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HomeMy WebLinkAbout0045 CANDLEWICK LANE - Health 45 CandleWicl�.Lane . Hyannis A = 268 — 243 I� o I f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In CIA Property Address 1-0 Maria Amaral V Owner Owner's Name information is required for every Hyannis ✓ Ma 02601 7/18/2016 page. City/Town State Zip Code Date of Inspection E•+ W 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 forms A. General Information - on the computer, 64 use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 8 Johns path Company Address B� S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 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 8/2/16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has,a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1�00* 1 r Commonwealth of Massachusetts .e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner,-r, Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. `,'" City/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 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1,000 gallon septic tank as well as a 1,000 GI leach pit. Liquid level in pit is 26 inches from invert pipe and there are no stain lines higher in pit. Down stairs sink was recently tied into existing 4" main line. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or`not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank,is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is Hyannis Ma 02601 7/18/2016 required for every y _ page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): '❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by-the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR ` 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 J Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic-ank 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liqu;d level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000-gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 / r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M a 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. City/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, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approxima=ion of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CN1R 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °7 45 Candlewick In Property Address Maria Amaral Owner owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: System contains a 1,000 gallon septic tank as well as a 1,000 GI leach pit. Liquid level in pit is 26 inches from invert pipe and there are no stain lines higher in pit. Down stairs sink was recently tied into existing 4" main line. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 178 Gpd Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: occupiedDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is Hyannis Ma 02601 7/18/2016 required for every y _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 l r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 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: 30 + Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 j Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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•3113 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 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. 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 El other(explain): Dimensions: Capacity: gallons DeSlgn 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is Ma 02601 7/18/2016 required for every Hyannis page. City/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 Na Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out cf box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. City/Town 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: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 „ Commonwealth of Massachusetts W Title 5. Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis, Ma 02601 7/18/2016 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ® drawing attached separately i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts , W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is Hyannis Ma 02601 7/18/2016 required for every y page. City/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: 10+ ft 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: Ground water indicated on usgs maps is 10+ ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 45 Candlewick In Property Address Maria Amaral Owner Owner's Name information is required for every Hyannis Ma 02601 7/18/2016 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 DEEROBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Shcl Color Soil. Other Surface(In.) (USDA) (Munsell) Mottling (Stnucturc,Stoned;Boulders. o islstency.%'Oravoll o t. DEEP OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Sail Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. >U DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Boll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Scopes;Boulders. Consistency, Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No / Yes ' Within 100 year flood boundary No.,,� Yes Depth of Naturally Occurring Pervious Material 1 Does at least four feet of naturally occurring pervious r�ttiterlal exist in all rheas observed throughout the area proposed for the soil absorption system? !