HomeMy WebLinkAbout0050 CIRCLE DRIVE - Health P '50 Circle:Drive
3 A= 288—037
Hyannis. .
r7 '�
Commonwealth of Massachusetts
4 Title '5 official Inspection Form
�m a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 Circle Dr. Hyannis MA 02601
Property Address
Jason Taylor h ,
Owner Owner s Name
information is Lexirygfon Lk4,.13 MA 02420 8/25/2015
required for every
page. Ci own State Zip Code Date of Inspection
r+w"I
I'4.Y
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms ;-
on the computer, /
use only the tab 1. Inspector: ` /`1,Z5
key to move your
cursor-do not Paul Martin
use the return Name of Inspector
key.
Cape Cod Septic Services
f� Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
Cityrrown State Zip Code
508-77572825 S15016
Telephone'
:Number License Number
B. Certification
I certify that 1 have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based,on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
i
C i
8/31/2015
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)�,within 30 days of completing this inspection. If the system is a shared system or
has a design flow;of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Ipgj
Vs
t5ins•3/13 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 50 Circle Dr. Hyannis, MA 02601 '
Property Address
Jason Taylor
Owner Owner's Name
information is required for every Lexington MA 02420 8/25/2015
_
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System in working condition.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need.to be
replaced.or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes "no" or"not determined'! (Y,.N, ND) for-the following statements. if"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is
required for every Lexington MA 02420 8/25/2015
page. Cityrrown 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,):
El 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):
El broken pipe(s) are replaced ❑ Y ❑ N. ❑ ND (Explain below):
obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
distribution box is leveled or replaced ❑ Y ❑ .N ❑ ND(Explain below):
❑ The system required pumping more than.4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
El
obstruction is removed ❑ Y ❑ N ❑ ND(Explain below)`
C) Further Evaluation is Required by the Board of Health:
,g ❑ -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.
I.'.,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 wihl protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is
required for every Lexington MA 02420 8/25/2015
page. Pity/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 aseptic 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:'
...E
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`
a ® 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 1/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
w v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is required for every Lexington MA 02420 8/25/2015
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E.). Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes' or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
4 . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is
required for every Lexington MA 02420 8/25/2015
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?
❑ Z 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)
0 ❑ 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:
Z ❑ Existing information. For example, a plan at the Board of Health.
El ® 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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x4=
440gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is
required for every Lexington MA 02420 8/25/2015
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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? Z Yes ❑ No
Water meter readings, if available last 2 ears usage d 2013=33gpd
9 ( Y 9 (gP )) 2014= 39gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
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•3/13 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 50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is
required for every Lexington MA 02420 8/25/2015
page. CityTTown 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: No Records
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract .
❑ Tight tank. Attach a copy of the DEP approval:
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is
required for every Lexington MA 02420 8/25/2015
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:
1983 Per BOH records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
31
Depth below grade: feet
Material of construction: ,
❑ cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: +1 p'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Line checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
i
Septic Tank(locate on site plan):
2,4„
Depth below grade: 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 0 No
Dimensions:
1000Gal H-10
Sludge depth: 4-611
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is
required for every Lexington MA 02420 8/25/2015
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
Scum thickness 0-2
Distance from top of scum to top of outlet tee or baffle
Distance from(bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal H-10 tank in good structural condition. PVC tee in place on inlet with baffle in place on
outlet. Tank at normal operating level. Covers 2'4" below grade.
j
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 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is required for every 9 Lexin ton MA 02420 8/25/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be 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
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M s 50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is required for every Lexington MA 02420 8/25/2015
page. Citylrown 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 Oil
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.):
H-10 DB-5 with 1 line in and 1 line out in good condition. Box is clean and level with minimal solids
carryover. No sign of overloading or hydraulic failure. Cover 3' below grade.
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 r Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is required for every Lexington ton MA 02420 8/25/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-6x6
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
1-6x6 leach pit with stone. 1' of effluent found at time of inspection. Staining no higher than 2'. No
sign of overloading or hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool r
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is Lexington MA 02420 8/25/2015
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont
Comments(note condition of soil, signs of hydraulic failure, level of ponding;condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
infgor. d for
is ton
re uire for every Lexington 9 MA 02420 8/25/2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor
Owner Owner's Name
information is
required for every Lexington MA 02420 8/25/2015
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: 11'
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:
Hand auger observed water at 11'. Bottom of leach pit at 7'. 4' separation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts .
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 50 Circle Dr. Hyannis, MA 02601
Property Address
Jason Taylor F
Owner Owner's Name
information is required for every Lexington MA 02420 8/25/2015
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® inspection Summary: A, B, C, D, or.E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
3
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
3
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LEGEND `:: ' ;F •, CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION. "OAO
EXISTING CONTOUR ---- 0 PHIL Lo7
FINISHED SPOT ELEVATION : wEIERc
FINISHED CONTOUR 0 V66 IN
APPROVED BOARD OF HEALTH A it . VA,0 p1.
