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' Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
Information is required for every HYANNIS MA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When
fillingng out A. Inspector Information .SI /SaBr
out forms
on the computer,
use only the tab Christopher Maki
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services
use the return Company Name
key.
Main Company
r� Company Address
W Yarmouth MA 02673
City/Town State Zip Code
r 508-775-2825 SI-14423
Telephone Number License Number
B. Certification
I certify that;I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes 7
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
3/23/2021
Inspecftor`s78ignat6rT 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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
Z 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 WORKING CONDITION
2) 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):
i
i
0
l5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
U 32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name.
Information is required for every HYANNIS MA 02601 3/22/2021
'
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired:
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken'pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 16
is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7
V, 32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021 ,page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. 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.
c. Other:
4) 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
l5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
U 32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
15insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage,Disposal System Form - Not for Voluntary Assessments
32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc rev.7126f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 1e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v % 32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information Is required for every HYANNIS MA 02601 3/22/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. 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
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
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 ears usage '20-194 GPD
9 ( y 9 (9pd)) '19- 143 GPD
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: CURRENT
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
0
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 COUNTY SEAT ST > ,
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
' Last date of occupancy/use:
Date
Other(describe below):
3. 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:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a .F' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. Citylrown State Zip Code- Date of Inspection
D. System Information (cont.)
4. 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):
Approximate age of all components, date installed (if known) and source of information:
2018 PER PERMIT ON FILE AT BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 1
'feetet
Comments (on condition of joints, venting, evidence of leakage, etc.):
LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY
PITCHED
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
•Depth below grade: 12"feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
I
I
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 GALLONS
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? 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.):
1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT
NORMAL OPERATING LEVEL. COVERS 2" BELOW GRADE
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V � 32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
I "
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
S. 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):
i
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
I
Commonwealth of Massachusetts
R Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,. 32 COUNTY SEAT ST -
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
j 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
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert EVEN
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, 'any-
evidence of leakage*into or out of box; etc.):
DISTRIBUTION BOX LEVEL AND WATERTIGHT
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r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V, 32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS NIA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
2-500 GALLON
❑ leaching galleries number: -
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
r
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2-500 GALLON CHAMBERS WITH STONE FOUND DRY DURING INSPECTION WITH NO
EVIDENT STAINING. COVER IS 18" BELOW GRADE
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction ,
Indication of groundwater inflow ❑ Yes. ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5lnsp.doc•rev.1121121111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS -MA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
L
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
• r
r
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
r
' 1
t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar f
® 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 PERFORMED ONSITE AT TIME OF INSPECTION 5' THRU BOTTOM OF DRY SAS
ENCOUNTERED NO GROUNDWATER. BOTTOM OF SAS AT 6'.
f
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V� 32 COUNTY SEAT ST
Property Address
DOROTHY HARRIS
Owner Owner's Name
information is required for every HYANNIS MA 02601 3/22/2021
page. Cityrrown State Zip Code Date of Inspection
E. Report.Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14:.Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5inap.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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1 � ``P�TOWN OF BARNSTABLE
LOCATION 3 of (�(�l ,+V S'`' Si SEWAGE#
VILLAGE r �A k asv-,l _ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. SGo S'6 jt c{ 0 0 C-f
SEPTIC TANK CAPACITY 5 1, . ' r
I. LEACHING FACILITY.(type) SOO L:gejS
i_ NO.OF BEDROOMS
OWNER _ •A C�c- C 6 '
PERMIT DATE:� � `� COMPLIANCE DATE: <�"
Separation Distance Between the: _ �}
' iVlazim'Adjusted Groundwater Table to the Bottom of Leaching Facility Feet mu y
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) /C - Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within <
300 feet of leaching facility) ;Feet -:
FURNISHED BY
4A
a �-33 .
