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0078 CHESTNUT STREET - Health
78 CHESTNUT STREET, HYANNIS A- T0'VVN,0 B4 ISTA;:BILL- 6 t)IV ." C SEWAGE .00A �# VILLAA�1 � _ �;SSFSSQJTt'S.MAP INSTIRUER'SNAME 8c IsHC?AIE:M(J SEF''I�C 7CAletZ�(:AP.�GI'Caf;�, �� LEACIMG-FACium oYpe) ItitO (�P'�EF.��t.Ot'1NdS BM,D,. R oil©wive SaprarP�oe� � vn�c:lrtweera t(�e Msx to the MUgmUiLCac;htfi Pa ility I Irraty w tc► Suppler.V`1u81� icl i.gaci8�ite lxaccltty k'a��y 1%exist ftmoito or*bW 200&dtld.6aoti q16-fuc TGity) �. � .. e: Fcl �p:yi< Ie�9a�c9 andLeacitinttfacility Of uny wrUandS exist tviQl�i4�'��Lf f�a4 'A4nC�litls Puq 'ry) r 7 � 17 .: Ptar«tsh�st6 to ,�' �r L � �u� � 6 Pi i o � ►� � L� � ram' r , rN Commonwealth of Massachusetts 3°9- b5° O, /I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments w 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name �! information is H annis MA 02601 3-10-16 required for every y page. City/Town State Zip Code Date of Inspection �+ C�11 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. A. General Information 1. -Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ` ® Passes ❑ Conditionally Passes ❑ Fails I ❑ Needs Further u by the Local Approving Authority 3-10-16 I pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address howthe system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 /0#a S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Chestnut St Property Address Hilda Velloso Owners, Owner's Name infor ion is Hyannis MA 02601 3-10-16 requir for every page.,es.a City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ one or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years•old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page_ City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are'repaired. B) System Conditionally Passes (cont.): ❑ observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box System will pass inspection if(with approval of Board of Health): ❑ broken pipes) 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): T. - ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR . 15.303(1.)(b)that the system is not functioning in a manner which will.protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s. 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. City/Town 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ H Any portion of the SAS, cesspool or privy is below high ground water elevation. El ® Any.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® , . Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ®" Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be a 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 t If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Tibe 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 M 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 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 conc ition 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•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Officials Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis L MA 02601 3-10-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? + ❑ Yes ® No Last date of occupancy: 3-2016 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) *' Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A 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/Altemative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is H annis MA 02601 3-10-16 required for every Y 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: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: ' 12"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins-3/13 Title 5 Official 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 M '~ 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" 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 14" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'D of 17 Commonwealth of Massachusetts u u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 78 Chestnut-St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis = MA 02601 3-10-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comm ents (on pumping recommendations, inlet and outlet tee or baffle condition, structural integnty, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Good condition with water at working level and no sign of back-up from chambers. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page'2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yea 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: I ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/afternative system Type/name of technology. Comments (note condition of soil,,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leach chambers in good condition and empty at inspection with stain line at 8"off bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. Cityrrown 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•3/13 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 M 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 Page. City/Town 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 4C - f 4 7r6 ... .�,n. h _ z8Y,, _417- L11-141 A � - 40 T e - lll/+P rCCCjjjj rnwr r �I"' ffP_ �. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Chestnut St Property Address Hilda Velloso Owner Owner's Name information is required for every Hyannis MA 02601 3-10-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Z Inspection Summary: A,'B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 N, 2-001_063 FeA/00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .✓. Yes PUBLIC"HEALTH DIVISION TOWN OF BARNSTABLE' MASSACHUSETTS 2pplicartion for Mioponf *p!tem Con0truction 3permit Application for a Permit to Construct( . )Repair(�j)Upgrade( )Abandon( ) ❑Complete System El Individual Components on Add ddee�s or Lot No Owner's Name,A¢ciess and Tel.No.5fj --7 90—5-7 Assessor's Map/Parcel 9 /�� cam! Installer's Name Ad ss,and Tel.No. —1 S�O��(Q Designer's Name,Address and Tel.No. - d C �i�5lJ� � �'�- FCC Type of Building: Dwelling No.of Bedrooms= Lot Size sq.ft. : Garbage Grinder(Aq Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 SO-0 Type of S.A.S. ' tea �4*A C_ (fl,(A -r6reAs Description of Soil II __,, ��,, nn o C_ Nature of Repairs or4lterations(Answer when a licable}�(\)5+ AL 6L Qe4Q e—S Lee 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 Certifi- cate of Compliance has been issued by t is B d of Health. Signed Date � Application Approved by �� S Date 3^ 2 5' 0 Application Disapproved for a following reasons Permit No. ZG 0 Date Issued 2 zoO �, .�k SAS To /�Ov�.+�A'(jGFJ No. Z061I r0 .�'s; �s �n.,s , l •= Fee THE C MMOI WEALTH OF MASSACHUSETTS - Entered in computer: .. Yes PUBLIC'HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS tlpiliiAtion for Mizpool *p6tem Con!6truction Permit i �.,1�1 Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) O Complete System 0 Individual Components Loc on Address o Lot o. Owner's Name,Address and Tel.No. So --7 57 j0 `]6 Ch S+nui- S tYe - I-�-�jO-4 ,S 'T -9 C �'ire't ra Assessor's Map/Parcel -3O9 / SD p 76 ' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. . 3(.oy- o29 9 C- 9<JJi J so,\ r S.&V-H L- EC-0 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder " Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank D O Type of S.A.S. `5-00 G/1 L. Description of Soil g Nature of Repairs or Alterations(Answer when ap Q-licable)� Uo N5- _ - O' �t .o '� S> <C_ f5A5� -+o e t�S � Efco 310a. 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 Certifi- cate of Compliance has been issued by!phi By d of Health. Signed + ��'' Date G�j Application Approved by Date 3^ 25 ^ o� Application Disapproved for t following reasons Permit No. 2.G O - G G Date Issued 2 2v THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS, Certificate of Compliattce THIS IS TO CERTIFY,that t On-site Sewage Disposa System Constructed ( )Repaired ( Upgraded<( ) Abandoned )by 6 n5t" S� C- at 7& (j,\eS4'-A t + ` t-f-eeA-. 40 N"\6 has been constructed ' acc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. �Ooq-06-S dated 3 Z c Zoo q Installer Designer Iff C-9 Tat ck The issuance of thi"permit shall not be construed as a guarantee that the syst i ,wt 1 funetio as desig ed. Date Gl M I Inspector ...- .,..-`-.'No. 2--------------.�..—.----------Fee -✓ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS Moogal *pztem CQn! truction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at R cbe h t)A- 1:4' eeA, \4tAoLNx,,, ✓_ 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: Construct)'on mV be"completed within three years of the date of-this pe t. Date:_ ZUQ Approved by �� Town of Barnstable Regulatory Services °�. • Thomas F. Geiter,Director • anttNsUBLIE 9� MAW. Public Health Division ATfD ,, Thomas McKean,Director 200 Alain Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Desiener Certification Form Date: 4-14A'0�7 Selvage Permit# yel'bfA Assessor's MaplParcel � S� Designer: -__R-CA/\ Installer: WM E `[ SIB- L Address: �`�� � �� 1 �C-�'e- Address: On S&- vas issued a permit to install a (date) ('installer) septic system at '] MeS;�ce - Wg&-1 �-GJO',V1)"-Sbased on a design drawn by (address) � dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which 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. (Iri r s Signature) No �_ (Designer's Signature) ( ........Zest-�r s w p Here] PLEASE RETURN TO B_ RNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE VVILL NOT BE ISSLBD L;NTIL BOTH THIS FOR11 AND AS BUILT CARD ARE RECEI VTD BY THE BARNSTABLE PUBLIC HEALTH DIVISION1. TF RINK YOU. Q: HealthiSeptic/Designer Certification Form 3-26-04.doc 1 TOWN OF BARNSTABLE 1, LOCATION SEWAGE# 0q VILLAGE ASSESSOR'S MAP&PARCEL 309- OP INSTALLER'S NAME&PHONE NO. o SEPTIC TANK CAPACITY M" LEACHING FACILITY.(type) `/� (size) 'I NO. OF BEDROOMS 3 OWNER ar/C A A PERMIT DATE: '7 COMPLIANCE DATE:_ �J — cl G y 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 fill 300 feet of leaching facility) // Feet FURNISHED BY / v b y ���i wA' j(/S tJ/1 �J 1 /ems ! f f � c � � � cry ?" � � � � Y lI� � _ ;� r � o oF� Town-of Barnstable P# Department of Regulatory Services aAxtvsrnste Public Health Division Hate /C ' Mnas .. 