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ffTOWN OF BARNSTABLE
LOCATION j C GU S/ SEWAGE# 2-010
VILLAGE I4 ph nrS ASSESSOR'S MAP&PARCEL 36? f 7U
INSTALLER'S NAME&PHONE NO. �GLn�2u�Lb� /!✓� JCTdd�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) I l 6_, 3 i"i)k- -to -elpsize) S
NO. OF BEDROOMS o
OWNER ca NNA_5. ctia-cto g PKA
PERMIT DATE: Zp- 11. - 'ZOID COMPLIANCE DATE: ( 0 ' !Z Ze 1 v
Separation Distance.Between the: .
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ., o 4� %! 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 o�fr leaching:facility). feet
FURNISHED BY
77
CP(P rz� g,
c
451
1
A
N 41 � r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
(60 " - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplicatiou for Mitpozat *pgtem Construction permit
Application for a Permit to Construct( ) Repair 9() Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. 1 S 6A4SZY1 VT S�r<ET Owner's Name,Address,and Tel.No. 'SA- rf
NY4 g SSc1„Qg tarrl,N'�
Assessor's Map/Parcel 30g I2C /itiwt� .+,w ,
Installer's Name,Address,and Tel.No. C4,04.j:e4. &vt4v Ym S Designer's Name,Address and Tel.No. 134Arc2 a1Ir
C P Van'%-;
Type of Building: 4
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building 5 inA.t.C � No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3a gpd Design flow provided 3 SO , t gpd
Plan Date 10 —(1— Number of sheets Revision Date
C
Title OS C,Aesrn J I @JT.
Size of Septic Tank (OOP Type of S.A.S. S IZA14_4 .SS 3�
Description of Soil .
Nature of Repairs or Alterations(Answer when applicable) &L,) i Vi�N I Aw lb r,J "G o><
Date last inspected: 20 tO
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 b this Board o ealth.
Sign
Application Approved by ate
Application Disapproved b Date:
for the following reasons
Permit No. Date Issued iD MIN
NAf2 (31C) - AV Fee
0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
13 . ,PUBLIC.HEALTH DIVISION --TOWN OF BARNSTABLE, MASSACHUSETTS
s 01ppIication�for �igp:o5ar *pgtem Congtructton'Vetmtt
Application for a Permit,to Construct( ) Repair()e) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. e 5'i n vT 5 1!2 e f Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel U
Installer's Name,Address,and Tel.No. r:��•�� �'I ^}'^;r> Designer's Name,Address and Tel.No.34xt C rZ `/L
(_�;�N;�'�!i{t ✓1q@ U Z b5L 1 k i c.,-.��. �rti'!* �
Type of Building:
a
Dwelling No.of Bedrooms -' / Lot Size � � / � � sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
i
Other Fixtures
Design Flow(min.required) gpd Design flow provided 2 � gpd
Plan Date IJ - 1 1- Number of sheets Revision Date
I Title �6 C to e S l"o f
Size of Septic Tank l�-> Type of S.A.S. S y'l v�C SS
Description of Soil s (cv, G c—, C( ,
�d
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: Sc� t�D
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 Board o ealth. K.
Signed ' - Date (� - 1 `(1 2 U
Application Approved by �� j�� , ate
Application Disapproved b Date
for the following reasons ,
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS t
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE/R�TIFY,that the On-site Sewage``Disposal System Constructed ( ) Repaired (X ) Upgraded ( )
Abandoned( )by
at C: ) G t�� n S 1 , I } ,tn v�; has been constructed ' acc rdance
�,
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Insta 0 - r 5 P S Designer O x r e( �^ hJ r`
#bedrooms 3 'Approved design flow v gpd
The issuance of is pe it shall not be construed as a guarantee that the system will u tiQi as designAd.
Date p 101 D Inspector VW,
l ,
j
No. Ft
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
t
Digpoot 6pgtem Cougtructiou permit
Permission is hereby granted to Construct ( ) Repair (x) Upgrade ( ) Abandon ( )
System located at
pkp'
:I
�l
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: Constru tionn st be completed within three years of the date of this it.
