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Home My WebLink About0049 CROOKED POND ROAD - Health 7 49 Crooked Pond Road Hyannis a A=291 - 051 5 N �i i I If f 4 LTown o P# Department of Regulatory Services ,,,R,, , F Public Health Division DateMA sb 9 ♦� 200 Main Street Hyannis MA 02601 Date Scheduled - Time Fee Pd. ell -0 Soil Suitability Assessment for Swage Di osal f� 9 Per By: Witnessed By: LOCATION&GENERAL INFORMATION Location Address Owner's Name �5i1 2:5 iTi2�L:s Address Assessor's Map/Parcel:- �) 1 JC Engineer's Name NEW CONSTRUCTION / REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests locate wetlands in proximity to holes) rA N � =fiNV r�� n Oj 7/Z y R>0-0 (Ze)-AO Parent material(geologic) Depth to Bedrock Depth to Groundwater•. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL ffiGH WATER TABLE Method UsedL in. In. Depth t0 Sgll mottles: Depth Observed standing in obs.hole: In. GroundwaterA Depth to weeping from side of obs.hole: dJustment fL Index Well# Reading Date: Index Well,level .. Adj.factor„n Adj.Ornundwater Level, PERCOLATION TEST Date 9 Z 'fime__� . !l�3� Observation l Time at 4" Hole# Depth of Perc J�"� Time at 6" -- // .. ., Ir1✓I Start Pre-soak Time @ /L �22s��,, 15me(9 -6 ) End Pre soak /f 3b Rate MinJlnch of l Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conselivation Division at least one(1)week prior to beginning. QASEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from �/ Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders. Consistencv.%Gravel)- 12& '' ' G Yet AA ` DEEP OBSERVATION HOLE LOG Hole# �2- Color Soil Other Soil Horizon Soil Texture Soil C Depth from Mottling (Structure,Stones,Boulders. M � (USDA) unsell) g Surface(in) N ) (M Consistency,96 Gravel) / 2(p DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. ConsistencL%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders. Co Flood Insurance Rate Mau: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No_ Yes Death of Naturally Occurring!Pervious Material Does at least four feet of naturally occuring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? - Certification. I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . described in 10 CMR 15.017. erds e and experience b � the required training,exp Pe . �1 Signature Date / �2 Q:%.SEPTI0PERCFORM.DOC Commonwealth & Massachusetts . . _ F Title 5 Official Inspec ion Form - Subsurface Sewage Disposal System Form :- Not for Voluntary Assessments 'GM 49 Crooked Pond Rd.: - Property Address: .... Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. Cltyrrown 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 filling out forms A. General Information _ on the computer, use only the tab ... - 1. Inspector: key to move your cursor-do not. . Matthew Gilfoy I. use the return key. Name of Inspector B&B Excavation, Inc: Company Name 14 Teaberry Lane Company Address Forestdale MA::. .02644.11 City/Town State Zip Code (508)477-0653 113640 Telephone Number License Number B. Certification p. _ . I certify that I have personally inspected the sewage disposal system at this address and.that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based,on my training and experience in the proper function and maintenance of on site sewage disposal systems.. I am:a DEP approved system inspector pursuant to Section 15.340.of Title 5(310 CMR 15000). The system: ® Passes, ❑ Conditionally Passes ❑ _Fails Needs Further Evaluation by the Local Approving Authority 12-9-13 Inspector's Sig ture - Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board ' s 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 thesystem owner shall submit the rs P appropriate I stem owner ,ort to the . regional office of the DEP. The on9�.nalshould be sent to the system and copies sent to the buyer,.if applicable, and the approvi rig: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. t5ins•3713 :: Title 5 Official Inspecti o :Subsurface Sewage_Disposal System-.Page 1 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 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 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): r- I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts IL W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken 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 FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: / ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters i due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . _ _Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °r 49 Crooked Pond Rd. Property Address i Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12 2-13 page. City/Town a. 