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HomeMy WebLinkAbout0056 BLUEBERRY HILL ROAD - Health 56 Blueberry Hill Road A=249- 070 HYA 0 a, gg! n ° p t t a I ° a II i� J ' - TOWN OF BARNSTABLE LOCATION /Uc be f(g SEWAGE # VILLAGE o 4iin I J ASSESSOR'S MAP & LOT LIQ � r INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY /Q ® ® 15.�'�� ® I LEACHING FACILITY:(type) P I T" (size) -1 ® j NO. OF BEDROOMS_�(_PRIVATE WELL OR PUBLIC WATER �+ ' BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No ' \: ��e I Fw 1 1:, ; -� TOWN OF BARNSTABLE } LOCATION 5 6 9�`J c �� �� �-� // SEWAGE #��' S .M VILLAGE y 4 h J`� S ASSESSOR'S MAP & LOT Iy f= 70 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / 6 a 0 LEACHING FACILITY: (type) (size) _ 07 5 'A z~< NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: 7 7 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching.Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachingfacility) Feet Furnished b y/ 3 19 1 S 'VN N � 4 S M _ �i f I .1 �r TO OF BARNSTABLE LOCATION � 2 %/'/, //4AWAGE#.2,0! —2 0 VILLAGE ASSESSOR'S MAP&PARCEL r_-2- ?-7e INSTALLER'S NAME&PHONE NO. ), 'All G ! S D y SEPTIC TANK CAPACITY /So LEACHING FACILITY:(type)C3) SC-1 0 CA Grp Sz,�size) /3 X a NO.OF BEDROOMS OWNER PERMIT DATE:���� �� COMPLIANCE DATE: l �J Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within , 300 feet of leaching facility) Feet ;: FURNISHED BY � W � 9 � w �N a o 0 i No. o-® Fee �V •""'`��`"" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[ppricatton for Biooal 6potem Cougtructiou Vermtt Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) LJ Complete System ❑Individual Components Location Address or Lot No. ,?'60'.B �C��I ,�//liL/� / Owner's Name,Address,and Tel.No. �a Assessor's Map/Parcel Z�� �J p �y o �j�.,w rj- l/,v// -7 zr'9 Pa 3,Z Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building il��"-� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) a gpd Design flow provided gpd �— Plan Date ' Number of sheets Revision Date Title Size of Septic Tank /Y c�L!i /? oo !�-�4t. Type of S.A.STatc��''cjy Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described,on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date �,X / �l Application Approved by Date 7-1 Application Disapproved by: Date for the following reasons Permit No. — Date Issued 13 — ,q jI d�� No o i �V v Fee THE COMMONWEALTH OF MASSACHUSETT$ Entered in computer: t PUBLIC HEALTH DIVISION - TOWN OF BARNST4BLE, MASSACHUSETTS Yes 4 ZippYic,ation`for MY.5po!6a�r',*pgtem ;C`origtruction periuft Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) U Complete System ❑Individual Components Location Address or Lot No. r6' �C��1/�(//liL/� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Bo,!ict- ,op o Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building /P.E J yp g No.of Persons Showers.( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design;=llow provided �' gpd Plan Date / // Number of sheets Revision Date Title Size of Septic Tank /Y 0-'�- /9 co G/fl. Type of S.A. y— K ZL } Description of Soil Nature of Repairs or Alterations(Answer when applicable) I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. y Signed Date / J j Application Approved by I Date j Application Disapproved by: Date for the following reasons Permit No. � (f "` Date Issued j "t ~ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by at has been constructed in accordance A with the provisions of Title 5 and the for Disposal System Construction Permit No. Poll— ;Ltd dated J� t �r �. Installer G��BOG�y/� Designer :tglii p E..B �i'�✓'o �1' #bedrooms _0" Approved design flow E^ 0 gpd The issuance of this permit shall no be Construed as a guarantee that the system yste will cti© a d signed. Date Inspector No. ( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS MtgPo.5al �&p.5tem (Cott.5tructiou 'Perm, i, Permission is hereby granted to Construct ( ) Repair ( Upgrade ,,Abandon (. ) System located at 5— 6' g'd o.ae -,eeoe s?y 1yi ZI 'Oeo and as described in the above Application for Disposal System Construction PermiUThe,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 thistaa' . Date Approved by W Town of Barnstable SHE,r: Regulatory Services Thomas F.Geiler,Director + BA�tNSTABUE, + a Public Health Division �arFa° a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644- Tax: 508-790-6304 Installer &Designer Certification Form Bate: Designer: C ,� Installer:. qvf Address: . 