HomeMy WebLinkAbout0206 CRAIGVILLE BEACH ROAD - Health 206 Craigville, Beach.Road
Hyannis !�� ;
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TOWN OF BARNSTABLE
LOCATION J96 Coo-,,4r!gV,Ile-&4cA SEWAGE#�.'/�0 _
VILLAGE fL GAft SOR'S MAP&PARCEL �
INSTALLERS NAME&PHONE NO. ;304JS—A e- Ay- 20/0
SEPTIC TANK CAPACITY /� J
LEACHING FACILITY.(type AoW 6-e-o-,P (size) 33•J KI-I 3 XZ
NO.OF BEDROOMS
OWNER
PERMIT DATE: 3 2.s.-Dp- COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility.(If any wells exist
on site or within 200 feet of leaching facility) /l�u N'�- Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac 'ng faci i �Aa- Feet.
FURNISHED BY
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No.. �w f K Fee J'404D /�
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
RpPlication for 33i5po5al *pgtem Con9truction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade(j Abandon( ) Complete System ❑Individual Components
Location Address or Lot No.906 '(!'*1q(11Ifq_%""
,swner's Name,Address,and Tel.No.
l/� B F✓AVCeS .11jcV0 4/d
Assessor's Map/Parcel �-t'o 7 /l0 O W S� -
Installer's Name,Address,an T 1.No. v Designer's Name,Address and Tel.No.
3
/ ous� �l r u�rIr- SQ n4c -e v_ -e Li-i SAnr�c.�e L'GL
&) G 6-j 5'.4 7 d—r.-A o � 3 -fl3—2-1 2?
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder V/0)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) T 6 gpd Design flow provided `T gpd
Plan Date —Zo — o Q, Number of sheets / Revision Date /Nofy
Title
Size of Septic Tank / n 9A�lo�r Type of S.A.S. (3 4-7 hQi-S X
Description of Soil 52 Pl/�rl
Nature of Repairs or Alterations(Answer when applicable) /fZV 14 C-2 f-ce 1-,ed G e sS,Ooc�
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 of Healt Q�
e Date
Application Approved Date
Application Disapproved by: - Date
for the following reasons
Permit No. CS '1�r�� Date Issued �t5
v No., ::k s,"t Fee /®f�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZipphCation,f or Mi5pont *pgtem Construction Permit
-Application for a Permit to Construct O Repair O Upgrade(k Abandon( Complete System ❑Individual Components
Location Address or Lot No.d206 Ga�wner's Name,Address,and Tel.No.
Assessor's MapTarcel .2 to 7 &U
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel No.
/3oci3 /t l ��. L/a✓y �P i _
�X l, 6r F,*4 ..�� � c25 .G 3 ah'c � � v_ e�47 SAn��3�Z/ 7?
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder (XIQ
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gP
d
Plan Date 3 — Z Q a ¢, Number of sheets / Revision Date N°w
Title
Size of Septic Tank S v //o✓► Type of S.A.S. �G7%�✓!l PAS �/3
Description of-Soil fv/4
x
Nature of Repairs or Alterations(Answer when applicable) ifs/4 C 4-r, bod C-e-S S,Ovo
Date last inspected:
Agreement:
f '
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 of Health.
SigTned\ Date Z 6
Application Approved by Date
Application Disapproved by: I Date
for the following reasons
Permit No. r� ' yt=% Date Issued .� L
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,,that the On-site Sewage D�i+sposal System Constructed ( ) Repaired ( ) Upgraded ( �'
Abandoned( )by � .5�o �d J �,_ 6464 J"Ptirul C 2 -^/C
at Z 0(, ('r//a AaG yr /y 3,,�� Gj oZ e a -7e i L, //has been constructed in accordance /h�/v
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
t
Installer 13Gc,5{-t / f��, /A" f2ivi 4 e-1�Designer /�/l,C el y/
#bedrooms Approved design flow q 9 0 gpd
The issuance of this perm' s all not be strued as a guarantee that the system ill fu ction as designe C✓
Date Inspector
� � ) dU
No. THE COMMONWEALTH OF MASSACHUSETTS Fee
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Migonl:�&pgtem Congtruction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (X) Abandon ( )
System located at .206
r P.4 ,�e�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty "
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be gompleted within three years of the date of this
Date Approved ,y
Town Of Barnstable
y� Regulatory Services
Thomas F.Geiler,Director
+ BA1iNS�'aBE,E, i
a Public Health Division
t63q. �0@
ArFoa Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 3 2®
Designer: �� �r i�y Installer: /&ate 69NL
Address: . ��r 1 Address: Gv � �
On J was issued a permit to install a
(date) (installer) /
septic system at �0 « T 7'*0 based on a design drawn by
nA `, I (address)
D �� ►'"t��i ^� �� dated
(designer)
I certify that the septic system referenced above was install 11
ed substantially according'to.