200 Mai Street,Hyannis MA 0260' Date Scheduled^: '� Time D _� _ Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed , LOCATION& GENERAL ORMATION ��© ( Location Address Owner's Name Address ) } Assessor's Map/Parcel: Engineer's Name NEW CONSTRUCTION REPAIR Telephone o`�� (� p ne# S Z� Land Use -1` �f W r I L Slopes(%) Surface Stones 1V C Distances from: Open Water Body O ft Possible Wet Area D U ft Drinking Water Well yy ft - Drainage Way" ft Property Line w ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) GROUNDWATER ADJUSTMENT / TP-2 } EXISTING GROUNDWATER LEVEL BASED ON TOWN OF BARNSTABLE GIS DEPARTMENT RECORDS. INDICATED GW 20.00 INDEX WELL A1W-230 4W ZONE C / TP-1 AV READING DATE FEBRUARY. 2mm9 i ® READING 23.2 �_— ADJUSTMENT 2.7 / ADJUSTED GW 22.7 1. ST,Q�Fr Parent material(geologic) I �7 Depth to Bedrock Depth to Groundwater. Standing Water in Hole: 1V0� Weeping from Pit Face ��k Estimated Seasonal High Groundwater See e;2�p V c DETERNUNATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: ___ in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adl,factor. Adj.Groundwater Level PERCOLATION TEST Date 3�f 6 °`I><•tme!iI'b© Observation I /� Hole# Time at g" 6 Depth of Perc (O� t Time at 6" a Start Pre-soak Time @ 1�"" 25 Time(9"-6") End Pre-soak I Rate MinJlnch i ;r rSite Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) `V Ir Original: Public Health Division Observation Hole_ Data To Be Completed on Back----------- i.,***If percolation test is to be conducted within 100' of wetland,you must first notify the y Barnstable.Conservation Division at least one(1)week prior to beginning. Q:\SEPTICIPERCFORM.DOC zoo (3(� r: SOIL TEST LOG DATE OF TEST: MARCH 16, 2009 APPROVED SOIL EVALUATOR: DAVID D. COUGHANOWR. u461 WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. PERC NUMBER: 12467 TEST PIT PAARENTUMAATERIA EPROGLAC ALD I OUTWASH PERC AT 60 to — 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 41.65 0-10 FILL 10-14 O LOAM 10 YR 3/2 NONE FRIABLE 14-18 A LOAMY SAND 10 YR 3/6 NONE FRIABLE 37.98 18-44 B LOAMY SAND 10 YR 4/6 NONE LOOSE 44-144 C MED-COARSE SAND 10 YR 5/4 NONE LOOSE 29.65 NO TEST PIT 2 PAARENOTUNDWATE MAATERIA EPROGLACIRALD OUTWASH 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 42.00 0-8 FILL 8-12 O LOAM 10 YR 2/2 NONE FRIABLE 12-20 A LOAMY SAND 10 YR 4/4 NONE FRIABLE 36.50 20-42 B LOAMY SAND 10 YR 4/6 NONE LOOSE 42-138 C MED-COARSE SAND 10 YR 5/4 NONE LOOSE 40.50 _ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%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. Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary No V' 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? e 5 If not,what is the depth of naturally occurring pervious material? _.. Certification NOU I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent wi the required training,e(xertise and experience described in 310 CMR 15.017. gtt OF MA �°°""^ J• Date 3 I6 � DAVID Signature o D. ". COUGHANOWR " s0 /CENSE0 Q 0 Q:\S..EPTlQPERCFORM.DOC /� E V A L U PL [1 -3- C0KINI0\WE ALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION -_ ONE WINTER STREET, BOSTON 11A 02106 (617) 292-5500 ' 9 A TRL3' ' COn ;S'e retard, H ^ 3 ARGEO PAUL CELLUCCI beD B.'S UHS Governor �� 57 Co ioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A d' �999 CERTIFICATION Property Address: 76 Wtj� ni't Name of Owner �~ Q / Address of Owner: 13� Date of Inspection: 4161D 9q ! _ �p C/o Tnw ja/a. Name of Inspector:(Please rirrt) Ck la, E, (,ld/,?i�t_'' _ am a DEP�WEBLE" stem U�LDING SERVICES Section INC of True 5(310 CMR 15.000) C�W�Y Name: /y B E!� V Marling Address: -PC) R0X F;10A1 Telephone Number: A I BB CERTIFICATION STATEMENT S'OS _730 —9-9 f O I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: . Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �c� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design.flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfTe system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS, t , revised 9/2/98 Page Iof11 ;w t'r,ried on Recycled Paper - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: '2 Owner: i1 � �.. Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: ' A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of i Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed _ y revised .9/2/98 Pagc2ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (140�7`/1✓r J 7 Owner: Fit4yt,e— ulale Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND 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 supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2Y98 Page 3of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: F2?lm k- W,a,e. Date of Inspection:-211619q D. SYSTEM FAILS: // ' You must indicate either "Yes" or "No" to each of the following: have determined that one or more.of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility-or system component due to an overloaded orcbgged 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: x Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office of the Department for further information. r. y revised 9/2/98 Page 4ofI'll 4 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B n CHECKLIST ?roperty Address: f7cv.` tlV l Owner: Date of Inspection: a/16 Ion Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving imrmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened; and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ` _ Existing information. For example,.Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)I The facility owner (and occupants,if different from owner) were provided with information on the proper.maintenan"-of SubSurface Disposal Systems. r revised`. 9/2/98 Page 5ofII , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ` (property Address: Owner: Fhft.Vlt-f— Date of Inspection: 9/ / �Cq / FLOW CONDITIONS RESIDENTIAL: Design flow:330 g.p.d.lbedroom. Number of bedrooms(design): Number of bedrooms (actual): Total DESIGN flow 330 _ Number of current residents: B Garbage grinder(yes or no1:_AO Laundry(separate system) (yes or nc)Ao; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no):—hp Water meter readings,if available (last two year's usage (gpo): Sump Pump(yes or no):__JQ Last date of occupancy: '►M.�*L� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow — — -- Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: n System pumped,:as part of inspection: (yes or no)__b© Ct If yes, volume pumped: gallons / Reason for pumping: TYPE OF SYSTEM ` Septic tank!dj9o4yj&4w-beu/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) ILA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: ,®, 13 Sewage odors detected when arriving at the site: (yes or no) revised '9J /96 Page 6(if 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,�" SYSTEM INFORMATION Icontirwed) erty Prop Address: 78 6k,-a► r�✓V f%—. Owner: Fatt"rt.- Date of Inspection: J& BUILDING SEWER: / 7 (Locate on site plan) Depth below grade: Material of construction:Xcast iron_40 PVC_ other (explain) Distance from private water supply well or suction line �iC i�rf` ey— . Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: y� (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: Sludge depth: 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 dimensions were determined: (pmments: Ncommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_con ete_metal_Fiberglass Polyethylene othei(eYrplain) Dimensions: Scum thickness: Distance from top of scum to top of outl tee or baffle: Distance from bottom of scum to bottom o utlet tee or file: Date of last pumping: Comments: (recommendation for pumping, condition of in.et and ou t tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) `revised 9/2/98 Page 7ofII r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) • �9 � Property Address: -7 Owner: nj--,, P44Zr_ Date of Inspection: /'/97 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day ' Alarm present Alarm level: Alarm in working ,rder: Yes_ No__ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and flba t switches, etc.) 1 DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids arryo r, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or N Comments: (note condition of pump cham er, condition of pumps and appurtenances, etc.) revised ``9/2,/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address: 70 (1 ' Owner: Fa-,rWN(,,e_ Date of Inspection: -;l-116/95 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: a' leaching pits, number: — `OOp G� leaching chambers,number:_ J leaching galleries,number:_ leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: //J Depth-top of liquid to inlet invert: O Ol mil— Depth of solids layer: pepth of scum layer: �^ Dimensions of cesspool: 1C Materials of construction: ✓3 Indication of groundwater: 11ma�e inflow (cesspool must be pumped as part of inspection) CLr Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r L occ- PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: ' Comments: (note condition of soil, signs of hydrauli ail level of ponding, condition of vegetation, etc.) revised `9/2/98 Page 9ofII ,y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION lcontinued) (property Address: g CQ --r n Owner: F:�Myl i Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 33 revised 9/2/98 Page HI of II r � y Commonwealth of Massachusetts Executive Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector Department---of -- P.O. Box 2119 • .Environmental Protection Teaticket, MA 02536 F.Weld (508) 564-6813 . _-_-rVllllsm — - Govemor - Trudy - 8ecrwsry, - Davld B.Struhs - Commissioner - — SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION_FORM PART A g d0 rt - - CERTIFICATION — ,_z �Property Address: ' � es �t ` Address of Owner: Date of Inspection: 1 qj (If different) Name of Inspector: Company Name, Address and Telephone Number: • 'q r r� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information repoed below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in tKe-proper functionrand maintenance of on-site sewage disposal systems. The system: _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails, Inspector's Signature: i" Date: �— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design, floe of i0,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection The original should be sent to me system O�%ner and copies ser„ to tier bu�cr, if app:icable and the appro,ing au:horit). INSPECTION SUMMARY: Che(D,or D: A] SYSTEM PASSE