Date D Approved by i
'i _ V :
r
10/20/2010 11:04 FAX 5084253928 GANL'IYlur L& vvJ.i Vv.L
OCT-20-2010 10r03 From:MRNST HEALTH 1SO979O6304 To:50S42e392e P. 1/1
Town of Barnstable
Regulatory Services
1 g 'Thomas T. (.ciler,DircctOf
1 �� = Pubbe He-alth Division
McKean, Director
200 Mnin Stycrt, Hyaunls, MA 02601
Offlk:e! 10R-R62-4644 enx: %8-790-G304
Date: O~20—/O 4ewt► eYermit#2010^4I Assessor's Mbplparcel
K
Installer & Designer Certiticaliou Form
Oedibner; 66tX 6ir O dro �u��l., �u�y lnstulter: ��tQltti�ctt t ..
Address: 19 J10rA Address:
A4 DZL.95
v—
t7n I0�rZI/o Is�!�! �v nI[j, wAs issued u.pc Tit to install a
((ints) (iinstnller)
septic;System-,It_3� eS4n ,4 mil. N 4nniS,-,o-----bUSVd o❑ 3 design di-awn by
(aa runs
t er A4 64 14eerrY-- dated 10112-110
X ( �tgrlc
_ . i certify 1h:11. the ;ethic system rercrcuccd alcove wan inshtllcd substanliullYy according to
the design, which may inclua:le minor appr6ved elianges Such as lateral reloculiun of the
distribution box and/or geptic tank. Stripout (if required) was inspected ano the soils
wcrc fuur►d satistactory.
1 certify that the septic ,�ystem Mt`errnc:cd above was installed witti major changes (i,4..
grcator than 1 U' lateral r ocution of the SAS or any vertical rclocation of any component
oC the sPpti0 system) but in accordance with State 0- h its, Plan revision OT
cortiriesd as-built by designer to toltow. Stripuut (if r eted crud the sails
were found suti::farctury. d' STEPHEN J,
D.
MATSON
CIVIL
tti CI' s. Si azure) No*"345
G 'dal A T EE��U���'�
)caibnur s S�gnnturc (Af iA llca camp I lerc)
PEFASC, RPTURN TO RARNSTARLF 1'URLIC_f1EALTH DIVISION. CERTIFICATE
_G0-K—r LAF��I L NUTT A TSSL1T,D UNTIL BOTH TH IS k'U ANDAS-
DMI,T CARD ARE 112CEIVED BY 7111E HAUJT SI-ABLk '�,URT.IC' "yAi.TI.1 DMWON.
THANK YOL1
,1'V7 a�N:C fAuR4tcsiJyc,.crlifcnl.i:,n f.,i m.A,c
T 'd 82s'.e2b80ST8:01 :WOHA ti0T :80 OT02-S2-iDO
Town of Barnstable P# 1 3 &S- �-
��►+�Tad
�y Department of Regulatory Services
wwsrABLB, : Public Health Division Date6�bo
MASS.
163 g 200 Main Street,Hyannis MA 02601
jf0 MP't�'
Date Scheduled 0 hU Time Fee Pd.