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 El ® 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 El - 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? El ® 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 El ® :approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential.Flow Conditions: Number of bedrooms(design):. Number:of bedrooms (actual.);. DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 462 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: current 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.): J Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract I ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 20'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appears to be in good working order with no signs of leakage. Septic Tank(locate on site plan): Depth below grade: 2 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: 1000 gallon Sludge depth: 211 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is Hyannis Ma 02601 12-2-13 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" 9 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good working order with no evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every y H annis Ma 02601 12-2-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection D-Box appeared to be in good condition with no evidence of carryover or leakage. 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.): I * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5-infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in good condition with no sign of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Crooked Pond Rd. Property Address Jane.Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: E hand-sketch in the area below Eldrawing attached separately A3. 33 A LI - 3)'q 51 t ,t R2- A U1 ��— LI4 i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: no GW @ 126" 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. 7-21-2006 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: Plan on file I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 49 Crooked Pond Rd. Property Address Jane Ellis Owner Owner's Name information is required for every Hyannis Ma 02601 12-2-13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 —T�0w N Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 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. A. General Information _ InIT � LY �� V �1? 1. Inspector: L`�s Shawn Mcelroy Name of Inspector. Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905' S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev ation by the Local Approving Authority 7-17-10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,.the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,:if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. m `V t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste •Page 1 of 15 Commonwealth of Massachusetts w Title 5 Official .Inspection Form ' -, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 page. City/Town State Zip Code Date of Inspection r B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D w , A) System Passes: a ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 t5insp official document•03/08 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 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 page. City/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. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-860-966-2448) Owner Owner's Name information is H annis MA 02601 7-16-10 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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: x 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 '/2 day flow ® - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑- ® Any portion of the 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. t5insp official document•03/08 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 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 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 `fes" 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 El ❑` 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name 'information is required for every Hyannis MA 02601 7-16-10 ipage. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the 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 official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is H annis MA 02601 7-16-10 required for every y page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 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 10 Last date of occupancy: Date Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? r ❑ 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): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 i Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 page. City[Town State Zip Code Date of Inspection D. System Information (cone.) General Information Pumping Records: Source of information:* N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El 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: 2006 - Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 I� Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18' 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 ---------------7---------------------------------------------------------------------------------------------------------- Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" 2 Scum thickness . Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 15' How were dimensions determined? Tape. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) ' Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: ' A �� 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): t5insp official document•03108 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 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up. f _Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Deposal System•Page 11 of 15 Commonwealth of Massachusetts • ' ' w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M '( 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 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: ❑ leaching pits number: ® leaching chambers number: 5-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Infiltrators in good condition and empty at inspection with no sign of back-up into d-box or surrounding stone. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 page. City/Town 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 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.): 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.): " t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 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. ge..G . 4 .e. v k t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Crooked Pond Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 7-16-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: r ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10, feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health --explain: ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 10'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System_-Page 15 of 15 \DEC-4-2006 03:02P FROM:JOSEPH HARVEY 5085485395 TO:15087906304 P.1 I Town of Barnstable Regulatory Services Thomas F.Geiler,Director BAPN"J � Public Health Division 2639. � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 11"3-0(o Sewage Permit# 2006 " 328 Assessor's MaplParcel 29/-OS) Designer: A/04M& 6/105SAW) Installer: - - Address: -16b07T P Address: Y6 ` C On 7 Q S7-IL was issued a permit to install a (date) (Installer) //�� septic system at �� C,,t�,� 140PO /to based on a design drawn by (address) KU104 VW) . 4/ 5*01AA�' dated 9- L7- tO°� (designer) Vr I. certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lat al relocation of the SAS or any vertical relocation of any component of the septic s ste ) but in accordance with State & Local Regulations. Plan revision or certified as-b It b designer to follow. (Instal is Signature) NORMAN o GROSSMAN ' No. 127Q5 cn CI1/I� �, �F� Eo (Designer's Signature) (Affix De ' C"4V re) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE R&CEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:HUM/Sepuc/Designer Cenificacion Form 3-26-04,doc 4 TOWN OF BARNSTABLE LOCATION LT 1 l-ceAte& �a-4& a SEWAGE# 02�6 -3Zp VILLAGE , am S�&&k ASSESSOR'S MAP&PARCEL Q i l INSTALLERS NAME&PHONE NO: �� ;$b74,La7� 7?fo -j0 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) jj ;//2�g (size) &118 NO.OF BEDROOMS OWNER PERMIT DATE: 'Zl —0 Go COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200'feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ® 3A —�� W 4—°33 `i c 6A - 3Z ' . & L3"�Z , �cx 7A- 3f 76- 62 3 t No. ' FEE a 1�v3. COMMONWLA LTH OF MASSACHUSETTS Board of Health, k�'7 �� MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑Complete System/Individual Components Location Owner's Name j' �/►�'� i1-5 Map/Parcel# l_- ®s/ AddressA&* 02� �tiJA�¢�P�,G1,l1 Lot# Telephone# Installer's Name Designer's Name ,�kfAdCW?0,- r ,4-) Address Address Telephone# Telephone# 3 _f Zo Type of Building L7LC. /•,l/J� Lot Size '9,s75 sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) gpd Calculated design flow `f 7VC) Design flow provided gpd Plan: Date 2D�� Number of sheets Revision Date Title /7 Ezu>�G'E DISP�.