH CLEAN MED. SAND / /p 1 / �� // / \' 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION APPROX. LOCATION OF / \ \'•� 96 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY j/ EX15T. CE551`OOL5JLEACH PITS ` i �� ��- i/ Q P �:�� �/' ' / \ AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING ! (SEE NOTE—r0) / r // \� 14. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED OTHERWISE) 10• 25' 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A TP /00 I �' \' GARBAGE GRINDER Sp =_- �' - \ 16. NO WETLANDS WITHIN 100 FT. OF,PROPOSED LEACHING 17. ALL INTERIOR PLUMBING TO BE VERIFIED' FOR PROPER DISCHARGE 37.5' � -- _ ��1 \••\ TO PROPOSED SEPTIC TANK. �18. DEN WALL TO BE MODIFIED WITH 5 FOOT OPENING. OF 1g-� �_.2 4t-'-------------�- _ �,,. ss9�y PROPOSED SEPTIC SYSTEM UPGRADE PLAN'-- _ 49 p4 1t VENT INSPECTION PORTS DA�IREN 83 BLACKBERRY LANE, HYANNIS, MA BENCH M 'A R K 0. 1140 "' Prepared for: Mike Dedecko MAP- 249 PAINT SPOT IN DRVEWAY p Engineering by: Surveying by: SCALE DRAWN JOB. NO. SURVEY REFERENCE: LOT.-081 'pfCjsl DARRENM.MEYER,R.S. Eco-Tech Environmental ELEVATION = ��; gg � 1"=20' DMM PLAN OF LAND BY CHARLES N. SAVERY, PLS DEED BOOK.-21890 t MN1TA? PO BOX981 (508) 364-0894 , 1964 DEED BOOK.-048 • BARNSTABLE GIS DATUM E4STS4NOWICH,M402537 DATE: CHECKED SHEET N0. DATED: JUNE 18 i 508-3U-2922 12/08/08 DMM 1 of 2 i 1 - NOTE; TO PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:44.39 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. vent required SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. T.O.F. EL.=53.22 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER \ �- ��� OF Mgss9� OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. 25.00 y J,��F.G. EL.=50.1 t F.G. EL.=48.0(MIN.) F.G. EL: 48.Ot t.G. EL: 48.0(MAX.) 1 o DA E M. Gr R '6. 11 0 P L = 10'"t L - 30' L = 8'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) P�G1 sl ® S=14 (MIN.) ® SCH4 (MIN.) 0S=1% (MIN.) T �---- 37.50'-� SOITk?, 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC / t0• 14• s• 11.3" To LEACHING DETAIL 1 C) 7 INV.=45.02 4B'LIQUID INVERT t£vET. INV.=44.77 GAS BAFFLE J PROPOSED INV.=44.30 4 ROWS TOTAL OF 21 UNITS AT 6.25'/UNIT = 25'-37.5'/ROW (LENGTHS VARY ��� SOIL ABSORPTION SYSTEM (PROFILE) INV.=44.50 DB-5 INV.=44.0 PROPOSED 1,500 GALLON SEPTIC TANK RESTORE VEGETATIVE COVER EXISTING SEWER OUTLET APPROX. EL. 45.22 TTOCTOP OF WITH CHAMBERS AN PERC SAND 75" NOTES: 1) SEPTIC TANK AND D-BOX SHALL BE SET LEVEL BREAKOUT=TOP ELEV..= 44.39 ; .., AND TRUE TO GRADE ON A MECHANICALLY COMPACTED INV. ELEV.- 44.0 SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 43.06 EXISTING SUITABLE 310 CMR 15.221(2). 2.83' MATERIAL 2 INSTALL INLET & OUTLET TEES AS REQUIRED. 5' MIN. ABOVE BOTTOM OF r� -I ) T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.83' = 11.32 �6- 3) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE (8.06' PROVIDED) USE 4 ROWS (LENGTH'S VARY) OF HIGH CAPACITY AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. BOTTOM OF TESTHOLE EL.=35.0 - ADS BIODIFFUSER UNITS-NO STONE PROFILE - i SEPTIC SYSTEM PROFILE TYPICAL]SECTION 16" N.T.S. K S 11.2 } DESIGN CRITERIA SOIL LOG P#: 12428 1 --34" � NUMBER OF BEDROOMS: 4 BEDROOMS DATE: DEC EMBER 8, 2008 SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. SECTION END CAP WITNESS: DONNA MIORANDI-TOWN HEALTH AGENT DESIGN PERCOLATION RATE: <2 MIN/IN TP-1 jDepth Elev. �t 16"" HIGH CAPACITY (H-20) BIODIFFUSER UNIT DAILY FLOW: 440 G.P.D. . Elev. TP-2 Depth DESIGN FLOW: 440 G.P.D. 47.5 A LOOAYMRY SAND 0" 47.91 A LOOAYMRY SAND °• MODEL 16" HICAP GARBAGE GRINDER: NO 47.0 B 6" 47.41 e 6" LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT PROPOSED SEPTIC TANK: USE NEW 1,500 GALLON CAPACITY LOAMY SAND I LOAMY SAND EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 10YR 5/8 10YR 5/8 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LEACHING AREA REQUIRED: (440) = 594.59 S.F. SIDE WALL HEIGHT 11.2" 44.34 !71 38' 44.75 38' .74 C C OVERALL HEIGHT 16" DISTRIBUTION BOX: 5 OUTLETS (MINIMUM) PERC OVERALL WIDTH 34" 4640 TRUEMAN BLVD PRIMARY S.A.S. } 54" 13.6 CF a HILLIARD, OHIO 43026 CAPACITY USE 4 ROWS - 21 UNITS (AS SHOWN) OF 16" ADS BIODIFFUSER H-20 UNITS-NO STONE ' BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER) MED. SAND MED. SAND (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC. SEPTIC SYSTEM/SITE PLAN (BIODIFFUSERS) 21 UNITS x 6.25 LF x 4.70 SF/LF = 616.87 SF 2.sY s/a 2.5Y 6/4 83 BLACKBERRY LANE, HYANNIS, MA ' DESIGN FLOW PROVIDED: 0.74(616.88 GPD/SF) = 456 GPD > 440 GPD req'd (� Prepared for: Mike