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HomeMy WebLinkAbout0122 BUCKWOOD DRIVE - Health 122tBuckw66.d"Drive Hyannis �....: A = 272 - 080 i o l` I I c e a e No. C7300 d o Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEA&H DIVISION - TOWN OF BARNSTABLE"IVIA§SACHUSETTS Yes Z[pprication for �Digogal *pgtemc (Construction Permit Application for a Permit to Construct(-) Repair( Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. ! ;?A 12 w4-w Owner's N e,. ddres and Tel. o. Assessor's Map/Parcel ) , .2 �/�00 Ins r' N A ess, Tel No. S Designer's Name,Address and el.No. ,6/� � Type of Building: 0—3 Y4; 14— Dwelling No.of Bedrooms � Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ��� � gpd Design flow provided Z gpd Plan Date Number of sheets Revision Date /j/"Lp— Title Size of Septic Tank ��� Type of S.A.S. — 70 Description of Soil Natur f Repairs or Alterations(Answer when ap licable) 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 e 5 of the Environment Code and not to place the system in operation until a Certificate of Compliance has been issued by oard of Healt . !/ igne mate Application Appro ed by Date `f 7 B _ J Application Disapproved by: Date for the following reasons Permit No. ��72 3 ek 3 Date Issued 'a 7 '"�: .�,F_ti. �': -:-•`Y A.�',ry .t. _., i.-:re^�'o-.�-.t,�3%,!'�+w+t+....rvrr�:'*..f 'r +h',�:;•,_.. ,itpo,�.Ir•,�,,�w.•.,,, o..�:,era+. sv+..-daii�+^'t.yl."�.,r.'-�,:...��.+..-r.,i.s..Y�r,-. No. . " Fee(: 0O y r THE COMMONWEALTH OF MASSACHUUSETTS Entered in computer: Yes PUBLIC HEAark`� �IVI_SION -*TOWN OF BARNSTABLEII; 1 ASSACHUSETTS Zi ppY cation for )X5pozar bpgtem Cott.5tructiott Permit Application for a Permit to Construct( ) Repair grade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. ��0 /�� Q �/Z Owner's N�m�ddres ,6w e_I.;Noj: Assessor's Map/Parce� 7A /�/ �l�A�d��// r tall, d Te'NVo�j �d4 S Designer's Name,Addres �Tel.rNo. �qs Type of Building: Dwelling No.of Bedrooms -2 Lot Size ��� sq._ft.«Garbage.Grinder:(��} --Other,.... ...—_ ..... .M- - . Type of Building z No of T Persons Shovelers( ) Cafeteria(. ) Other Fixtures 2 Design Flow(min.required) 3�� gpd Design flow provided } gpd Plan Date �/�JD� Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil { � r. Natu11 f Repairs or Alterations(Answer when applicable) s7 - 7,o o �� IOIC. 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 o le 5 of the Environment • Code Van4t to place the system in operation until a Certificate of Compliance has been issued by s oard of Healb. ign �-� ,c e pate 7 Application Approved by t: __ _ = "Date=' j.cq Application Disapproved by: Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed (' ) Re aired (� Upgraded ( ) Abandoned( )by l/1}� /. II�YL/✓�f y. o 11 ,S 1 L. at lo6j�1 ' JJ has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No. C' '-3 3 dated 7/ b ,/7 Instal er 1"3 "J �s/�Vj Designer'Z)QL� �yy'�l/y1, A s. #bedrooms Approved design flow. gpd The issuance of this permi shall not be construed as a guarantee that the s stem will function a designed. Date Inspector- =———————————————019 —_ —————— No. - -- Fee /d U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Wtgpoal *pgtem Co rut ton Permit Permission is hereby granted to Construct ( ) Repair ) Upgrade (, ) Abandon ( ) System located at S 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 tliis�per it: � /� Date Approved.by _ Rug 06 2007 10: 54AM . HP LASERJET FAX --- p' 1 Aug 06 07 11:53a P' 1 Town Of Barnstable Regulatory Services .