U32 , 36
,Ayz1.7
GZ� S CUn C-O KfS
5
No.(Zw Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
9pplication for Voposal bpBtEUY Construction permit
Application for a Permit to Construct( ) Repair C ) Upgrade( Abandon( ) []Complete System Vndividual Components
Location Address or Lot No. 3 c®v tiNy Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 04�11— 1 SV4 \A���~
Installer's lye,Addr s,and 1.No. Desig er's Name Address,and Tel.No.
lscokt .Awe,
��' UW �r.�r.,o� . 2J -Ew�cc\^ ' 1st Gcta ridc,- rid s-
v a goV3WOYi
Type, Building: �j� ciC{ 00(oC1
Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder(Iq
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 2 3o, Q gpd
Plan Date 114 Number of sheets Revision Date
Title ` `4 n
Size of Septic Tank D 6S"V 0e� ��L Type of S.A.S.
Description of Soil <kE?�_� y X /�,�' )C ;L lr-e4
Nature of Repairs or Alterations(Answer when applicable) r 12.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ofHealth.
S' ed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. c7.01 —� �3 Date Issued
+rwviSyi�Gwn�ar+17F {'�1aa't*a '�e".' a �2 .uicX :s � tiar . "r
No. /V- . Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Ripfication forwsposal 60stem Construction Vermit ' t,
Application for a Permit to Construct( ) Repair(/) Upgrade( ). Abandon( ) ❑Complete System [�,fdividual Components (
Location Address or Lot No. T2 C Ov\ley Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel \Aya"1S 45.
Installer's Nipte,Addrsss,and el.No. Designer's Name,Address,and Tel.No.
�.cOk\ \C i Occ� rtrt�rG.rho��'h R� f-WAt«� 1 Gco R d�t►1w t�2t�lfS, �/G�1
A !C wU V a b i IW o f l 4
Type of Building: j 6ti aei q oo(011
Dwelling No.of Bedrooms Lot Size 3 ` sq.ft. Garbage Grinder( U
Other Type of Building _ No.of Persons Showers( ) Cafeteria(
t Other Fixtures
Design Flow(min.required), gpd Design flow provided 30. 4 W gpd
Plan Date L.( I-X! % dumber of sheets Revision Date
1, Title
Size of Septic Tank 0 1�C t S\l L(�On rc(n`. Type of S.A.S. VJ I C) ;M U C w"', tl s trt)/
. Description of Soil
/- .
Nature of Repairs or Alterations(Answer when applicable) , ( gyp •e k ss�\nL
t Cn r"C_c,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ofHealth.
Sit ed Date
Application Approved by \ Date
.> Application Disapproved by Date
r
for the follow*ng reasons
1
Permit No. c f Date Issued��7
THE COMMONWEALTH OF MASSACHUSETTS +
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
TIES IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( )
Abandoned( )by
- at �� t�V!0�—aSt c� y6.n+ Q has been constructed in accordance yz
with the provisions of Title 5 and the for Disposal System Construction Permit No`. f /3gdated
Installer SCv I VC Designer 0 A{.Lt ,
#s bedrooms r Approved de sign-.oow 2, Q. 6 L4 gpd
=The issuance of this p(ymits all not be construed as a guarantee that the system will function es[ ed.
'Date / !/ �� Inspect%. P ��
----------
--------------------------------------------
No. f '' �i y Fee 1(5)
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction permit
Permission is hereby granted to Construct( ) Repair(V Upgrade,( ' ) Abandon( )
System located at_ 3 C,U �,kY b--E C.
and as described in the above Application for Disposal System Construction Permit. The.applicant recognized his/her duty to comply with
Title 5 and the'•following local provisions or special conditions. r'
Provided:Construction muss be,co pleted within three years of the date of this permit.
Date •/• 1/ p Approved b
`4 '�
i
THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF THE SEPTIC SYSTEM
EXISTING LEACH PIT
THIS IS A DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY`INCLUDING
TO BE PUMPED PLACEMENT OF ADDITIONS, SHEDS. FENCES OR SWIMMING POOLS, OWNER
/f� Q SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SRVEYOR.
l�®C�OG�
AND FILLED. U �
PLAN
USE COLOR PLAN ONLY
FOR INSTALLATION �. SEPTIC INFO AT
FULL DETAIL IS BEST E C O o T 2 C M.U S
VIEWED IN LS lti W
FULL COLOR
F7777 36_ 37
38 �•
3p6 /� 39 40
114.37
ft 41
37.1
38 1
MINIMAL \��JP / nl.�
39 l
0 \PROPOSED eel 0\\ o OAK
/ � in -
OAK cr
�
�" 12 in
I OAK 1
I
41 2 PROPOSED
ti� » ft SOIL
` ABSORPTION
N
EX0S r§NG 1 SYSTEM
—
1 -SEE DETAIL
42, 1 1 3 BEDROOM SLAB N ON BACK
' D WELL§NG C? �
'TGIF OF i §VDN
EL o .4 3.17 �a
o� - - - - - I
a^ Z
LOOT 20
.. I
44 AREA _ -
\`, s 13615 sf+
O LAND'COURT PLAN 14034—H
¢ ASSR MAP 291 PCL 159 ^PAVE
o? 3 15 in OAK 'DRIVEWAY...