1 �j1 �� Address: _ waWt s issued a perm*to install a date (installer) septic system at ased on a design drawn by (address dated'' Ws-igner)certify that the septic system referenced above was installed substantially accbrding'to �he design,_which may include mini approved changes such as lateral relocation of the distribution box and/or septic tank, I certify,that the septic systern referenced above was installed wadi'.major,changes greater th a"10' lateral relocation-of the.SAS or any vertical a ocat.on of arty coxnpon�t. of the septa�syste�n)but in accordance with State&LOCal,RegdIations. Plan revis oxi of certified as-built`t1ydesz er-t6follow. :. (Installers Si attire) �• n �7ASON. _ SgAl1TAR�P� ' '(D&Sier s Signature) (Affix er's Stamp Here) PLEASE RETURN TO l6-- STABLI PUBLIC.,.HEALTB DIVISION. CERTMC .TE OF CONL�PLIANCE �VhI.L N®TE SSUED BOT$ : S FOR1VI"t BUILT CARD ARE RECEIVED BY T E:B�At SABLE P?EJ]BIJC BI]EAl<►T DIirISI -N THANK Y(IIJ. Q:HealWept c/Desib er Certification'Forrt { F. J m i . 3 � L-4 0 L I QG�PI�Z Rd:9jjj A I. i i 4 Jlr O� 8 f �pf l I � �. i j i 1 i t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. Clty/Town 10/30/10 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 filling out A. General Information forms the I computer, r,use Inspector: r^ only the tab key `(1 to move your DOUGLAS A cursor-do not BROWN use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name r� P.O. BOX 145 Company Address CENTERVILLE MA Cityrrown State 02632 Zip Code 508-420-4534 S14297 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 , 10/30/10 Inspector's l* nature 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•09I08 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System•Page 1 of 17 f }e �4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �~ 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is required for CENTERVILLE MA 02632 10/30/10 every page. Cdy/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excludingthe SAS located ated on site. ® ❑ Were the septic tank manholes uncovere d,ed, 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-09M Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 O Commonwealth of Massachusett s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 56 BLUEBERRY HILL RD Properly Address MEDLIN Owner Owner's Name information is required for CENTERVILLE MA 02632 10/30/10 every page. City/Town State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK CESSPOOL AND LEACHPIT Number of current residents: UNKNOWN Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 09-396GPD 10-437GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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 D No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 10/30/10 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E;always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310CMR 15.303 or in 31 0 CMR 15:304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 l I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. Clty/Town ZipCode Date of Date of i 0 State Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Flealth in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is required for CENTERVILLE MA 02632 every page. City/Town tate Zip-Code1 S Dateate of of inspection B. Certification (Cont.) 2. System will fail unless the Board of Health;and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 Yz day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f �O Coommonweaith of Massachuserts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 56 BLUEBERRY HILL RD Properly Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 10/30/10 every page. Clty/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:. ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No El ❑ 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 CM 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•0908 Tide 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 5 of 17 �O Commonwealth or Massachuserts Amm'. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Properly Address MEDLI N Owner Owner's Name information is CENTERVILLE required for MA 02632 10/30/10 every page. Clty/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 Z No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): TANK CESSPOOL AND PIT t.5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is required for CENTERVILLE MA 02632 10/30/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: APPEAR TO BE ALMOST ORIGINAL Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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: feet Material of construction: concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal; list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON Sludge depth: t5ins-09M Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 f Commonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Properly Address MEDLIN Owner Owner's Name information is required for CENTERVI LLE MA 02632 every page. Cityfrown State Zip Code Date of Date of I 0 Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND NEW TANK DUE TO HEAVY CORROSION ON INSIDE OF TANK Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09M 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 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 10/30/10 every page. Cltyrrown State Zip Code Data of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 11 of 17 \ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Property Address MEDLI N Owner Owner's Name information is CENTERVILLE required for MA 02632 10/30/10 every page. Clty/Town 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 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.): NO D-BOX 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09IO8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 7 O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 10/30/10 every page. Cl mown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): CESSPOOL IS IN VERY POOR CONDITION AT THIS TIME Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 BETWEEN TANK/PIT Depth—top of liquid to inlet invert LIQUID AT INVERT Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction BLOCK Indication of groundwater inflow ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. City/Town te ZipCode 1Date a of I 0 State of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewaae Disposal System•Page 14 of 17 f Commonwealth of Massachusetts vTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. City/Town State Zip Code Date of Date of I 0 Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name information is CENTERVILLE required for MA 02632 10/30/10 every page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Pape 16 of 17 \ Commonwealth of lviassachuset`t., Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 56 BLUEBERRY HILL RD Property Address MEDLIN Owner Owner's Name inormation is CENTERVILLE requiredfor MA 02632 10/30/10 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Z 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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pace 17 of 17 New Page 1 Page 1 of 1 TOWN OF BARNSTABLE LOCATION 6 -- �v rf �- 3 / SEWAGE# VILLAGE—,Ly a�+h', s ASSESSOR'S MAN&LOT, P=7d INSTALLER'S NAME&PHONE NO. e-r SEP71C TANK CAPACITY LEACHING FACRXI Y: (type) (size)_o? `5 6,< . NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: t! /-2y/? Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o.leaching#a 'lity) Feet Furnished by ! W. i t k.f /oov 4°I ° Y2 - b� �s ~ LX� 2 s�oa ti http://www.town.bamstable.ma.us/assessing/20I O/HMdisplay.asp?mappar=249070&seq=1 11/4/2010 — d TROY WILLIAMS SEPTIC INSPECTIONS ' Certified by MA Department of Environmental Protection 6 I9 (508) 385-1300 19 Hummed Drive 98 A South Dennis,MA 02660 M COMMONWEALTH OF MASSACHU�ENT EXECUTIVE OFFICE OF ENVIRONMFF-AI'RS Q DEPARTMENT OF ENVIRONMENTAL PROTECTION Q� ONE HINTER STREET. BOSTON, MA 02108 617-292.5500 WILLIAM F.WELD Governor TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr PART A CERTIFICATION Property Address: S6 Q1 Ue berm �cl. J�y rr Date of In 9 13 9 Address of Owner: Inspection: (If different) Name of Inspector: Troy W i 1 1 i a m s I am a DEP approved system inspector pursuant to Section 1S.340 of Title S (310 CMR 1S.000) Company Name: Troy .Williams Septic Inspections S�; t� ac7 Mailing Address: _19 Hummel Drive , cnuth Dannis , MA 02660 /Vj O Telephone Number: _(_ 8) 385-1300 &1x /iorp O1 'Z 3S CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection: The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature lnf�c�!'dDi. Date: 5//,? The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection..The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B) SYSTEM CONDITIONALLY PASSES: /U/9 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. Indicate yes, no,or not determined (Y, N,or ND). Describe basis of determination in all instances. If'not determined',explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal• is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will,pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health (jr-1—d 04/25/97) P.q. 1 or 10 p SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 56 Blueberry Hill Road,Hyannis,MA Property Address: Arthur Beauchaine Owner: April 3, 1998 Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) N /� Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HE ALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 56 Blueberry Hill Road,Hyannis,MA Owner: Arthur Beauchaine Date of Inspection: April 3, 1998 D) SYSTEM FAILS: 1,,i1,4 You must indicate ei;,,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged 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 112 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 Soil Absorption System, cesspool or privy is below the.high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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 front,a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: A111-9 You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. I r"vI a e d 04/75/971 " P.