�. _ Thomas F.Gciter,Director Public Health DfviSlon ■eye. � Thom is McKean,Director 7,00 Main Street,11yaunis,MA 02601 nftis4:.5OW62.4644 - F3x: 508-79D-6304 Installer&DLiemcr Certification Farm., Date: I lip <A Installer: -�IQ_ �? lJr�/��� Address: . T � ,Address: Cd 6 v/` "_CJ�0C, S G 1N14 OZS33 on � ,�_ 11 f6AIAI s� issued a permit to install n (d ) mslalrcr� septic system at V _based on a design drawn by inaa des;gnm tcertify that the septic wAtem rcfereaced above was installed substauti•ally►according to Wie desi n •ch un include miiaor • •roved- es such as latgaal ielocntimx of the tribution box and/or septic tw&. I oertify.that the septic system referenced above was imgal1cd witti'rnajox cliaages'(i.c, greater tfiqu'l0' lateral relocation ofthe SAS or amy veard6d'xdboation ofazIy com? onew of the septt7c,, tam)but in accordance with State&1.bctil,Reotations. ,plan rmmioA or certified t!s-butt y csigacr to follow. .Y• .1 mee OP '�, (lasts 1 1$113 � ., �� • '�� y� , 'sgNITAR1Pa ._ Ocsi `S n ttiuc�— ( e gntxx�s.StsdaP Rcxc) ' PLEASE S.E RETURN 10 RA NSTA Qi .PURLT ,HEALTH DIV,L4Ita .• C . FIG '1'L O1[� COMPLIANCE WILL'NUT E•' `SUED.. L 'TWS FO D ARL SU 'r CARD ARF.RFCEED B .Tl .B STARLTa r313C.Y I:Sit)N. TI R. A Q Flcnithl�epticli:csigne:t;erhlieatiPig m SEWAGE INSPECTIONS 4')CATION � ?[��L2 <�� ^l. DATE !Zm/t YILLAGEt ASSE SOR'S MAP & LOT 'INSPFiCTOE ���, ' Vn� > SEPTIC TANK CAPACITY 1 00A ct� LEACHIIdG FACII.ITY: (type) CY (size) CO ^q NO. OF BEDROOMS BUILDER OR OWNER C-Gkutiyl"Q— iQ J OWNER MAILING ADDRESS •� , 9` - d 1 TOWN OF BARNSTABLE 3 SEWAGE# LOCATION'- _ v ASSESSOR'S 1VlAP&PARCEL( Si 3NST4LL$RSNAME+g PHONE NO. 17. Q+r'c --. L] SEPTIC TANK CAPACITY �1- 3o n * (size) NJ LEACHING FACMMy.(type)__._-- O NO.OF BEDROOMS, 3 OWNER. PE PERMIT DATE: COMPLIANCE DATE.•Se) . 'tsoa Distance Between the: $qmm. Feet Pn� Maximum Adjusted.Gcoundwater Table to the Bottom of Leaching Facility et Private Water Supply Well and Leaching Facility Of any wells exist � �f on site or within 200 feet of leaching facility) a' exist �t Ed€ Edge of Wetland and Leaching Facility( any set m within 300 feet of leaching facility) ,t FULFMISHED BY f Ck l � I i � 4 s -- t V Town of Barnstable P# Ile Department of Regulatory Services f R,,'S;A ; Public Health Division Date • �P lU 10 9. ,e� " ' 2 n Street,Hyannis MA 02601 Date Scheduled ime Fee Pd., ' ' 10 O-q Sol uda lity Assessment for Sewa Disposal Performed By:C Jev I 4 ,- Lr✓l i P Witnessed By: -- - S LOCATION& GENERAL INFORMATION Location Address i/�/'�/J / (� \ Owner's Name II'• Address //(� �Cie[itJZ/D(QAt 4Aa.413 t1tlCi,i�lv1/S ". 'P Assessor's Map/Parcel: �7 � �� I ` Bngitieer's Name '���'��' Icr✓fR'e (" NEW CONSTRUCTION `/REPAIR Telephone# (.�) 775� Land Use —r Slopes(4'0) Surface Stones Distances from: Open Water Body ft •Possible Wet Area "117-ft .Drinking Water Well _�' _ft Drainage Way A'1,04 ft' Property Line /O ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) l J UGSC, l� 00C), ' / Parent material(geologic) Depth to Bedrock �/0 0 Depth to Groundwater: Standing Water in Hole. '77" Weeping from Pit Face Estimated Seasonal High Groundwater G S J DETERMINATION FOR SEASONAL HIGH WATER TABLE _ Method Used: Depth Observed standing in obs.hole: _ in. Depth to soil mottles: Depth to weeping from side of obs.hole: _. ,_m in. Groundwater Adjustment ft• Index Well# Reading Date: Index Well level— Adi,factor___ Adj.Groundwater Level PERCOLATION TEST ' bate Thne -�---- �' Observation Hole# Time at 4" r' Depth of Pere Time at G" Start Pre-soak Time @ �� Time(9",G") End Pre-soak .c. /S- Rate Min-Anch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division ~' Observation Hole Data To Be Completed on Back=`- ------ �. i ***If 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:\SEPTIC\PERCFORM-DOC i DEEP-OBSERVATION HOLE LOG Hole#�� Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Moulin