of Suitability Assessment for Sewage isp�osal
Performed By: > ®V� 1/� Witnessed By: v ��' tv-
LOCATION & GENERAL INFORMATION
Location Address Q C j is kl� Owner's Name W t bs�Q✓
0 �(/1�1 vJ✓!r f Address
Assessor's Map/Parcel: 3 o 1 — l:z U Engineer's Name
NEW CONSTRUCTION REPAIR Telephone#
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body ft Possible Wet Area it Drinking Water Well ft
Drainage Way ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
Parent material(geologic) Cact D --, Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: r Weeping fro n.Pit Pace
Estimated Seasonal High Groundwater t)S= - 1 �9 S�►�c�-e�N 12 c' j f e`f '�Z°
DETERMINATION FOR EASOAL: TIOH`VEAL _TEIa
Method Used:
Depth Observed standing in obs.hole: in. Depth to sell tnottles: _ .._.. .__
—--- in,
Depth to weeping from side of obs.hole: _ ln. Groundwater Adjustment
Index Well# Reading Date: Index Well level Adj.factor Adj,Groundwater Level_T
PERCOLATION'BEST DMO Tlnia
Observation
Hole# � Time at 9"
Depth of Pere Time at 6' I
Start Pre-soak Time @ 0 7 Time(9"-6") 1 a
End Pre-soak
Rate Min./Inch
Site Suitability Assessment: Site Passed�_ Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you inust first notify the
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:\SEMC\PERCFORM.DOC
DEEP OBSERVATION:HOLE LOG _
Fepth HOIe#
Soil Horizon Soil Texture Soil Color Soil Other
.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Cons--y.%Gravel)
ladC-a
1 iIt
o_12� (��t�cs�s�,,►
DEEP OBSERVATION HOLE LOG Hole# IL
Depth from Soil Horizon Soil Texture Soil Color
Soil
Surface(in.) (USDA) Other
(Munsell) Mottling (Structure,Stones,Boulders.
�� Consistency,%Gravel
d yr o
e.
16 s-5`-F
60 �
b O S--C.—
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil
Surface(in.) (USDA) ( Other Other
) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
DEEP"OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Sail Other
Surface(in.) (USDA)
(Munselq Mottling (Structure,Stones,Boulders.
Consistency, o ray 1
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes
Within 500 year boundary No_X Yes
Within 100 year flood boundary No X Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious ma erial exist in all areas observed throughout the
area proposed for the soil absorption system? --�9
If not,what is the depth of naturally occurring per ion us material? -
Certification
I certify that on 00 (date)I have passed the soil evaluator examination approved by the
Department of Fnvir I onmental Protection and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017.
Signature Date r 0
Q:\.SEPTIC\PERCFORM.DOC
I
COMMONWEALTH OF MASSACHUSE17S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 85 Chestnut Street RECEIVED
Hyannis, MA 02601
Owner's Name: Doria Blanchette MAY 12 2003
Owner's Address:
Date of Inspection: April 10, 2003 L
TOWN OF BARNSTABLE
HEALTH DEPT.
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford Map:309
Mailing Address: P.O. Box 49 Parcel: 120
Osterville,MA 02655-0049
Telephone Number: (S08)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further-Evaluation by the Local Approving Authority
Fa s
Inspector's Signature: Date: April 14, 2003
The system inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or `.
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfilration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Chestnut Street
Hyannis, AM
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
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(lxb)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
h Page 4 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either`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 '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
1;Pd•
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
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 I1 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
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:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2002-4,500 gals.
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): _______gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 9"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000lzal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: Meamintz stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakalze.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
�- ^TOWN-�F BARNSTABLE .
LOCATION `�' 'e' n�! ST. SEWAGE #
VILLAGE ASSESSOR'S MAP& LOT 3001 1-io
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY l0'Ui� Gn�
LEACHING FACILr Y: (type) Ce a�� (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER b Or)A l,Cl�►�.t'
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist 0
within 300 feet of leachin facility) l Feet
Furnished by =r►S,QGton FOG
o W �•
6- Q`
G�
n
�t-
t
A
Page 8 of 11
0
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: 1
Innovativelalternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
The overflow cesspool was 5'W x 6'T x 8'bottom to grade and was dry. The scum line was 2'up from the bottom. The cover
was 12"below grade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
, O
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
Map:309
Parcel: 120
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.
