HomeMy WebLinkAbout0048 CHERRY STREET - Health 48 CHERRY STREET, HYANNIS
A=309-122
1
1
I
TOWN OF BARNSTABLE
/ .' r
LOCATION �B �6ir�i�ly SEWAGE# `rLQI® =3(g
VILLAGE ASSESSOR'S MAP&PARCEL:n lit y
INSTALLER'S NAME&PHONE NO. Tf(G J`(,
SEPTIC TANK CAPACITY tOQ® j S'I�o N
LEACHING FACILITY:(type)1 jhA+qt Vo rj (size)I'ROUDEE C� S'
NO.OF BEDROOMS 3
OWNER CyIUCAA4
PERMIT DATE: COMPLIANCE DATE: I ��
Separation Distance Between the: Sidi'te._n .Q
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 SC Of-r' &CvJ1C
F
s
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIPPYtcatiou for Migo!w �&pgtem Cow5tructiou permit
Application for a Permit to Construct( ) Repair(v4 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. `A izg.y���S(y S.N- Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
s
Installer's Name,Address,and Tel.No. De igner's Name,Address and Tel.No.
Yr
Type ofgilding:
Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required)_ Z 2 0 gpd Design flow provided t., gpd
Plan Date AS41
I Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
W
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) =' L C)Cti�-{-1
I 7 : rper. �y ��1 �„��-r ( . � sc%j &J
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this B"Loard of Health.
Si e Date
Application Approved by Date alilio
Application Disapproved by: Date
for the following reasons
Permit No. ��_��^ 4 Date Issued
'No. 1�/v 365 Fee /v
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBS IC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for Oigool 6pgtem Construction permit
Application for a Permit to Construci( ) Repair(,gyp Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components'
Location Address or Lot No. L � ��� �� Owner's Name,Address,and Tel.No. d
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. De igner's Name,Address and Tel.No.
SCOT ,r:C"YL. Xw R� t
Type of uilding:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) `�'2 Q gpd Design flow provided gpd
Plan Date ��� (�6� Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. k 0 VA aC> �t �
Description of Soil me
T
Y�t
Nature of Repairs or Alterations(Answer when applicable) C_-c C p
Date last inspected: }
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place,the system in operation until a Certificate of
i Compliance has been issued by this Board of Health.
Si 11 e Date G1 C7
1
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. U 3�,_,5 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance , ---
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired') Upgraded
Abandoned( )by So.
at C 5,. r#- r has been constructed in accordance
with the provisions of Title 5 and for Disposal System Construction Permit No.
e dated U�
Installer SCo �r r ,. y( Designer�`5 - WC: G 4 e
4 bedrooms Approved design flow gpd
The issuance of t s pert it shall not be construed as a guarantee that the system will tune o as designe .
Date 1 / 0 Inspector
No. !1JL Fee
- - THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
t XDi!5po!5a[ Abpttem Construction Permit
C
Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( )
1 System located at t `,
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the da e' fo thi emnit.
Date 30 Approved by
Y
P
'Rug 09 10 09: 00a p, 1
R,
'own of)3:x-.jLstab1e
rI ?
Dctmrt[nelrtofR ;ldatorpScrvicC4
Public hcalfb Division
araZA MA 026Ut
""� $ 200 M.in StrrrC Ilyruus
°6sM1
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Tcc
D;rta Scbcdulnd
$Oil SuitabilRy A..ssessr{zadfor S'e �ag*,C ISPOS
�Q A. Q.� W i�erd 1[p:f �-�� -•�- 'F
Fwfornad By'...
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r f C pwn<,rsNnme •.".
��i1L1i'� Sll-�Sfb
luwaod Addrest ' Q.t•i
Ynr i Address . N fArIJ.J•N
Aasu,59r'sMaplPateeC ja (22- 1 Pnfinctfs}jsme E)kc_ro.^ A,
!SV Baru,RUdjmty G�b G 2 i 2 Z
um Use
. ' ° nQidP.wat�l w�1t��
Z 4
Disla�4+xs GOm' t11�Wpter Oatr�OO f[ 1'dss�hle Wei Atea 7: S't 17fi
l d v R rfnpc,lyDnc_ r _R OarFr—
YY I)raim p War—_—. '— ,
,�'Z(ETC ■:SSlrac n9rrr.CimmsWt6'of Iu4 tFar.L haaiirms ul[M1kl ln)Us&9��IaIS luGr[°WdlatrdS io pr0>omilr to hcl«)
Tlj
ty
r
P�centrnatnial(gc�W(�c)�-- --
p l}prn PIK rr6t.+ —. �•
rky1h to Urnandun{dr:Stanrang Walerin Halt:_I..: ti�1+. _ Wee lns!
Cstidmted geysrmpllf'iRh(Cpundwata
DATE ATION FOR SrASO�AL HIGI i WA,Tr"t TABIX '
Morhdd U•& iu Uepth to 5011!mottles:
rxpa Ot>gr�atitandingwtdss Mlle _-- i in OtdundwbWrAdJdsmwt_•�....�-�-••-
I]epar trrlweepiny frtdh&dc of(ft.h0e:_ �...���••�•�• faetor...�.�A.CM-d--tevA,,,... `.