g (Structure,Stones,,Boulders. Con isten % ravel �� C z, o !Z 4•!O. DEEP OBSERVATION HOLE LOG Hole#' Z Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) Other (Munsell) Mottling (Structure,Stones,Boulders. Consi en �' !9 LrcS, 10 7 DEEP OBSERVATION HOLE_ LOG Hole# Depth from Soil Horizon Soil Texture o Surface(in.) Soil Color Soil Other (USDA) Soil Mottling (Structure,Stones,Boulders. Cnitec vel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) Other (USDA) (Munsell Mottling (Structure,Stones-,Boulders. Consistency, Flood Insurance Rate Map.• f� Above 500 year flood boundary No yes., J (i Within 500 year boundary Nov' Yes Within 100 year flood boundary No k YesDe th of Naturally Occurring Pervious Material �,.ti"Does at least four feet of naturally occurring pervio us terial exist in all areas observed throughout the .area proposed for the soil absorption system? '- If not, what is the depth of naturally occurring pervious material? "Certification '-I certify that on d� mil. (date)I have passed the soil evaluator examination approved by the t --Department of Envir mental Protection and that the above analysis was performed by me consistent with . ' Zthe required training,ex rtis and xperi nee described in 310 CMR 15.017. Signatur Date Q:%S.EPTICVERCFORM.DOC f.' ♦ ryw. DATE__2L81_Q4_-- PROPERTY ADDRESS:_-catherin� 122 Buckwood Dr. Hyannis, MA 02601 ------------------- RECEIVED On the above date, the% _iseptic system at the above add es S E P � 5 2004 was Inspected. This system consists of the following:. TOWN'UF BARNSTABLE HEALTH DEPT. 1. 1-1000 yai-eon hePtic tank. 2.4-6 ' xV e0nc2ete giock ceZ,3/200.e Ba sed on inspection, I certify the following .conditions: �te�n �� �.n �Z2o�Zea wo2k.�ny oacle2 at the p2ezent time 4. The he/zt is zy i e.' 5. The wa�5te .i�atea .�n ee�s�/�oo� way 5' 6" �e.�ow the .�nve2t R R SIGNATURE'S - - >_-='---- Name: R�•1��.rt-��.x��-_---------- �, To�Ph Inc. Company n :_��- --- ��- P.O. Box 66 �/� Address----------------- 4RCEI 0066 /gypT' �-..-,�-�,. Phone'_(508) 773_3338_____ _____ DOES NOT CONSTITUTE A GUARANTY OR THIS CERTIFI CATION WARRANTY JOSEPW P. MACOMBER & SON, INC. Tanks,Cesspoots-L'eachfields Pumped & in'stalied. Town sewer connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775.6412 I COMMONWEALTH OF MMSkCHUSETTS EXECUTIVE OFFICE OF E+•NVfRMM'MAL AFFAIRS C A DEPAtTMEN'p OFNVIIQI� iEN'I`Ai.�ROTCTION y TITLE 5 OFFICIAL INSPECTION FORM—.NOT--:D SFO-0L NT-- EM FORARY M SUBSURFACE SEWAGE PART•A CERTIFICATI.ON- PropertyAddres§:' 122 u,,:•le,.v,r,ri nr Hvannic Mn Owner's Name: c' l-be-i ne ro s ^U Owner's Address: Date of Inspection: 9 /9494 Name of Inspector: (please print) Company Name, Mailing•Address: Cerz �l�b►•0263z Telephone Number: 5 0 8-7 7 -�3 3 3 CERTIFICATION STATEMENT 1 certify that I have personally inspected of he time oflsposal the inspection.The inspection as at this address And performed based on my reported below is true;accurate and complete as training and experience in-the proper function and maintenance of on•4ite sewage disposal systems.I: a DEP . approved system inspector pursuant to=Section.IS 340.of•Title 5(31.0•CMR,dS:a00). The system: XXX passes -Conditionally Passes Needs Further Evaluation,by the Local Approving.Authority Inspector's Signatmre: ''�` Dater. 