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HomeMy WebLinkAbout0125 CARLOTTA AVENUE - Health -- 48-227 1 1 TOWN OF BARNSTABLE LOCAJION /eb-��f tr,4Ot't4 A✓'-- SEWAGE # VILLAGE I��1Q�I 4'3 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.S• rn• .Ones ( in�s>n e_T SEPTIC TANK CAPACITY 6 x q 1000 G a-L L o n J LEACHING FACILITY: (type) (size) II NO.OF BEDROOMS Wi BR OWNER 1)OA•eG -Aktrr e_1 CU PERMITDATE: COMPLIANCE DATE: 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 f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:125 Cartoon Ave.Hyannis Ma.02601 Owner:Denial&Patricia Kelly Date of Inspection:9/102005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including des to at least two permeneM refem slaodmarks or Beachmarks.Locate aU wells within 100 feet Locate where water supply enters the building BACK OF HOUSE B A DECK TANK I A-I rol O B-I=43' O D-BOX Ej 2 A-2=26' SAS 3 A 3=61 B-3=21' r 1 �<C\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February 2, 2010 required for y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form..Inspection forms may not be altered in any way... Important` A. General Information When filling out forms on the computer,use 1 Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not. Name of Inspector use the return key. Septic Inspection Services Co. Company Name - 189 Cammett Road Company Address Marstons Mills MA 02648 reran City/Town State, Zip Code 508-428-1779 S1 12855 Telephone Number License Number B. Certification 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 February 2 2010 �pect&s e 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. 10-18 Kelly.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Dispo I System•Pa e 1 If Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February 2, 2010 required for y ry every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching pit was empty at time of inspection. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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 10-18 Kelly.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February 2, 2010 required for y ry every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 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 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. 10-18 Kelly.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments * " 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February 2, 2010 required for y ry every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 st:.pply.%klell**. 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_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 10-18 Kelly.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is required for Hyannis MA 02601 February 2, 2010 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. [Tlhis 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. 10-18 Kelly.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February required for y 2, 2010 every page. Cityrrown State Zip Code Date of Inspection C. Checklist ` Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of.water been introduced to the system recently or as part:of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank. inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑. Existing information. For example; a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 10-18 Kelly.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 r. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments µ 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February 2, 2010 required for y rY every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 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 ears usage d N/A Irrigation g ( y g (gpd)): system. Sump pump? ❑ Yes ® No Last date of occupancy: UnknownDate 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: — Last date of occupancy/use: Date Other(describe): — 10-18 Kelly.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February 2, 2010 required for y ry every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Tank pumped three years ago. 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 contact(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: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 10-18 Kelly.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February 2, 2010 required for y ry every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ' Depth below grade: 1 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 •--------------------------------------------------------- --------------------------------------------------------------- I Dimensions: 8.5' long x 5.2'wide - 1000 gal. Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6" — Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured — 10-18 Kelly.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 L ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is H annis MA 02601 February required for y 2, 2010 every page. Cityrrown 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.): Liquid level was found at bototm of outlet invert, tees were intact and clear. Tank is not in need of pumping at this time. 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 Comments (on pumping recom rendations, 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): 10-18 Kelly.doc-06f06 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is required for Hyannis MA 02601 February 2, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 ❑ Na Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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 solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-18 Kelly.