�+�G 1J f'7 GL� Description of Soils) �J0j� Soil Evaluator Form No. Name of Soil Evaluator"'• A9at f Evaluation Z/ ' -S�' DESCRIPTION OF REPAIRS OR ALTERATIONS The under . e agr a install the a ve described Individual Sewage Dispos Syst m in accordance with the provisions of TITLE 5 and furthe ees to no lace t m' peration until a Certificate of Co lian has been issued by;the Board of Health. Sign Date / Inspections ... .�.' �i '��. FEE v 10;Boara of Health, APPLICATION FOP, DISPOSAL. SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade Abandon( - ❑Complete System/z Individual Components Location / fQ f Owner's Names a1,g7 ---Z j Map/Parcel# 2 !..- Q j µ.,k Address�)e 7/2 AMflpd5X A44 Lot# / Telephone# Installer's Name C�. Designer's Name Address Address R3IgVw /ht-760Z- j f 1�*4/y Telephone# Telephone# Type of Building Lot Size `sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures / Design Flow (min.required) 4�yO gpd Calculated design flow Alelo Design flow provided 1462 gpd Plan: Date 2D0S Nu/m�be�r,of sheets cO- Revision Date Tit1eJ� �SE��6E D/SPD ..J 9 E%J ax)w r -a, Description of Soil(s) Soil Evaluator Form No. Name'of Soil Evaluatoi"/�lif4�tlf�J1-S C Dat of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS # The undersi e'd a rees10 install the a)0"described Individual Sewa a Dis os S st m m accordance with the rovisions of TITLE 5 and g" �• g P Y P furthena ees to not o •lace the st m' operation until a Certificate of CZ.2 lian a has been issued by the Board of Health. Sign Date / 0 Inspections ` No. C FEE O V COMMONWEALTH OF MASSACHUSETTS Board of Health,'az:,"�-- MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete Systemn "'""* A N The undersigne here certify that the;(a,e Disposal System; Constructed ( ),Repaired Upgraded ( ),Abandoned ( ) a: by: (_Gvt4 G f at f1U4 has been installed in accordance with with the pr°/visio /of 310 CMR 15.00 (Title 5) and e a proved design plans/as-built plans relating to application No. & 3 Uy dated Approved Design Flow (gpd) � Nt 1 +� Installer 14, ;y Deslgner:� °, r _ r . •Inspectors a r-: ,.5s. �;%� Date:.. ,t ry The issuance of this permit shall not be construed as a guarantee that the syst✓'mwill function as designed. w f No. f FEE /00 F WO Board of Health, �'` �- �$ IV MA. y DISPOSAL SYSTEM7M-1397RUCTION PERMIT Permissionds hereby granted to; Constr ( ) Repair( Upg de,( ) Abandon( ) an individual sewage disposal system at .•': as described in the application for Disposal System Construction Permit No.c ^ dated " Provided: Construction shall be completed wit/hin three years of the dat Cofi r 1 �calnditions must be.met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date �/�I �� Board of Health • r } c c� TOWN OF BARN ABLE ABLE LOCON 7 T �r.yA e P, SEWAGE # AcT I VULLAGE 14V 44 (S ASSESSOR'S MAP&LOT- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 10Ov LEACHING FACILITY: (type) �v►fi• �T/� r (size) NO.OF;BEDROOMS _. BUILDER OR OWNER PERMITDATE: COMPLMNCE 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 witMn 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any we( ds exist within 300 feet f leaching fa itity)l � nor � � Feet Furnished by u w h �— ra V ��` V � J 0 a w TOWN OF BARNSTABLE 9 LOCATION 6 c4 Q SEWAGE VrLLAGE ASSESSOR'S MAP & LOT�Z INSTALLER'S;NAME & PHONE NO. SEPTIC TANK CAPACITY /oo G LEACHING FACILITY:(type) /0 D G (sue) NO:OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER--T' BUILDER OR OWNER DATE PERMIT.ISSUED: !/--cj DATE COMPLIANCE ISSUED° VARIANCE GRANTED: Yes No _- ., i J �_ 'mil �. a s� �� E� - �� -- ,� 1f. \ , � � , -� \.� 1� '� - , � � � ��. -�'=� �' No..,l.. FEs......�.3 0....0 0.... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Uiipuiial Workii Toustrur t -tz onto Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: Y 9 . .Crooked Pond Road, Hyannis , MA ---------•------•----•------- .......................... •--- --•-- ....... - Location-Address or Lot No. Patricia Thomas Same ......................-.............. - _........_..-----------•---.. ............._.......------••••--•••••...........•••--......-•---••---•-----••------••---....--•-- Owner Address W W.E:...Robinson Septic Service P_:0-:_-__Box•_•1089-,••.Centervi-1.1 e•,...MA,..... _-•-•, --------------•-•- Installer Address � Type of Building Size Lot... ........S q. feet � Dwelling—No. of Bedrooms..........3................................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building ............... No. of ersons.....................__--_-. Showers — Cafeteria Aa YP g ------------- P ( ) ( ) 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. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by........................................................................... Date........................................ ,_l Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.._._._-_--.