0 inspector shall submit a copy of this inspection -to the.App"roving Authority(Board of Health or The system p If the$ystepi is a.shated syAtM or has a design flow of 10,000 DEP)within 30 days of completing this inspection. regional,office of the gpd or greater,the inspector and the system ewne�and pies senft tt rthe buye to the rp f applicable and the approvving. DEP.The original should be sent toltho system.. . authority. Notes and Comments ****This'report only describes conditions at the time of inspectida•and under theconditions same e t fhat � time.This inspection does not address how the system will perform in the fgtur e un4er ferent conditions of use. c,�nnn Daze 1 . Page 2 of 11 OFFICIAL INSPECTION,FORM—.NOT FOR VOLUNTARY ASSESSMENTS SiIBSURi.ACE SEWAGE DISPOSAL SYSTEM INSPECTION 10fM ' PART'A CERTIFICATION(continued) Property Address: 122 Buckwood Dr_ Hyannis, MA Owner: Catherine Gei nk Date of Inspection:A/R/n d Inspection Summary: Check A B C,D or..E/ALWAYS�complete-all of Section D A. System Passes: no 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The hept"ic 3y,3.tem "i.6 :in /2/LOPe2 wo2k.ing o2cleic at e /2/Lezent time. B. System Conditionally Passes: no One or more system components as described in the"Conditional Pass":section need to be replaced:or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not.determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n o. The septic tank is metal and over 20 years old*or the septic-tank(whether metal.or not)is:soucturally unsound,exhibits substantial.infiltration or exfiltration.or tank failure:is:j mminent: System will pass inspection if the existing tank is replaced with'a complying septic tank.as-approved by_the:Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available_ ND explain: n.o Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection-.if(with approval of Board of Health)' broken.pipe(s).are replaced. . obstruction is removed distribiltion box is leveled or replaced ND explain: no 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 pipes)are replaced obstruction is removed ND explain: -2 Page 3 of 11 OFFICIAL INSrPECTION FORM-NOT VOR VOLUNTARY ASSESSMENTS SUBStWACE SEWAGE DISPOSAL SYSTEM INSP'ECTI6N.FORM PART A . . CERTIFICATION(6oritinued) : Property Address: 122 Buckwogd'Dr_ Hyannis, MA Owner:. Chthe Date of Inspection: 9/s?,/_0 4 1 A t' C. Further Evaluation-is Required by the Board of Health: Conditions.exist whichrequire further.evaluation.by.theBoard:of*Health;in-order.:to:detertriine ifthe system is failing to protect public,health,.safety or the environment. 1: System will pass unless'Boara4fHealth detertnines4h secordance with 310.CMR 15:303(l)(b)that the system is functioning in.a-manlier.w. hich will.protect public health,safety andIbe-.environment: a-o- Cesspool or privy is withinz 50 feet of asurface water as Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. System will'fail unless the Board'of Health(and Public Water Supplier,`if any)determines:that the system is functioning in a martner that protects thepeblic health,safety and environment: n o The system has a septic tahk and soil absorption system-(SAS).:and the SAS is within 100 feet.of a surface water supply or-tributary to a.surface water.supply. no The system has a.septic tank and SAS and the;SAS is within a Zone 1 of a-public water.supply. n a The system has a septic tank and.SAS:and•the-SAS is within:SO feat of a private water supply well. rLQ_ The system has a septic tank and SAS and the-SAS.is less than 100 feet..but 50 feet on.more frorl a private water supply well". Method used to determine distance' mea-6uaed "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from-pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm,provided that no other failure criteria are triggered.'A copy of the analysis must be.attached to'tis form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR.:YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 2 2 gi,rkwnnrl Dr Owner:s Hyannis, MA l}er}e 6, e1: Date of Inspe—ction: QT8 4 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to.each ofthe:fQ1lowing,fbr all inspections: Yes No x Backup-of sewage.:int%facility.or.system component due to overloaded:or clogged SAS.ar.cesspool x Discharge:or ponding of effluent to the surface.