Qy
QAc.� AV
0
A 3 ,
77
i a
1 76 a® O
13 / 3
a �6
3 30.6 ml-6
10
' Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Chestnut Street
Hyannis, MA
Owner: Doria Blanchette
Date of Inspection: April 10, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the overflow cesspool to grade wn 8' Using the Barnstable topographic map and the Cape Cod Commission water
contours map, the maps were showing approximately 25'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
I
I
. . ■-..,.e� l� A}Ir `! v M••• SEPTIC SYSTEM CONSTRUCTION NOTES
r 1 -.z__ LEACHM AREA REQLIRLIII WS GENERAL NOTES
•- _ SOIL LOGS - DATE 9/10/10
t •. ``� �' 1. ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE WITH TITLE V OF THE STATE SANITARY CODE DATED 4/21/06, AS AMENDED THROUGH
a . ._�/ NITROGEN LOADING UMITATiON: NA
:;�;., ,• r� . f �' , , �,, I � • ../ � _' . THE DATE OF THIS PLAN, do ANY LOCAL RULES dt REGULATIONS APPLICABLE )
_ RESIDENTIAL 3 BEDROOMS 1 THE INTENT OF TINS PLAN IS TO DESIGN A SEPTiC SYSTEM REPAIR AT LOCUS. THIS PLAN IS NOT TO BE CONSTRUED
r , _ "• .• 1 ,a AS A PROPERTY LiNE OR EXISiMtG CONDITIONS SURVEY.
`ri _•
a s DAVID W. STANTON, R.S.• x 110 GPDIBEDROOA�I
2. ANY CHANGE TO THIS PLAN MUST BE APPROVED IN WRITING BY THE ENGINEER. ELEVATION INFORMATION MUST NOT BE CHANGED WITHOUT WRITTEN PRIOR
= 3 ♦ • -�►- �_ 1 04;xr ' r 2 LOCUS AREA IS COMM OF.
r, }*. 4 APPROVAL BY THE ENGINEER. TEST PIT 2 TEST PIT 2 TOTAL DESIGN FLOW = 330 GPD (330 MINIMUM) )
.•�Jti= '., .•1 Ja' .: G.S.E. = 42.4 G.S.E. = 42.4 GARBAGE GRINDER (NOT INCLUDED) = N/A
t �" "*' f 3. WHEN EXCAVATION FOR SAS IS COMPLETE, PRIOR TO INSTALLATION, NOTIFY DESIGN ENGINEER FOR ZONE RB OVERLAY DI5TRICT: NOW
b w Ap 10YR 4/4 SANDY LOAN Ap 10YR 4/4 • SANDY Law
13 '• _ INSPECTION. PERC RATE _ <5 MIN. ,� INCH (CLASS 1) ASSESSOR'S MAP PARCEI 120
x -." _ ." 18' 40.9 R aAKE 18• 40.9 FRN0LE LIAR = 0.74 GPD S.F.
r„ '1 1 1.� 4. WHEN CONSTRUCTION tS COMPLETED, PRIOR TO BACKFlWNG, NOTIFY THE BOARD OF HEALTH AGENT / THE PROPERTY LAVE WORMARON IS AS SHOWN PER THE DEED RECORDED AT THE BARNSTAR E COUNTY REGISTRY OF
. p,
,v i{ AND DESIGN ENGINEER FOR e ; 10YR s/e; SANDY Law s : 10YR a/s; SANDY Low MIN, LEACHING AREA OF SAS. REQUIRED: IN PLAN 87 95.
EER INSPECTION.
330 GPD/ 0.74 GPD/S.F. _ DEEDS BOOK PAGE
45• 38.a FRUBI.E 45• 38.6 FRIABLE 446 S.F. MIN.