}teadiog Urue—-- Fndex W�L 1cYEl A4• .
RCOLAT% N T ST . nm.�
()IrceNali[m Timm at 4" -�•��
at Nc-snavrimc 2.1 ----
r,n6 rsarrrax
Rale tvT•in/1nc1r ——j—��=—�~
--. .••y—•— Ac6fitl[1dalT�t"36'NecQe�1(Yl1d) .
,rim C�ilaL•_—.—.--
SilosuirabiliryASdryraUetrt• Silc l'asxA X {
pr4gidoc L4rUGc tlr}tth uivisirm Obsr:ivatinri 1Lo1a 1)ataTo 73t•('ontpkted on AacK------ .
i.'
Rr*u itCrculaa�i0u test Fs to Uc.cx,nt)rrteJ wi/bin XQQr of wctlstltd,Yola uaust first nUtity t11c
XSartLstjtUjc C:RSsllscrY2tiOn X)ivisuon ail.Least one(1)wcCk(STiOr ttt bcl;MnrLlnly,
•,19ug 09 10 09: 00a p. 2
�P
r
pEl�,p 0135I,RVATION D.IOLI
Snil'1'exlmt
Soil Catnr Soil m.SLOW,
UeP,h from ggitlWf»sm Muns��l Muffling (Shuoxwe,SWnex,Uw rs• —
su+facc(in.) (USDA) ( ) , fig Gravcll —
FG
II t � � to�S -1� - —c rannvl,.•r
balf *,On
LEI, �_ J
UEEI'Yz-
013SERVATION HOLE LOG Dole#_
i I C.uk- soil Odra
lkgkhr-nm SOil Floc jinn Snil'rW.rllre M—n) Mnulinx (Sln.elum.Srnnts.BOHIders.
tiurGuefinJ (USIA) ( Siylcncv.rd s 1�_
not_• L 1[� M �k_A[.�- �C, fJ�'�'I✓ —h� _. — —
��I 14t911
, —t�ij— Ulrmm, A(
c ) Y —� p
- I.— —+ — -ILL
- rsSan��y'
f)EEl'OWARVATION 11'O1,TEOG
sailr DIM Snit Other
So>it Hrnixuu Suil Ycxlmt p�r��,glnocs,Ilnuldcss.
Dcllrh fnm� �s1yA) (Muascl9 MNlliag tsunxix(GOr�rl�.sjr�--
-__ _ - - � - - - 1
l,,EP OBSI.RVATION IIOLE 1.OG lIolo#F
Suil Ttxtulc Veil LLlm' loll (Mier
DtPlh frv,n Suit lirvinurr Mutllinx (ShutrnrW St$tnnc8.Houfdors.
s,.rtacs(�.,.) a..` (()SDA) (Munscll) Or,vdI
Flood Xng1IrRnIre R"O Mu 1:
Ahmc Sea yc#fllnal lxlrn"Y No Yt'�..—
.W add SM Mm I-4u)• No Yes .
W ilbla I DO year hood hounduy No. : Yes—
Pc th nE)yaturull t)mrrrin 1'e (ouK Mntrll 1n1
Dies at(cast frlur feet of ttaturdlly occurring pcRr""Elal?
sist in alltrey n(lserved thNughout the
;rrea pnlposed for the soil absorption system? .lfnit,whatisIhodepthofnaturallyoce.urrint.
" 'eRITCntinn IL� .0
1 t:ertily dlat on I l�—(date)I have passed the spit evah,utor examination appnrvtd by the
Departrncatt Lnviron cafe protcctien and that the above analysis wa-K lxerferntcd by me consistent with
tfu regoircd liar i ti,expo tend,experienc:o desedhed in 310 CMk 15.017Date
(}.�yAf'SSUI'l7RCFt)RM!>i)C'
F
Town of Barnstable
OF ZME 1p� /
Regulatory Services
YntwsrnBLE Thomas F,.Geiler, Director
MASS.639•
i Public Health Division
639 ��
"A°'�A Thomas McKean,Director
200.Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: ® Sewage Permit# Assessor's Ma \Parcel
Designer: �� ( A, "AA!, PE Installer: 5essrr__ q.