" At G
1y5.15.8 5
------ SCALE, I 30 DATE 03 .08 83
DATE AGENT
r3A/`Si.DL
DL KEDGE ENGINEERING CLI ORIENT �`"`D..... ".—....�' 1 .CERTIFY THAT THE PROPOSED
83olq BUILDING SHOWN ON THIS PLAN
EGISTE6dE REGISTERED JOB NG•.....- -- CONFORMS TO THE ZONING LAWS---
C I V t L LAND DR.BY"�=---
ENG NEER RV OF SAF3NSTA® E, MASS.
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712. MAIN STREET. CAI, BY H YA N N I S, MA3s. SHEET.-�..:OF 2 DATE a. LAND SURVEYOR.
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L0CAT.ION SEWAGE PERMIT NO.
VILLAGE
_-
INSTLAEaIs NAME A ADDRESS
� u I L D E R OR OWN ER
--- �'
DATE PIIt III IT I SIDED _
DAT E C0 MIPLIANCE ISSUED 2_0
I�
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD W !-i E ' 'T
.. � �' OF...... .... . .
Applira tiou for Biupuuaal Wor�) or
uwitrurtion amit
Application is hereby, made for a Permit to Construct Repair ( ) an IndividiA Sewage Disposal
System at: .n .. .... ... .
6
Lo - ddres or Lot No.
.. . ..... ....--•-------------- --•------ /.� .. ..---.........------------------.----.........
�r n Address
af..2... .. .............................. .............•--------............................ ...... ......•.
Installer Address
Type of Building Size Lot...........................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ..................................
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................. Diameter................ De tl _----__-__---_--
W
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area._ _ ZK...._.sq. ft.
x
Seepage Pit No----------_-------- Diameter.................... Depth below inlet.................... Total leaching area.. 4 ...sq. ft.
z ` Other Distribution box ( ) Dosing tank ( .)
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ .. .
r � -fit - ------------••--•-•---••---•--•-•-•---•--.,.........------•--------•----------••--
Description of Soil--------- Y h .
x ........................................... --- -- . . ..... ...../
.
w
UNature of Repairs or Alterations—Answer when applicable...____.........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' ed by the bo o iealth.
igned.=-- � m^�
ApplicationApproved By------. •-•--•. . •. .................................................................. ..... .......................
Date
Application Disapproved f o th following reasons--------------------------------------------------------------------------------------------------------•--_.....
----------------------------------
•-•------------------------------------------
------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEA. TH
...../ :.................OF....... �/ ✓�/'. . ..r! .. ..............................---•
TrrtifirFa#r of TompliFana
T S IS T ERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by..•. .. ----... .
Installer
at....3..._... - .= j
has been installed in accordance with the p isions of Tj � )��he State Sanitary Coda cr ked in the
application for Disposal Works Constr on Permit No.. _________________________________ dated _-__.__ _____ .___._...._._.____..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISF CTORY.
pp,, ,
DATE............ ...�P ��J Inspector .�_�' -----------------•-••---..............._........_......--
{
N01 fle FEs... .................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® HE
...... ... ..............OF....... ... .:. ... : :.._.. s�T
Appliration for Dhip000l Work owitrurtion rrutit
Application is hereby made for a Permit to'Construct ( ) or Repair,( ) any IInndivid Sewage Disposal
System at:
Lo ddres /�,,y r /y ( j-or Lot No.
._. h_ .._.... !_ --
..................... -'.,-----.....'-.--... .......-.----......_._.._.._...._..__..._.....
W
Address
/ .f n +.... ............."""-""........_._..........____
Installer Address 15
/j
Type of Building Size Lot_______---------------------------- feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type.of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
aI Other fixtures _______________________________ __
W Design Flow...................._.......................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ e
x Disposal Trench—No_____________________ Width.................... Total Length__ g . }}.....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. I.............._:minutes per inch Depth of Test Pit.................... Depth to ground water__-_____-_______--___-..
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
_f
�q / C
O Description of Soil.......
,! -- `�
x ., r l .
w
�� ...............
--------------------------------•-"---"---------.--•-""-._.._.._..-"---"--""---"-"-""-...--------"--------""•"-----------"--------""""-...--"-------""""----""--"---"-------______._---•-...--•••-••---
U Nature of Repairs or Alterations—Answer when applicable...._...........................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 5 of the State Sanitary Code— The undersig5rA further agrees not to place the system in
operation until a Certificate of Compliance s been d by the boaA of ealth.
..
' 2
gned- .•- -----------------• ............... ..........................• --- •---•• f-. _.....
Application Approved BY _____ ..t ._.. :_ �
- -• Date Application Disapproved for th f ollowing reasons_______________•______._.._..._•________________.._..___...__•_____________________._._________._______-__•_...._
............................-•-----_____-••-•-••••-••--•.....................••--------______••••-•-------______________••-•-•-•••-------•----•--....................................................