OAK 42
ft -
-
_Mrs tiC, y
44 43 n 98.32 ft
at* ti t w - v w PA VEMENT_�•c v"�I M -+ v' INSTALLER i TO
EDGE' Of h' "" `� n .•: ' VERIFY LOCATIONS
OF ALL UNDERGROUND
A
r UTILITIES BEFORE
EXCAVATINGI FOR
oj3 SYSTEM.
LEGEND
/r�L A N
SEPTIC COMPONENTS
ul�
EXIS T 1000 GAL
SCALE: 1 _in = 20 ft p�04OILE GIs DA �j2`., SEPTIC TANK
20 40 GARB ELEVATION I EXISTING
43. 17 � LEACH PIT/
A
0 10 20 1G OT 0A OF FQUNDP�N 0- CESSPOOL
PRINT ON 8-112 X 14 in A OWED DISTRIBUTION BOXY
PAPER FOR PROPER --SCALE
TEST PIT
FALMOUTH RD !�o
oka RourE 2B�.� - E SEWAGE DISPOSAL
� Q UE �x ��tH �ss9�y �P�tH 01 ti'1ASsq� �� �� -ro SERVE S TIE M �F�L A KING
W AVEN o DAVID GJ o DAVID 9G
BRISTOL m ° D. �� DOROTHY
W D �+ COUGHANOWR w u COUGHANOWR ,,,
m No. 1093 No. 461 l� A. H A R R II S
V T V, C�� OWNERS) OF RECORD
CpDUNTY SNOT SFG ER�� soq R ° /� RESPc� 2;k 32 COUNTY. SEAT STREET
R To LAP HYANIS, MA
SCALE 155 Geo Ryder Rd S PROPERTY ADDRESS
HYANNIS. MA - Chatham, MA 02633
LOCUS MAP Dovidcou@HotmaiLcom DATE: APRIL 25.2018,
508 364-0894 PG.1/2 1 JOB, E T E-4 2 7T ABODE
-- DATE: 1564 24. �018 DEGION CALCULATION
� S®OLD TEST L®� PERC# 15649 ` � E � I N CALCULATIOo N �
SOIL EVALUATOR: DAVID D. COUGHANOWR. ASE #461 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD
WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT.
SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS
TEST PIT I NO GROUNDWATER ENCOUNTERED PERC AT 58 In - 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN
ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOUND STRUCTURAL CONDITION. IF NOT. INSTALL
INCHES HORIZON TEXTURE IMUNSEL MOTTLES NEW 1500 GALLON SEPTIC TANK.
41.75 0-8 A LOAMY SAND 10 YR 3/2 NONE FRIABLE INSTALL UNIT DEPICTED BELOW.
p DISTRIBUTION BOX.
39.25 8-30 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE $OIL ABSORBTION SYSTEM:
30-129 C MEDIUM SAND 10 YR 5/4 NONE LOOSE
31.00 THE LONG TERM ACCEPTANCE RATE FORA CLASS ONE
SOIL WITH A PERCOLATION RATE BELOW S MINUTES
r�
NO GROUNDWATER ENCOUNTERED PER INCH = 0.74 GALLONS PER DAY PER SQUARE (FOOT.
TEST PIT 2 2 MIN/INCH IN C SOILS THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY
ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DEPICTED BELOW CAN LEACH:
INCHES HORIZON TEXTURE (MUNSELL) MOTTLES I
41.85 BOTTOM AREA = (24 x 12.5) = 300 s . ft.
0-10 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE q
39.18 10-32 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE SIDEWALL AREA = (24+24+12.5+12.5)x2 =146 s' . ft.