r= L-e- Su RN ��=G, l uL,
Address: qZI p-& ,z e,A Address: i13 pL'D Y/ 9_K6-c7r+
Yr-R+d av-n+Fb a- , HA- azt,-j H YMj�r S, Nt . y2" i
On J� _ t,(,� }L. was issued a permit to install a
(date) (installer)
septic system at � ,
�� 5w,,CarNk based on a design drawn by
( dress) I
le�P H � A. 1-�•1��j }'�E dated
(designer)
,ZI certify that the septic system referenced above was installed substantially accordingto
the design, which
c may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
----ALstaller's Signa - q
AL
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH.THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic\Designer Certification Form Revised.doc
Commonwealth of Massachusetts A
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS
required for MA 02601 3/10/10
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information
I
forms the
computer,
r,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not use the return Name of Inspector
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145
Company Address
( CENTERVILLE MA 02632
City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
u-1 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
f— Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
Glty C14
MT,❑ Needs Further Evaluation by the Local Approving Authority
�X
01
�-- / 3/10/10
In ector'P19nature Date
zz
The system inspector shall submit a copy of this inspection report to the Approving Authority(BDaFA
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system Cr
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submitthe
report to the appropriate regional office of the DEP. The original should be sent to the system over
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-09/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
D
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS required for MA 02601 3/10/10
every page. Cltyrrown 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:
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-09I08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. CltyfTown Date of 0
State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
ass inspection if
p p (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):
I
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•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Properly Address
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. Cityrrown Date/10
State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**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 Y2 day flow
t5ins•09N8 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
p Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS
required for MA 02601 3/10/10
every page. Cityfrown 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
� El ® 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 ri p vate 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 f ils. 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—I WPA)or a mapped Zone I I of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered'yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CM 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins-09/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS
required for MA 02601 3/10/10
every 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
approximation 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 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•09M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�t 48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS required for MA 02601 3/10/10
every page. CltyrFown State Zip Code Date of Inspection
D. System Information
Description:
SEE AS-BUILT ATTACHED
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 years usage(gpd)):
Detail:
HOUSE VACANT
Sum ?p pump? ❑ Yes ❑ No
Last date of occupancy:
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS
required for MA 02601 3/10/10
every page. CitydTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
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):
r t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS
required for MA 02601 3/10/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
S.A.S INSTALLED IN 1998 ACCORDING TO AS-BUILT
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:
feet
Material of construction:
❑cast iron
❑40 PVC El other(explain):
Distance from private water supply well or suction line:
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑ polyethylene
y ❑other(explain) �
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 GALLON
Sludge depth:
t5ins•09M Title 5 Of ctal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yr. 48 CHERRY ST
Property Address
Owner Owner's Name
information is
required for HYANNIS MA 02601
every page. Cltyrrown Date of Inspection 3/10/10
State Zip Code
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
l5ins•09/08 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal 8 P System•Page 10 of 17
e•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is
required for HYANNIS MA 02601 3/10/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be at time of inspection)
pumped p n) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09N8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS required for MA 02601
every page. Cltyfrown State Zip Code Date of Date of 0
Inspection
D. System Information (cone.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0"WITH STAINING ABOVE OUTLET INVERT
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
STAIN LINE IN D-BOX ABOVE OUTLET INVERT
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS required for MA 02601 3/10/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
INFILTRATORS
❑ 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.):
EXCAVATED DOWN TO TOP OF S.A.S HEAVY SCUM AND STAIN LINE AT THE TOP OF
SYSTEM INDICATING HYDRAULIC FAILURE
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•09N8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS required for MA 02601 3/10110
every 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.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is
required for HYANNIS MA 02601
every page. City/Town Date/10
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
t5ins•09108 Title 5 Official Insp
ection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS
required for MA 02601 3/10/10
every page. Cltylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑. Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation
Accessed USGS database-explain:
You must descnbe how-you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09,08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'( 48 CHERRY ST
Property Address
Owner Owner's Name
information is HYANNIS
required for MA 02601 3/10/10
every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
New Page 1 Page 1 of 1
TOWN OF BARNSTABLE
LOCATION _ �� CA 4,t-$e - SEWAGE#y S�a,Y 15"
VTU.AGE_ ASSESSOR'S MAP&LOT O LL-
INSTALLER'S NAME&PHONE NO. /
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) U t.Y✓ ��(size)'
NO.OF BEDROOMS__ 3
BUILDER OR OWNER
PERMITDATE• L/ - 7- `,� $ COMPLIANCE DATE•
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
v .
3
I�` ttp://www.town.bamstable.ma.us/assessing/2010/HMdisplay.asp?mappar=309122&seq=1 3/12/2010
t
Town of B• r nsta.ble. P#
Department of.Regulatory Services
Public Health Division Date S
press
s639 per 200 Main Street,Hyannis MA 02601
Date Scheduled �7 �0 Time_ Fee Pd. /
i
"Soil Suitability Assessmenifor Se age isposal
Performed By D',-'-' ` " M L V- Witnessed By:
LOCATION & GENERAL INFORMATION
Location Address .41 �'P --F_a p Pt - j Owner's Name 4 GG 0 P SSTl
Address >`liS
// 1 Y
Assessor's Map/P4rcel: Jog/1 7- I Engineer's Name 2J�. ,.� k>
NEW CONS1RUt�`170N REPAIR Telephone# �v% 36 Z-.Vq ZZ
Land Use ,S l Pip 'l Ad Slopes(�o) �5 /a Surface Stones
Distances from: -Open Water Body 7 20 i5 ft Possible Wet Area >2_D ft Drinking Water Well 200 ft
Drainage Way it. Property Line ��� _.ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&petc tests,locate wetlands in proximity to holes)
1
-2-
C Z
Chu 5�.' CD
0
co
F c ftE KY
Parent material(geologic) ICe GLOL �v� w,5LS 1\ j Depth to Bedrock
Depth to Groundwater: Standing Water in Hole:' i Weeping from Pit Face
Estimated Seasonal0gh Groundwater
D : ATION FOR SEASONAL FIIGII WATER TALE
Method Used: In.