I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. e] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair-, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street a Boston,Massachusetts 02108 a FAX(617)SWID49 a Telephone(617)"2-5500 10 Primed on Reacted Papa r__ SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION (continued) Property_Address: Owner: �\� - Date of Inspection: - B) SYSTEM CONDITIONALLY PASSES (continued) - Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed _ pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspectionif(with approval-of the Board of Health):- broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). _The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced - obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or pray is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRON�1ENT- i nP �%Stem nd> a �euti( tan' an U )Uu ab,orpLlon syj,ktm drid a Y l*J,*i"l i vv icci i S..r,ru a Su'-CE -a:�• !'> G "u --��, utd�r t., surface water supply. The s\�!Pn- ha, a septic tank and soil absorption system and is within a Zone I of a public water supply well. the system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The s',sten-, has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 F _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - __ _- PART A CERTIFICATION (continued) Property Address: _ -Owner: Date of-Inspection: D] SYSTEM-FAILS-(continued): - _ 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply 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 11 of a public water supply well) The owneF or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 I[l it L - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ _ -PART B. .. CHECKLIST `1� Greer - Property Addr s: Owner: - O_ Date of Inspection: Check if the following have been done: j=?44rnping_information-was requested of the owner, occupant, and Board of Health. L--None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. C1�As built plans have been obtained and examined. Note if they are not available with N/A. L/fhe facility or dwelling was inspected for signs of sewage back-up. j.-The system does not receive non-sanitary or industrial waste flow _L_.Ihe site was inspected for signs of breakout. system components, excluding the Soil Absorption System, have been located on the site. ye septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. LThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b\ non-intrusive methods Tke fa„l;t, n,. i4 ,,. a.,tc it diriPrpn! frnn, n\ti'np• were orovided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _. — __ SYSTEM INFORMATION Property Address: - -Owner: Date of Inspection: \ \C,� 1 FLOW CONDITIONS RESIDENTIAL: Design flow: aalfons - — Number of bedrooms: Number of current residents: — Garbage grinder (yes or no):Cxl�l Laundry connected to system (yes or no):' �� Seasonal-use (yes or no):—C,(b Water meter readings, if available: - Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or,no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy- OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING ORDS and source of information, System peed as part of inspection: (yes or no)01:�>--E \(?,C*� If yes, volume pumped gallon Reason for pumping: TYPE OF SYSTEM _,/�ptic tank/distibut'orrtTox/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: —I(DS Sewage odors detected when arriving at the site: (yes or no)n� (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART - C SYSTEM INF ORMATION (continued) Property Address: - Owner: Date of Inspection: -SEPTIC TANK: _ (locate on site plan - Depth below grade: - Material of construction: _concrete _metal _FRP —other(explain)- Dimensions: Sludge depth: - 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:Zft (locate on site plan) Depth below grade: Material of construction: _concrete metal _FRP _other(explain) Dimensions: Scum tnickiie_�. Distance from top of scum to top of outlet tee or baffle: Dicta,ice from bottom ni cri t^ hnttom of outlet tee Qr baffle' Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, eviden a of leakaee, etc.i (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C (�Q- SYSTEM INFORMATION (continued) Property Address: - _ Owner: � Date of Inspedion0. � TIGHT OR HOLDING TANK:11 ( (locate on site plan)_ Depth below grade: - - -- - _ Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Capacity: f;allons Design flow: eallons/dad• Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note it level and distribuUui eyuai, e,,durice Gf, so:ids cofi�v•er, e\Idence of leakage Into or out of box, etc.) PUMP CHAMBER:X�!',\(�- (locate on site plan) Pumps fn working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) t (revised 8/15/95) 7 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ Q. SYSTEM INFORMATION (continued) - Property Address: p CA\(n1\_f)1.Jk 5�• - - Owner: 0.L� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):I_,----'— (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: - - — Type. - - leaching pits, number: g � _ leaching chambers, number:_ leaching galleries, number: - leaching trenches, number-,length: _ - leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of draulic failure, level of ondin condition of ve etation etc.) U ocn 1� W g p g, g Gl pk n v' Y1Ct CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: e C` o V-\ Depth of solids layer: j Depth of scum layer: y Dimensions of cesspool. Materials of construction: -,c ndicatoon Of group,.