.. ... W ) OWNER:
4. ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 4 SCHED 40 PVC. UNLESS OTHERWISE NOTED HEREIN. 3 NAME'S E OLGA L WEBSTER
�.�• C . 0YR 7/4, FINE SAND tOYR 7/4; FINE SANG 85 CHESTNUT STREET
_' 1 1 LEACHING BED CONFIGURATION, 16 CHAMBERS 1 ROW-3 CHAMBERS, 2 ROWS-4 CHAMBERS,
HYANNIS, QN 02601
`' r 5. EXCAVATE UNSUITABLE MATERIAL AS NOTED, AND 1 ROW-5HWAMBERS
TO THE "C HORIZON" FOR A HORIZ. DISTANCE OF 5' SURROUNDING THE LEACHING FIELD, AND REPLACE w/ooeeLlrs w/cof�et Es
• �.y. ;' ;�a WITH CLEAN SAND PER 310 CMR 15.255 :TO THE TOP ELEVATION OF THE SAS. 9 - 34.9 LOOSE
IN 90- 34.9 LOOSE
IN�D EFFECTIVE AREA 1.67(2.8x(18,99+(2x25.32)+31.65 = 474 SF
�- 4) PROJECT BEIVCFIMARK : BM #1: MAG. NAM. SET EL = 41.90
t- r A 4►fir ,` �. ', �..,' _ s C2; , COARSE SAID C2; 10YR 7 4; COARSE SAND' tOYR T/4• / BM 12: SPIKE SET EL = 42.60
6. INSULATE ALL PIPES AGAINST FREEZING AS REQUIRED WHEN LESS THAN 3 OF COVER. LOOSE TOTAL EFFECTIVE LEACHING AREA = 474 SF
LOM�4• '"t +� , `�` +* ' r >' i = SYSTEM DESIGN CAPACITY = 474 SF x 0.74 GPD/SF = 350.1 GPD
7. THE SEPTIC SYSTEM DESIGN DOES NOT INCLUDE GARBAGE GRINDER DISPOSALS. 120 (EL. 324) 120 (EL 32.4)
5) DASTiNG CONDITION INFORMATION IS FROM AN ON THE GROUND SURVEY, PERFORMED BY BAXTER-NYE ENGINEERING ON
- _ _ PERC AT 66• SEPTEMBER 27, 2010 AND FROM GiS INFORMATION OBTAINED FROM THE TOWN OF BARNSUBLE CIS DEPARTMENT. THE GIS
SEPTIC TANK SIZING: 330 GPD x 200X = 660 GAL
8. CAUTION: THE CONTRACTOR SHALL CONTACT DIG SAFE (AT 1 SMs DIG SAFE) AND UTILITY COMPANIES TO LOCATE ALL EXISTING UTILITIES, AT LEAST 72 (EL-36.9) USE EXISTING 1000 GALLON TANK�. MIFORMATiON IS APPROXIMATE IF ANY DffS11NG M1F0RMATiON SHOWN IS DETERMINED TO BE INACCURATE OR MV CONFLICT
HOURS BEFORE THE START OF CONSTRUCTION. THE CONTRACTOR SHALL DETERMINE THE EXACT LOCATION, BOTH HORIZONTALLY AND VERTICALLY, OF ALL ��_ /IN
EXISTING UTILITIES BEFORE THE STARE OF ANY WORK. THE LOCATION OF EXISTING UNDERGROUND UTILITIES ARE SHOWN IN AN APPROXIMATE WAY ONLY, MAY CUSS i WITH THE DESIGN, THE SHALL CONTACT THE ENGMVEER MIEDMTELY FOR REVIEW AND POSSIBLE REDE5K1.
LOCUS MAP Scale: 1 = 2OW NOT BE UMITED TO THOSE SHOWN HEREON AND HAVE NOT BEEN INDEPENDENTLY VERIFIED BY THE OWNER OR ITS REPRESENTATIVE. THE Cow I CERTIFY THAT ON JULY 7,
AGREES TO BE FULLY RESPONSIBLE FOR ANY AND ALL DAMAGES WHICH MIGHT BE OCCASIONED BY THE CONTRACTOR'S FAILURE TO LOCATE THE UTILITIES EXAMINATION APPROVED BY THE DEPARTMENT OF ENVIRONMENTAL AREA OF MINIMAL FLOODING.