Depth obperved standing in obs.hole: _in. Depth td SOU mottles[ 1
Depth toiweeping from side of obs.hole: ? in. Oroundwnter AdJusttnenth
! _ A factor - Adj.OroundwtlterLevel,,,,e. a
index Well#— Reading Date Index Well level - g
Date Time S
PERCOLATION TEST
Observation I I Time it 9"
Bole#
C1 {'� Sam Time at6" .....
Depth of Pere
IE
10
Time.(9"-6") ..._..-- —
Start Pre-soak Time.@ t
End Pre-soak
L
Rate MinJInch
Site Suitability Assessment: Site Passed
X Site Failed __— , Additional Testing Needed(Y/N),
Original:.Public 1141th Division Observation Hole Data To Be Completed on Back---------
**If percolation testis to be conducted within 100' of wetland,you must first notify the
Barnstable C44servation Division at least one (1) we6k prior to beginning.
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel
an- (
%1'-15D C-Z 44 2-SY V b oa fanL'lAr
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel)
Lo b sib
tl_ d c� 21 r!G p Y�►'
. �� _a�H G�, a►� Co �Gj . ass � ���
ALL Steel 21
DEEP OBgRVATION HOLE LOG Hole# 1A
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) SDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
consistency. ra "I
Flood Insurance Rate Map:
Above 500 year flood boundary No Yea
Within 500 year boundary No Yes,,
Within 100 year flood boundary No_ Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring per ous material?
Certification
I certify that on �v (date)I have passed the soil evaluator examination approved by the
Department<Environ enta Protection and that the above analysis was performed by me consistent with
the required tral t ,expertis and experience described in 3,10 CMR 15.017.
Date
Signature
Q:\SEPTIC\PERCFORM.DOC
- it
TOWN OF BARNSTABLE
-OCATION
SEWAGE
VILLAGE ASSESSOR'S MAP&LOT •30rf-12�
INSTALLER'S NAME.&PHONE NO. r a
SEPTIC TANK CAPACITY
-LEACHING FACILITY: (type) U tA✓.fi (size)
OF BEDROOMS 3
BUILDER OR OWNER
> PERMTTDATE: U - 7- COMPLIANCE DATE:
Separation Distance Between.the:
Maximum Adjusted Groundwater Table and Bottom.of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site.or within 200-feet of leaching facility) Feet
>rdge of'Wedand.and,Leaching Facility{if any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
vP —
WIT
T
I
COMMONWEALTH OF MASSACHUSETTS
[ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
Jdt „ i DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
r:
f.
V
I TITLE 5 `
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 48 CHERRY ST HYANNIS,MA 02601 � \��
Owner's Name: ALLISON TODOROFF
Owner's Address: 48 CHERRY ST HYANNIS,MA 02601 C��44
Date of Inspection: 10/29/01Name of Inspector: (please print) JOHN GRACI PV
2QCompany Name: SEPTIC INSPECTIONS �rMailing Address: P.O. BOX 2119 TEATICKET,MA.02536T�&<�
Telephone Number: 508-564-6813 FAX 508-564-7270
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 4 '„
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
I
X Passes {
_ Conditionally Passes
_ Needs Furth r yvaluation by the Local Approving Authority
Fails
Inspectors Signature: Date: 10/29/01 ,
Z X
The system inspector shall submit 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 r :;
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ,
f
° Notes and Comments
THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG � .
THEY SYSTEM'S USEFULL LIFE.
""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 f 3
Title S Tmnrrtinn Form h/I50000 0 I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _
{
PART A
CERTIFICATION (continued)
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01
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:
THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG
THEY SYSTEM'S USEFULL LIFE.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, t;
upon completion of the replacement or repair,as approved by the Board of Health,will pass. x-
Answer yes,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please explain.
n/a 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 inspecticn if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a 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: n/a
n/a 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 theaBoard of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01 '
C. Further Evaluation is Required by the Board of Health:
i
_ 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 Y-
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 f
supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is 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.
-1 r
_ 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 dsed to determine distance n/a = '
i
"This system passes if'th&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 'r
of the analysis must be attached to this form.
3. Other:
n/a
3 l
� v
.I ;
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMjl
` PART A
CERTIFICATION(continued)
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
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 3
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 '/z 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 nla.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
' _ X Any portion of cesspo4or privy is'within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or,privy,is within a Zone 1 of a public well. N
X Any portion of a cesspool or privy is.within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for 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 s
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.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. '
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 9200'feet of a tributary to a surface drinking water supply
;.%,q
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped r
Zone II of a public water�supply well `
E
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 systemhas 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.
Page 5 of 11
! F
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
trJ-
Date of Inspection: 10/29/01
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 fi
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period? Y
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ,S
X _ Was the facility or dwelling inspected for signs of sewage back up? w a>
X _ Was the site inspected for signs of break out?
3,
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the mot'
baffles or tees,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 t°
of subsurface sewage disposal systems?