" .le design, which may include minor approved-changes such as latern., relocation of the
6tribution box and/or septic tank.
I certify:that the septic system referenced above was instalke wth''ntaor,changes
greater than.'10' lateral relocation of the SAS or any vertical relocation of any component
of the septik�system)but in accordance with State&Local:Regflations. Plan revisozk or
certified as lhit;lt by designer to follow.
��KdOf 4�As
2bNVID . �y.
(Inst er's Signature) B. �
>: hIASON m
(ll er s Signature) ( fix gner's Stai�ip Here)
PLEASE RETURN TO BARNI StAE.LE PUBLIC.HEALTH DIVISION. C RTIFIC TE
OF. COMPLIANCE WILD N®'TE': SSUED . BOTH:-THIS 3F0�: . AS-
BUILT•CARD ARE RECEIVED W TH BAR. STABLIE PUB IC�IEALTIH'D SION
THANK YOU. ,
<<
• i
Q: Healtii/SepbcMesigner Certification•Forr3
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Town of Barnstable Barnstable
j� Regulatory Services Department I e"a�i
BARNSTABLE, _ I
9 ,�� Public Health Division
�'pTfa MAC" 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
May 13, 2008
Frances McDonald
206 Craigville Beach Road
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 206 Craigville Beach Road, Hyannis,MA was last
inspected on January 16, 2008,by Patrick M. O'Connell, a certified septic inspector
for the State of Massachusetts.
The inspection of the septic system showed that the system"Fails"under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Cesspool has excessive solids, inspector observed a high stain line above overflow pipe..
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
aTHE Bl ARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\206 Craigville Beach Road.doc
Commonwealth of Massachusetts ( S�
Title 5 Official Inspection Forms or
LSubsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is Hyannis required for Y MA 02601 January 16, 2008
every 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.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell _
cursor-do not Name of Inspector
use the return
key. Septic Inspection Service_s Co.
Company Name
� 189 Cammett Road
Company Address
Marstons Mills MA 02648:`
Citylrown State Zip Code,, =
508-428-1779 '+
='t
Telephone Number License Number
`2 }
B. Certification
r
I certify that I have personally inspected the sewage disposal system at this address an that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience,in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
N(\ 0 January 16, 2008
Ins ector'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.
08-12 McDonald.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis __ _ MA 02601 January 16, 2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (Cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CM 15.303 or in 310 CM 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or 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.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed y A
08-12 McDonald.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. Clty[Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
08-12 McDonald.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (Cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
® ❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than_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.
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 CM 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.
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. Cltyrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) (310 CMR 15.302(5)]
08-12 McDonald.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Unknown_ Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ® Yes ❑ No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
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:
Last date of occupancy/use: Date
Other(describe): ---------
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
N _ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald _
Owner Owner's Name
information is required for Hyannis MA 02601 January 16, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: None
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1930's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is Hyannis MA 02601 January 16, 2008
required for Y ry
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
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 ❑ No
---------------------------------------------------------------------------------------------------------- ---------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
_ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. Citylrown 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.):
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
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):
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage,into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fo
rm
o rm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M •''- 206 Craigville Beach Road
Property Address
Frances McDonald _
Owner Owner's Name
information is Hyannis MA 02601 January
required for y _ _ 16, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type.-
El leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number:
One
❑ innovative/alternative system
Type/name of technology: —
Comments note condition of soil signs of hydraulic failure,
( g y e, level of ponding, damp soil, condition of
vegetation, etc.):
Overflow in hydraulic failure. Possibly not on property.
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form.Subsurface Sewa
ge Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration One with overflow
Depth—top of liquid to inlet invert 2
Depth of solids layer
3'
Depth of scum layer 01,
Dimensions of cesspool 6x6
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool has excessive solids, observed a high stain line above overflow.pipe.
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.):
08-12 McDonald.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w.. 206 Craigville Beach Road
Property Address
Frances McDonald
Owner -----------...__...------_..._._.-..