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is required for Hyannis MA 02601 February 2, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: One 6x6 pit. ❑ 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.): Leaching pit was found empty at time of inspection, does not appear to have been above 50% capacity. 10-18 Kelly.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is Hyannis MA 02601 February 2, 2010 required for y rY every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 10-18 Kelly.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1:3 of 15 Commonwealth of Massachusetts - Title 5 Official 1�nFspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is required for Hyannis MA 02601 February 2, 2010 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. / r r'r'r r r r ! ! ♦ ANW, rrr •'r r r r r r / r / / / / / / / • / r r r r / r r r r / r r / / r r r • r / / / r r ,r z:, r .4 r r r r ! ♦ r / r r r r / r / ! ! / r r r ♦ r r r r r / / ♦ / r r r / r r r • / ♦ / / • / • ! r / J ! r • / / / r / r • r r • rrr / / • • r ! / / ! • r • / / / / / / / / / / / / r / • r r r . / 21 15 32 14 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 125 Carlotta Ave. Property Address Daniel Kelly Owner Owner's Name information is required for Hyannis MA 02601 February 2, 2010 _ every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20feet 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: IISGS topo map and town GiS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 20 and topo map shows property at el. 50. 10-18 Kelly.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page IS of 15 Commonwealth Of Massachusetts Executive Office Of Environmental Affairs Department Of Environmental Protection TITLE 5 Official Inspection Form -Not For Voluntary Assessments = Subsurface Sewage Disposal System Form Part A r,•_� .�- F.Y., Certification Property Address: 125 Carlotta Ave.Hyannis Ma.02601 n a� Owners Name:Daniel&Patricia Kelly �a Owners Address:125 Carlotta Ave.Hyannis Ma.02601 UI r,,. Date of Inspection:9/102005 V . .1/4 Name of Inspector(please print)Sean M.Jones Company Name: S.M.Jones Title V Septic Inspectors Mailing Address:74 Beldan Ln. Centerville Ma.02632 Telephone Number:580-778-4597 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: X Passes Conditionally Passes Needs further evaluation by the Local Approving Authority Fails Inspectors Signature Date: e/ t aoo S The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:dwelling is served by a functioning 1000 gallon tank and 1000 gallon leach pit. ****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. Page 1 A OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTNUED) Property Address: 125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.System Conditionally Passes: One or more system components as described in the"Conditional Pass"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. 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 the 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 structurally sound,not leaking and if a Certificate of Compliance Indicating that the tank is less than 20 years old is available. ND explain: 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 distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(coNTmum) Property Address: 125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 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 310CMR 15.303(1)(b)that the System functioning in a manner that protects the public health,safety and the environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Surface water supplyor 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 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 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 this form. 3.Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTMUED) Property Address: 125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded 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 '/2 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 water supply. X_ Any portion of cesspool or privy is within Zone 1 of a public well. _X_ Any portion of cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of 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 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 pp,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _X_ (Yes/No)The system fails.I have determined that one or more of the above 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:N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: 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 H of a public water supply well If you 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 CM15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 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 provided by the owner,occupant,or Board of Health X Were any of system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X_ _ Was the site inspected for signs of break out? X _ Were all system components,excluding 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 tee,material of construction,dimensions,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 C is at issue approximation of distance Is unacceptable)[310 CMR 15.302(3)(b)] I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-3— Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203 (for example): 110 gpd x#of bedrooms): 330 Number of current residents:-2— Does residence have a garbage grinder(yes or no):— no-Is laundry on a separate sewage system(yes or no): no_[if yes separate report required] Laundry system inspected(yes or no):_n/a Seasonal use:(yes or no)_yes_ Water meter readings,if available(last 2 years usage(gpd):_2003=300gpd--2004=191gpd Sump pump(yes