-._.-..__--- L4 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ a ----•-•---•----•------•-----••--•-•-••-•-••-••••...-•-------•--••••--•-------------•-•-•--•-•••••-•.......................................................... 0 Description of Soil......Gravel................................... x W U Nature of Repairs or Alterations—Answer when applicable._-_---Two--stone-packed...infiltrators _-____. --------------------••------•---------------------•---------------------•---•-••---------------•--......----•---------------------------------•--------------------------------------------••••••••••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issuedPy ?oA of health.Signed ..... �1 ......... ..-- - . S/--� ...... Dale Application Approved ...... :.. .....� ...��. ---------- -- Da[e Application Disapproved for the following reasons- -------------------------------- ----------------------------------------------- ................................... v- ---------------------------------------------------------------------------------------- --------�...----------------------------.-...... 9/ Dace Permit No. ---- --�-- .......................................... Issued ..-- �� Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD' OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tvnu�uari Application is hereby made for a Permit to Construct ( ) or Repair (ic ) an Individual Sewage Disposal System at if - 3?--CROoked Pond Ra4.d --- � n js, ' Location-Address or Lot No. Patricia Thomas --------------- ----------Same--------------------------------—----------------_---- --- Owner Address W W.E Rob nsQ nS t - .� .. x � .. � _3 P, P�vI i i M� Installer Address Type of Building Size Lot___________________ q. feet U Dwelling—No. of Bedrooms_______._3 -------------------Expansion Attic ( ) Garbage Grinder ( ) C14 Other Type of Building _________________•-___--_•- No..of persons---------------------------- Showers ( )'.= Cafeteria ( ) dOther fixtures -----•------------------- ---------------------------------------------------------------------------------------------------- w Design Flow--------------------------------------------gallons per person per day. Total daily flow----------------------- WSeptic Tank—Liquid capacity------------gallons Length-_•:--_--___--- Width---------------- Diameter_______________ Depth-___-_-_-----_-- , x Disposal Trench—No--------------------- Width-------------------- Total Length-------------------- Total leaching area----------------__-sq. ft. Seepage Pit No-_------------------ Diameter-------------------- Depth below inlet--_--_-__---_-_._- Total leaching area------------------sq. ft.- z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water--_--•-_---••-__._•_-__. 114 Test Pit No. 2----------------minutes per inch Depth of.Test Pit-------------------- Depth to ground water-_--•_•--------------- O Description of Soil-----Grave 1---------------------- - -- ----- - -- ------------- x .- w ------------------------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable------Two-_s t o n e_-p agkp d___i,a£a._I t:r a t n�r q_______ - - ------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t a d of health. Sigqed ✓////, �j �� ------------------- -----_----- ---------------------------------- -, ;ism Application Approved, = r -----� --�- i --------------T---- -------------------------- 1 � _ Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------.. _---_.---------------. _______.....--.._--.-___-__--____.._-_-.-___-____._-___.._.___-___-__---__....._._ _____-___---__�[e_______--__--__ Permit No. ----- -------- L-1 Issued ------------ ------------------- �� Dare THE COMMONWEALTH OF MASSACHUSETTS II BOARD OF HEALTH TOWN OF BARNSTABLE Clex#tf rate of ( ontplin re THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by.....W.E. -Robinson -Sep t i c -Service,- . -Centerville_ -'----MA---------------------- -------------------------------------------------- at ...'T Crooked Pond Road, Hyannis, RA" ��¢¢ - -------------------------------------------------------------------------------------------------------------------------------------- has be&Uinstalled in accordance with the provisions of TITLE of The State Environmental a as described in the application for Disposal Works Construction Permit No. .�✓ ------- �� dated _ ,I _=_ ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------/-. � Inspector - : -L- V THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE .x No.ZGam— FgE$30:00...... Rapouttl Worko TrInstrudiatt Itrrmit Permission is hereby granted___.W-.E.