Owner's Name
information is
required for Hyannis MA 02601
----------------_...------_........_--- - -- January 16, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
Property
Line
Laundry
Discharge line
r / r / /
Water
Service
Craigville Beach Road
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Craigville Beach Road
Property Address
Frances McDonald
Owner Owner's Name
information is
required for Hyannis MA 02601 January 16, 2008
every page. Citylfown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: N/A
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:
08-12 McDonald.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
Town of Barnstable
do Regulatory Services
.nxxsrnscE, Thomas F. Geiler, Director
1639. A�O� Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future,nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
r
QASEPTIC\Disclaimer Private Septic Inspections.DOC
LOCATION : 5EW&C4E PERMIT UO..
1 4
--DATE._P_E-RM1T__LS.SUED-_.�=�= S- -
J
I '
I �
No...... g Fx$... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Opi HEA
-.. �j � .._..OF............. .... .. --------
Applira#ion -for Dispoiial Works Towitrurtion Vrrmft -
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: e
- `
lLocaf�sA-Add re or Lot No.
Owner Address
-------------------------------•----._....--
Installer Address
dType of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms______________________________ __ _Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons_-__--__-__-_______-_.__ Showers ( ) — Cafeteria ( )
Q' Other fixtures --•-----------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter---------------- Depth.--------------.
x Disposal Trench—No- ____________________ Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area-----.------------sq. it.
z Other Distribution box'( ) Dosing tank ( )
aPercolation Test Results Performed by--------- ----•-----------------•----------._........-----....-----•.----- Date----_----------------- --------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water.______-._.___--___.--.
Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water----------------____.--.
----------------------------------------------------•-•-----•---------••-•--•---•--------•---------........................................................
0 Description of Soil......................................................................---------------•--•---•--------------------------------------------------------------------------
U ---------------------------------------•--------------•-------------------------------------------------------------------------------...-_...............---........---------...._..._....---...--
------------------------------------------------------•---•--------•---------------------------------------------...
U Nature of Repai s or Alterations—Answer when pplicable......_.__ __ _�✓I - ---------------------
�j Z--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
7
Sig d-. 7...J--•---
,{� -- -------- •
i Dat
Application Approved By------ / - 7 - Dat e
Application Disapproved for the following reasons---------------------------•-----......---------------------------..._.._.......------------------------......---
Date
PermitNo......................................................... Issued----_----------------------..........................
Date
(�J
No.......t-•--Cj_ Fms.................. .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
_. ......../..U1.�+'..1........OF....... ---..........-.-....
Appfirtttiuu -fur IN-4puottf Workfi Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: . r
67//� ocatio •......Add r� or Lot IVo.-�. .:�' �41-----------_- --_------ --------------------------------------------------------------
Owner Address
a --------- .
Installer Address
d Type of Building Size Lot----------------------------Sq. feet
U Dwelling-No. of Bedrooms______________________________ __ .Expansion Attic ( ) Garbage Grinder ( )
per, —Type g p Showers ( ) — Cafeteria ( )
Other—T e of Building ____________________•-•_-... No. of el-soils.._______.--------•----._.-•
Q' Other fixtures ------------------------------- - -
W
Design Flow--------------------------------------------gallons per person per day. Total daily flow--_--_____--_--_----___________-----------.-gallons.
9 Septic Tank—Liquid capacity------------ -.gallons Length________________ Width ........--.... Diameter................ Depth----------------
xDisposal Trench—No_____________________ Width-------------------- Total Length.................... Total leaching area--------.-----------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.............------- Total leaching area.___------_-.-_. Sq. ft.
z Other Distribution box ( ) Dosing tank ( )
'—� Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
W
Test Pit No. 1----------------minutes per Inch Depth of Test Pit.................... Depth to ground water-.._____------..-----.-.
G14 Test Pit No. 2----------------minutes per inch Depth of Test Pit----_............... Depth to ground water--------------._-__----.
9 .....-------•-•--------------------------------••-•----•--•----••-----•-------------••--••----------.........................................................
0 Description of Soil------- -----------------------------------------------•--------------------------------------------------------------------------------.---- --------------------------
x
W ----------------------------------------------------------------------------------------------------------------------'--------- --------- ---------------------------
VNa re of RepaiLs or Alterations—Answer when pplicable--.-______- - -.. . mil .
--•----------------•--------•---------------------------------------•---.---------•---------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been p sued by the board of health.
Signed
7 ;7
Date
Application Approved By---......!i�,t •--- ......... • • -- !L. . ............................ ---7- 7 — 7
Date
�!
Application Disapproved for the following reasons:.___..