©€the:,ground or.surface waters due to anoverloaded or clogged SAS or cesspool x Static liquid level in the distribution box above outlet invert due to an.overloaded or clogged SAS or cesspool x Liquid depth in-cesspool is less than.6"below invert or available volume is less than'14•.day flow x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of.the SAS;cesspool or privy is below high ground water elevation. _ . x Any.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface T water supply: x Any portion.of a cesspool or privy is within a;Zone l of a.public well x Any portion of a cesspool or privy is within.50 feet of a private water supply well. x 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 coliforin bacteria and volatile organic compounds indicates that the well is free from pollution;,fr..om:.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 niust be attached.to this forts.] rc o (Yes/No)The system fails.I have determined that:one or.more-of the:4-bove.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;00.0 gpd to 15;000. gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in.addition to the criteria above) yes no x the system is within 400 feet of a surface'drinking water supply x the system is within 200 feet of a tributary y tary.to.a surface drinking water supply X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water supply well If you have.answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner-or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional.office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM•—NOT FOR y'OLLTNTARY ASSESSMENTS �— $J jRSURFACE SEWAGE DISPOSAUSYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 22- Buckwood Dr. _ Hyannis, MA Owner:. Catherine_ ick Date of Inspection: A 48j Q 4 Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No x — pumping information was prpvided'by the owner,occupant,or$oazd of Health — Were any of the system components pumped out in the previous two weeks? x. Has the system received normal flows in the previous two week period? _ x Have large volumes of water been introduced to the system recently or as part of th a inspection? x Were as built plans of-be system'obtained and examined?(If they were not available#rote is 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'? x 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,dimension(,depth of liquid, depth of sludge and depth of scum? x _ 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 x Existing information.For example,.a plan at the Board of Health. _ x Determined in the field(if any of the failure criteria related to Part Cis at issue approxitnationof distance is unacceptable) (310 CMR 15.302(3)(b)] �. w; 5 Page 6 of 11 OFFICIAL MSPF)CTI-.ON:-]F.QRM'-N0T FOR'VOLI NTARY ASSMWNTS S ,BSURFACE.SEWAGE Dj$F,0SAL�SYSTUM,%IWEC TION:CORM PART.0 SYSTEM Il!FORKATION Property Address: 122 Burkwc)nd nr- Hyannis,, MA Owner: Cat;heri nP C,ai rk Date of Inspection: A FLOW CONDITIONS RESIDENTIAL Number of bedrooms(desig):, 3 dumber of bedrooms(actual): 2 . DESIGN`:flow based on*31�0 CNdI 15.203'#or example:'1 I0 gpd z#-of bedrooms): `3 x l 10=3 3 0 gp d Number of eurrent residents: .: 1 Doesresidence have a garbage grinder(yes br no): np Is laundry on a separate sew4gAystern(yes ormo):.ap [if yes separate inspection required] Laundry system inspected(yes or no):u e s Seasonal use:(yes or no): 20 0 2:4 8,.0 0 0=/3/. 