32-126 C MEDIUM SAND 10 YR 5/4 NONE LOOSE TOTAL AREA = 446 eq. ft.
31.35 FLOW CAPACITY = 0.74 x 446 = 330.04 gal'/day
INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED
BELOW. FLOW CAPACITY = 330.04 gal/day WHICH EXCEEDS
g
330 THE al/do REQUIRED FOR A THREE BEDROOM DESIGN.
�1 100.O .,G LON SEPTIL. TAM
NK
. wm my, d AftwaKow •- n ma SPOIL ,A � S�jORr`TI�O
TANK TO BE PUMPED DRY AT TIME OF INSTALLATION
AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL @'V@TRW
NEW PVC OUTLET TEE EQUIPPED WITH A GAS 3AFFLE.
REPLACE WITH A NEW
1 in 1500 GALLON TANK DRYWELL 24.0 ft
TAPER IF CRACKED, ROTTED (h
OR OTHERWISE �r
COMPROMISED. �w
c w c)
° U? cO
Ct v= (V
° NOT N
4, co
TO c�
SCALE STONE
3.5 ft 8.5 ft 8.S ft 3.5 ft
N0
8 ft
_6 /n
SOO GALLON DRYWELL
INLET OUTLET DIMENSIONS & DETAIL INSTALL ONE INSPECTION
COVER COVER RISER TO WITHIN THREE
INCHES OF FINAL G ADE
---- USE & INDICATE LOCATION
3 IN DROP H-10 y "' ON AS-BUILT
—► I! F LOW LINE ,.: •
UNIT
FROM _ 33
BUILDING 10 in 3 -- 14 TO
I c- ry BOX— -G ':�� 'a� in
48 inp.
LIQUID GAS BAFFLE
LEVEL 0p�
O
a
it � +
102 !n
b In STONE BASE IF NEW CROSS SECTION VIEW
SEPARATION BETWEEN INLET & OUTLET INSTALL AN APPROVED GEOTEXTILE
TEES NO LESS THAN LIQUID DEPTH FABRIC OVER STONE
CROSS SECTION VIEW
BOX
28 3/4 in TO o 24 in a• 3/4 In TO
DISTRIBUTION IU X 1-I/2 In GRAVEL 10 EFFECTIVEo 1-1/2 In GRAVEL
in DEPTH
DIMENSIONSD—BOX TO RUN LEVEL
jAND DETAIL FOR 2 FEET BEFOREDOWN
' 46 in 58 in 46 in
--- 150 in
12 In
C MIN -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE
N� STARTING WORK.
Lr) FROM = -i -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM
REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC
N TANK b b TO @ CODE (310 CMR 15).
O p ^ SAS -INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND
T UTILITIES BEFORE EXCAVATING FOR SYS`!EM.
-ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION
\� 6 In STONE BASE OF LOW FLOW FIXTURES & APPLIANCES, AND PERIODIC
2 PUMPING OF THE SEPTIC TANK.
I 2 CROSS SECTION VIEW
III n -SYSTEM IS NOT DESIGNED TO WITHSTAND:VEHICULAR LOADING.
S DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM.
TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE TO BE 4 in SCH. 40 PVC
EL = 43.17 +- 6 in OF FINAL GRADE AND TO PITCH AT 1/8 In/ft MIN
41.15
i I D-BO i 3' i
USE H-20 M A X
EXISTNt('a�, 38.15
EXISTING 1000000 GALLQN PRECAST
SEp���
0 TANK �380016 in 37.48 DRYWELL
XI TIN +E s G REFER TO DETAIL BOX ��OL� G�C�3 O[� O
37.65 STONE �� p��0�
6 /n STONE BASE /F NEW BASE 37.40 SYSTF=M -REFER TO w
EXISTING 35 ft 5-10 ft II L�IIVII DETAIL BOX 9
310. NO GROUNDWATER V 35.40 MOTTLING OBSERVED _ 3�OOW
-SEWAGE DISPOSAL SYSTEM PLAN ;32 COUNTY SEAT STREET HYANIS, MA APRIL 25, 2018 ETE-42791 PG 2/2
t
t
X Town of Barnstable
Regulatory Services
Richard. V. Scali,Interim Director
MftNS7'ADI�. -•
MAM g Public Health Division
A�Fo�p Thomas McKean, Director
206 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer S. Designer Certification Form
Date: Is�ho �� Sewage Permit# as P —�3(/ Assessor's Map\Parcel 025'/-,ISM
. i
Designer: �)Aki fa>J CZWr Installer: �ZCbti .•1 ��,�,,.t,c
Address: f=���se 0 vd v 0--j Address: . f(:3 nk d yk_ k%, 2�
CV.c,�1�.t:.r�' ti.C, 0�6 3.3 1-Su� tati�' ^mac c�'d-6 of
On S /i c �i C'� r c-r„�,as issued a permit to install it
(date), (installer)
septic system at 32 County Seat Street based on a design drawn by
(address)
David D. Coughanowr, + dated . E..l a,S" l2 v 18'
(designer)
l 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. Strip out (it'required) was inspected and the soils
were found.satisfactory:
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. Strip out (if required) was inspected and the soils
were found satisfactory.
