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HomeMy WebLinkAbout0029 DELTA STREET - Health 29—b to a Street Ennis P t = .292 212 —— -- 10 �` / TOWN OF BARNS 1ABLE LOCATION. SEWAGE #,oO,/—, e`✓ILLAGE 1 1`KC%1A I- i ASSESSOR'S MAP & LOT ZtI INSTALLER'S NAME*PHONE NO. 40-e--100' 7) S ! 3 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) S O S (size) Y C> NO.OF BEDROOMS BUMDER OR OWNER PERMUDATE: 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 GNI >s. a n " T WN OF BARNSTABLE ���LOCATION aC) � SEWAGE # o.VILLAGE_JTAn,11 S ASSESSOR'S MAP & LOTa'ga - INSTALLER'S NAME&PHONE NO. L� y SEPTIC TANK CAPACITY C�Ss�aol LEACHING FACILITY: (type) SS I (size) (�00 NO.OF BEDROOMS 3 BUILDER OR OWNER 1t 1 f GOS.S PERMIT DATE: 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 lea ng facility) Feet Furnished by FOi� Q3 O 00 Ono 7r a Town of Barnstable P# I l ?°p Department of Regulatory Services Public Health Division Date "y. �� 200 Main Street,Hyannis MA 02601 D Mid l I i t -Fee Pd. D CADate Scheduled Time Soil Suitabilisesstnent for Sewa)Ze Dis t Performed By: i Witnessed By: LOCATION& GENERAL INFORMATION Z�� Location Address Z (]�f L� 5 �-- Owner's Name g �1hn�G `-/f a vLY�! ` f�/(/ tq I't 0 2�c7 C t Address Assessor's Map/Parcel: � ,� 1 I✓ v v Q f �� � � � ( � Engineer's Name NEW CONSTRUCTION REPAIR Telephone# UAS- Land Use p ( ) Surfacc tones Distances from: Open Water Body Possible Wet Area /y"'�t'T tZ Drinking Water Wel( ft Drainage Way ft Property Line /D , ft Other ft SKETCH:(Street name,dimensions of lot,exact lb/cations of test holes&pere tests,locate wetlands In proximity to holes) N n.� ono Parent material(geologic) �V Depth to Bedrock L `emu Depth to Groundwater. Standing Water in Hole: 'A .i Weeping from Pit Face Estimated Seasonal High Groundwater DETERNUNATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in, Groundwater Adjustment tt• Index Well# Reading Date: Index Well level Adj,factor Adj.arouttdwater Level,ma PERCOLATION TEST Date Thne Observation Hole# Time at 9" Depth of Perc _ Time at 6" Start Pre-soak Time,@ — Time(9"•6") -- -_ End Pre-soak Rate MinJlnch } Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) •4 Original: Public Health Division' Observation Hole Data To Be Completed on Back----------- ***If percolation test is.to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. o istenGravel) Z. 2 •� 0 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nsi to %Gravel) 01 � 4,," d `Gel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Gravel) f DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture _ . !;•Soil Color Soil Other Surface(in.) (USDA) (Munsell) "Mottling (Structure,Stones;Boulders. cmijitency, • i Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes Within 500 year boundary Noes Within 100 year flood boundary No L/ Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi u aterial exist in all areas observed throughout the area proposed for the soil absorption system? If no4 what is the depth of naturally occurring p ious material? ,.�. Certification I certify that on /b 4 (date)I have passed the soil evaluator examination approved by the Department of Environ/nental Protection and that the above analysis was performed by me consistent with . the required training,expertise an experience described in 310 CMR 15.017. Signatur Date Z �� Q:\SEPTl0PERCFORM.DOC No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION . TOWN OF BARNSTAB:LES:MASSACHUSETTS 2pplication for ;Digpozaf *pgtem Contruction Permit Application for a Permit to Construct( . )Repair(Upgrade( )Abandon( ) Xomplete System ❑Individual Components Location Ad�ss or Pt No. �� �/� i Owner's Name,Address and Tel.No. c<. L ©,a/ro 5-r4i,T Assessor's Map/Parcel ��1�41�jprx(10�7f Installer's rl Name,Address,and Tel.No. Designer's Name,Address and Tel. ) 5 Type of Building: Dwelling No.of Bedrooms � Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow .3 D gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /' S oC) Type of S.A.S. 3 3 e,)s o 7 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 no to place the system in operation until a Ce cate of Compliance has been i b th' and Health. Si Date Application Approv Date ?3 Application Disapproved for the following reasons Permit No. Zo06 — 7 Date Issued No. Fee_ W THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication forklpi000ar *pztem Conotructiou Permit Application for a Permit to Construct( )Repair( ,��Upgrade( )Abandon( ) O ymplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. � n Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Te.No. E Type of Building: Dwelling No.of Bedrooms "� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow --gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank c9 Type of S.A.S. r� L.u s=. /< c 7 d k Description of Soil L— Nature of Repairs or Alterations(Answer when applicable) 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 Certifi- cate of Compliance has been issped-by this Boar'd"'of Health SignedDateY Application Approved tiy/ ;Date cYrD. Application Disapproved for the following reasons rr . Permit No. 2006 _ 7 V Date Issued v THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( XUpgraded( ) Abandoned( )by f)"A '0._ G /--/ at 1 r/��A 9�r R '1�Y ra .✓ ;:ri f has been constructed in accordance with the provisions of Title 5 an e for Disposal System Construction Permit No. �2066—37Ydated ?3 Installer J Designer The issuance of this permit shall not be construed as a guarantee that the system i� f n i n as designed. Date 4" I'a'3 //, __ Inspector - . No. QCJ 0 b- 7 / Fee Dd " THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS mizpool *pgtem Cow5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at - c 17 e 12 tr Z 7_ 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 completed within three years of the date of th it. Date:_� 3 �� Approved by Town Of Barnstable Regulatory Sorvlces Thomas F.Geder,Director .i Public Health Division ' Thomas McKean,Director 200 Main Street,Hyannis,AM 02601 Office:.508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form .Date: ZDD�o Designer: � Installer: ���f� �•�Srr Address: . �I_ 'Lw-'I n (�'� Address: o/ On Z ZC06 4— k6 iV �0,"­57— was issued a permit to install a (date) (installer) septic system at Z L _DlEk- b� c TWT Lil N1gb based on a design drawn by (address) �d OpL 4A 1�60-__,J dated 22. zcc�L (designer) 1-certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateraal i�location of the distribution box and/or septic tank. (4 I certify that the septic system referenced above was installed with major changes (J e,, than greater 1.0 lateral relocation of the SAS or any vertical relocation-of any component of the.septic system)but in accordance.with State&I.ocafltegulations. Plan revision or certified as built by designer to follow. NQFM D?AVIDy , (Ins er's Signature) MASON S G o —r � ao:toss y �. 9FG Pw iTA �BTE (Designer s Signature) (Ax er's.Sp Here) PLEASE RETURN TO PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE 'S ILL'NOT BE ISSUED UNTIL BOTH -THIS FORM AND Ax BUILT CARD ARE RECET'VED BY THE.BARNSTABL]E PUBLIC:HEAL7 I'DIiTLSI4i\T. THANK YOU. - Q:Health/Septic/Designer Certification Form Z9 o wnF g�ctu' .ICL..D� °!�of runs ono oocc►u�nuU"0 rrum 117 fr v. . St}ecnLT jrlRr'c4i 17 la Thd plans and specifications for every on-site system shall be prepared as follows: (1) Every system shall be designed by a Massachusetts Registered Professional Engineer or a Massachuseas Reglstered.Sanhaaan provided that such Sanitarian shall not design a system designed to discharge more thait 2.000 gallons per day ptt .mt to 310 CMR 15.203. Any other agent of the owner may pmpam plans for rite repair of a system designed to /discharge not more than than 2AW gallons per day pit to 310 CMR 15.203 provided / they am reviewed by a Massachusetts Registerad Saithmaa and aprovW by the approving VVV authority; (2) Every plan submitted for approval must be dated and bear the stamp and signature of J/ the designer, (3) Every plan for a pew system or plan for the upgrade or expansion of an existing system which requires a variance to a pwpcsry line wbaek dizumcr,'must.olto refaerca a plan which bears the stamp and signature of a—Massachusetts_ Licensed Land Surveyor in accardance with M.O.L..c. I t2, f SLD; ' (4) Every plan for a system shall be of suitable scale(one inch=40 feet or fewer for plot plans and one inch a 20 feet or fewer for details of system components)and shall include depiction af; a) the legal boundaries of the facility to be served; (b) the holder and location of any easements appurtenant to or which could impact the . stem: (c) the location of the an dwellings)or building(s)existing and proposed on the facility.. and identification of those to be served by the system; '(d) --the•'location of misting or proposed impetvious areas, inclutfing driveways and pit:ate. e) location and dimensions of the systwn(including reserve areas (f) system design calculations,icicluding design daily sewage flour.septic tank capacity / (required and provided); soil absorption system capacity (required and.pmvidodl; and T/ whether systern is designed for garbage grirtdw. 