— 1 ,.. n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 56 Blueberry Hill Road,Hyannis,MA Property Address: Arthur Beauchaine Owner: April 3, 1998 Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yeses No Pumping information was provided by the owner, occupant, or Board of Health. _ um (3e_ cc c_�`a�.,, � None of the system components have been y flow rates Pumped for at least two weeks and the system has been receiving normal during that period. Large.volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. 1L _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner)were provided with information on the proper maintenance of / Sub-Surface Disposal System. Y Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (rwised 04/25/97) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 56 Blueberry Hill Road,Hyannis,MA Owner: Arthur Beauchalne Date of Inspection: April 3, 1998 RESIDENTIAL: FLOW CONDITIONS Design flow: yy0 g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: O Garbage grinder (yes or no): /Vd Laundry connected to system (yes or no):2t S Seasonal use (yes or no): Ald Water meter readings, if available (last two (2)year usage (gpd): q 7 = /�� Qd o �/,r s 9 6 = o? 7 3 oa d Sump Pump (yes or no): A10 i Last date of occupancy: COMMERCIAUINDUSTRIAL: A1119 Type of establishment: Design flow: Qallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if.available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: I'-w+ A I/.2? /93 6�is" s' 7/3a/ �:� System pumped as part of inspection: yes or no)_IAVt If yes, volume pumped: gallons Reason for pumping: TYPE QF SYSTEM Septic tank/disccibutiea-LL soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, .if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information wr L k c-A P: 4- 000 I arc ?d . (.cwc.L Imo, t 4 S c�cddc� 7 /otr Sewage odors detected when arriving at the site: (yes or no) A/0 �C.v1..c J.;2519 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 56 Blueberry Hill Road,Hyannis,MA Owner: Arthur Beauchaine Date of Inspection: April 3, 1998 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:- (locate on site plan) i Depth below grade: Material of construction: �oncrete _metal _Fiberglass _Polyethylene --other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: S < 9 "X-6 " /6 O CI / h Sludge depth: 02 ' 4/ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: /VDAti ' Distance from top of scum to top of outlet tee or baffle: A10 S C I Distance from bottom of scum to bottom of outlet tee or baffle: A/a S C U P%n How dimensions were determined: /Or—y F, , Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) C ti�rL f` � �r o /� �n WGr� v,„ �h w6✓ , ,,. 6 r J 7< /e Ck -lvru uc✓c yr U Cyr Gc.- f.. U /L•. 41 L� GREASE TRAP:/.9 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert, structural integrity, evidence of leakage, etc.) (r.vio.d 04/25/97) - P­ 1 -1 �n I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 56 Blueberry Hill Road,Hyannis,MA Owner: Arthur Beauchaine Date of Inspection:April 3, 1998 TIGHT OR HOLDING TANK:�/-(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) .Depth below grade: Material of construction: _concrete _metal._Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes; No Date of previous pumping: '— Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_IV/�I (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: /V (locate on site plan) Pumps in working order: (Yes or No) Alamo in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (rw1�.d 01/7S/9�i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 56 Blueberry Hill Road,Hyannis,MA Owner: Arthur Beauchaine Date of Inspection:April 3, 1998 SOIL ABSORPTION SYSTEM (SAS): --L/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type.. C �� �leaching pits, number: o ti e L G4 /, p,_ ,✓; 07 S h 2 , leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length:_. leaching fields, number, dimensions: overflow cesspool, number: c"0 e- 6. Alternative system: Name of Technology: Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation, etc.) I G a�V C, L ih . - w G. G. .✓ x S i ca. 7� r ca_.