5 gad Water meter readings, if available(last 2 years usage(gpd)):`2 p 3:2 7 019 0_7 4 gl2d Sump pum (Yes or no): n_o ' Last date o�occupancy: /z 2 e.6 e n t COMMERCUSTRIAL Type of estatMAP fit: 'a on 310 CMR 15.203): n¢ s;Dd Basis.of duo"Iflow(seats/persons/sgft,etc.): n n Grease trap�present(yes or no): na Industrial waste holding tank present.(yes or no): na Non-sanitary waste discharged to the Title 5 system.(yes or no): na Water.meter readings, if available: n a Last date of occupancy/use: . na OT4ER(describe) M rz a GENERAL INFORMATION Pumping Records " Source of information: na Was system pumped as part of the inspection(yes or no):_aD If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for.p:amping: N;. TYPE OF SYSTUM x Septic tank,distribution box,soil absorption.system _Single cesspool —Overflow cesspool _Privy _Shared system-(yes or no)(if yes,attach previous inspection recbrds,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) �. —Tight tank. _Attach a.copy-of the DEP.approval Other(describe): Approximate age of all components,date installed(if known)and.source of information: Were sewage odors detected when arriving at.the site(yes or no): no 6 - Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 122 Buckwood Dr. Hyannis., f4A, Owner: Cath.Pri np Geick Date of Inspection: 9.1 R.10A BUILDING SEWER(locate on site plan) Depth below grade: 1 0" Materials of construction: x cast i pn _40 PVC_other(explain): Distance from private water supply well or suction line: 1 p f Comments(on condition of joints,venting,evidence of leakage,etc.): loin is a22van t i ah f ai., pv ' nro 01 .leakage Se2.t.cc zYztem vented thaough houze vents. SEPTIC TANK:_(locate on site plan) Depth below grade: 12 Material of construction: x concrete_metal fiberglass_polyethylene _other(explain) — If tank ismetal list age:._ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 4 ' 10`wi d v/5 ' g" /R' 6".eon g Sludge depth: ?" Distance from top of sludge to bottom of outlet tee or baffle: 46# _ Scum thickness' f n n n n Distance from top of scum to top of outlet tee or baffle: an Distance from bottom of scum to bottom of outlet tee or baffle: i5o How were dimensions determined; m e a,3 u a e d Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 12um2_tank evvau 2- 3u0rjz,s - n-P- t and 0ut-eet tees ate in piace Tank a2pn_aaA .tLzur•ivaa iU Aound •No evidence o-1 .Reakage GREASE TRAP:n o (locate on site plait)) Depth below grade: n a Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): n a _ . Dimensions: n a Scum thickness: n a Distance from top of scum to top of outlet tee or baffle:n a Distance from bottom of scum to bottom of outlet tee or-baffle: n a Date of last in : na pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage.,etc.): Cf2ea/�et2aR 170.E R /,onf•_. Page 8 of I I OFFICIAL IN-S•PECTIUN FORM-NOT FOR VOLUNTARY ASSESSMENTS .9,"RU .ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: 1 22 RnrkwnndDr llyannirsi MA Owner: C r __ Date of lbsipectioni TIGHT or HOLDING TANK:no (tank must be pumped at time of inspe`ction)(locate on site plan) Depth below.grade: ri Material of construction: na concrete metal fiberglass___polyethylene_other(explain): Dimensions: na Capacity: na gallons Design Flow: na gallons/day Alarm present (yes or no): Alarm level: na Alarm in working order(yes or no): na Date of last pumping: na Comments(condition of alarm and float-switches,etc,): DISTRIBUTION BOX: no (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.): l��.stai�ut�on Sox no.t 122e.6en.t.- PUMP CHAMBER:nO (locate on sife.plan) Pumps in working order(yes or.no): na Alarms in working order(yes or no): na Comments(note condition of pump chamber,condition of pumps and appurtenances, ett,); Pump cham9e2 not pee.6ent.