or no): no_ Last date of occupancy/use: COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping records Source of information: Tank needs to be cleaned Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was this quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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 the 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 sewerage odors detected when arriving at the site(yes or no): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_X (locate on site plan) Depth below grade: 18"_ Material of construction:_X_concrete metal fiberglasspolyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 6x6x9 1000 gallons Sludge depth:_2` Distance from top of sludge to bottom of outlet tee or baffle: 1` Scum thickness: 10" Distance from top of scum to top of outlet tee or baffle:_1" Distance from bottom of scum to bottom of outlet tee or baffle: 3" How were dimensions determined: opened covers,took measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): Tank requires cleaning,inlet and outlet baffles intact,tank structurally sound,liquid levels are ok,no evidence of water infiltration or exfiltration. GREASE TRAP:_N/A_(locate on site plan) Depth below grade Material of construction: concrete metal fiberglasspolyethylene 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): P OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of Leakage into or out of box,etc.): Distribution box was level there is only one outlet and the water level was correct,no evidence of solids carryover,box was not leaking. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 SOIL ABSORPTION SYSTEM(SAS)_X_(locate on site plan,excavation not required) If SAS not located explain why: Type _X_Leaching pits.Number:- 1-Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternitave system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): soil was drv,no signs of hydraulic failure,no ponding around leach pit,vegetation was normal CESSPOOLS: N/A (cesspools 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A (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.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12`below SAS—feet Please indicate(check)methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain: TOB GIS Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was determined by checking on Town of Barnstable web site/GIS I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:125 Carlotta Ave.Hyannis Ma.02601 Owner:Daniel&Patricia Kelly Date of Inspection:9/102005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building BACK OF HOUSE B A DECK TANK 1 A-1=24'6" O B-1=43' D-BOAC ❑ 2 A-2=26' SAS 3 A-3=61' B-3=21' lazl Date: 69//o TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: BUSINESS LOCATION: MAILINGADDRESS: /�S �( . l A��l i✓� 4el Mail To: TELEPHONE NUMBER: Jai' °��5 P ® y� Board of Health Town of Barnstable CONTACT PERSON: P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: ��I`//Ii"�/V� Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO � This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(forgasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes- Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS DATE:---- ---___ (� PROPERTY ADDRESS:?_ Carlotta Ave Hyann �• ----------- -- 02601 ---------- on the above date, I Inspected the eeptlo system at the above address. This system conslsts of the following; 1 . 1 -1000 gallon septic tank. 2. 1 -Distribution box. 3 . 2-1000 gallon preca t le hi g Based on my i�naPOW on,� ob'A glhe following oondltlons: 4.. This is a title five septic system. ( 78 Code ) 5. The septic system is in proper working order- at the present time. Both of the leaching pits were dry at time of inspection. 6 . System was upgraded 11 /12/92 Permit # 92-537 See Following page. SIGNATURE;,/ _..C.: Name 1,_P �.2tDS.4c ttr_ _----- Company: Joa.ph_P _ Hecomb•r_& Son , Inc . Address:_ Box-66— Concervi 'I L Ha__02632-0066 Phone:___ ------- THIS CERTIFICATION 00es NOT CONSTITUTe A C)UARANT'Y OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tinks•C9sspools•Loachflilds Pumped L Instsilod Town Stw•r Connsotlons P,o. Box 6775.3JJ8 �g77, MA 02632-0066 GQ w t a I THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HEALTH No•-z TOWN OF BARNSTABLE FEEA...30.00.. 3�is�rn,�ttl urk,� �ur����tr#iun ���mi# . ... 'Permission is hereby granted..... J..- ...I` &G.QAJ�2�x...s�x....................:................•.................................................. .... to Construct ( ) or Repair XX4 an Individual Sewage Disposal System at No.....12,5 .Ca,x.1Q . &..A.3I�...Hya.I�Cuh�...•........................ .......................................................................... Street G� ••••••-•--••- as shown on the application for Disposal Works Construction Pe> t N'o....... .. - J .Pe ���3�Dated.....f/'� DATE......... soars of Healt �......_ FORM 36508 HOBBS Q WARREN.INC.,PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE SS �Er#ifirtt#E of Qlumjulian.cE TJ IPI`�yTQ CE4 eIFY�r That the Individual Sewage Disposal System constructed ( ) or Repaired�XXX) by ...................................................................................................................................................................................................................................................... Installer at ........125...Carl91t.a.... ve..... yann.is...........................................: ............................................................................................................ has been installed in accordance with the provisions of TITLE of The St e Environmental Cody a.. described in the application for Disposal Works Construction Permit No. ........ �,. . ...... dated ..1,1..:.+....�`.....:.-. .......... THE ISSUANCE OF THIS �ERTIFICATE SHALL NOT BE CON �AS A GUA TEE THATTHE SYSTEM WILL FUNCTI N SA SFACTORY. DATE.........................:...�,... ...G. .qcl............................ Inspector ...... .. .. l -\ COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 125 Carlotta Ave Hyannis,Mass. Owner's Name:Robert Somerville Owner's Address: 15 .21 arri d Road --Nowto,n m s -02.1-a9— Date of Inspection:,")f.f R I n T•. .__ Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name: J.P.Macomber & Son Inc. Mailing Address:Box 66 Centerville,Mass. 02632 Telephone Number: R_7 7`-3 3 318 CERTIFICATION STATEMENT I certify that 1 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 Section15.340 of Title 5(310 CMR 15.000). The system: ✓Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: i Date: - D The system inspector shall s mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. . Title 5 Inspection Form 6/15/2000 page 1 1 ,r Pat of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 125 Carlotta Ave Hyannis,Mass. Owner: Robert Somerville Date of Inspection: 2/2 8/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S stem Passe (ji 0 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"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. 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. ND explain: ,416 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 distribution box is leveled or replaced ND explain: 1.)d 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 obstruction is removed ND explain: 2 a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 125 Carlotta Ave Hyannis,Mass. Owner: Robert Somerville Date of Inspection: 2/2 8/01 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 tle 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 manner that protects the public health,safety and environment: 4/0 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. A)6 The system has a septic tank and SAS and the SAS ip within a Zone I 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 1�0,� feet bu 50 feet or more from a private water supply well". Method used to determine distance U��2j)Z "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 this form. 3. Other: 3 r 5 Page 4 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 125 Carlotta Ave H annis,Mass.. Owner: Robert Somerville Date of Inspection: 2 28 01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no" to each of the following for all inspections: Yes No _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or yclogged SAS or cesspool Static liquid level in the distri,utjon box above outlet invert due to an overloaded or clogged SAS or cesspool C ivt Liquid depth in cesspegl is less than 6"below invert or available volume is less than ii day flow VRequired 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 AS, 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 eAn ter supply. y portion of a cesspool or privy is within a Zone 1 of a public well. _ y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 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 this form.] (Yes/No)The system fails. 1 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 c 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• 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 i/the system is within 400 feet of a surface drinking water supply !/ a system is within 200 feet of a tributary to a surface drinking water supply cat a nitrogen sensitive area Interim Wellhead Protection Area— IWPA or a mapped _ the system is located to g (_ ) PP Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "ves" 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 1 r OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 125 Carlotta Ave Hyannis,Mass. Owner: Robert Somerville Date of Inspection: 2/28/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No No information was provided by the owner, occupant, or Board of Health Z'Alere any of the system components pumped out in the previous two weeks? —ZHas the system received normal flows in the previous two week period ? �ave 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,,h*cluding 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 ? --1 — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no �_ Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of I I • OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 124 Carlotta Ave Hyannis,Mass. Owner:Robert Somerville Date of Inspection: 2 28 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_ 4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 'JAV=Aw Number of current residents: _0 Does residence have a garbage grinder(yes or no): S Is laundry on a separate sewage system (yes or no):416 [if yes separate inspection required) Laundry system inspected()es or no): S Seasonal use: (yes or no):Y S Water meter readings, if available(last 2 years usage(gpd)): '5rt 9 = yn�l�O Sump pump(yes or no): , Last date of occupancy: V& COMMERCIAL/WDUSTRIAL Tvpe of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): A,�i9 Grease trap present(yes or no): A Industrial waste holding tank present(yes or no):,& Non-sanitary waste discharged to the Title 5 system (yes or no): ,14-14 Water meter readings, if available: Last date of occupancy/use: IVA- OTHER (describe): GENERAL INFORMATION Pumping Records ,/ Source of information: 'YL -5 G �"'✓` C'�'�''� Was system pumped as part/of the inspec ion (yes or no): ' If yes, volume pumped: /100_ga lops-- How w s quantity pumped determined?.,e2 /v6,UW Reason for pumping: )t� 4 l' �C_Z/ Z:t)vrf%:� TYP OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool AJQ/ Overflow cesspool A Q Privy ALb Shared system(yes or no)(if yes, attach previous inspection records, if any) �VC Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank AZ,!