-.a: <\C"(� inflow (cesspool must be pumped as part of inspection) Co m ents: (note condition of soil, signs of hydraulic failure, level of pondi g, condition of vegetati. ) v �t1-V, e . 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.) (revised 8/15/95) 8 �.`y�� •x"�_s� 'Y����` �sr�'7%' �j'C�� �iy "C.r����i�,}2��'�,'�.:�4��� `��'�rM,� � �� ��_�� ?�'�� � f _ -- SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM-- - PART C - SYSTEM INFORMATION (continued) - - - Property Address: C(1•eS�f Ok - Owner: - - --Date-of ll on:' - f SKETCH OF SEWAGE DISPOSAL SYSTEM: - include ties to at least two permanent references landmarks or benchmarks _ locate all wells within 100' e � G�- -a A Ob DEPTH TO GROUNDWATER Depth to groundwater:�feet method of determination or approximation: C \ft a-, i-cX\a (revised 8/15/95) 9 TOWN OF BARNSTABLE LOCATION "` ` �C� S SEWAGE #VILLAGE ASSESSOR'S MAP & LOT=L' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY <QxIo &a-L LEACHING FACELITY: (type) ��� (�L� (size) 1 6o� CI ec\ NO. OF BEDROOMS BUILDER OR OWNERQ PERMTTDATE: COMPLIANCE DATE: t a� �! 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 ep cw O n a LO'CATION _ SEWAGE PERMIT NO• d1.LLAGE I N S T A LLER'S NAME ADDRESS 0 U I L 0 E R OR OW13ER �A .11 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED TO s tj 5 ,4.C// No.80- ce��-_ Fxs...... ... �.��...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............Town............O F...............Barnstable................................................ Appliration for Uhip ial Works Tumitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: 78..Chestnut St:.....Iiyannia,...U..Q26()i................. Location-Address or Lot No. Gus Matto --.......................................................................... 78__�hesbnut._2t.�T liyaruai.s.►-._MA.....02601.............. Owner Address a A_.&__B_.Cesspool_Service----••..................................•..... 128-3ishflps_Terxace.,...ILyannis,-..A-----C264I..... Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms....................3.....................Expansion Attic ( ) Garbage Grinder ( ) ►-+ Other—Type T e of Building ............... No. of persons........ Showers — Cafeteria a YP g ------------- P ( ) ( ) p' Other fixtures ----------------•-•-----•-••---. ._. . W Design Flow............................................gallons per person per day. Total daily flow-------------------------------- ............gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage'Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit__________•__-_.____ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --------------------------------------------------------•----------------------••---•--•---------•------------------------ ••--------••-------.----.------.-. ODescription of Soil.......Sand-------•-•-------------------••---::...............--••--•----.....-------------------------------•----------•----------------------------•-•---•----- x W -•-•------•---- ---------------------------------------------------------- -------•--------------------------------------------------------------------........................................... UNature of Repairs or Alterations—Answer when applicable..._.. m: al atlson..o.f__a__1000-_ga.11on._pre.--cast, stone-.packed-•leach_.Dit_._(overfl ow) ..---•-••••-•----•---••---•-•----•--••---------------•--••-•--•-•------•-•-••-•-••-•••---••--------•---•-...........--••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:T ' 1 p 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar of hea �..--3,1BSJ..... �7 Date Application Approved BY-----� ----k/�-•G--�---- -- - - - - .. ...-•---------a-2/--3/.8SJ....... Date Application Disapproved for the following reasons:................................................................................................................ ..-------••---••-•-••-•-••••...•••---••-•••---••••--•••-•----------•-•-------•-•••--.....•••-•-•••---••-----•••--...---•-----------•---••------••------------------------•----•-----•---•--•••••-••••-•- Date Permit No. 80---------------------------------------•--. Issued-----------1?1.3/80......................... Date No.80....� .. FEB....$... .'.OA....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town.... OF.......:......BArnstable.--.............................................. Appliration for Elhipaii al 10orkii Tnnotrurtion Vrrtnit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: 78 Chestnut St , Hyannsa,- A-026Q .-- ..........•-•••-•-••........... -•--••--------------•---...-•-•-•-----•-••----•--..........-----------------.......--•------•-•... Location-Address or Lot No. Gus Matto Location 7$._Q.heato t___2ta. _.-Hyannla,._.'A.....02601............... Owner Address aA .. •.Cesspool _Service------•--------------•-----•-•-•----........... 