Dedecko 35.0 150" 35.41 1 150" Engineering by: Surveying by: SCALE DRAWN JOB. NO. DARRENM.MEYER,R.S. Eco-Tech M2v/ronmenW NTS P.T.M. PERC RATE 12 MIN/IN. ("C" HORIZON) PO BOX981 NO GROUNDWATER OBSERVED EAST SANDWICH,MA02537 (508) 364-0894 DATE CHECKED SHEET NO. 508-W-2 n 12/08/08 P.T.M. 2 of 2 I i Town of B instable. r# �• � Department of Regulatory Services D� -' Public'Health Division. Date ,1 $ 200 Main Street,Hyannis MA 02601 ��fD 't x '• �J'I./ Date Scheduled ® i Time ' Fee Pd. I ,soil Suitability Assessment for Sews e Dis Performed By: 1�-1 • 1� `Qi� ! Witnessed By: LOCATION & GENERAL INFORMATION Location Address .g $L�� BE UJ` ! Owner's Name LEA P kv PA;,kAo �� �g13J g,-- Ryktj rJ l S VV11K G 2,6 O i Address r 7 ?` Assessor's Map/Parcel: 2� r�b� ' Engineer's Name DP(2_a,1_A I NEW CONSIRULNON REPAIR �_ Telephone# �b 4,' Land Use �� ; 1 yv� Slopes(96) — O ' Surface Stones fW n Distances from: Open Water Body ? ft Possible Wee Areal ',' ft Drinking Water Well 110 ft i Drainage Way > to ft. Property Line ft Other ft I 7 SKETCH:(street name,dimensio6s'of lot.exact locations of tqt holes&Pere tests,locate wetlands in proximity to holes) 1(' t • \•.i � /•�\fir'`[. ./`�'' s or LEAO PITS T, TP-1 I , . YVl� I / OYt I Depth to Bedrock N Parent material(geologic) f� Depth to Groundwaldr: Standing Water in Hole:' ! Weeping from Pit Face Estimated Scasonal l•�igh Groundwater AA i DI TEItMIN TION FOR SEASONAL ffiGI�WAT�cR T"LE Method Used: ill. Depth to soil mottles: Depth �bperved standing in obs.hole: _ i i11, Groundwater Adjuslincnt Depth tolwceping from side of obs.hole: I A�,(petor_— A dJ.(Itwundwater LeVcl,,,e index Well tl Reading Date Index Well level PERCOLATION TEST Date Observation I I I Tinle at 9" {` -- Role# i y S y Time at 6" . Depth of Pere 07 j Time(9"41) — Start Pre-soak Time.@ End Pre-soak � L ZM'i0 t i I Rate MinJlnch Site Suitability Assessment: Site Passed Site Failed; Additional Testing Needed(YIN) — Observation Role,Data To Be Completed on Back------ original:.Public Health Division _ ***If ercola�ipn test is to be conducted within loo, of wetland,beoun unst first notify We _ P ..._ .•ta....,..,�*;„�Division at least one(1)wedk prior to g g I _ DEEP OBSERVATION HOLE LOG Hole# jem Soil Horizon Soil Texture Soil Color Soil Other in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %GravelgN p U r an Z. y DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other j Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel Me DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. ra I I Flood Insurance Rp_te Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes,, Within 100 year flood boundary No 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 petivious material? Certification at o I certify thn (date)I have passed the soil evaluator examination approved by the Departmen of Environmental Protection and that the above analysis was performed by me consistent with the required�tra' ing xpertise and e�cperience described in 310 CMR 15A17. Signature Date Z �q 0:\.4F.PTICVERCFORM.DOC THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA - 150 �3 614.kbe�� \4Lt� 1 . � r - V Aj S . I S I �01.SI�10 "►� £ bid L 1 .339 goon i • QVZ rv,� v C�Os�t �Lxc ST S T lroE2 ' -- ----... . I i 1 i 14�ahh,�,M/j i Ij Le 1 i �4f co LO �&1 SEW OCtE PERMIT k10. VILLAGE IWST�LLER� 1 &KAE ADDRESS BUILDER5 Q &MF- iNDDRESS al�P ANTE PERMIT DATE COMPLI &MCE ISSUED. — C 1 `; ... �i'` i �� �5' i .. � I 0 -�---� � � i .�) U 4 � "' _�� �� � -. � "'� �a��� 1� �� No. `��• ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH 0 ....................... Appliration -for :43hiposal Works Tonstrurtion Punift Application is hereby made for Permit to Construct or Repair ( )-tin Individual Sewage Disposal or S—tern at* ---------- .... .. ........... ...................................... ..... Loe.a) n r L6t N ... ...... ....... .... .... ........<4............................ wrier Address .�5e...... ! --47ns_ja1_1_er-------------- ------------------ ---------------------------------------------Address s------------------------------------------- Type of Building Size Lot_-------------------------Sq. feet U 'Dwelling—No. of Bedrooms.............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building -----------------_--------- No. of persons............................ Showers Cafeteria ( ) Otherfixtures ..................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity.............gallons Length................ Width----...--....... Diameter.--------------- Depth----....