F
1 certify that the system referenced above was constructed in compliance with the terms
of the l\A aliproval letters (if applicable) -
v��ySti OF 1.!9Ssac v,�yZH of rtgSc
DAVI N o DAVID yes
D. D. ,
(Installer's Signature) COUGHANOWR ^ N
NO. 1093 COUGHANObVR
C'(SIflik O� CENS �O
(Designer's Signature) ner's Sta i e—l"
PLEASE RETURN TO BARNSI'ABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT ;BE ISSUED UNTiL BOTH THIS FORM AND AS-
BUiLT CARD ARE IZECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Sq)dc\Designer Certification form Rev 8-14-13.doe
DEEP OBSERVATION.HOLE LOG Hole# 1
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones,Boulder.
i Consisten.• %Gravel
`g l,.00latY dad W F_3& • ' dltQ F r',1b le
30 C,
,. .a,.,..., f � DEEP OBSERVATION O HLE LO G ;��� Hole# - Z
Depth from Soil Horizon Soil Texture, 'Soil Color Soil ' 'Other
Surface'(in_) ' ' ~ ' - (USDA) (Munsell) Mottling ,,(Structure;Stones,Boulder.
C_onsiggggy,%Graver_
-io ,rog �l S�tnA tp�'(R3�Z •-� lnr ''' '�V�q��
[v-llm -Stihd ID�fRsl6' FI`��Ib,�e
�j2,- t�v . � Med �•Id�1 l fl �/�f/� (l' y1a' � It }I S�y't
}
' DEEP OBSERVATION HOLE LOG Hole# A: '
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones,Boulders.
Consistency.%Gravel)
t
DEEP OBSERVATION-HOLE LOG „r Hole#,
Depth from Soil Horizon Soil Texture. Soil Color Soil Other
Surface(in.) (USDA) (Munsell)----- Mottling . (Structure;Stones,Boulder.
'` Consistencv.%Gravel)
.J
1 .
4. t
Flood Insurance Rate Mai): •.
Above 500 year flood boundary No_ Yes t/
Within 500)-ear boundary No Yes
Within 100 year flood boundary No Yes
Depot of Naturalh'Occuriin¢Pervious Material
,Does at least four.feet of naturallv_occurring_ pet- Pus material exist in all areas observed throughout the
area.proposed for the soil absorption systei --
If not,what is the depth of naturally occ e►wi'ou i a;erial?
� °9c
CettiGcation DA .
I.certify that on NO J 1a7� (d }` I ave a'SnVIDsed'tlie valuator examination approved by the I ;
Department of Environmental Prote n re alysis was performed by me.consistent with u
the required training expeipe and a de-scri i 0 CIVIR`15.017.