//G Aget� ��✓� or 'o0.0 r.lc✓z ✓erg Va CESSPOOLS: 41j9 i h �o /�. i�. e' f �✓ �; 1- ><-,7� c o (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /✓11-9 (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs.of hydraulic failure, level of ponding, condition of vegetation, etc.) (—vl••d 09/7S/97) P•9• 8 or 10 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 56 Blueberry Hill Road,Hyannis,MA Owner: Arthur Beauchaine Date of Inspection: April 3, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 0-c— /000 d ss L le,CC—r �; f 1 I 's (revised 04/25/97) . page f or 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 56 Blueberry Hill Road,Hyannis,MA Owner: Arthur Beauchaine Date of Inspection: April 3, 1998 Depth to Groundwater = Feet adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ,Observation of Site (Abutting property, observation hole, basement sump etc.) V/Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) cI-C 11 ,r,S GJ o L-) �✓ 7'0 r. �a tr'e�ot�, : !-7.-2 i /_ w S .,,.�/� U c..- G •/1 �, �1. y `" C�re /r-. c� G-�c�4-c r L/O Q9 LOCATION SEWAGE PERMIT NO. VILLAGE IN.STA LLER'S NAME & ADDRESS B U I°L D E R OR OWNER DATE PERMIT ISSUED _ ,77 D A T E COMPLIANCE ISSUED 77 bo . d f C'S r 2 0 No ----- /�_ THE COMMONWEALTH OF MASSACHUSETTS 01,0 BOAR® OF HEALTH 4 q �,2..........OF....... . - . ..U'e---_-------------------- Appliratilan liar Ditipas al Works Cfnnatrartiun 11amit Application is hereby made for a Permit to Construgt ( ) or Repair -(�an Individual Sewage Disposal Sys at: l I.. a.. _ --•-•- ----- ...... y 1 oc n-Address or Lot No. (.Cl ................----------- ----------------•----------•--••-----•------•--...-•-----------•----------------............... Address ....... a.... t .�9......_..+ !►�. .............................•......... _ ........................................ Installer Address i UType of Building/ ' Size Lot............................Sq. feet Dwelling—✓No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( . ) Otherfixtures ------------------s--------------------------•-----------------•----------- W Design Flow............................................gallons per person per day. Total daily flow..............................._............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_________-_-__...__- (Z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to.ground water........................ a --------_--- -- Description of Soil------.. ------ ....'= - --- - - ................ x W ............ . . ......... •-- --- ....... ---- ---- . ................. ----- --....... -•----••-------- x U Nature of Repairs or Alterations—Answer when applicable______--.��__ ___:®'_ ........... � .slJ......._.. v Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TILL LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be sued �by the bo�ofVeaa h. eA AS,ig/n ,eK�9""`� /d �' �'- __.... DateApplication Approved By.---•- .. r `. .... . Date Application Disapproved for the following reasons:............ -----------------------------------------•••------ ••------........_.. Date / S' Permit No......................................................... Issued.....d.. - Date NO. Yi ...•.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H .------......d W eV..----- ....0F.......1..2.#.. ....�J. l �......................... Appliration for Disposal Works Tonstrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( I-)"'an Individual Sewage Disposal System at: / ............ .......... ... - o-- •.. / LocMnAddress or Lot No. AV.V'1.1........ ............................ ..............................................•------......-•-•--••----...............-•--•-----.. caner Address Installer Address Type of Buildings Size Lot............................Sq. feet U Dwelling No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) '._1 Other—Type of Building ............... No. of ersons......................_.__.. Showers G.I YP g ------------- P ( ) — Cafeteria ( ) a' 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (Z Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_................. 9 ----------y� ...._ ............................................ D Description of Soil........Yfi 1f�..q4_ 2 -------•----•---•-----------------------------------------------------•-----.----------- x W ••-••------•-----------------------------------•---•---•-------------------------------•-•---•----••----•-•-••-•--- - --------------------- ----------- . . U Nature of Repairs or Alterations—Answer when applicable.______•_-._�'L'_______-IWO-__-___Q ��d�4°�_t�d-------------- ...------•------•--•--•-••-•--------•--•-•-•-----•-------••-•-•-•---•-••--•••••-•--------------------•-•-------•------------------••-•-----••••-----••--••------•------•--------•-•-•--........---..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b sued'by the bleard o h alth. Si_gn. :..._ ... ------J D_a_ te . .....•.._ __. . -- •--------•------- --APPlication Approved B ........ . ._. _. _._. --- - •� Date Application Disapproved for the following reasons:............................. •-•••----•----•••••------•-----••-•••-•-•-•----•---•--•--•........................ ----------------------------------------------------------------•----------------........................-••-••-----•-•-•-•--•---••---•--------•---•--•--------•-----•-•••-......•----•-•-••-•-•---..--- Date PermitNo...................................................... Issued•-----.....-•--- -•----•------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF 2 HEALT' , . / ........W..�..............OF....: .AsJA�e S `�.. . ................................ fit vantifirate of Bunt# anrr TH IS T CE TI , That t e Individual Sewage Disposal System constructed ( ) or Repaired V � � 4. s by.. A .R...... d -. := In staller at---.v�6....... &a%g �.x. _------•--.. ..._ ----------- .#/------------------------------------------------------------------------------------- has been installed in accordance with the provisions of T F r f/7 he State Sanitary Code as described in 'the application for Disposal Works Construction Permit No___-- ._... f0 --------- dated... Q."__l ..�`. ..,........ THE ISSUANCE OF THIS CERTIFICATE SHA NOT if STRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 4lt'.� �y.�U�STE� �*. 1 tt'��n+,W,F�'�R'C l.w�+�" ,N�'e • Y mjk.r+ '��' �i��P�tOr wa-_.,W�P �r i�El:19u !x ;'Y 7+ _ A��L''& i,_<r bt�h a.}X-t 21�4. y�.R'�px�➢tz�r�l . .., .+ . ,. . .. ... �. �.? ....r��.V u...� "+r'�tPYa.kr�N �%�C��t�y`i•'�iw'�'�.��� "�^ THE COMMONWEALTH OF MASSACHUSETTS'' BOARD OF HEALT 7 �' n �f ...............OF......4�wlv�1 � ._....._......--•--........ No............... FEE.._V................. 01spu� u k u otrttrt� n rTO? it � _- Permtss>on is hereby granted.....-----�1'� - ------�--..- t d� - --•--� ---------------------•----------.......---._.. to Construct ( r Rep, it ( an In 'tIid a Sewa g�isposal Sys - ...------= �-�...-••....... '----------------.................................................... Street as shown on the application for Disposal Works Construction Perpal No_____ __________ __ Dated.._ `_'Z'�. ........ ..... ; {fJw �c/� Board of Health DATE._--•F/--(-'�------=-----`------------------------•-------......____._._...----- /// FORM 1255 HOBBS & WARREN, INC., PUBLISHERS :n « Town of Barnstable P# Department of Regulatory Services M Public Health Division Date 2XJ i639. �� 200 Main Street,Hyannis MA 02601 . Ep t,Ntl� Date Scheduled 2Y/g Time......4L : Fee Pd. Soil Suitability Assessme�tt for Sewa I e Disposal Performed By. Witnessed By: LOCATION&GENERAL INFORMATION Location Address ��{ ,Owner's Name i Address�6�LG�8���f��(/JL��['�O• Assessor's Map/Parcel: Engineer's Name'4*w1v4p NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) p a Surface Stones Distances from: Open Water Body ft Possible Wet Area . ft Drinking Water Well ft Drainage Way ft Property lane ft Other ft SKETCH:(Street name,dimensions of lot,exact lac ' perc ts,locate wetlands fn proximity to holes) ' 4L -A Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: 1 Weeping from Pit Face Estimated Seasonal High Groundwater Z� Method Used: DETERMINATION FOR SEASPNAL HIGH WATER TABLE Depth Observed standing in obs.hole: In. Depth to soil mottlas: in. Depth to weeping from side of obs.hose: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level,R Adj.factor- Adj.Groundwater Level,,;m PERCOLATION TEST Date Tyne Observation 4 Hole# Time at 4" Depth of Perc Time at 6" start Pre-soak Ti me @ Time(9"•6"). End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back------------ ***If percolation percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP.OBSERVATI --------------- Depth from Soil Horizon ON HOLE LOG Hole# Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. o 1jisttencv 96 Orav n z A, C:5 /0 2 a C �25 At DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsi en 96 MUD- - DEEP OBSERVATION HOLE LOG Holer Depth from Soil Horizon # Soil Texture Soil Color Soil Other(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencz DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency, a Flood Insurance Rate May: Above 500 year flood boundary No_ es J Within 500 year boundary Noes,:_ Within 100 year flood boundary Noes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u material exist in all•areas observed throughout the area proposed for the soil absorption system? If.not,what is the depth ha rally occurring pervi us material? ,.�. Certification I certify that on 4 (date)I have passed the soil evaluator examination approved by the Department of Environ enta Protection and that the above analysis was perfo by me consistent with . the required training,exper' e eri nce described in 310 CMR 15.017. Signature Date Q:\SBPTIC�PERCFORM.DOC 1 t � 9 s07 -99bu612 Health Department Drop-Off Hours: 8:00 AM -4:30 PA Town of Barnstable Received by Health " �oFzwe u R r°hy Regulatory Services Department on .