�E Attach a copy of the DEP approval djI�Other(describe): Apprompa a aee of all comljonents date installed (if kn )and source.oaf inform ti n: + c% Were sewage odors detected when arriving at the site(yes or no): 6 E Page 7 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125, Carlotta Ave Hyannis,Mass, Owner: Robert Somerville Date of inspection: 2/28/01 BUILDING SEWER(locate on site plan) Depth below grade: it't _ Materials of construction:�_Q cast iron _Z, 40 PVCitJll-other(explain): NA Distance from private water supply well or suction line: id,1' Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight-No Pyidpnrp of leakage System is vented /Iec'qh�5 through the house vent. SEPTIC TANK: Zlocate on site plan) Depth below grade: ,i,P Material of construction: concrete VmetalAM, fiberglass 4L_polyethylene /J4bther(explain) /✓ If tank is metal list age:A)Q Is age confirmed by a Certificate of Compliance (yes or no):4)4 (attach a copy of certificate) / Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: _ Distance from bosom of scum to bo om of outlet tee or baffle: C1 How were dimensions determined: ,M 47 Comments(on pumping recommendati ns, inlet and outlet tee or baffTe condition. structural integrity, liquid levels as related to outlet invert, evidence of leakage,.etc.): Pump septic tank every 2-3 years Tnl Pt R nutl Pt• tees are in place. The tank is structural sound No evidence of leakage GREASE TRAPA/. ., (locate on site plan) Depth below grade:A2 Material of construction:A�*concrete,jmetal +3 fiberglass�c olyethyleneoother (explain): ,vie Dimensions: A�3 Scum thickness: _ A),4 Distance from top of scum to top of outlet tee or baffle: 4 Distance from bonom of scum to bottom of outlet tee or baffle:_A14 _ Date of last pumping: AO Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Grease trap is not present 7 Page 8ofII OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Carlotta Ave Hyannis asq Owner: Rnhprt RnmPrvi 1 1 e Date of Inspection:?I/?A /n 1 TIGHT or HOLDING TANK:¢(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: AM Material of construction: Aconcrete�P metal,t)A fiberglass A&I polyethylene vi _other(explain): AM Dimensions: A Capacity: Alh gallons Desien FloA: a gallons/day Alarm present(yes or no): _g&_ Alarm level: 4)4 Alarm in working order(yes or no): Date of last pumping: A Comments(condition of alarm and float switches,etc.): Tight or holding tanks are not pres nt DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:AL— 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.): ; Distribution box has two laterals No evidence of solids carry over Nn Pvi HPnrP n 1 aakage into o 61ilt e-f the bex. PUMP CHAMBER• �j (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is not present- 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 25 Carlotta Ave Hyannis,Mass. Owner: Robert Somerville Date of Inspectio : 2 28 01 g-/" 6 t- A SOIL ABSORPTION SYSTEM (SAS): il (locate on site plan,excavation not required) If SAS not located explain why: e-'4 r Type leaching pits, number: v� tleaching chambers, number: >D leaching galleries,number: O A0 leaching trenches,number, length: G� ,Vb leaching fields,number, dimensions: t'y overflow cesspool,number: _ r�7 innovative/altemative system Type/name of technology:lsT. �.. 2 Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to fine sand.No signs of hydraulic failure or ponding. Soils are dry-Veg a -ion is normal _ Both 1 aching pits are presently dry. CESSPOOLSy✓�(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 laver: AM Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Cesspools are not present. PRIVY:/ i (locate on site plan) Materials of construction: AM Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Pri u > i g nni- prrpGeni- 9 Page to of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con.inu.ed) . .... Property Address: 125 Carlotta Ave Hyannis,Mass. ' Owner: Robert Somerville Date of Inspection: 2/28/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. • � t I r 10 Page 1 1 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Carlotta Ave Hyannis,Mass. Owner: Robert Somerville Date of Inspection: 2/28/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water , � feet Please indicate (check)all methods used to determine the high ground water elevation: Aoiined 'r m s stem desi tans on record if checked,date of design plan reviewed: ervsite a uttin roe / bservation hole within 150 fees of SS S) with local Board of Health-explain:j) �f5 : Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used Water Contours Man_ Gahrety fG Mi 1 1 Pr 12/1 6.194 1 ► y•...+nr+•—n.rr�-rr•aenrrn•neen.s••nn r�rr.rrrn:•.�+ea,.n+mt*mnanrnnu*�-�a�snnn+ .rtr-�••r-w--a•-. - _. .' TOWN OF Barnstable WARD OF HEALTH _•Y-' -_ r^Sl1IfSURFACF 9F.HA(;F DISPOSAL SYSTEM INSPECTION� FORM - PART D^T CEIZ'f�1 FI Cr1TIUN r -TYPE OR PRINT CI.EARL1'- P/lOPERTY INSPECTED STREET ADDRESS125 Carlotta Ave Hyannis,Mass. ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Robert Somerville PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Intt: COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 nl CERTIFICATION STATEMENT 9 I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations 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 : _/�ISystem PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public 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 form . System FAILED* The inspection which I have con\___�ucted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature 4, //A Date ne copy of this ce ification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF IiEAL7111, - It the inspection FAILED, the owner or"�oorator shall u� P pgrado ' the ayetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 16 , 305 . partd . doc '_LOC r 7/ 5EW&C�E PERMIT k10: LI�I.STI�LLE-R�S_1J_�tJIE__�_ADDR�ESS l DATE_ PE.RNAV. _ISSUED ==-. 