--...... Disposal Trench—No-------------------- Width....----....------.. Total Length.....--.--.......--- Total leaching area....................sq. f t. Seepage Pit No--------------------- Diameter--------.----------. Depth below inlet--.................. Total leaching area------------------sq. f i. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date---------------------------------------- Test Pit No. I----------------minutes per inch Depth of Test Pit--.................. Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water..........------........ ----------------- ------- -------------------------- ---------------------------------------------------------------------------------------------------- 0 Description of Soil.,S a........ ................................................................................................. U .................................................................... ........................................................................ ------------------------------------------------ ...................................................................................................... ......... ----------- U Nature of Repairs or Alterations—Answer when applicable......: ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued by the board of fialth. i e .... .... -_--------------------------- C1. ............. ----------- ------- Application Approved By------.... --- ---- Date igne Application Disapproved for the following reasons:...................... .............................................. .......... ...... ..................................................................................................................................................................:--------------------------------------- Date PermitNo......................................................... Issued........................................................ Date -----—-------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF..... rz .l :t,�.. .: ( �_........ ......... Appliration -for Jiopoottl Works Tonotrnrtion Urrulit Application is hereby made for yPermit to Construct ( ) or Repair ( )-an Individual Sewage Disposal Systems at 4...r G j6 L .._..._---------------------------------------- ------- -•- ----------------------_-•--- ----- --.---- ooati dres // fy / or Lot No ��s Jam/ Owner Address af.................................t ............................................. nstaller Address VType of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms--------------------•-----_-___._--.--.---_-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.................----------- Showers ( ) — Cafeteria ( ) 44 d Other fixtures --------------------- --- ---------------•---•--------------------•-------•----------•-•-•---.---•--------------•-•------- W Design Flow...................:........................gallons per person per day. Total daily flow............................................gallons. WSeptic.Tank—Liquid capacity------------gallons Length................ Width.......,........ Diameter_--......-..---_ Depth---__--.----- xDisposal Trench—No. .........________t__- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet..................... Total leaching area......_-----_----sq. ft. z Other Distribution box ( ) - Dosing tank ( ) W Percolation Test Results Performed by................... ...................................................... Date---.-----•--------------------•-------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water-..-.--.--.-----------.. f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..................... ------------•-- -------------------ram--------.•_---• ----•---------•-•--------------•---•---------......................................................... O Description of Soil.....: .:`.......iF_...._..`__.__. _ � �'`__...�,. x ----------------------------------- ------------•--------------------- -.-------------------- --------------••----------•----------------------•-•-•---------------- .....•-••=--•-•W - ••-----•-•------•--e--------------------_---- =-•----•------- ---•---•--------------------------------•--•------------------ .. --•--------•-•--•..•••••• -�1 -------- U Nature of Repairs or Alterations—Answer when applicable......_ _ ---•-- -- - •------------- ------------------------••----------•---------- ----•------------------•--•-•------•----------------------------------------------------•-•-•-----------------------------•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. i`r/ signe = ✓ ... -- --------- ......