2007 I HAVE PASSED THE SOIL EVALUATOR 6) COMMLMITY PANEL "Wt. 250001 0005 C OF THE FLOOD INSURANCE RAZE MAP DEFINES THIS AREA AS ZONE C,
EXACTLY. IF ELEVATION INFORMATION DIFFERS FROM PLAN INFORMATION, THE CONTRACTOR SHALL NOTIFY THE ENGINEER IMMEDIATELY FOR POSSIBLE
PROTECTION AND THAT THE ABOVE ANALYSIS WAS PERFORMED BY ME
REDESIGN. AT UTILITY CROSSINGS, VERIFY IN FIELD THE LOCATION / INVERTS OF ELECTRIC, GAS, TELEPHONE & DATA/COMM AND RELOCATE IF CONFLICTING CONSISTENT WITH THE REQUIRED TRAINING, EXPERTISE AND EXPERIENCE 7)
WiTH PROPOSED INVERTS PER THE ENGINEERS DIRECTION. THE CONTRACTOR SHALL PRESERVE ALL UNDERGROUND UTiLRiES AS REQUIRED. DESCRIBED IN 1 CMR 15.017 • SITE IS NOT WITHIN AN 1A.C.E C. (AREA OF CRITICAL ENVIRONMENTAL CONCERN).
SK VATURE DATE Z Ol • STYE 6 NOT WITHIN AN AREA OF ESTIMATED HABITAT OF RARE WILDLIFE PER
\ i / M NHESP MAP OCTOBER 1, 2000 I TiMATED HABIUTS OF RATE MAW •
FOR USE WITH THE MA KX4NDS PROTECTION ACT REGULATIONS 310 CMR 10.
,- MAG. NAIL SET ( )
i / EL 41.90 _ -_-
\ R - SITE DOES NOT CONTAIN A CERTIFIED VERNAL POOL PER NHESP MAP OCTOBER i, 2008
41.5 "Comm VERNAL POOLS.
1x -
- - -- - ,- /� _ ' •SITE IS NOT WRMN A PRIORITY HABITAT PER NHESP MAP OCTOBER 1, 2008 "PRIORITY
/ `r _ .4 HA81TAT5 OF RARE SPECIES FOR SPECIES !TINDER THE MASSACHUSEiTS ENDjANGERED
SPECIES ACT, REGULATIONS 321 CMR10.
iiiiiiiiiiiiiiiiiiiiiillillilllllllI 42.041.8
x
42
CB/" SITE IS NOT M MV A ZONE M (MET LHEAD ZONE of CONTRIBIlTKWI)
41.2 8) UTILITY MIFORIA47 .
INSPECTION
TIP o o PORT. n EXIST
P. -EXISTING SEPTIC SYSTEM INFORMATION OBTAINED FROM THE TOWN OF BARNSTABLE (NO CARD /, NO DATE).41.9
1
�I MAP 309 -WATER LINE SHOWN WAS TAKEN FROM MAP #1662 PROVIDED BY THE HYANNLS WATER SYSTEM ON SEP'TEtW 1, 2010.
PARCEL 119
5' ovum SEE xcq .4 �
CONSTRUCTION `O
NOTE M 1 1.6 " EXISTING FENCE
t iri TO BE REMOVED
1 / TIP #1 a h AND REPLACED
f ro 41.6
MAP 309
PARCEL 120 x 43.0 Zo.1# 2
A.