1. 75�/-_-___-_-._ -------- ----- - D-ATE-COMP_LlWACE_ � c�2�'" �� � � w , 1 � !Y' � � 3 �?..� ��� . ..-�t ---.. J r Td No..... ................... Fsa ��................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ^ - -------.OF.......... ��.� !s ., ,�................. Appliratinn -for Uhipoiittl Warkii C onstrurtion jJrrufit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: Location-Address or Lot No. r� � C.. ............... wry _ i p _11�� ----./sz r✓ice Owner Add r ss Installer l' Address Q Type of Building Size Lot Z� ......Sq. feet Dwelling—No. of Bedrooms..-3 ------------------------------------Expansion Attic (4'0 Garbage Grinder (A4) Other—Type of Building _- ic� +�C__-._-_- No. of persons___________________________ Showers ( ) — Cafeteria ( )�. Q' Other fixtures ............................................ W Design Flow-- � �_______________________________gallons per person per day. Total daily flow _____.________.______..._.._..gallons. P4 Septic TankLiquid capacity�006gallons Length---------------- Width................ Diameter----------...... Depth-----.--_-.-._. Disposal Trench—No. .................... Width.................... Total Length.........._......... Total leaching area--------------------sq. ft. Seepage Pit No..�j__<_t(!< __ Diameter-------------------- Depth below inlet-------------------- Total leaching area---------------__.sq. ft. z Other Distribution box V ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------_-------------------._ Date--------------------------------------.. a Test Pit No. 1-----------------minutes per inch Depth of Test Pit.................... Depth to ground water...---------.----------- f� Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water............---------- .. R+ ' '--•-"-••------------------------------ Description of Soil-_ !A` — -- t� .���c — ct " 7 = ` = 1 t'- . - ' x rri ..t V ---------------------------- -p.:-t = .: �+. -..<- .c.... , ,��n --- -- --------------------------------= --�.-_.---_---_J.�y_......I---K- L....._`�.� _�✓___'A____ 'w!t1� _ __l_--______.--____---__-_-._--_-_-_--..-___--._._-----____-__---- v Nature of P.epairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------- ............------------------------------------------------------.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been " ed by the •card f health. 7 �` Signed.-/// "` ��/l��{t�l 44. Z. -•----•-- •- Date Application Approved By-=---%�. ....`_`/- .......... ''` �t---------------------------------------- = " ------- Date Application Disapproved for the f b'low g reasons-------------------••----•-"-----•-----•-"------•----------------------•--•--•-•---•--.----- •------------------ --------------------------------------•••---.--•---•-----------------------------•----•----------------------------•----------------•-------------•--- --...•---•----•-----------------••------.••.----- p2/— 73 _Hate PermitNo......................................................... Issued...........11-------- ............---•------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. ............--- OF........Lhrl, Appliration -for Did uiittl Worko Cnotulrurtion Vrrmil Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: C.JyL GTrh' E ' &N'c� Location.Address or Lot No. �.. _ N%r _.................... . " _�N.��_L elf- v��- - -------- Owner Addr ss a r y v s • -CC-- �i//� .... _s s------------•------------------- Installer / Address �. Type of Building Size Lot/o__ _ _ ..._.Sq. feet Dwelling—No. of Bedrooms.__3-------------------------------------Expansion Attic (NC/) Garbage Grinder (A,(C a q Other—Type of Building p., yp g ---/ll.�.!!!f- ....... No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ __ W Design Flow gallons per person per day. Total daily flow,�3�d.............-----------------gallons. Septic Tank Liquid capacity J_O0G_gallons Length................ Width................ Diameter................ Depth.-------__.-.._ xDisposal Trench—No____________________• Width-------------------- Total Length.................... Total leaching area--------•......-----sq. ft. Seepage Pit No..l---CtC!.2.. Diameter.................... Depth below inlet.................... Total leaching area------- ----------sq. ft. z Other Distribution box V ) Dosing tank ( ) aPercolation Test Results Performed by------------------------------------------------------------------------- Date-------------------------- --------- ... a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water..--_____-_--__-----.--- GL, Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water--._-----__.-_--___..... tx ------ ----------- •--•---.•... -------------- �= .. .�'-- --•-----•----•---•--------- D Description of Soil. 6 `rD -- — ` -' x --i--------------------------------------- U r-� W - ---------------------------------------------------------- ------------------ ------------- --• / ------ .e --------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------............................ . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ed by t pard f health. Signed --- .... �1/I--6& `----------- — � --� -- Date Application Approved By----- . .. •-------•-------•.--•------•-•--------------------------••. - 7 Date Application Disapproved for the f to g reasons:----••---------•---•-----•-----•-------•-------••-•-----------•---•-------••---••--------------------•---------- --...