---•-- �,� / Date _/ ---------1----1_/.. Application Approved By-------- -"-- ---''----.----•--------------t/v`/_-�&-- --------------------- t---------- Date Application Disapproved for the following reasons:- ----•------ --•----• -----••---••--•----•-••------•----------------•--------.--------•--••----------••.... ---•----•----•-----------------------•------------------•-----------•--•------------•--•-------------•-----------------•---=----------------------••----•-----------------•-•---------------•------•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtifiratr of Tompliatta THIS LS TOCERT-IFY, That the,Individual Sewage Disposal System constructed ( ) or Repaired �' f z ti by '�'------ f t n-,taller . .... .. / ICry�G`--2.-� x--n C, p -- ---••-- o isi__• --••------- •----•---------••-----------------------•-------------------------------•--•---•-----•------- has been installed in accordai with the provisions of Article XI of The State Sanitary ode as described in the application for Disposal Works Construction Permit No------ .��................... dated--. ___ -�.f.`.=.f..�_:__--.---•-•-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector-----------------------------------------------------------......................... -- - - -------------- ���_ THE COMMONWEALTH OF MASSACHUSETTS BOARDy OF HEALTH _ . - t' ..... O F 1.p......--�, No......................... FEE--- %sVoittl Morkp Qlami#rnrtion Prrmit Permission is hereby granted...... to Construct ( ) ot`1�Rep it (�n Individual Sewage Dtspo AYste at No..:l.:ll� PLC' - Y��A✓ _ �, r � � ---•--......................... 1 - - -- s.tr-9-t/ `,-- , as shown on the application for Disposal Works Construction P:i -i't No__1..�____117-. Dated /.._ _.17f............. ._. 7L. •Board of Health DATE --.... -- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - _ k r I TOWN OF BARNSTABLE I LOCATION L,�`���p SEWAGE # VILLAGE A %NS$ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. r SEPTIC TANK CAPACITY LEACHING FACILITY: (type) _3 a ssrrx�� _ (size) NO. OF BEDROOMS_ q BUILDER OR OWNER A ,DATE: LLU�Q COMPLIANCE DATE: I 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 i within 300 feet of leaching facility) Feet Furnished by i Gq 3 , No.. l.. 3o�'Y vG Fa$... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HEALTH f .........OF.... ..... ... ./.�/lyC--,!/�. '...G�- ......................... Appliration far Mfipofi t Works Tonstrurtion Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage,Disposal Sin at• == Locat' res$ or Lot No. Owner Address W Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.-- ...............................Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building .............:.............. No. of persons..--_--_-._---______-__---- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------ -- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter-----_......... Depth................ x Disposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area.-___._.-_._--___sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. I................minutes per inch Depth of 'Pest Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ----------------------------------------------------------------------------------------------------- I xDescription of Soil......................................---------•---------------•------------------------------....................--------•--------•----------------------------------- U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- W } ------------_-------- - - - ---- - UNatur of Repairs or Alterati �,—Answer he applica e._.r __ ,--�_.':___ _..: �d�..V �...._... e. ..Q �� ...... 4�1�-•-•--------•-------•----•--•----•--------------------------------------•-"- A reement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the bo Y ar o he h. Signe .. n ( �. ...... �C!'-7' `.. ... Date ApplicationApproved By.................................................................................................. ---------------------------------------- Date Application Disapproved for the following reasons----------------•---------------------•--••-•---•------•--------.------._----- .................................. .. .........................-•-•--•---•-------------------------•--..........-•-------•--•-•---................--------------------•---•-••--..._........-•-•------------------------•----..--_.._.....--•- Date Permit No........ 5 ................................ Issued.......d. 3----- .:._ y.?.y.. Date � . -.� . � ', . . �.\ r � -� ,. .. .. '.. .. �•� � d 1 1 1 No... .1.3 F$s.. .... ........