- 8 � Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART:C SYSTEM INFORMATION(continued) Property Address: 1 2 2 1111ckwood Dr 'N �annic M Owner:. rather}ne—Qe-ick Date of Inspection: n SOIL ABSORPTION SYSTEM(SAS):_.(locate on site plan,excavation not required) If SAS not located explain why-. Located gee a e 10. Type no leaching pits,number:_ leaching chambers,number: no leaching galleries,number: 0 leaching trenches,number,length: no leaching fields,number,dimensions: .�y overflow cesspool,number: 1 no innovative/alternative system Type/name of technology: Coments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, m etc.): no evidence 01 /zond.tna o2. hud2au e is CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1•/6 'x 8' Depth—top of liquid to inlet invert: 5 ' 6" o .i n v e a.t Depth of solids layer: 0 Depth of scum layer: 0 Dimensions of cesspool: 6 'x 8' Materials of construction: c o n c.¢e.t e tt.Q o c k Indication of groundwater inflow(yes or no):n°. Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:�_(locate on site plan) Materials of construction: na Dimensions: na Depth of solids: n q Comments(note condition of-soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 . Page 10 of 11 OFFICIAI.INSPEC'HON FORM=,NOT,FOR'VOLUNTARY:.ASSESSMENTS / SUBSU,RFA:CE>SEWAGR:DISP.OSAL'SYSTEM-.INSPECTION-:FORM PART C SYSTEMEO �TL01�1(continued) Property-Addrm: 922 Buckwood . DIL. Owner: aLLiz4z Gv k Date of Inspection:29/8/0 4 SKETCH OF SEWAGE-DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includingfies to at Ieast two permanent reference Ixttdmarks or benchmarks.Locate all.wells within 100 feet:Locate where public water supply enters the building. Y. 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 122 Buckwo od D z., Iltlanniz, Ma.� Owner: Cathe_a ne qeick Date of Inspection: 9/8/0 4- SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 6 0, feet Please indicate(check)all methods used to determine the high ground water elevation: n o Obtained from system design plans on record-If checked,date of design plan reviewed: 42/,Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: noChecked'with local excavators,installers-(attach documentation) Accessed USGSdatabase-explain: hjt7,.,40w Q q Q 4 1 a 9,ee ma uz You must describe how you established the high ground water elevation: u,3ed •Gahe2.tu X fl.ieie2 modee 12116194 G2ound Uate2 4&ove Sea Leve-e ijAPr, .T , hn_. raZ_ P„ 000fin 92-000-1 12iate#2 Jan.• 1992 Rnnual 2angea n e nnn„nrl wnfon o Pt,z)a _J'onA Top of Ground Leaching Pit ,:eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpterr Method q Therefore,the vertical separati on distance between the bottom of the leaching pit and the adjusted groundwater table is �/1 feet. 11 >•,�-„-�,->t,.,�,.,.r.,,�.-.,�:..,�-,a-,,.=,�-:=-T::•,-.-r�.r:,,�-�•,:-�.,�-,-u„�-�.�,-�,TOWN OF BOARD OF IIEALTII 91JIIS1)4FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION Ci _•t-r••.-::r-.+r.-.c-nr.-m•rr.•rs-s+rr'+rsz•rr+'r•r:s,ms:b:slrmrT++�T`�?Q�'^=P'^�° —TYPE OR PRINT Ct,EARLY— PROPERTY INSPECTED STREET ADDRESS 122 Backwood [72., ASSESSORS MAP , DLO„CK AND PARCEL # 272-089. , OWNER' s NAME Cathea-ine Ge.iek PART D - CERTIFICATION R.o•&eat jaoiin.i NAME OF INSPECTOR COMPANY NAME ;,.P,.Nacom&e2 and zon, T0nc. COMPANY ADDRESS Box 66 Cent eay.ii ee Na., 026 32 Street Town or City State LIP COMPANY TELEPHONE 508 775 - 3338 FAX ( 508 ! 790 - 1578 ( ? CERTIFICATION STATEMENT I certify that I have personally reporteddishtrue�,aaccurates,aand i ysterti at r this address and that ttte t omplete as of the time of .,inspection , The inspection was performed and any ecornrner�.dations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on site sewage disposal systems , : Check one : XXXX System PASSED Tile inspection which I have conducted has not found any information t adequately protect public fails o the system fa q which indicates that. . Y health or the environment as defined in 310 CMR. 15 . 