-------•.............•-•------•--••-•••-•---•--••-----------•--.._....----•---•--•-----•--•---•--•--.._---•------........__.......-----•---•-•----•--•---•--•---------•...._.._..--------••-•------. Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH �........OF........ .. 1. �? �`' ..................... rrtffiratr of f ompliaurr -- T S IS TO TIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b ' �'Sf+ nstaller has been installed in accordance with the provisions o Art' , I of The tate Sanitary Code as described in the application for Disposal Works Construction Permit No. __-_-'S_._.__L__. ._____------ dated.--._`a.__-____5- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................---------------•----------------------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA"J_%t__4U'1cV ............... FEE /---a............. tt �ark,� �a�t.�trttrti�at �rrmit Permission 's ereby granted___"' 6 .............. .. _ _ ................................................... to Cot ) Re.qai. ( ) - Indiv' ual ewage Disposal S s m - t I at No./. = L .......... .... Street as shown on the application for Disposal Works Construction P m No -•--------1_'___ tted_._.____.`_ •- ..... ...... . ---• ------• .........-- - ------ v(--- -- oard of Health DATE_.`".. °2__/�_ 75� FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Z0T �6 9 Al S9 2cq a J o /Q zBS SQ.�r �-- Q �--- 30 --�- o QQ p � 0 Lor A 93 ' CEO TiFiFO �LoT PL.9N . !ac'qrion. %,VALSs, ScAt E / 20' axe GW. i9 PZAN :FO.Q .POGk/iV �P��GTy T.E&Z7' ANQ DEC0&6" .eE6/STley OF.• 44--"-S ^I UN T•`/i.i AL�l . �r,�..� _ �•,,'`�'. GONF'O.�°/`9� TU >.+,E ZON//VG L�9Gt/S iw 7oc j/v o/= .Bi9ieiv.S li9AaL E • ,9.oe/� z�/yes ��• • �' -�"� L-Vivp ,S&,e Ve Y TOWN OF BARNSTABLE ; .00ATION SEWAGE # r VILI AGE ASSESSOR'S MAP & LOT ` INSTALLERS NAME & PHONE NO. SEPTIC TANK CAPACITY 0C)0 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER - DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t�, 4 ,. � � �� \�� .. \ 4 >. /� \ � � �,r� ,� � � �� �M /� -� —\© a e uJ > >__ L l l No... -� .00......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH APPROVED TOWN OF BARNSTABLE ® stable Omorvetion Department Applira#iun for Biipuiia1 Works Tom4rnrti amn Date Application is hereby made for a Permit to Construct ( ) or Repair NXX) an Individual Sewage Disposal System at: 125 Carlotta Ave Hyannis ............ ._......... -•-.......................... ...... ------• ..............._..-•-- L cation-Address or Lot No. Nathan Auerbac$z •---------------------_.._... - - ................................................. ..........-•...................................................................................... W J.P.Macomber Jr Owner Address Installer Address Type of Building Size Lot............................Sq. feet 4 U Dwelling�No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ....... No. of persons............................ Showers � YP g --------------------- P ( ) — Cafeteria (-----)- Otherfixtures ........................................................--------------------------------------...--•-•-•----------------- 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 of Test Pit.--------........... Depth to ground water-..--.-..--------..-,... �r4 Test Pit No. 2................minutes per inch Depth of.Test Pit.-- ................ Depth to ground water........................ P4 -•----------•--------••------•--•-•-----....--•-•-----•------------•---------•--•............................................................................ C) Description of Soil........................................................................................................................................................................ _Sand...&...Gxa.val................................................................................................................................................................. UW •-----------------------------------------------•--:------------------------------------------------------------------------------------------------------------•-------•--------------•--------------- Nature of Repairs or Alterations—Answer when applicable............................................................................................... 1--1J!JQ__ -�llpn leaching �it...P.acked In stone. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian e has be is ed y the boa of health. Signed = 11/_2/_92— --- :.:.- Date Application Approved By . -�. ----- ----------------- ��--- Date Application Disapproved for the following reasons- ................................. ------------- ------------- . ..... -------------- ---.------.........---...... -- -- --- ------ --------------- --- ---- -------------------------------- ---- ----------------------------------------------------------------------------------------------------------- .................................. Date Permit No. ��"�� �'------ --- -----------�✓..... .....---....--------- --.. Issued ...................,��-. -----��-..... ------------ Date FEa...30a.00...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrurtiodprrmit Application is hereby made for a Permit to Construct ( ) or Repair Y(XX) an Individual Sewage Disposal System at: 125 Carlotta Ave Hyannis .......... -- .... ...... .............................•---..__.....------ .......................................................-.......................................... Location-Address or Lot No. Nathan Auerbach - -----------------------.-..... .............................................. --•••-...•-----------•......