Vit
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For ekainple,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
:w
unacceptable)[310 CMR 15.302(3)(b)] `
f.
r x
Mom'
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION d
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01
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: 4
Does residence have a garbage grinder(yes or no):NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Lau
ndry
system
em inspected(Yes or no :NO
,
Seasonal use:(yes or no): NO F
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15!203);n/agpd
Basis of design flow(seats/persons/sgft,etc:): n/a
r
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the'Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION x* r
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool ,
_Overflow cesspool
_Privy
Shared system es or no if. es 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)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,`date installed(if known)and source of information:
1990 BY ASBUILT 90.503
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C h '
SYSTEM INFORMATION(continued)
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01
BUILDING SEWER(locate on site plan)
Depth below grade: 14"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade:8"
Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7"W-4' 101"I
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
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: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND
FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S
USEFUL LIFE
GREASE TRAP:_(locate on site plan)
3 .
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a '
t
'l
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION(continued)
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass—polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day R,
Alarm resent
p (yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO : .
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) } `
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
STRUCTURALLY SOUND. ''
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
T
y y
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 2
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: nla �&
n/a 4�i' .+ t innovative/alternative system
Type/name of technology: n/a
{
Comments(note condition of soil,signs bf hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE NEW PIT HAS NOT
HAD MORE THAN 1"OF WATER IN IT.BOTTOM AT 9'
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a y
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a y
PRIVY: (locate on site plan)
r
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a ,.
n
Page 10 of l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM = t'
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01
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.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 48 CHERRY ST HYANNIS,MA 02601
Owner: ALLISON TODOROFF
Date of Inspection: 10/29/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 13+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
GROUNDWATER DETERMINED BY AUGER-NO WATER AT 13'
.s
I� a
I1
r
I _
TOWN OF BARNSTABLE
LOCATION aetnt e - SEWAGE #
YI1�AGE-, J ASSESSOR'S MAP & LOT
INSTALLER'S NAME_&PHONE NO. /
'SEPTIC TANK CAPACITY ®cam
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER S rpru- ►
* PERMUDATE: L _� _COMPLIANCE DATE: > / 21?
r,.Separation Distance Between the
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
I h
F _ .
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1"
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for �Dtg�og r *pgtent Congtructton Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �` G Cv j Owner's Name,Address and Tel.No.
Assessor'sMap/Parcel -30c(_
Installer's Name,Address,and Tel.No. 1 Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms *ZF Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow -AD gallons per day. Calculated daily flow ��{�( gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank q-z-i ST!�.. ( Q>m Type of S.A.S. a,& Ca e4tr4=-P�L.mTorf
Description of Soil ;eV� 5_*00
Nature of R airs or Alterations(Answer when applicable) � d e&t5'T S 5
e
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environments ode and not to place the system in operation until a Certifi-
cate of Compliance h7by
lth.
d Date
Application Approve - Date
Application Disapproved for a owin easons
Permit No.—:-s� �' �� Date Issued
No. Fee )
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
0(ppfication for ;Dizpo.5 Y *pgtem Construction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �-, Gy ST Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 3 O_\
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
ROOST'.
¢*r- (2fl-
Type of Building:
Dwelling No.of Bedrooms 1_31 - Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 30 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 4;Ze<? 51,!* 1 CTM Type of S.A.S. Cu�OGTT � �LTryTof2J
Description of Soil s-A Z
Nature of Rep/airs or Alterations(Answer when applicable) i;K7 S; W
l`/p 1-c,aer r �_ xw4( LTya�G{�S G�- Y/ oti, 51,or-r -t-/� yk..Q, e
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental ode and not to place the system in operation until a Certifi-
cate of Compliance has_", issue lth. -
Signed �r / Date
Application Approved by - Date
Application Disapproved for 'e f owing easons
Permit No. rI Z��� '` Date Issued
-.
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the QjL-Sqe Sewage Disposal System Constructed ( )Repaired( )Upgraded
Abandoned( )by — r
at E ST F rVPui has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. t r" dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date - i n Inspector
No. -� l��
ll Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
%Diopotal 6p$tem (Construct, n Permit
Permission is hereby granted to Construct( )Repair( )Upgrade Abandon( )
System located at w'
r
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Proviced:Construction must be completed within three years of the date of this permit.
Date: Approved by
�I
Is To Be Used For the Rep
air•Of Failed
} NOTICE: This Fo _ -
Hc 5 terns Oniy.
Sep Ys
}
. N p 'SKETCH AND APPLICATION F�
CERTI�'ICATIO
5,.. WORKS
CONSTRUCTION PERMIT'(WITH
DISPOSAL W ENGINEERED PLANS, ' *.
f ^a
I
r that the ll Won for disposes works ,
here ce;�
cxrn ng the
Ll
permit signal by me d
�` amshuction
meets ell of thedy !
LAO
Gv S�
.r 3 Immed at
•
1
foltaaing crj e.
hMs teem
There ere tb"N"ds lowed woo too fkt etdhe proposed Ieee
. 14 ' 11wte ere n�1��well!wNhM`1 SO het of the propoxd i 1
1s ne h M tlow indlot che» M peP° r
_, ,ue tie rerienoes 1eq ed°�`Needed. .