/ j If not,what is the dept of naturally occurring pervious material? S1 Certification O} I certify that on /`J (date)I have passed the soil evaluator examination approved by the Department of Env' onmental Protection and that the above analysis was performed by me consistent with . the required training,ex ertise an xperience descriped in 10 CNM 15.017. Signat ure Datb Q:\S.13PTICWBRCPORM.DOC � Town of Barnstable P# i Department of Regulatory Services s' k Public Health Division Date a63p 200 Main Street,Hyannis MA 02601 Date Scheduled a ( Time Fee Pd. (� �-, • N Soil Suitability Assessment for Sewage Disposal CA Performed-By: Witnessed By: LJ LOCATION&.GENERAL INFORMATION Location Address Owner's Name le,e- Perti(c, •�-j-� D�j �� 1 s t m� Address Os- 6 C"A k- k0(C-k 141' ` IJ cwni s �►14SS Assessor's Map/Parcel: ` Engineer's Name Y NEW CONSTRUCTION REPAIR Tele hone# Sub)4 SI -/I 64 Land Use Slopes C2 -� Surface Stones Distancea from: Open Water Body fl ft Possible Wet Area ��tft Drinking Water Well `U>�ft Drainage Way I ft Property Line 2 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&Pero tests,locate wetlands in proximity to holes) Parent material(geologic) Dcpth to Bed�'ook r?�(� Depth to Groundwater. Standing Water In Hole: v�. Weeping from Pit Face Estimated Seasonal High Groundwater /2,0 /1� , DETERMINATION FOR SEASONALMIGH WATER TABLE Method Used: �p Depth Observed standing in obs.hole: '�v`r In. Depth to soil mottie9: Dc{th to weeping from side of obs,hole: In, Groundwater Adjustment Index Well-# Reading Date: Index Well level__;,_.�r Adj,•factor...,,_,-,.,_Adj.Groundwator•Leval..._ _ — PERCOLATION,TEST Date_._ , Time Observation Hole# ' t Time at 9" _ Depth of Pero 3 U t Time at 6" Start Pro-soak Time @ _ Time(9"-6") rb End Pro-soak Rate Min./Inch Site Suitability Assessment: Slto Passcd Slte Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Consepvation Division at least one(1) week prior to beginning. Q:ISEPTICU'ERCFORM.DOC (`k giro%�� r -4-YI-4 0 0 � I -A � 45 Candlewick Ln,Hyannis, MA 02601 Page 1 of 1 1 45 Candlewick Ln,Hyannis,MA 02601 I _ Mon 7/11/20169:53 PM ' Froln:Eric Davis(edavisc2l@yahoo.com) To:dbitner@todayrealestate.com(dhitner@todayrealestate.com) ....................................................................................................[)vlage.Prev[ew.................._.......................................................................................................................................................................................... Download All Attachments ' Download All Attachments[45 Candlewick Ln,Hya].zip offer 45 Candlewickpdf 3,291 KB checkjpg 42 KB pOKW rurtwwci 104 , �xxc 6sakolMferics 1:0310001361: 004635112592+'0104 check.)pg(388:388) l . http://mail.todayrealestate.com/Main/f-mMessage.aspx?popup--true&folder=Inbox&messa... 7/12/2016 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE H.....q ........ ...--....OF........ .. ...... Appliration for DifiVosal Works Towitrurtion Permit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Di posal Syt at --------- --- -------- ...... .... ......... ............. ........... ;7 L ion- ss t N ..... .. .. ............. . .... . .... ------------ ..... ner dd s s........... .......... Installer Address Type of Bu W ldi1 Size Lot---_-----_-------------Sq. feet U Dwelling K No. of Bedrooms........--.7.........................Expansion Attic Garbage Grinder ( ) PL, Other—Type of Building ---------------------------- No. of persons____________________________ Showers Cafeteria ( ) Other fixtures .- ---------------------------------------------------------------------------------------------------- -------------------------------------- Design Flow............................ - ------ allons per person per day. Total daily flow........ V-7-4r ----------gallons. WSeptic Tank—Liquid capacity?�'�gallons Length---------------- Width________________ Diameter.._.....______.. Depth------_------>1 Disposal Trench- Total leaching area..._._ ,No.:.................. Width....... Total Length.- sq. ff. At-e Seepage Pit No.:.1................ Diameteyr- Depth below Total leaching area___Z���q. 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__-___-___--_-______-._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit-_______-________-_- Depth to ground water..___....__..._.__...--. P4 ............................... ----------------- ------- .................................. ---- -- ------- ­­---------------------------------------------------------------------------------------- 0 Description of Soil..........................................T� U .................................................................................................... ................................................................................................... --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: I . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. S,jl*g Ed- ..........................................--_---------------------- ............. Application Approved BY----- ---el Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo........................................................... Issued........................................................ Date ---------- -------------—----- --------------- - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration, for Rapaaoal Worko Taan.6trurtion Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S st at T �L//'��V\ ��A✓� J//�J �A'/i�,7,(/) . ..�...... l... w:'9..,r9. .."'..i.. 5s _ '--1 .+^'ri.+..+-lr'i�'L/ �rf� .__-_____.•_._.., `? � Location- dress i( f. P ,or Lot No ff-- ' ` .� s•-- .L.,Jrc.dF r ✓,. r .ESg,� �d � Address r Address Q Type of Buildins,,, Size Lot----------------------------Sq. feet U Dwelling Z No. of Bedrooms......... ............................Expansion Attic ( ) Garbage Grinder ( ) 44 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ............... ......................... _ Design Flow gallons per person per day. Total daily flow________, __" ---------------gallons. W WSeptic Tank—Liquid capacity/f'l__•gallons Length-__-____-_-_:.. Width---------------- Diameter.•-..---_.__-_- Depth-_---_-.--...- x Disposal Trench—No_ ____________________ Width.__ _- Total Length....... Total leaching area--_-_ --_____sq. ft. Seepage Pit No._j________ _ Diamete ,?r °�- Depth below inlet------ ._.._._ Total leaching area__- • sq. ft. Z Other Distribution box ( ' ) Dosing;.tank ( ) aPercolation Test Results Performed by:< Date........................................ Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water---•___---_--_.__--_--. (Lf Test Pit No. 2----------------minutes,per-"inch Depth of Test Pit.................... Depth to ground water-------_-_-__-__-_-_._.. w -- D Description of Soil .,-swstr_. .-" =-------------------------------------------------------------------------------------------- V -•--•••-•••---•------•------------------------•----•---•------------••--•. 1 --------------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable.-_--------------------------------------------------------------------------------------------- --- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until.a Certificate of Compliance has been issued by the board of health. Si?ed-------;r --•----•••••---•••-•••-----•••--•-•---------------------•-•----------- •--- --------- ---------- / ) 9 Dat Application Approved By_--- z�`' - 1- �� d �""' :---•------------- _, -.--------- r�'I - Date Application Disapproved for the following'reasons:----,----•-•-------------------•-------..._..------•---•-•-•---------------------------•-•-•-------•-•-•- --•-•---------•--•----------•------------------------------•------------•--------------------------------------------------------------------------------------•----------------------------•--•---•--- Date k s. Permit 1Vo......................................................... Issued........................................................ Date t THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH ✓'�'`!i5e/ ..........OF....... ............................... e TUrdifi ratr of fP ompliaurr T rg IS„TO C IFY, f hat the Indivi al a -age D' posal System constructed ( <or Repaired ( ) ler y� g„d at y w/� y�yy v ........................... le '-",w+_,p3•-2----- .i�f__ ---1_---'___^.C_.�s4`.-r�R�_ � ___•__fi^`_�-`h��--_ _py�. /�� leG•S+'{. has been installed in accordance with the provisions of Article XI of The State;. anitary Code as descri ed in the application for Disposal Works Construction Permit No............................... dated_.---_.-_ `i ---------------; THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r . DATEe-30 - Y2' _ Inspector----------------- ............................................................... THE COMMCNWEALTH OF MASSACHUSETTS r dry �O)A,RD HEALTH . '.. i....O F.... e...3 �m�,, !.... ..... ....... m 131.-6pa-,11 1 Mark n urtijan Pet it ' Permission is hereby granted___..�. --- .a._ ----- ,� _�___ ._ ......... .......... to Constru t ( r Repa' ( ) an 1Ind S wa ge Disposal System at No.-;¢ -- r __' °�.. w 1= f � Street as shown on the application for Disposal Works Construction Permit No . Dated-_-- � - �` -.__� �f< Board of Health /"' !'DATE-••••7/6-./_7)-----------------------------------•----- - t° FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No...... Fus.............................. THE COMMONWEALTH OF MASSACHUSETTS EOARD EALTH .OF.......... ...0 " . Appliration -fur Miip iat Works Tote rurti rrutit Application is hereby made for a Permit to Construct ( ) or Repair (f Ian Individual Sewage Disposal Syst at: - n C�9L1 w S -------------------------- ------••--- -=--- Loc ti Address or Lot No. W ner Address ------------------ ------------------ ------------------------------------------------------- ------------------------------------------- Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons_-_..-__--_________--_-_-_- Showers ( ) — Cafeteria ( ) fl, 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-------------------•------------------- a Test Pit No. 1________________minutes per inch Depth o Test Pit.................... Depth to ground water------------------------ f14 Test Pit No. 2................minutes per inch Dept Test Pi -----__---_______. epth to ground ater--------------------- a ------------•- ------- - -----•-------------- •••-- --------------. ------•••-- •................................... Description of Soil---------------------------------------------- _ - --- ----------- ...... --------- t'-�`----------- x ---=-------------------------------------------------------------------------- ---------------------------------------------------- . . --- --------- --- U Nature of Repairs or Alterations—Answer whe>applicable...