•••-•••-•-•---•---........-----••....••-•-........................---- W J.P.Ma e omb e r Jr Owner Address , Installer Address Type of Building Size Lot----------------------------Sq. feet I—I Dwelling;v No. of Bedrooms........... ...............................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Buildin yp g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ---- W Design Flow............................................gallons per person per day. Total daily flow____-----.-----_---------•-----_............gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of.Test Pit-----__—.......... Depth to ground water........................ P4 -•--•------------------------------------•-•------•••---------•....•----....-•--• ---- .---- --------------------------------- •....... "..... •----- ••-- 0 Description of Soil...............................................................................------------------------------------•-----------------------------...........---._..._.. U Sand... ................... -----------•--------------•--------.......------------•--------------------------------------•--•-----........---•-•-----•--•••---•-..........-- W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ........ -] DO...g-a_flan...1_ea_ching._p t.-Aacked...in-stsne.---- ----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is uedd by the boa�, of h`ealth. Signed -- � ....--- - '�------.-------r--�� -- ------ ---- r Date Application Approved By `...-.- -•,!! G '-- --.. �� ` 21.. - ........... �' r (J Dace Application Disapproved for the following reasons:. ..................................... .-----------.---.........--------.....---- -------------- .------ - - -------------- - -------------- --- ------------------ --- --------- -- -------------------- ------------------------------------------ ------------------ -----------..................... Permit No. ,+ -. ------- Issued -��.......:� .. t ...Date------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE V er ti i a e of G raylian e THI ISJO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired Y(XXX) Jr.by.....................*"acomber --------- -- --------------------------------------- --- ----------------------------------------------------------------------------------------------------------------- Installer at ........125.... a.rlo.tta..--Ave--.H.v..anni.s----------- -- ---- -------------------------------------------------- -- -- -------- -------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. , , .A.. c! �' dated ...// -- ...- .� THE ISSUANCE OFi THIS CERTIFICATE SHALL NOT`BE CONSTRUED AS A GUARANTEE..THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE - -------- t.. ���v,--.#-�------------------------------ Inspector ---- o-----...--------.. :.--..._..�_........... --------------1 j THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE $ 30 00 No.............`......... FEE........................ Disposal Works Twnnstrn.dUan .rranit Permission is hereby granted..... .._Jr... to Construct ( ) or Repair `(Xl� an Individual Sewage Disposal System atNo..... ('ax].otta.-..Ave_...Hyannfks...................................................................................................................... r Street 7o--I ��� M as shown on the application for Disposal Works Construction Permit No."tl ".__ ______________ Dated_._._��__.__ _._._.___ �.`.�._.. Board of Health: .......... 77----------- ......................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS - i EXISTING I ' ill I� 11 i �;II it L, r% o UlUl U. m } u 1r - ADDITION REAR ELEVATION SCALE: 1/4" = 1'-0" w ,I a > a � w - - < Q U 1O SWEETA OF 3" ADDITION ADDITION EXISTING EXISTING fi RIGHT ELEVATION ' LEFT ELEVATION SCALE: 1/4" 1'=0" SCALE: 1/4" - V-O" 108: 0517 DRAWN BY: KW DATE: 9/q/05 V - _ -- -- -=-==- =--=-===== - ------ \ PIT r. - III �------ / i i SEPTIC ( I TANK I - -'�� • 1 ADDITION TT Tr 13'-0° _ 12'-0" NOTE: \ll�) 7 WINDOW DESIGNATIONS ARE I I (3) 31 1/2"x W" 242I0 ANDERSEN WINDOWS. l II STORM DOORS- I I T _ CONTRACTOR SHALL VERIFY LOCATIONS 4 DIMENSIONS PRIOR r TO WINDOW ORDER 4 INSTALLATION � .�,Ii I 7 1 Y NEW WALL � � `a 11 i NEW NEW I NEW 111`t�p -I. DECK I I SUNROOM I KITCHEN REM n : OVED WALL I.. " ... I I P5510 ) IIO w i I EXISTING WALL i I i I u) REF. . P5510 I tl 2) 9 1/2' LVL BEAM LU , m 1 I I LI.J LU i II � III II u Q � Q EXI5TING EXISTING N Q J n FOOT PRINT { C, ,E IL (1 I Q v Lh - i I iSHEET 2 OF 3 Jc - -- 44'-0' FIRST FLOOR PLAN SCALE: 1/4" I'—O" JOB: 0517 f DRAWN BY: KW DATE: 9/9/05 . s-lo° r' 4r I ------------ ------------- . . _ j In o- I j I- i �2- I -2x8 RIM JOIST 4x4 P.T. P05T GALV. METAL POST ANCHOR ni I i I I 12" "SONO TUBE" PIER TYP. III I % I NEW z of ' Iyu� CRAWL SPACE VAPOR BARRIER Wo III - I 30 �I I II o iii o I ; a x III x IL d 0 6.COURSE 8'.CMU.WALL a w I I 10'xl6" CONTINUOUS FOOTING CREATE ACCESS OPENING �✓/ �, Illl�� EXISTING BASEMENT �I FOUNDATION PLAN k'. 1I SCALE: .114" dP) �1� 1 E RIDGE VENT I. ASPHALT SHINGLES 12 5/8' CDX SHEATHING MATCH EXISTIN4 *8 p r 2x8's P 16' O.G. R 30 F.G. INSUL i - _ \�e0 LLA �Ix3 STRAPPING i6ro y+, 112" GYP. BOARD C 1x8 FASCIA - Z 8' VENTING SOFFIT W Z KITCHEN SUN ROOM ALUMINUM GUTTERS t DOWN SPOUTS Q O FRIEZE BOARD AND MOULDING _ LIA 3/4" PLY SUBFLOOR -.-. _ - - 2x4 STUD WALL / R13 F.G. INSUL. N RI9 FIBERGLASS INSUL. _ _ _ 1/2' SHEATHING / TYVEK (OR EQUAL)/ W.C. SHINGLES (L —1 i . MATCH FELXOIOSRTING— ov ONII .II II II TRIPLE T JOIST OIST UNDER WALL II 2-2 x8 RIM JOIST IST N Z U xe aOR 10' OG. P.T. Q GALV METAL ANCHOR J 84 GMU WALL 12" 'SONG TUBE' PIER TYP. fL CRAWL SPACE 6 MIL VAPOR BARRIER 1. o U. U SWEET 3 OF 3 SETIA 4 SCALE: F 1/4n . JOB: 0517 DRAWN BY: KW DATE: 9/9/05