Date
PermitNo......................................................... Issued.................-------------------•----....._.._...---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD. . HEAT ,
....... .................OF..... .��. .. . ..1..-4�-. _............................_...-...........
Trdifiratr of Tootplionrr
T,- IS T RTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by................. .. . .. •----- .... _._....--•----------�---__ _ ----_-------------------------_------------------_............................._____-
Installer
has been installed in accordance with the pr isions of TI C 5 ' 1,e State Sanitary od as ibgd in the
application for Disposal Works Constru on Permit No......................................... dat .. .. .................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE {
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................................... Inspector..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEAL
....... 1/v -.::
No. FEE......................
Map Wor %Tono#rt ion rrntit
Permission is eby granted__ ' _ _.
to Construc .Repa,ir,:( , anon ividual Sewage Disposal System
c -
Street
as shown on the application for Disposal Works Construction Permit No........... ated._�_...___.____����.............
.................................... • ........................................................
DATE........................ :• ........................... bard of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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'A v� {=tf\.J11NL� ASSOGiAT�s
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LEGEND ` �;� : CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION. 10><0
EXISTING CONTOUR.--- 0 PHI LoT 5 -
FINISHED SPOT ELEVATION Cam] 0 wit �ERc {-1�//�tJ►J I S PCB(Z-T�
FINISHED CONTOUR "— -si IN
APPROVED I BOARD OF HEALTH `�� 'S.T0`G% . �,�
�...,"_'Ali` . a. ' JJ �V'��.,.�� iNSS*
I�,ve�t .c o�•2S•£13
SCALE I > 30 DATE , 03
DATE AGENT
J�Ars.�� •
,ram DLDL REDGE ENGINEERING CQ IN CLIENT "`,... ' -`� 1 .CERTIFY. THAT THE PROPOSED
EQISTERE REGISTERED J0� N0.,.,.,�'�0'9 .- BUILDING SHOWN ON THIS PLAN
CIVIL LAND , E CONFORMS TO THE ZONING LAWS
ENO VEER RV DR.BY �.�.... .- O,F', PARNSTAB E, MASS.
712 MAIN STREET. W. BY Rw
.-�- o4 3
HYANNIS, MADS. _ gHEET!.:OF ti DATE _RE 0. LAND SURVEYOR
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President: Member of
ROBERT BRUCE ELDREDGE.R.L.S. CAPE COD SOCIETY OF PROFESSIONAL
Office Manager R,EL - ELDREDGE ENGINEERING ASS 71 AND SURVE ORS
JOHN R.EL LIS,H.L.S.
MASS ASSOCASSUC OF LAND SURVEYORS
Associates: AND CIVIL ENGINEERS
ALBERT A.MORSE.P.E.,R.L.S. COMPANY, INC.
PHILIP WEINBERG,P.E.,R.L.S. AMERICAN CONGRESS ON
SURVEYING AND MAPPING
AMERICAN SOCIETY FOR
-_1?-9 EP 2fU rJ\8 i3tnG 2f� TESTING AND MATERIALS
c.rand C(vi[ 712 MAIN STREET.
esu¢ver�ou CncJinee z� HYANNIS,MASS..02601
TEL.(617)775-2244
May 12, 1983
Mr. Ronald Gifford
Board of Health
367 Main Street
Hyannis, Ma. 02601
Re: Lot S, Circle Drive, West Hyannisport, Mass.
Dear Mr. Gifford,
At your request our field crew obtained "as built" elevations on the septic
system on the above-mentioned lot, a grade .&r Simmons Pond was also obtained;
The elevations were taken on the morning of May 11, 1983.
Design and "as built" data appear below:
DESIGN "AS BUILT"
Water elevation, Simmons Pond 9.6 9. 76
Top of foundation 22.0 21. 72
Soil pipe invert at building 19.5 17.89
Inlet septic tank 19.3 16.75
Outlet septic tank 19. 1 16. 18
Inlet distribution box 18.9 15.99
Outlet " " 18.7 1S.88
Inlet leaching pit 17.6 17.11 - `1 0 3•(/
As. you are probably aware the Cape is experiencing exceptionally high water "-3
levels, I quote from the March 1983 publication of Current Water Resource 3 3 5
Conditions In New England: . . ."water levels in seventeen wells in southeastern
New Hampshire, eastern Massachusetts, and Rhode Island were the highest for the
end of March. Nine of these wells exceeded the previous highest recorded
water levels for the period of record."
Our septic system design criteria specified a three bedroom dwelling on this lot;
it is my understanding that you and Mr. Brian Dacey have resolved the question
relative to the number, of bedrooms actually contained in the building.
Should you have any questions do not hesitate to call.
Veer t.�rf'�/''n{�y yours,
Gam—.-v
L,John R. Ellis, RLS
Office Manager
JRE/jne
copy to: Bayside Building Company, Inc.
i