--------•----------------•--------------------------•------------•-----------------. ----•----..---
--•-•-•..................•--•--••---....----•----.....---•--------------------•-•---------•--•-----------------•------------------•----------••--------------------•--------------••-------------.-----
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
/.....Qy .........OF........ :�. .... ....
ffff (Intifirtttr of f.1,11mlifiaurr
TH S-IIS TO CERTIFY, Tha the Individual Sewage Disposal System constructed ( �r Repaired ( )
by - -- -- - - .�------ -•`-------------- ..............................
!! ,,JJ
...........at.. --.............. r- ---- :�ll/v ..............{'�l/... . i ................
has been installed in accordance with the provisions of :Art' e XI of The State Sanitary Cod as described in the
application for Disposal Works Construction Permit No.______j .__/...��Y !' .7'S—
dated ? ---------------•----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON A GUARANTEE THAT THE
SYSTEM WILL F CT�N SATISFACTORY. �
T
DATE...." ----------..�1------------------------------------------- Inspector-- ..... --------•• ... ------ ............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O/f HEALTH
r O
1 r,T .r/ ..............OF..-......
No......................... FE -• •....----..........
�i��u�ttfurk,� C�uu�tr�t � ivat �erotit
Permission is hereby granted - - -- - ----------------------------------•-•------••---•-----.......----
to Construct )/6r Repair I ;divi al Sewage Disposal Sy te
Street
as shown on the application for Disposal Works Construction mit Dated___ _7`7 S
------------------------
I
DATE 7 � ,JBoard of Health
•---. --------------------------------•---------•---•---------......
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
ASSESSORS MAP :__... G'ro Z _ TEST HOLE LOGS NOTES:
V PARCEL: _6
FLOOD ZONE: SOIL EVALUATOR :
..._._ . .,_ . v_ ..___ . _
W I TNESS : 19DOW Q MID fPt4AJV1, 1) The installation shall comply with Title V and Town of Barnstable Board of
REFERENCE: _� p evd>4: :_* �A9�.��#�8 r g --r-- Health Regulations.
DATE: �2 .� � z Lob g
/�L F�...1 •tac k !76 X;'- 4 `37 PERCOLATION RATE: � Z-���, t 2) The installer shall verify the location of utilities, sewer inverts and septic
--�------ components prior to installation and setting base elevations.
�acx. OIL EL.. 37. .+ 3� y�
__._...... . . _ � � -� � 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
TH- 1 TH-2 two feet out of the d-box to the leaching shall be level.
�9k/Oy �q�4u�( A cS'�-/ray y 4) This plan is not to be utilized for property line determination nor any other
A, I/ /0 3 _ purpose other than the proposed system installation.
Gog1uYr� Lblgwte� �,r../� 5) All septic components must meet Title V specifications.
�a�Q � 6) Parking shall not be constructed over H10 septic components.
�Z 7) The property is bounded by property corners and property lines.
LOCATION MAP (A/
8) The property owner shall review design considerations to approve of total
I Co. design flow and number of bedrooms to be considered for design. Receipt
" C y ! of payment for the plan and installation based on the plan shall be deemed
In���t C 17�(L7 approval of the design flow by the owner.
9) The existing leaching or cesspools shall be pumped and filled with material
q per Title V abandonment procedures. Those within the proposed SAS shall
a be removed along with contaminated soil and replaced with clean washed
I`� I
--� sand per Title V specs.
10)System components to be 10 feet from water line. Sewer lines crossing the
IZ117
\ water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if
SEPT 1 C SYSTEM DES I G N applicable.
/ \ 11) If a garbage grinder exists it is to be removed and is the responsibility of the
/ owner to ensure such.
FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line.
�O 13)The installer shall verify the location, quantity and elevation of the sewer
3EDROOMS AT GAL/DAY/BEDROOM - GAL/DAY lines exiting the dwelling prior to the installation.
SEPTIC TANK
' V C4y()GAL/DAY x 2 DAYS - GAL
vo `' USE /60 GALLON SEPTIC TANK
SOIL ABSORPTION SYSTEM
IV / if
a'swas
!
t
° o ►o' j SIDE AREA: ZX �r�--} X 7-'G k• = 1.37
BOTTOM AREA: 35,5
j
06-'' :
I C SYSTEM SECT ION
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SEPTIC TANK
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SITE AND SEWAGE PLAN
TAR��`% FOrION . Zt�� �C �II,L� ✓ ' f��l
o- PREPARED FOR :
' SCALE -
° pA Za
TM.�.. .� .-:- ... DAV i D B . MASONi'�5 TE Z0w
- = DBC ENVIRONMENTAL DESIGNS
EAST SANDWICH . MA
3 DATE HEALTH AGENT ( 508 ) 833- 2177
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