N O ,
Signahire S _ Date Pf, I S 01 g
Q_ISEPTIC\PERCFOR_M.DOC
Town of Barnstable P#
Department of RegulatorN Services ' A/
Public Health Division Date
C%V.Main Street;Hyannis MIA 02601
Date Scheduled 1 �t 20 1 C4 Time �jlFee Pd.
j
Soil Suitability Assessment for Sewage Disposal
Performed By: ti�� �(� �9170 t4r Mr Witnessed Bv: T)i"4�� �L*S MCI►e4 I S
LOCATION& GENERAL INFORMATION
Location Address Z Co U 17 ' 7 ez) t 5'f Ovmer's Name b oiv+h y A H Gt rr is
H yq h n/ 5 Address 3 Z C oo n t y S ea fi SF
AYC11111's wlA OZ661
Assessor`s-Map/Parcel: 2 C(1 31 Engineer's:`lame Da,,a ,Co 0 h q„owr
\'EW CONSTRUCTION REPAIR � Telephone n S o-9 364 osQ
I
Land Use Rec.,AEVI'�1 iol S lopes(%) 0 SurfaceAl Stones 50 he-
Distances from: Open Water Body `v D * ft Possible Wet Area,1 V VJ/�/1+ ft Drinking Water Well 1 00+ ft
Drainage Way � 0ft Property Lin n
e l D + ft Other ft
SKETCH:(Street name;dimensions of lct,exact locations oftest holes&pert tests;locate wetlands in proximity to holes)
� 2® N
A ��.iz` A_ 1$'0-06
�'pvtvT�{ SEAT 5TR-Ee -
Parent material(geologic) f 8fl 1 C1614 f 00 fi w 61 S vl Depth to Bedrock 0 to to-
Depth to Groundwater: Standing Water in HoL: t10 K Q Weeping from Pit Face N ��
Estimated Seasonal High Groundwater
DETEI�VIL�TATION FOR SEASONAL HIGH.WATER TABLE
Method Used: 610 4-9' 'e S Depth Observed standing in obs,hole in. Depth to soil mottles: 11°ne..Qif (U in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft
Index Well_ Reading Date: Index Well level Adj.factor Adj.Groundwater Level
if
PERCOLATION TEST Date 4 Z4 1% Time 10 A M
Observation
Hole 1 I/� Tune at 9" �/q
Depth ofPerc Sg Tim=.at B'
Start Pre-soak Time @ D-00 Time(9:-6") !�)
End Pre-soak-
Rate%4jn1Inch c�i1P l
Site Suitability Assessment: Site Passed r/ Site Failed: Additional Testing Needed(Y Ni) ,y
Original: Public Health Division • Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted Within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q 1SEPTICIPERCFORMI)OC
I
L --
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you.must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL, 367
Main Street, Hyannis, MA 02601 (Town Hall)
DATE: Fill in please:
wr�, ;r�tan�.q�....•�' :,. Y APPLICANT'S YOUR NAME/
�.q ''� a+ �F�� Q S NESS YOUR HOME ADDRESS: l c�-� ,y �gPo
TELEPHONE # Home T ephone Number
NAME OF CORPORATION:
NAME OF NEW BUSINESS Cul c/ Gg TYPE OF BUSINESS 6}IWA- ,
IS THIS A HOME OCCUPATION? Y NO d Go,
ADDRESS OF BUSINESS c . 1 �f ����5 �'� �MA /PARCEL NUMBER S (Assessing]
Wheh-starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended.to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1: BUILDING CO MISSIO ER'S O ICE MUST COMPLY WITH HOME OCCUPATION
This individ al h s e ninfo m d f a p mit requirements that pertain to this type of business. RULES AND REGULATIONS. FAILURE TO
COMPLY MAY RESULT IN FINES.
rJA
Authoorize i atur
MMENT (�21
r
E .
2. BOA OF HEALTH `
This individual has en infor e of the mit r uirements that pertain to this type of business.
Y1,417 All All
Authorize d Si4h ature** ft {?
MIUSY'v,0IVLY WM AU.
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
If, ,
�i
Date:/l l i/
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: efjAtA ?f41)j Acj3QJ119
BUSINESS LOCATION: Z r l INVENTORY
MAILING ADDRESS: TOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON: Ire R R i_ ev �k�•`/�
EMERGENCY CONTACT TELEPHONE NUMBER: -7,:?/- MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, '
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible f
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
r - (including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
W ITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's i ure Staff's Initials
� e Date
Physical Street Address-Check database to ensure it exists
orking Phone Number
[ 'Actual Amounts -( ie. gas being used to fuel machines, thinner to
clean brushes all count as hazardous materials-no blanks)
Storage Information - location of storage, how long is storage for?