2w° wtn be loeeted with wetlehds.h� tnlltn edj sled1
• M ZSO het etenY . I .
proposed kechM6 Aril ►
keeltMd Iseenitlt will Iotsited less then�fourteen(14)feet above
%able eletatlon. I ;
II
tote the ton er►let=
A)•1'oP etoredMd 8bn
(9"dMg to the Nearing Y)ivtsio++0 )
' to Blevetlon(eeeording to Health Olvision well Mop)-2 �
DATL
>►111M8ER
S�PTtC sY3t`g1�INSTALLER M THB'rOgM OF BARNs't'ABLE ,
L� �.
NK pO�MM� dwifud PlaitatNh. i
tAtIM i air p1M attln
Ake It**1%wwW
'I
'' thb pho should be suernitted). ! a
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t� �b ���•F3 � tYF1.• .Y x i�F rl
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-y..M .w 4.._v..VT+...is rHtO w..«...,_ -. «4,� +•.e.:e .'.^<tw+..h ...�. ..- .. -
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4
TOWN OF BARNSTABLE
LOCATION = SEWAGE # C/o-
VILLAGE' ASSESSOR'S MAP 6i_
INSTALLER'S NAME`fz.P1 ONE NO.
SEPTIC TANK CAPACITY17
`zD_ p `
LEACHING FACILITY:(type).'~ (size) %00
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNE� /�� i✓
DATE PERMIT ISSUED:
DATE COZIPLIANCE ISSUED: ��'q' qll
VARIANCE GRANTED: Yes No
���
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� ��.
.3�
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Fi
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THE COMMONWEALTH OF MASSACHUSETTS +
BOAR® OF HEALTH /2
TOWN OF BARNSTABLE - T-
Appliration for Disposal Works Tonstrurtion rrmit
Application is hereby made for a Permit to Construct (1 ) or Repair ( ) an Individual Sewage Disposal
System at: ..�. ✓ � � � III
.. .. _ ---- . � ----•---- !fir S- -------•---------•---•--........•-----••-
cat on-,Address or Lot No.
a ------.---••• O r� - -c----•- ................./. 1L�1.LI3 C.---1Jrs'•---•---------------------------------------
Installer Address
T of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--- �L__________________________________Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons____________________________ Showers — Cafeteria
j P4 Other fixtures --------------------------------------------•••-- . •-
W Design Flow......................5_3---------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 ( )
aPercolation Test Results Performed bY------------------------.....................................------------ Date........................................
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.----_..---____.__-----
a ••---•-•••---•---------------•••-••-••-------••------••--------•-••--•._....._......----------------..........................................................
0 Description of Soil..............................................I.......................•-•-••••-•••-••----•••---•------••---•-•••-•._...----•-•••••••-•-•••••••-•-•--•-........._•-_---
x
W ••-•-•••--•--------------------=--•-••---•-••-•---•••-••--••--•---•-••---••---•••-••-•---••-----•••----•--•-----•--- --
U Nature of Repairs or Alterations—Answ when Ali D e-------- 4 1f1D1J ...............
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 Comp ' ce has b en issu by th board of health. q
Signed -
-- . (-
Date
ApplicationApproved BY ---- - --- - - - ----------------------------------------------------------------- ---- -'.....
Date
Application Disapproved for the following reasons- -----------------------------------------------=--------------------------------------------------------------------------------------
------------------------:------------------------ ---------- ......................................... ------------...............----------------___........................................... .................D..-a....................
te
PermitNo. .......... --'- ----------------------- Issued -----------------------------------------------------------------
Date
r fi+
qq ,
No.. f/ Fps..... ?..........
THE COMMONWEALTH OF MASSACHUSETTS -
BOARD OF HEALTH r
TOWN OF BARNSTABLE
Appliratiott for Disposal Works Toustrurtion Orrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: S4)Q - ........gynjov;s. -- ... --•-----------------------•--.....---•----........
L cation-Address or Lot No.
............ .......
__..... ..................... .......................... ......• •••---•-•-----••-••-••---•--...........--•---.
- V- :.........................................
/ Installer Address
Typ"ee/bf Building Size Lot............................Sq. feet
U DwellingNo. of Bedrooms.._.✓�....................... .__..Ex anion Attic
a — --------- p ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------•---------••-•-•----•-----------•---- •-•----•-----••--------•---------•--......--------•---------.
W Design Flow........................_,3 ........gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trencli—No..................... Width.................... Total Lerigth-__ ` 1...._... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.__`..._......_.._. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
�_t 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....................
O Description-of-Soil'.........................
V ........-•--------•--•-•--••----•-----------••--------------------------•-•----------•.---....----•-•-•...-----------•-•------••------•---------•------------•--•••--•----•..........•------•.........._.
UW Nature of Repairs or Alterations—Answe when a H ble.--------_,___�___..._ �� Sul df1/�11 n
p ------------- ...