1.(g) Notttt arrow and existing and proposed contours; (h) . location and log of deep observation hole tests including the date of test.existing ✓/ grade elevations utadmil on each tear. and the naaws of rho mpromtative of the N approving authority and soil evaluator. (1) location gad respW of percolation tests including the ante of nest and the names of the representative of the approving audtority and sal evaluator, astir and certification number of ttre Soil Evaluator of tocotd; '00 location of every Water supply,public and private, L:_witWn 400 feet•of the proposed system Location in the cm of sulfate wain suppUw and&mom:psowd public water supply wells, 2. within 250 feet of the proposed system location in the case;of tubular public water.supply wails,and /� . 3. within-150 feet of the,proposed system location in the case of private water A-,, ' supply (1) Loead=of.atT surface waters of the Commonweattk rivers, bosdring`veld wetlands. salt marsh s.,4niand or coastal banks. regulatory floodway. velocity aoae,y surface water sapphm tibutaries to smhw water supplim cadfied vernal pools.Private water sWrIes or sermon'.Lines, gravel packed or tubular public v astir-rieppty wells.. subsurface drains,leaching catch:basins.or dry welts; and the location Of' -tutrogen . -. ensitive area Ldet Mcd in.310 CMR 15.215 within which portions-bf U►e;proposed Vswm am located. m) location of water]tuts and odtarsnbstuface utilities on the f tr a) observed and adjusted ground-waiet.elevation in the vicinity of the sysu=nt o a caupkte pro6k of the sy `_„' . ' ;..: (p) a note on the plan Ustittg all variances to the provisions of 3 0 CMR IS.Ofl[-sought conjunction with'the plan: a (q) the location and elavadon of on bettcbmar wiztan 50 to 75, forK of the facility :. , which is not to @ or loss dtumg On„thc lEtl (r) whert dosing La proposed.t�ntplew.;design Addration Of the dosing system proposed including but not limited to doling charal er capacity(requued aid=pravided),- guy eaves and ems.natnber. f.nosing cycles and tltgth per (s) when a Recir culating Sand Filter er equivalent alien rive.t firtotogy is or Proposed.a complac plan and speci limtioti for the system,incfudmg;e hydraulic profile. t a lace,plamto show the location aelka facrilrt'y'includ'uig the nearest-coasting sttse�. Cu the street numba and lot number,if any,of;the factIrry; ttad t� G 3 r� L� a I co f� -r � LO 7> LA ro z � m � s � 0 5 Y v �Fl IT 11 l l ------------ �-- � I i 1 ks �I 'ago 3 �z 1373 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED J U L 10 2003 u,p TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 29 Delta Street Hyannis, MA 02601 Owner's Name: Bill Goss Owner's Address: Same Date of Inspection: July 2, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map:292 Osterville,MA 02655-0049 Parcel:212 Telephone Number: (508) 862-9400 Lot: 4 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F I Inspector's Signature: Date: July 6, 2003 The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the. DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Delta Street Hyannis, AM Owner: Bill Goss Date of Inspection: July 2 2003 Inspection Summary: Check A,B,CM or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or 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 distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) I Property Address: 29 Delta Street Hyannis, MA Owner: Bill Goss Date of Inspection: July 2, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria.are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 s Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 29 Delta Street Hyannis, AM Owner: Bill Goss Date of Inspection: July 2, 2003 I). System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No _ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or. cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 1'd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 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 "des" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 29 Delta Street Hyannis XM Owner: Bill Goss Date of Inspection: July 2, 2003 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period ? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? n/a Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 29 Delta Street. Hyannis, MA Owner: Bill Goss Date of Inspection: July 2 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALIMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection (yes or no): No If yes, volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool ✓ Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Delta Street Hyannis MA Owner: Bill Goss Date of Inspection: AN 2 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: 10" Material of construction: _concrete _metal _fiberglass _polyethylene ✓ other(explain) cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x 6'6"Tx 9'bottom to grade Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: 1" 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: Measuring 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.): The cesspool had 4'of water on the bottom The outlet tee was present. The cover was 10"below grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: . Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Delta Street Hyannis MA Owner: Bill Goss Date of Inspection: July 2 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Delta Street Hyannis AM Owner: Bill Goss Date of Inspection: July 2 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers, number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: 1 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.): The overflow cesspool was 5'W x 7'T x 10'bottom to grade and was dry. The scum line was approximately 2'6"up from the bottom There were no signs of failure The cover was 20"below grade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Delta Street Hyannis, MA Owner: Bill Goss Date of Inspection: July 2 2003 Map: 292 Parcel: 212 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 4 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. � 8 «k as;' a 01 S. 10 10 Page 11 of I I • OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 29 Delta Street Hyannis MA Owner: Bill Goss Date of Inspection: July 2 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 28 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 28'+/-to ground water at this site This.report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 . I'lIII1111r11�1Ah411� ASSESSORS MAP : TEST HOLE LOGS 4— Nw S: 0i PARCEL : - - - �� FLOOD ZONE: wwt t SOIL EVALUATOR: + M� �J�-'' I _.- ) comply Barnstable Board of �1 REFERENCE: +!- J ;- C77� DATE: t bD 1 Health installation coin 1 with Title V and Town of cam- PERCOLAT ON RATE': Z. I , + 2 The installer shall verify the location of utilities, sewer inverts and septic R,1�.1 'F � Z �' 9. ) i - - /-- -- --- - 1 components prior to installation and setting base elevations. s TH- I TH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first two feet out of the dbox to the leaching shall be level. fill V`'� Aj 4) This plan is not to be utilized for property line determination nor any other _----- - r _ purpose other than the proposed system installation. p1A,Z (�7 5) All septic components must meet Title V specifications. fd , 6) Parking shall not be constructed over H10 septic components. LOCATION MAP 1►f,` 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt of G0 -�14 �j lI7 ,� payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. G a 9) The existing leaching or cesspools shall be pumped and filled with material ]' �iefv d bro per Title V abandonment procedures. Those within the proposed SAS shall be / removed along with contaminated soil and c A replaced with 1. p can washed sand 0 per Title V specs. 10)System components to be 10 feet from waterline. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPT I C SYSTEM DES I G N applicable. 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE owner to ensure such. �`�---�o � 05 ID� , -- 2)The installer is to take caution in excavation around the gas line if applicable. r BEDROOMS AT GAL/DAY/BEDROOM GAL/DAY - SEPTIC TANK — _ -- / o e GAL/DAY x 2 DAYS - GAL USE GALLON SEPTIC TANK 'C SOIL ABSO tPfiiON SYS'f Krt _ 99V �N aF Mq w�`N DwD t x7!^ .. ups NAASON' m a t ems., �! R >G : -�12,2 Z.X b,� _ �o.toss 1 S 1 ICE AREA .. 9� do B TTOM AREA: ISTS /nv,c o, - - T I C SYSTEM SECT ION " 2/ate J--- 5 44 1�€��; MA1t• �1C,,1L���'c�ll � 2 e GAL u 11 D o o SEPTIC TANK u�kk51 Zi'u' O 0 O _ ! e ft o -wi- Vr 7 rr SITE AND SEWAGE PLAN LOCATION : 4ZI L T 13 PREPARED FOR : 1u,;- kfe Q 6E(IG % Zl1 SCALE: ( � 90 � o - W DAV I D B . MASONIV6 DATE: M a DBC ENVIRONMENTAL DESIGNS J W DATE HEALTH AGENT EAST SANDWICH . MA 3 ( 508 ) 833- 2177 W Z i