�- Richard V.Scali Director �.B"NST"LE,1639. Public Health Division 10 Thomas McKean,Director ;, 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE Property Address: _ r% C� -t t (, �� �� /?✓/Ills Assessor's Map/Parcel Number: —D -910 Applicant(s) Name: l )69 Phone: '� r�� � � E-Mail: __ Size of Lot: —2a. How many bedrooms exist at your property nowt 2b. How many bedroom are you planning to add as part of the Accessory Affordable Apartment Program application? 2c. How many bedrooms total are proposed at this property(including the Accessory unit)? 2e. Is the proposed Accessory Apartment contained within: . b/the main house; OR a detached,structure Zf. Submit floor plans for all buildings on the entire property. Show all existing rooms in the dwelling and the proposed accessory apartment. Label each room clearly. Label measured width of all open doorways. Use straight edge for hand drawn plans and bWsu a all.labeling is legible. Signed: f = Date: l.2 1 ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE FOR STAFF USE ONLY 1. Is the dwelling connected to Town sewer? ❑ Yes l No 2. Dwelling located ❑ INSIDE ❑ OUTSIDE the Saltwater Estuary Protection Zone 3. Dwelling located ❑ INSIDE ❑ OUTSIDE public supply.well Zone of Contribution 4. Dwelling is connected to ❑ ON-SITE WELL ❑ PUB IC WATER 5. Disposal works construction permit on file? Yes ❑ No 6. If yes, how many bedrooms were allowed by-this permit:- bedrooms 7. Were building permits ,obtained for additional bedrooms? ❑ Yes .❑ No 8. Engineered septic system plan: a. On file at the Health Division? ❑ Yes ❑ No b. If r p oposed accessory unit is detached from principal dwelling, is that plan on file? ❑ Yes ❑ No 9. Existing septic system capacity is L' bedrooms For the accessory unit to receive approval from the Health Department the followin action must occur: xistin system g y accommodates proposed additional bedroom(s) ❑ Upgrade existing system to accommodate additional bedroom(s) ❑ Must remove a bedroom from the main house 0 Must connect detached structure to the existing septic system ❑ Must install septic system for the detached structure ❑ Other Signed Date / 2 6� 4 z j C. f q� frvwo^ Futi:� �Y 5 .. .j7{j � � 0 ��•AO d d , 4y � yy Vi I t s UT � � r e -_. 1 i II ASSESSORS MAP : TEST HOLE LOGS NOTES: PARCEL: 70 FLOOD ZONE: SO I L EVALUATOR WITNESS : h1 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: / �'� c�� / �j fj' DATE: (X Health Regulations. 1 PERCOLAT I ONJ 15 ATE: .-C / , ;' ' 2) The installer shall verify the location of utilities, sewer inverts and septic -- p ��•�� ( components prior to installation and setting base elevations. TH- I TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first two feet out of the d-box to the leaching shall be level. l 4) This plan is not to be utilized for property line determination nor any other 2 - purpose other than the Y system installation. 5) All septic components 'j proposed must meet Title V specifications. t �2j � 6) Parking shall not be constructed over H10 septic components. L 0 C A T I ON MAP ( • •!7� G ��`'{ 5 � ril J'A`l 7) The property is bounded by property corners and property lines. � , � 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 1 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated�� � � � g soil and replaced with clean sand per - , --__�_ , Title V specs. ' j 10)System components to be 10 feet from water line. Sewer lines crossing the kL +� water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM1 DESIGN applicable. The proposed SAS is being installed below the water service a line. The line is to be sleeved as aforementioned and maintained in place. 77 27 l0 FLOW ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the 5 _ / 7owner to ensure such. Ip BEDROOMS AT I I O I GAL/DAY/BEDROOM - ' U GAL/DAY 12)The installer is to take caution in excavation around the gas line if such exists. �EPT 1 ANKy - - - 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. O GAL/DAY x 2 D11 S - GAL -- -- USE I�Jw GALLON SEPTIC TANK - SOIL;ABSOR T{ON SYStEM N ''JJ ���^ O O ���\�)i --, S U '� � r12� �,X� ��� +'� 1 l�� P��t1 OFtijgS'n� I J , \ / O C�fq� l �' •.� SIDE AREA• c .. /3 X Z �' U,� - /�,7, v:. S©N, w ,.'�- - BOTTOM AREA:- 162- x 45 -1y d,7 - 11 8 v ' u�tu0oss',� �� u (v') 0 w \� -c3 ,s - t (Aef/ SEPTIC SYSTEM SECT I ON ' 7` ! - AzIo7lEZ _(Q liZFl1 02 GD _Pdk y J �i�1 4 •-per-� v vo / � 1�.. —_�� �`� _� SEPT 1 C TANK h�Zo SITE AND SEWAGE---�`:, - E PLAN 0 I LOCATION : 4 iV HILL PREPARED FOR : �"1►'�'1 I- �3DV S (l C_. �;7 / o ` 7 SCALE: 11 0 LU z �3 I, i DAV I D B . MASONS DATE: 1 Z01� J W - i�/ 0_�00 DBC ENV r RONMEN AL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA W Cj ( 508 ) 833- 2177 Z i