If none, note that.
Disposal Information -where and who? If none, note that.
Applicant Signature - understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? -give a vehicle washing policy-and
explain it
Attach the Business Certificate with your sign off and comments
*"The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
LO CAT SEWAGE PERMIT NO•
)Ln.n-- zn
VILLAGE
INSTALLER'S NAME i ADDRESS '
Mho►K) i L�r4,
GUILDER OR OWNER
�A h)
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED' /a� 5Ay
C
Z
01,
410
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THE COMMONWEALTH OF MASSACHUSETTS
` BOAR® OF HEALTH
-•........................................O F.........................-.--.-.........
Appliration for llispas al Works Tonotrurtion rnmit
Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal
System at:
0 S + S�. LQ�Jrvi 5
Location ddress or Lot No.
��lL....t-� b..... � . 13c�._..........w .......... �,�,�� s
O n Address
a -•-------------•-•--______.........
Installer Address
UType of Build" 2 Size Lot__�3q.A_.&/S.__._____Sq. feet
• �., Dwelling RNo. of Bedrooms_______.__3...__________________________Expansion Attic ( ) Garbage Grinder (-K)
Other—T e
a yp of Building ____________________________ No. of persons............................ Showers ( f ) — Cafeteria ( )
Otherfixtures - .------•----•--------•••------•-•-----•................•------.........._.._._
w Design Flow................. •s......__...._.__.�.gallons per person per day. Total daily flow...........3__ ...................gallons.
WSeptic Tank—Liquid capacity_]00gallons Length................ Width................ Diameter----:........... Depth................
Disposal Trench—
eaching
Seepage Pit No �_.______ Diameter idt/D�-......_ Deptlobelow inlet..... .�.._._.. Total lleaching aarea__d-__70_...sq. ft.
Z 'Other Distribution box ( ) Dying tank re��•--- ............ Date_._.____-�, __''' Percolation Test Results Performed b ........J-_��_. . :_ 7------g� ----------------
Test Pit No per inch Depth of Test Pit....... ........... Depth to ground water._._'!! ! _...
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....:................... •
O t t._...
Description of Soil-•--Q--= �f._._..L.�4:r✓(._ __ .Y_ .5.0�f I� . `v
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 iITL� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of ompliance has been isstft b the board of h h. ;
�' . igned--V• ----•--•..... ...... � — f
/� � /�
ate
Ap lication Approved BY .: . � `-� � /
Date
Application Disapproved for the following reasons-------------=----••---•----.._..---•---••--•----_____--•--------•--•----------------•--_._..-•------------_.....
--•------------------------------••-•----..._.__....-•-•---------•-••------------••----••--------...-•---.._.._.__....__..._..--.-------•----••-•-----••--••-•----------._....------------------••-•-----
Date
PermitNo......................................................... Issued....................................................... .
Date
t
1 SOB ry F�s3o'".................
THE COMMONWEALTH OF MASSACHUSETTS
} BOARD, OF HEALTH
...........................................O F................-....--......-....................
Appliratiun for Disposal Works Tonstrnr#iun "rrmit
.r
Application is hereby made for a Permit to Construct. ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.._._ ' ..... ...... �... ............... '. ..........................................................
_.._�....��)"ofa�i.- ddress�'r�� "�� ����/L�ftit-
f' y
- : ................"- .... r Lot No. ........
:.
n
•
a
.............. •--•-.. _ __.. •./ w: _.."�..(.,S/ • Kayress !q Q�/ _ t
-,
Installer ,. Address '.
d Type cof.Buildm
Size
a Lot.
Sq. feet
Dwelling No. of Bedrooms.___.__.__._..................... Ex Expansion Attic ( ) j6 � yGnnder �)
aOther—Type of Building ___________________________ No. of persons........... Showers ( ( ) — Cafeteria ( )
Otherfixtures ---"-"-"---••---"--"-""-"----"•--"--"..."-"-""-""--•-"•"-"""........-"----"----------------"---"-"-"-""-•""""""-"-""....:..:_.......
W Design Flow________________5 __:__._____.....___.gallons per person per day. Total daily flow--......... 3.0
WSeptic Tank—Liquid*capacity./.S=.Fngallons Length................ YV�idth................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area...........:.._.._.sq. ft.