__i� Robinson Septic Service, Centerville, MA o - - - -•--- to - ---_ Construct or Repair (X ) an Individual Sewage Disposal System at No._________�'_Crooked Pond Road, Hlrannis , A -Mstreet----j------------------------ �------------------------------- --as shown on tKe application for Disposal Works Construction Permit Nd_'Z.:°�� Y ated______� '"__tom__ ' ------------------ 'l - — Boar of Health DATE----- -� ----------------------------- (,f� L•�-�^F^O-R"M 3630E HOBBS Q WARREN.INC..PUBLISHERS Lat11 Lot 3 40t3 40 75 00, 40 N, Shed Remove Exist Overflow 39.8 f�-+. IfContaminated Soils \\ 41 40.8 41.3 \ a M / \ / 19, 41 \ _ _ \ #1 amp-on ve 9 5' Exist Leaching 4 If Contaminated Soils4� — D 20 Existing \ 14M I Septic Tan \ O 4 j r \4d 0 S�2 \ / ` Deck � q 41 Existing ` Lot Is 43 4 Bedroom \ \ 43 Dwelling 42.9 \\ - F. FL =44.9 ) 41� House#49 Lot 58 43.2 43.4 43 4 / LOT 1 99275+/- S.F. 44 75.001 43+5 2 4 42.9 43 vo CROOKED POND ROAD LEGEND Exist. Spot Elev............. 353 Exist. Contour................ - - - 36 - - - - Prop. Spot Elev.............. 35.9 Prop. Contour................. 36 Setback Dimension........ 13' Perc, Test Location........ 50 Prop. Water Service...... — VV— REVISION DATE BY JJ-�� Maple St t �o Lind - 33 `�s�° Efmst t SITE & SEWAGE AK Qi r,� MaryaliceUn ChesfnuoSt_ C George St m r 7 G P a4� $ yrts ve , v ats 4 DISPOSAL PLAN G�$6A No q3Hyannis, a ��` #49 CROO'v-uD POND ROAD D"�w►«� Crooked Po d Rd, MA L 'Sj�P9� Ha<m� rR 'q?� r 7 '+S •s Q` Qq��omitchellSWay ��o I� E� Waay� NR Jp`� BARNSTABLE, MA, W f > South St o� � tN QF5�9� S ainStMa'nst v '�� APPLICANT: ENGINEER: fD le Maple Ave 1 ✓' i nor 5`J�a¢tP 1 �°�� o2P �I PO BoStevex Norman Grossman, PE, RLSSM N� W1 0 2126 93 Falmouth Heights Road, #4 No. 12775 0� Mashpee, MA 02649 Falmouth MA 02540 q 0 w � F LOCUS MAP 508-539-7931 508-548-1920 LINO MAP SEC PAR LOT FLOOD ZONE ELEV. MAP SCALE DATE SHEET NO. PLANV'NO. k 291 51 1 C --- 2500010005C 1"=20' Sept. 27, 2005 . C 49Crooki 1 OF 2 H-943-1 r t .� 44 hi y. � , a SEPTIC SYSTEM PROFILE FIRST FLOOR NOT TO SCALE ELEVATION 44.9 FIN. GRADE AT FIN. GRADEOVER FIN. GRADE OVER FOUNDATION SEPTIC TANK FIN. GRADE OVER SOIL ABSORPTION SYSTEM TOP FOUNDATION 43.0 42.8 DISTRIBUTION BOX 41.0 ELEVATION + + 41.5 43.9 + + + RISER SET TO W/I INSPECTION + ++ 6"OF FIN. GRADE PORT + + INVERT AT ,. 2"MIN. DOUBLE WASHED 1/8"- 1/2"STONE FOUNDATION 40.0* +++ 3„ 38.00 + o *(VERIFY IN FIELD +++ PRIOR TO START + 39.7�` EXISTING OF INSTALLATION ) +++ 1000 GALLON 39.08 + + 39.25 �,U 1 ,1�IAS, D� + SEPTIC TANK + INSTALL NEW +++ GAS BAFFLE ON OUTLET TEE 3 HOLE DIST. BOX 4.00' 5 INFILTRATORS @ 6.25' 31.25' 4.00' + 35.50 BASEMENT FLOOR + ++ <" 36.2 + o000000000000000000000o H-10LOADING ELEVATION o000000000000000000000 � TO BE SET ONALEVEL OTALEFFECTVEWIIH WIDTH 1 83'+ + + AND STABLE BASE TOTAL EFFECTIVE DEPTH = 2.00' + + r . co SOIL EVALUATION34" DESIGN DATA HIGH CAPACITY INFILTRATOR CHAMBER DATE OF TEST: SEPT. 27, 2005 6.25'x 2.83'x 0.92' --- H-20 LOADING NUMBER OF BEDROOMS................... 4 LOGGED BY: J.E.LANDERS-CAULEY (OR APPROVED EQUAL) • WITNESSED BY: DON DESMARIS' SOIL ABSORPTION SYSTEM G.P.D./BEDROOM................................ 110 G.P.D. TOWN OF: BARNSTABLE TOTAL DAILY FLOW............................ 440 G.P.D. PERC RATE: <5 MIN/IN GARBAGE DISPOSAL.......................... NO SOIL CLASS: I ( 0.74 GALS./S.F.) NOTES: LEACHING REQUIRED........................ 440 G.P.D. LEACHING PROVIDED. ....... 462 G.P.D. GROUND WATER: NONE ENCOUNTERED 1. ELEVATIONS BASED UPON TOWN OF BARNSTABLE GIS. SEPTIC TANK REQUIRED................:.. 1500 GAL. 2. TOPOGRAPHY BASED UPON AN ON-THE-GROUND SURVEY. SEPTIC TANK PROVIDED................... 1500 GAL. 0" 40.8 TEST PIT#1 0" 42.1 TEST PIT#2 3. PROPERTY LINE INFORMATION FROM LCC 14034K. �r SANDY LOAM SANDY LOAM 4. NORTH ARROW NOT TO BE USED FOR SOLAR ORIENTATION. SIDEWALL AREA................................. 8 O/A 8 O/A 5. ALL PIPING TO BE CAST IRON OR SCHEDULE 40 PVC. NORMAN 250.3 S.F. 10YR 4/4 10YR 4/4 6. ALL SYSTEM COMPONENTS TO BE INSTALLED IN ACCORDANCE s GROSSMAN BOTTOM AREA.................................... 425.1 S.F. WITH SEC TITLE V AND LOCAL BOARD OF HEALTH REGULATIONS. " No. 12705 TOTAL AREA........................................ 625.4 S.F. 7. NO CHANGES TO LOCATION/ELEVATION OF SYSTEM COMPONENTS CIVIL TOTAL AREA X 0.74 G.P.D./S.F........... SANDY LOAM SANDY LOAM WITHOUT WRITTEN APPROVAL OF ENGINEER AND BOARD OF HEALTH. 9• 462.8 G.P.D. �" � 1STER 30 B 10YR 5/8 30 B 10YR 5/8 8. NOTIFY ENGINEER 24 HRS. IN ADVANCE FOR AS-BUILT INSPECTION. F NAL N OF S\` s�, LO REVISION DATE BY NORMAN 3 U .9 SHEET NO. ctaos 2775 Lu Steven Giatrelis DATE o! 20F2 � MEDIUM SAND a MEDIUM SAND �F�ISa�`0J 126"1 C 10YR 6/6 126 C 10YR 6/6 PLAN NO. ,fit L�►�o� 30.3 11 31:6 #49 Crooked Pond Road, Barnstable 09/27/05 H-943-2