�1 / pR
i
r _
{
y
,✓
10.48
23.6'
G
1 4' RESERVE101R.( �
I �'�• W 5tv
g 43 g3
Nam' w lop OF �3.0 � 42.6
Av
RECE FLOCATE WATER RESERVE aTWIf
(MINIMUM IW-SEPRKAHN)
1 / 42.6
Kl_ 42.0
SITE LOCATION:
86 but Street
O
Rpnnis, MA 02601
\ EXISTING SEPTIC TANK
x 42.6 RE MAIN EXISTING LEACH PIT PREPARED FOR
TO
z APPROXIMATE LocAT1oN of eE PUMPED
DRY CAPEWIDE ENTERPRISES
(A \ SEPTIC COMPONENTS SPI SU FILLED WITH SAND
\i •A 42.60 2.3 AND ABANDONED P.O. BOX 7630 CENTERYI" MA 02632
42. 508.428.4028
\ STp(3C 42.10TiTLE
\\ ADECIE
\� REPAIR PLAN FOR
ON-SITE SEWAGE DISPOSAL SYSTEM
r �\ MAP 309
PARCEL 121 BAXTER NYE ENGINEERING & SURVEYING
TYPICAL SYSTEM PROFILE ;/ 4 3
� Registered Professional Engineers and Land Surve ors
�. � TOSCy
NOTES: _ FiNI1M GRADE 78 North Stmet 3rd Floor,Hyannis,Massachusetts 02601
1. ALL MATERIALS SHALL MEET H-20 LARDING REQUIREMENTS IF PLACED 36"MA)C.-9"MI /�//�/�������������c .� .R�f�i���������������������� Phone- (508) 771-7502 Fax- (508) 771-7622
WITHIN 10 FT OF A ROADWAY OR DRIVEWAY. �' '
TOP OF CHAMBER z N MAS
SET FRAME OOVE1t TO 1NITININ 6. OF 2" LAYER DOUBLE WASHED S'ME 1/8• TO 1/2 0 Q- 0 Q ` e
OR GEOTE MLE FABRIC PER 310 CMR 15.247 ~' '
SET FE COVERS To 1ITIIIN 6' OF FINISH GRACE RISERS COVERS SHALL PE INVERT
� S EN
RISERS COVERS SHALL BE WWERiIGNT CLEAN SAND ' o 0 10 20
'" PER 3t0 CMR ETFECTNE
•- DEPTH
_,. 15.255
SCALE IN FEET �u a 345
FNNISFIED GRADE OVER D. BOX - 425 LFACTiMG BED = 424 ago
Yr r=1 ��C
\ [ZWOK
GRADE OVER TAW - 42.6 OOiIPAJLIED FILL O �F S
1 �
g• (min) Corer .) TONAL E�1
STE
CONNECT TO EM11M SEPI TANK. 3r (ma) Cww ONE INSPEcnoN PORT IN
INSTALL NEW TEE & GAS BAFFLE. 18 IF (LONGEST RUN) � t� " \� " �O\d
4 SCH 40 PVC OS-2.0x (1% MIN.) 2- LATTER DOUBLE MAS IED ~1/8"_,
�35 LF»4• SCH 4o PVC OS+�2ox (1x MIN.) 12• FIRST 2' (TO BE LEVEL) TO 1/2. OR GEOTExTItE FABRIC PER
CSCH. 40 PVC iOP 310 CMR 15.247 i ( ) NOT TOSC LE
10" MIN. OU11-4029 2
PVC (ASSUMED INVERT our) INv No �59 ► • SUMP . our- �.42 4• SCH 4o PVC 2.8 31.G5 --i DATE: 1%6/10
CHAMBER INN 0- 39.1
` CONTRACTOR TO VERIFY INVERT IN FIELD . 5 » BIOD FFiW 1100Bb OR
oPRIOR E';Ia1r0 IFONOIFFE NOTFY
REHr R °°uaa
MCI"-CHAWERS
REINFORCED CONCRETE 14" POSSIBI REDfSIG14. r'.y. -Y+' r. D BOX
Z BOR 4 » MODff'FUSER 1100BD OR EgUAL)
(V
r CRUSHED 25.32
STIONE
�X 3~eloolFF�uaI 110oec cR 9WLN
BY DATE REMARKS
TT DIST. LINE IN (TYP.) • MTid IGN CK BY: DRAWM�G
a UNSUITABLE Sots, �lA1Ir THE PFAS'TONE ELEV (TOP 5 MIN LEXHING
EXISTND MID OAMON T NUAW
T1) BE INSTALLED STABLE BASE OF SAS), SHALL BE REMOVED To THE _CHORIZON•
- SEE CONSTRUCTION NOTE 05 HEREON. 1 NO GROUND WATER TO ElF1/. 324 2.8
SCL ABOORPIM Syww iaA81 I--18.99' 0:\2010\2010-043\CML\PLOT\2010-043SP.dwg
TRENCH (TYPEAU
Nrs JOB 12010-043
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