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 Comply ''ce has b en issu d by the board of health. q
Signed . //~'�"'/' '
�.............. ..
to
Application Approved By ----------_`�'�n� �. .. --/..... �. ----...---'--"----------'-'-------------------------------- -- ............�...
7 J J Date
Application Disapproved for the following reasons- --------------------- ..........................-----...---........------------------...........................................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
----------------------------------------
PermitNo. ........... .'.. C3.'?...---'--............... Issued ........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#ifira to of Gntplittxcce
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by ..........---------- ............� _ >� < t° _...........
/e�/� Installer
at .......... u 1 y(�... :...........C�.T ...=....-..>..�� -..n - s l .......--
has been installeyyn accordance with' Vhe provisions of TITLhC5��yf,, The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ......0-'..-�.G-- ...... dated ................ .....---....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......... q /
'.. ... - .....1.- Inspector ............._ ......:-. = --..:..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No..7 TOWN OF BARNSTABLE
Disposal Works Tonoirudion Permit
Permission is hereby granted-----•-......-_.�.,---.-- ^a: ,...---.s ... ..-t 1......................................................
to Construct ( ) or Repair .n Indi idual Sewage Disp' 1 System
atNo............................. ... ...... 1 ...-��'.T -- -'� �s�_�a..............------------------•-•--•-•--••----...-•--•........
St eet Y� C16
as shown on the application for Disposal Works Construction Permit No.. .�.....,.... . Dated..........................................
.............................. �- 3_..•---- ----------------------------•-----•------
Board of Health
DATE....................•-----------.....-------•----...............----•-----...... ���...///
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
i
A.�.GE55, C,O,Y dd� kU$3 BE _l TH1rf .} nr C { l J �} NOTES :
, 7-r
INSPECTION 9 AtlNthfuP,'. - l? I E A I OIV S L? N C TER A GENERAL /VO / Ly S :
6 OF F"fNl`SH GI
?ADS PORT 3' MAXIMUM COVER
INVERT' OUT ,S4*PT1C TANK: 9f 0 DESIGN FLOW:
,,. ♦' __ �'' I PER; I.. TflS PLAN /S F K` THE DESIGN AND CONSTRUCTION
. O , 3 B_DROOMSINVER7 fN 1)1SI :8OX:
-'"--= -�- INVERT OUT DIST. "BOX: 97.E BEDROOM EQUALS 330 U.f .D. OF _ SE111AxE DISPOSAL SYSTEM ONLY.
' CHAMBER:
INVERT IN LEACH t _, _ _^��_- ---CLEAN SAND BACKFILL - 97 2 2 Vr'1?TIE ASSUMED FOR BENCH MARKS
< E307'TOr OF LEACH CHAMBEtd 96 5 NO GARBAGE GR I NDEN VERTICAL DATUM l a" CH M RK
f AROUND AND 2` OVER CHAMBER; '
,_,.�. •' �8,U SET• SEE SITE PLAN.
U,AS 67 J/ a 97. 96.5 ADJUSTED GROUND WATER: NIA
BAFFLE .�, SEPTIC TANK REQUIRED:
l0 HIGH CAPACITY INFILTRATOR OBSERVED GROUND WATER: NIA
� 3 OUTLf-_"T �f3U G.f'.D. X 2009 - 660 .UAL. 3. ALE, CONSTRUCTION METHODS AND ,4IATEIIIA!S AND
EXISTING CHAMBERS IN TRENCH FORMATION, 2 x 5 BOTTOM OF- TEST HOLE �I: 06.0 MAINTENANCE OF THE SEPTIC SYSTEM SHALL
D--BOk ` - SEPTIC: TANK PROVIDED: I000 GAL EXISTING
1000 GAL CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
SEPTIC' TANK 6' CRUSHED STONE OR SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
CUI�fPACTED BASE DESIGN PERC RATE" C 5 M1 NIINCH
! " SOIL TEXTURAL CLASS o f ALE. SEPTIC SYSTEM COMPONENTS LOCATED UNDER
PR 0F' I l._ E : NOT TO SCALE
EFFLUENT LOADING RATE' - 0, 74 GPDISF AREAS SUBJECT' TO VEHrCULATi' rsdAFf le OR GREATER
_ < r THAN if' I N DEP T11 SHALL BE CAPABLE' OF W I TH-
33O GPD / 0. 74 GPDISF' 4 16 S.r. REQUIRED
STANDING 1.1-20 WHEEL LOADS.
PROVIDED: l0 HIGH CAPACIT)' INFlL1R�i1.OR
CHAMBERS IN TRENCH FORMATION. 62.5 FT x 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR .
7. 79 SFIFT - 467 SF x.74 GPDISF - 360 GPD APPROVED EQUAL
ti. 61 SEPTIC 'TANK AND D-BOX SHALL BE REINFORCED
®sT SOIL TEST Ili/ 1 DA TA (9 PRECAST CONCRETE AND WATERTIGHT. D-80X SMALL
41) Io HI(31 caPACITv I3E f/A7ER TESTED TO C`I-IE`CK FOR LEVEL WHEN THERE
! gc r-I NF I L rteA rOR CHAUBFR S I ND I CA TES _ I NO i CA TES
'-!If OAKK- PERCOLAr10AJ OB,iE'RVED f S MORE THAN ONE OUTLET.
p.