12$__ ieho�_s_ a xac� H�tann ,_. �A-----02601------ Installer Address d Type of Building Size Lot............................Sq. feet U g— ......................Expansion Attic Garbage Grinder( ) ( ) a Dwelling No. of Bedrooms___________________ __________ Other—Type of Building ............................ No. of persons........_................... Showers ( ) — 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 ( ) aPercolation Test Results Performed by......................................................................... Date---------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ GZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -- ODescription of Soil-....................................................................................................................................................................... x W ---------------------------------------------------------------------------- ------------------------------------------------------------•-------------------------------...-•--•--•-••-••-•-----••--- V Nature of Repairs or Alteratio s—Answer when applicable.____installation of a 1000 gallon pi--cast, stone__-packed_.leach pit-__(overfl ow ................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I- p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of lieakb `�' �_ ' '` . 12/ 3/ � igned_ I_.Gc °a--- =NQ. l � ..--=---• at Application Approved BY �'I .. I2 Bo Date Application Disapproved for the following reasons:................................................................................................................ ...................................................... ---•-•-------•----•••-•-••-••-....--•---......---•••-••-•••-••------•---------------------•••-••-----------------------••-------•--•---•-•---•--- Date Permit No.......80-........................................... Issued_----------12/ 3/80 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ...............................OF..................._................................................................. C�rr�ilirtta af,f(�nnt�Ilt�anrr � , Nil0 CER I Y hat th d� dal Se .1 e Dis os S stem construct ) o e (X ) H T T T Q� al A l I Cesspool etvice, 7�Vs` ops` rrrs c�, Hynnis, MA Oe2t�1 - 7 - bY..............................................................................................•-•-•-----••-•--••---------•k••••--•-------._................-•••--•--------...----•-•----•••......_ 78 Chestnut St. , Hyannis, MA 02601 I=Stdtis Matto at............................................................ ---------------------------------------------- has been installed in accordance with the provisions of TITI r , he aje Sanitary Code as de-crib d in the g. f ` application for Disposal Works Construction Permit No........ .: ........................./ d,l.ted_._._..._....._.1— 3/__��_._........ \ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTR D AS GUARANTEE THAT THE SYSTEM WILL/ FUNCTION SATISFACTORY y DAT� 12 3x� ti� .........................................-. InsPs �a �'.'"`�.s y ✓ ra.+k,� ......� �,�'�. ,•,... ;:r. ,. �- :lj� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / ......... Town Barnstable 80-(A�qq of........................•--... ................................................... $ 5-00 No....................1... FEE........................ %posal Work. 01,111marnr$ilaat rrntif A & B Cesspool Service Permission as hereby Q gran(tedl --- .... •. . •---•-----..-- ....--••---•• \ to Con$t�uct s nu S ,,r IIydCri'11 ndUdu�koyge Disposal S st at No.....-- -..••. ----•--••--•--•--•-•-•••• Matto S, Street _ as shown on the application for Disposal Works Construction Pe No _� .-�1.._... Dated________________�2�•.3�c.....•..-_ !/ -U44 -- 12 O^ Board of Healt� W r DATE-----------------------� --------•---------------------••----•--------.....-- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS �,,.�+• ,:��•" (�� ' `O T F"C--' . ELM STREEr ` EXISTING CESSPOOLS ARE TO BE PUMPED. GARBAGE GRINDER C O N T O R S N COLLAPSED AND REMOVED. EXCAVATE' IS NOT ALLOWED - - - - - Locus ��� WITH THIS DESIGN. EXISTING - - 50 ALL ASSOCIATED CONTAMINATED SOILS / STREET AND REPLACE WITH CLEAN MEDIUM MINIMAL GRADING PROPOSED J SAND PER TITLE 5. / `�� m� G�ESjN CHERRY LL 0CD INSTALL A 40 MIL POLYETHYLENE \ STREET Z?Q� LINER BETWEEN FOUNDATION AND / nThl m SOIL ABSORPTION SYSTEM AS owe N INDICATED ON PLAN. / 61 m J CD mm N �� / \ HYANNIS. MA LOCUS MAP w>Q / - LEf1CHING GALLERY NOT TO SCALE O m U z W �w _: _' `_ -SEE DETAIL ON REVERSE :,ii' ti 18-D co / / Q W Q 1 p a�p� < W w� LEGEND — 0 p d d H j O / / �� 90M1< \ O ~o -i LO j z 3 i �° �ls . ' kW <r �� 1500 GALLON cn e_" U Lit = WI W z w p % / �� Tj �, tyFp 12-H/ SEPTIC TANK wu Jw W> U J > 0 _)C9 ' co /� TP-2 O <z �Q ILp Ld < z < _ / T `a< / �Q 42 / EXISTING LEACH e N m W r��cc11 W W / �� �'� � ` jRO� G1} 'mot PIT/CESSPOOL • >W W CD v V O ti, du < z� m w 2 ti Q�b UTILITY POLE $ Z, ff U w a '' co �zQ J wQ m 7i;;i7;;;: 42 TEST PIT ® D-BOX O Z f / DECIDUOUS CONIFEROUS W W W O< X N /� QQ / time TREE o0o. TREE �Lc WO W z O co m \ / �60e 12-M /�12-P '- � W L m m __ / /� PARCEL 50 Q O W � r Lr)'. / � -NUMBER REFERS TO DIAMETER IN W z I INCHES LETTER DEOTES TYFIE = ❑ m n / \AREA = 0.21 0% i- / O OAK M MAPLE PNPINE C-CEDAR UW z �O DEED BOOK 122:!6 TP-1 / PAGE 267,a-Lc x � U) — O I VoTzo- / ® jN OF e � �� / �42-- / BENCH MARK sq jHOFs A E z W z �� `� / TOP CORNER OF �o�� DAVID cy�s o�� DAVID q�yG W �m / \ t,� / FIRST STEP D. e Q z P 1/ o -a o' D. >Z 3 --Z / �VED �° / ELEVATION = 42.