Seepage Pit No.......{............ Diameter....__$L.____.._ Depth below inlet.......S_a....... Total leaching area.. ....:... ...sq. ft.
z Other Distribution box ( ) )�osmg tank ( ) a 7r�
Percolation Test Results Performed, by-....... :. (....... .........J ... Date....... �_f: ................
c
1 Test Pit No. 1� � �4�rYinutes per inch Depth of Test Pit......1�,,s....... Depth to ground water..____ . _ .._
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-_N� .�......
P .........................--- :"--""""""""-"-"•"----•"""""...--""-""""............:...................."".............."-........_._...........--.-••--
Description of Soil... •.- ;-----�tiGi itlj.....�U��5d��=--"-----"-•""" ��- �./. - • rviR 1
V ...._......--•--•-••---•••--•..............................•-•••--•........_.._..................•••-__.....•••----•-....._...••••....------•-------------------•-•----•••-------•----------------------
W
VNature 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 TITTLE-E- 5 of the State Sanitary Code—The undersigned further agrees not to place.the system in
operation until a Certificate of ompliance has been issued by the board of health.
� oti igne --------• •. ..... ............... . ......
_...
�+ ,..
Ap lication Approved By.---�, ... -
. r
4' Date••-•-•---"--_-
Application Disapproved for the following reasons:....................... "-""-"""•"••"-••--•----•--••""•-•---"-"....----"---""""........___..__.........._------
"•-"""-""""-""""•-"""""""-""""-"•"-"""""""""...........-""•""..".."-•"""--•-----""""-"•----""•-""-""""....-""-"•-"-""---"-"------"""....._....-•"""---•""••"•--•---""""•".--•-•......................••-
Date
PermitNo......................•--.._..._..•-•......------•-••••. Issued--•--....""--•-•........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .�.. ✓4.........................................................
Trrtif irate of,Tuftpliaurr
TIM IS E IFY, That th Individual ewaze Disp 1 , ystem constr ted o Repaired ( )
...- --- -
o�-O r^+Iuer
-�y/�
at ..................................................................
..........
has been installed in 'accordance with the provisions of T T'71 5 of The.;State Sanitary Code as described in the
application for Disposal Works Construction Permit '
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE. Inspector.__. ..............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF` HEALTH
.........................................OF. -...-..._ . ........_...._........_........................... FE
No......................... :3 ....
his tt r Vk trtuliot rrmil ,,,,_,
,� ..� - ,�
Permissio4yrs hereby granted.............. --•. . ............ s -r-y
to Constr c ( or. F ►�u�&�; .�.} an ivies Dispo System `
atNo........................................ .................................................... --- =
St ileet
+ as shown on the application for Disposal Work's Constructio mrt No..................... Dated...........................................
` _. .............................................
DATE...... ealth
...._..-""-•-"-"•-•"•_........_--_..... i
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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I-�•~�1 /� nutitE�:G f3 i•lCriMA�'6 - TOP SP/t-4 e- HY'019 fJ'r , LOY 20, E = IcaO.r�o r
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sac(�. s C3 I c7 ' . • �
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LEGEND 4 CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION Ox0 `'F t'+ss
EXISTING CONTOUR --- 0 --
FINISHED SPOT ELEVATION : ALBERT.
FINISHED CONTOUR 07---
No.109S1 O Q• 1 N
APPROVEOs BOARD OF HEALTH AvFs7►s����`��` rs SAJlk,$ tA9JaJ2, WA8�•
ONAL,
DATE AGENT SCALE$ i ''= �� ' DATE& •O8 • /�.• ? J
LOREDGE ENGINEERING CQ /N CLIENT RY`�&/: I CERTIFY THAT THE •PROPOSED
EGISTERE REGISTE JOB N0. R//0 BUILDING SHOWN ON THIS Pl!AN
CIVIL LAND CONFORMS TO THE ZONING LAWS.
E RISURVEX: DR•BY', " ----- OF BARNST SLE, A�S�S.'
712 MAIN ST. CH. BY ,J' 19 ► ` � ��-� --
HYANNIS, MASS. SHEET-L OF ?,. DATE G. LAND SURVEYOR
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