_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT �r � .........0 F.... � / �� ..................... ... Appliration 'for DisVosttl Yorks Tonstrurtion"i Vrrm t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at V Locat' �dresb or Lot No. Owner Address ` ,' q Installer '' • Address UType of Building Size Lot............................Sq. feet .1 Dwellin No. of Bedrooms__................. ' Ex ansion Attic Garba e Grinder ^a aOther—Type of Building,,•:_-------------------------- No. of persons............................ "Showers ( ) — Cafeteria ( ) d Other fixtures -------------..................................... W Design Flow...........................................gallons per person per:day. Total daily flow............... ------------------_............gallons. WSeptic Tank—Liquid capacity.............gallons Length.................. Width---------------- Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching-area....................sq. ft. 3 Seepage Pit No..................... :__..:::__ .Depth below inlet.................... Total leaching area------------------Sq. ft. z Other Distribution box ( ) Dosing tank ' Percolation Test Results Performed byy:........................••-•-...:..•-------•------•••----•-----•---•••---- Date.................................... Test Pit No. 1________________minutes per inch`�,D,eplh..of Test,Pit.............. ...... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth o est Pia:,,_,____.--____-_-- Depth to ground water------------------------ "y, . .5_.-'-•-----•--......-•--••----•-•---•-------------------------------------•------- DDescription of Soil----------------------------------------•-----------------------•-------------- x x -•-•-----•-•------------------ --------------------••----•--- ................................................ -- - . . --- ...... Nat of Re airs or a ' t?rs— nswer It e_: ... ..._.. � � lGa�.. U PP , • .... �' •- ?greement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary ode— The undersigned further agrees not to place the system it) y . operation until a Certificate of Compliance has Aed, issuedby the board oUp S 416:;R&4.10....... Date ---r ApplicationApproved By................................................................................................... '• ........................................ Date Application Disapproved for the following reasons:..............................................................`.....----.._......---•-•. --------•--•. ....................... ....t a• . .. ................................................................................ ..................':.........._......_........-._.___..................._.__....... .._ ....... Date 4 Permit No........ Sw.............................. Issued--:..:=rra_.3 -...... �. Date s THE COMMONWEALTH OF MASSACHUSETTS s BOARD OF HEALTH ................ ......................OF...�. .a.a sT�,btc� Trrtif irate of G."omlitttnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ("'�)"'or Repaired ( ) ',• by............... ---••-------••-•--. °.`+•...... /�.el4 • S /_/ OVk0�_/sInstaller �? at..................•---••-------.._..-•---•--•---------------........... --•-•-•---•--1---• ------•-•---------.........--••--•---•-•-•--....-•-•-•-•:---.............._..._...-•---••--••-•. has been installed in accordance with the pr�ovisions of rticle XI of The State Sanitary Code as described in the applicatiod for Disposal..Wor ..................... dated-------- ............. THE ISSUANCE OF THIS`` ERTIFICATE SHALL NOT BE CONST ED A OGU ANTEE THAT THE SYSTEM WILL FUNCTION SAT' FACT RY. is DATE......... '' .: _ Inspector. --••••....... . _ w ,... y Y�tl•a. •' ��,ir„�f\Y':.,.� «w'Q'4WSY 4r.✓ �.•:pV• '.•R'S`*ra✓'�;�v tom`' J1i'.� 'a';a '�.i•l..aye., ¢= tF THE COMMONWEALTH OF MASSACHUSETTS BOARD 0 EALTH OF /�R,S ,6 NO. �+ FEE M Aisvosttl Works (Donstrurtion Prrmit Permission is hereby granted....... .)�-------_.........�. .1`S G-S ............. .to Construct ( ) or Repair an Individual Sewage Disposal System at No..... D.S K.A�.I� .:.. 1 � `t - ---------------------•-----.......-.-..--------------.-.---....---------------------------------------•-----•-------- +•rt ,; :,,,!' .�, t.y`'1� St ec{ , .. - 7 L as shown on the application for"Nis sal Works Cons tty ttont Isets>ntt No.�.._....2..:.__. Dated.......................................... ' ............................... e t -----------_----•-.---•- �s Board of Hh DATE...J-". ]...----------------------------•-•••= FORM 1255 HOBBS.& WARREN•;}INC'. P.UBUlSHE4S' K