303 ► Any failure criteria° not evaluated are as stated in the FAILURE CRITERIA section of this forin . System FAILED* The inspection which I have con t,rcted has found that the system fails to protect the jiublic health and the environment in accordance with 'Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART..0 -....FAILURE CRITERIA of this iryCectjpp form . Inspector Signature -- Date copy of this certificationmust be provided to the OWNER, the BUYER Onwhe ere applicable ) and the DOARD OF HEALTH, . * If the inspection FAILED, the owner or operator shall upgrade ' the system. within o•ne year of the date of the inspection, unless al,low.ed or requAy ed otherwise as provided in 3J0 CMR 16 . 306 , partd .doc ASSESSORS M... .2 - r r- S T HOLE_ LOGS NOTES: 1 PARCEL : FLOOD ZONE : .r SOIL EVE\LUATCR :^� �Yfr �>, PfV'o WITNESS : %pG �, t;;�l �, ir1 ]) The installation shall comply with Title V and Town of Barnstable Board of F ER ENCE : ),qL j G�-t 1" /7"' D,�TE : 1+ !, "_; ���r�1 'i Health Regulations. .�/ 2) The installer shall verify the location of utilities, sewer inverts and septic �u 1 � � �� � �C`� PERCOLATION RATE : ----~ - r.. c:• Y components prior to installation and setting base elevations. 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. 4) This plan is not to be utilized for property line determination nor any other I+ ( lu'41 i Z _, �! its; ;,. _ _ , � purpose other than the proposed system installation. �y �( ""fl4p D t?, ( ,�t,.tt� �,y�,;� I 5) All septic components must meet Title V specifications. �+ • �G+.� '_(,, 't�? Q l ?U� � r , (> 6) Parking shall not be constructed over H10 septic components. 7) The property is bounded b property corners and property lines. 1 ` 'OCAT ! ON !v!!�P Y P P Y P P Y �! � � l,y ✓� S 4F !1 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. 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 soil and replaced with clean washed sand fi i V\ID t. 1� -klf-) per Title V specs. a 10)System components to be 10 feet from water line. Sewer lines crossing the --�-_ --' water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DES I G N applicable. 11) if a garbage grinder exists it is to be remo�.;d and is the responsibility of the owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if applicable. I DAY/B GAL 2s� 13)The installer shall verify the location, quantity and elevation of the sewer lines EEDP,OOMS AT GAL/DAY/BEDROOM -32GAL/DAY �'� t /3r' 2 / t� `v` --;�►. ', r exiting the dwelling prior to the installation. f y t l "Ir SEPT '(' TANK 3;; t00AI-/DAY x 2 DAYS GAL ¢ i cl� USE I 0003ALLON SEPT I C TANK (0C,t �• i SOIL ABSORPTION SYSTEM S I DE AREA 2�c ���.A44- 12,12—';,1x.7 X X l� BC? i-0!,, AREA. o -7`t '41l l o? U W L T►o _ _ _ . 1c'__ .. _ .__. ._ . __ 5 i ,. / ✓ =j�• - —'r---- .._..`fiJ�7V�t---P►�,!U M'e;,�� �__-___----__ti 1---`--'--" ��- �., Z.O t"' 31e. ' J TDL^I try. '1�.,.!'Cw�_ T1"IGTr�1( .�16 f� l r —� ✓ '�t ab� (p�' ` b tt D B X- O 0 1 I 0i 57, ! 3 Von 0 F 7� Hi)'�,R, Z�,QV, S I rl, -1 ,;.__•_ 'w r`i" f r.`� .�.�o. ._— _ _ ... ..d... ..w.�. .� _, _ ___ ...---- - AND S :YVAG E P !AN l``CAT + ON / AJ (_ PPEPAR'-7D FOR SCALE ' D A V I P . MASON) IZ,`S DATE; 7 / / _, �'JC =NV ! r,L','MEnTAL DES I GNS W DATE HEALTH AGENT r � 5!�+' ) 3;53- '? 1 77 { ..,f..�.1 s-L.s.... ..-ai.�-'_- -.rpfR - _ - ..-•.lviYi�O+.s'.if.Y Y4.1�IbiiOY'l.i ...JYc � f1..ci:fi.Yft 2 blfY.v...lca�1�/,CirY�... ..J_ "��"_