SOIL RFt osAt. T
If P 1 ' 6Jo TEST GROUNDWATER
-FXISTING SAS 7. BEFORE CONSTRUCTION CALL "DIG-SAFE',
SEE NOTE 3.-- r C?
r TP 1 P#12931 TP #2
1-8 8-DIG-SAFE AND THE LOCAL WATER DEPT.
8
FOR LOCATION OF
UNDERGROUND UTILITIES.
HORIZON TEXTURE COL. 100.5 HORIZON TEXTURE COLOR
,v p �} I_DAMY I UYR �_. L UAMY I OYR _ _ 8 UNSUITABLE MA TER I AL (A tv B 'IOR I ZONE.
40 MIkL POLY
' __. H ALL
U u-Box SAND 4/2 SAND 4/2
v POR BEsRRIER -'"r r �• `�. C2 LAYER, EXISTING .SAS AND CONTAMINATED SOIL
f`i I4 r U. CORNER 'PATIO , q r 6' . .......................................... IOO. O 7' ,,,,,,,,,,,,............................ 9`9.8
'-, ENCOUNTERED BELOW THE INVERT OF THE LEACHING
, �`�� ` ,.� L DAr�I Y I D YR LOAMY I o`fR
r xt-lat_2a �_� �. - FACILITY TO BE REMOVED FOR A DISTANCE OF `a'
\y� 6 S
t{#...'• r C4` SAND `/" "AND 5/6
FXISrrNG ` AROUND,AND REPLACES) WJ TH SAND IN ACCORDANCE'
_ rP*a 39 .._. ......................................... 97.3 4U"__ .......................................... 97. 1 SEPTIC TANK ��v / Mf_ l Ua�I 2.5Y c / HEED I UM 2.5Y
rS'I TH TITLE 5.
�� SAND 516 SAND 616
59
s72'.-.. .......................................... 94.5 66-- ------------- ......................... 94.7
3 'sriAf� SANDY LOAM IOYR � SANDY LOAM IOYR
<��✓c �•2 FRIABLE 6/6 �'- FRIABLE 616
r' 96---- -- ................. _ 92.5 94 ,,.,..................................... - 92,6
NI_-D I UM_ 2.5 Y
► c�' SAND 6/6 _ SAND 61688.0 L -�
I �ti 15oNO WATER NO WATER 88.4
4t - DA T'E, MA Y 17. 20 10
- TEST BY: DARREN MEYER
WITNESSED BY: DAVID STANTON
CATCH BASIN AREr1..8. 5l 4± S, `
PERC RATE: C 2 MI NII NCH
Rrha-99.2I c9�- '� 4
MAINSInvo
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v ' a
an
tvm
j
��F ~ '•' CATCH BASIN
m"
up
RIAd-99.13
`♦•
VAR i l t l I�11 G-�.� R O IRE D
TITLE 5, MAXIMUM FEASIBLE COUPLIANCE
SEC'T 10N !5.2 l I : (I 1 7r71 N I1 f0M SETBACK DISTANCES TA 3 RA L. ( / 1 )'"A 1'`,//v / :C RMSAeloA
20` IS REQUIRED BETWEEN THE SAS AND THE FOUNDATION WALL, �
18 ' IS PROVIDED, A L' ' VARIANCE r5 REQUESTED. T,
F ..4 f - F F
/ { {
CB CONCRETE BOl1Iv71 w> CA L L / 2 J A U(_-US 7-" .24 4 0 ! 0
rr ,1 �� / rY __ WATER LINE
HYDRANT
. �:..---. �.- r. -�-i %.,a� pry1� AS LINE r__.. a � _. J :�,, ..,a:,,
G.��. CI _
%
LOCUS 1 ti - - OVER HEAD WIRES _.> �� a �
�. ` � 4 ; `:, - EIGHT POST _ - o u t.e E3 A
y 4 _ E-- - UNDERGROUND ELECTRIC LINE J�'• z_" Y<_ rri-ic7u t h p r
UrVDERGROUNI)` TELEPHONE LINE ��`<<% ..•-,• tF \;�:;;�, �; :,`�: �C~?E3 ::5 6 2_---a `1 z 2
UNDERGROUND CABLE'VISIGN LINE C:�!� v•,`'�s'/,%� 1�r ` `a <.. ` _- - r -.-
+40.4 SPOT ELEVATION
E"XISTING CONTOUR r
PROPOSED CONTOUR
,
O 10 2O 0 1 -
_ JD _ N( . Oaf .L C EI /EcK GA G . SArI. GF- C_ D N, ..5 l
IJ 1�I to Waft:�.� c� L r ..wa � t
- L: Q A P
n r
4
r:
• ,
.e T.
- >
.; ... ..,. .. ,..„... ..,.- x sx.. .c. S- .. ... s._r". ... ,.-->< =.t., x .. ,. s ... :• . _ :" r.3 - -xS,?. -
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