-r7 s' t ------------------_---- ------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article X1 of the State Sanitary Code— The undersigned further agrees not o lace the system in operation until a Certificate of Compliance has been ' ed he d of h th. ij Signed_. _ Date Application Approved By....... --- - --------- ---- - ---- - .. .... Application Disapproved for the following reasons-------------------------------------------------- -------------------------------------------------------------- - - -- - ------- ---- ---- ------- ---------------- Date ---- Permit No......................................................... Issued.•-- zr� Dat/ �� •�• THE COMMONWEALTH OF MASSACHUSETTS �OARD EALTH -OF.......... ... - -for DhipOOttI Morks TOO rOrp rrO�i Application is hereby made fo a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal t�rn Sys at ..��► t Loc t' ddress or Lot No. ner r,. Address. ---• ••¢- --•-- -- ...C,". ,- ---------------------------------------- ----------------- ---------------------------------------------------------- Installer Address Q Type.of.Building Size Lot____________________________Sq. feet U Dwelling—No. of Bedrooms__............::..........................Expansion Attic ( ) Garbage Grinder ( ) Other Type of Building ____________________________ No. of persons---_------------------------ Showers ( ) — Cafeteria ( ) al Other fixtures .....__----------------------------------------------- W Design Flow---------------_____________________________gallons per person per clay. Total daily flow--------- 9 Septic Tmik—Liquid capacity------------gallons Length---------------- Width..___..-- _.._._ Diameter----:----------- Depth.__-_._-.__--. xDisposal Trench—No-___________________ Width-------------------- Total Length-------------------- Total leaching area--------_-----------sq. ft. Seepage Pit No.,_,_,.,.,_..___.___. Diameter.................... Depth below inlet.................... Total leaching area------------------sq. It. z Other Distribution box ( ) Dosing tank•( ) Percolation Test Results' Performed by--------------------------------------------------------------------------- Date---••---------------------------------.. Test Pit No. 1..........------minutes per inch Depth ol "Pest Pit-------------------- Depth to ground water_.-------------.-------- (� Test Pit No. 2................minutes per inch Dept Test Pi ______--_--__--_. e th to ground ater__.________._______---- fx . 0 Description of Soil............................................. '. x ----- -- ------ - --- ----- -- ----- -- ------- --- --- ------- - U ---------------------------------------------------------------------------------------.................................................................................................................. --------------------------------------- ....................... ------ -- U Nature of Repairs or Alterations—Answer when applicable._. _.. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees no lace the system in operation until a Certificate of Compliance has been ' d the d.of h. Signed - - --- ____ Date -p Application Approved BY---- -- �.� . ,' l r -- �f D s Application Disapproved for the following reasons:............................................::.. ..............................:............................... ---------------=-----------------------------------------------•-•----•••---•----------•-------•----•=------------••--------------------------------------- -.----•---..----••----------•---•-......... Permit No--------------------------------------------------------- Issued.--- ........... Date r THE COMMONWEALTH OF MASSACHUSETTS rBOARD OF ' HEALT ems" ` .OF......... ... ........ Trrtifiratr of TOmpliana T S TO TIeF t the Individual Sewage Disposal System constructed ( ) or Repairedby 1 . --- •--• • ---------•--•-----•---------••----•--••••-•-•------•---------------------------------•-•. r at . ........................• ----------------:--------•••-------=---==-------------••--•----- has been insta led in accordance with the provisions of :Article XI,of The• State Sanitary Code. s d cr' 'n the application for Disposal Works Construction Permit No-------------- _______ dated..r,_ _dl__ :_ : ____-_--------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G a4RA TEE THAT THE 4 SYSTEM WILL UN ION ,SATIS ACTORY. • Inspeco ------------------- -•-----•-- DATE-- %- ----- THEiCOMMONWEALTH OF MASSACHUSETTS BOARD,4, OF...-............................... No. FEImo''K�.�•----------- BinpOfittl OO dulu Vami# Permission is hereby g me ,.. -• -•--- ----- :. ------------ ------------•-•- --- to Const t ) Repit 1 ewage ste + .. - N Streetas shown on the app'cation for Di posal Works Constru ,"" P` o L DATE'- ` = oa un rd of H7---------------- FORM 1255 HOBBS & WARREN. INC.. PUB-LISH ERS � - .t ��,r r 7""'' .. r ,/ I � h r ..