�� �' COUGHANOWR N f O = srp\ Q. /' COUGHANOWR Wo Z_ Z__ _ __ �Eivy�� � 3��lJNPAVED BARNSTABLE GIS DATUM No. 1093 W(n cn O3 m R = 3P4.19 �� KING / ��GISTER�O `r0 �"CFNSE0 0 W > m v �F_ i�� AR� S�NI %PN /� OPT eW W ESNU L / T MENr Wier � 17, W 1 W z v / SEWAGE DISPOSAL SYSTEM PLAN W w u� Z �'� ®� ��� z _j Q Q E �. -TO SERVE EXISTING DWELLING �L m J .fit / EST. JORGE PEREIRA & HILDA VELLOSO 3 Q Q W J o O LD m Z Q OWNERS OF RECORD 0 Z o -1 '-' 78 CHESTNUT STREET n o m 4. cn � 2� 1JJ5 ��' HYANNIS. MA O I � C � wFLAN ®�®Nii��� PROPERTY ADDRESS N _ ASSESSORS MAP 309 PARCEL 50 O f VARIANCE REQUESTED 43 TRIANGLE CIRCLE � ri SCALE: 1 in = 20 L SANDWICH MA 02563 PLAN BOOK-PAGE 98-65 & 87-95 O �. MAY BE GRANTED IMMEDIATELY BY HEALTH AGENT OR HEALTH INSPECTOR. 506 3 6 4- 8 J 4 DATE: MARCH 17. 2009 o 20 e 20 4e 310 CMR 15.211(ll - SDIL ABSORPTION (L W Qi JOB E T E-31(d 2 PAGE 1 F 2 VERSION: O m X m cv SYSTEM TD CELLAR WALL. 20 f L MIN I_ v 0 10 20 THIS PLAN IS BASED ON AN INSTRUMENT SURVEY AND IS INTENDED LL W REDUIRED - VARIANCE TO 12 f t SEPARATION REQUESTED, . SOLELY FOR INSTALLATION OF THE PROPOSED SEPTIC SYSTEM DEPICTED HEREON: FOR ANY OTHER CHANGES TO PROPERTY INCLUDING PLACEMENT OF ADDITIONS. SHEDS, FENCES OR SWIMMING POOLS, OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. SOIL T E a T LOG DATE OF TEST: MARCH 16. 2009 s " APPROVED SOIL EVALUATOR: DAVID D. COUGHANOWR. u461 DESIGN C A L C u L A T I 0 N S „WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. PERC NUMBER: 12467 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD 1 SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS TEST PIT 1 NO GROTUNDDWATE LENCOUNTE ALD OUTWASH INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) PERC AT 60 to - 2 MIN/INCH IN C SOILS DISTRIBUTION BOX: USE 3 OUTLET D-BOX. ELEVATION SOIL ABSORBTION SYSTEM: THE LEACHING GALLERY DEPICTED BELOW CAN LEACH DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER A b o t = (22.33 x 16.50) - 1/2 [(5.33 x 5.33) + (3.67 x 3.67)] - [12.5 x 3.67) = 3 01.6 3 sF (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING A s d w = ( 17 + 7.54 + 11.17 + 6.16 + 5.19 + 12.5 + 12.83 ) x 2 = 14 4.7 8 a 41.65 0-10 FILL Atot = 446.41 sf Vt 0.74 x 446.41 = 330.34 GPD 10-14 O LOAM 10 YR 3/2 NONE FRIABLE USE THE LEACHING GALLERY DEPICTED BELOW. Vt = 330.34 GPD > 330 GPD REOUIRED 14-16 A LOAMY SAND 10 YR 3/6 NONE FRIABLE 37.98 16-44 B LOAMY SAND 10 YR 4/6 NONE LOOSE 29.65 44-144 C MED-COARSE SAND 10 YR 5/4 NONE LOOSE L EA CHI NG GA L L ER Y USE SHOREY PRECAST 500 GALLON NOT TO LEACHING DRYWELL (H-10 LOADING) SCALE TEST PIT 2 NO GROUNDWATER ENCOUNTERED PARENT MATERIAL: PROGLACIAL OUTWASH CONSTRUCTION DETAIL 2 MIN/INCH IN C SOILS 1500 GALLON SEPTIC TANK ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER STONE DIMENSIONS AND DETAIL NOT TO (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING DRYWELL UNIT USE SHOREY ST-1500-H-10 SCALE 42.00 0-8 FILL 17.0 Ft 5.33 f t 8-12 O LOAM 10 YR 2/2 NONE FRIABLE 12-20 A LOAMY SAND 10 YR 4/4 NONE FRIABLE �:,� v� Tm-'6 38.50 20-42 B LOAMY SAND 10 YR 4/6 NONE LOOSE � `` m , z 42-138 C MED-COARSE SAND 10 YR 5/4 NONE LOOSE m m `` t O 5 F t- 40.50 LO N L08 in (DGROUNDWATER ADJUSTMENTare o.or� �.� �EXISTING GROUNDWATER LEVEL F3 1t0BASED ON TOWN OF BARNSTABLE 3. 77GIS DEPARTMENT RECORDS. t 6.16 Ft INDICATED GW 20.00 INDEX WELL AIW-230 2 2.3 3 f t ZONE C INLET CENTER OUTLET READING DATE FEBRUARY. 2009 END COVER END READING 23.2 500 GALLON DRYWELL M.M ADJUSTMENT 2.7 DIMENSIONS AND DETAIL 3 IN DROP ADJUSTED GW 22.7 INSTALL ONE INSPECTION X, vFLOW LINE LSE H-10 LAVIT O WITHIN THREE FROM INICHESSER TOF FINAL GRADE BUILDING 10 In 14 TO �^ AND INDICATE LOCATION to D-BOX ON AS-BUILT PLAN 48 in LIQUID GAS LEVEL BAFFLE NOTES 0 33 °a°1 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. oao�000�000 �00�o In CROSS SECTION 'VIEW 2) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 000000ao 0� STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH �0 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. lez In 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS SEWAGE DISPOSAL SYSTEM PLAN OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). CROSS SECTION VIEW INSTALLER MAY ELECT TO SUBSTITUTE AN 41 INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES APPROVED FABRIC IN P ACE OFLE -TO SERVE EXISTING DWELLING BEFORE EXCAVATING FOR SYSTEM. THE 2 PEASTONE 5) EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED. AND REMOVED. LAYER SPECIFIED. JORGE PEREIRA & HILDA VELLOSO 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE. 2 in PEASTO 2 in PEASTONE 76 CHESTNUT STREET HYANNIS, MA 7) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES 0 O AND APPLIANCES. AND BIAN 24NUAL PUMPING OF THE SEPTIC TANK. z 3i4,n ro EF in FECTIVE ECO-TECH ENVIRONMENTAL 1^ GRAVEL DEPTH 1-112 In GRAVEL 1n 81 SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT 43 TRIANGLE CIRCLE SANDWICH MA 02563 PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. ETE-3102 MARCH 17, 2009 2/2