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0173 DUNN'S POND ROAD - Health
173 Dunn's ;Pond Road .Hyannis.. -sp �A 270 005002 J 0 I s c Commonwealth of Massachusetts a oUr-r .00 Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Dunn's Pond Road Property Address r r .. Rodman Scace and Christina Racine t Owner Owner's Name/ information is Hyannis V MA 02601 09/22/2020 required for every H y ' page. City/Town State Zip Code Date of Inspection`- _ I 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. Inspector Information 13 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails /29/2020 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to I` the buyer, if applicable, and the approving authority. { Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: This 3 bedroom home has an H-10 1000 gallon.septic, an H-10 1000 gallon pump chamber with a D- Box feeding 15 Biodiffusers. At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form <yI' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis annis MA 02601 09/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form !} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,�p Title 5 Official Inspection Form �1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: . ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation 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)] j t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. , 173 Dunn's Pond Road u Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 — page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gp ))� Detail: From 1/21/2019 to current 115,192 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy:, occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: New leaching was installed on 6/2/2009 Were sewage odors detected when arriving at the site? ® Yes ® No 5. Building Sewer(locate on site plan): " Depth below grade: 21 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I . Commonwealth of Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No . Dimensions: H-10 1000 gallon Sludge depth: ` Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2" 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 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 173 Dunn's Pond Road V� Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v- 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is Hyannis MA 02601 09/22/2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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 the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 173 Dunn's Pond Road V� Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes No* P 9 ® ❑ Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I ran the pump and tested the alarm *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: One- 15'X 20' w/15 biodiffusers ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form tiI; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.):. I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately - f ® 3.23 7') �cr_� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 8 plus feet 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: I augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 c Commonwealth of Massachusetts +� ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 173 Dunn's Pond Road Property Address Rodman Scace and Christina Racine Owner Owner's Name information is required for every Hyannis MA 02601 09/22/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ' ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 is No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipphratton for Otopogal 6pgtem Con0truction Vertu Application for a Permit to Construct( ) Repair(m/'Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. J7;) 17oWt C,y ,,xv Cr�� a!�� . Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ; — ®6——0 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 'EbA 514, _6 oAs�a e "Jc 5 11 0-110 iei rr��" e E� ✓ t�l,� 1CdP-%!7T.�113 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building �,Za w No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.Brequired) !3!3C gpd Design flow provided gpd Plan Date 5"ir/� Number of sheets Revision Date s Title Size of Septic Tank Type of S.A.S. Description of Soil fe, �6 Nature of Repairs or Alterations(Answer when applicable) 0 S.A ,C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig ® t Date Application Approved by 6 Date Application Disapproved by: Date for the following reasons Permit No. Date Issued ——————————-- —————————————————— 1— ——————— No. �` �.a ,f Fee F Entered m computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for �Digonl ,pgtem Cott.0truction Permit f Application for a Permit to Construct O Repair(41110"Upgrade O Abandon O ❑.Complete System ❑Individual Components Location Address or Lot No. /'7 S VVPO F) ROv� (WIS Owner's Name,Address,and Tel.No. % n vi / Assessor's Map/Parcel o&"-� V rJ16pnbort's . Installer's Name,Address,and Tel.No. Desiiner's Name,Address and Tel.No. Zb� 14 S A 11zpWa_X�Ic �,v5,Nre""'ovl.Jd-(kS 5o8-11T7' 930 Type of Building: Dwelling No.of Bedrooms Lot Size ;2$7+ O sq.ft. Garbage Grinder ( ) Other Type of Building t-v,%j!!,� No.of Persons 0 Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) !330 gpd Design flow provided 3' gpd Plan Date 5-14)Oy Number of sheets 7-- Revision Date Title ` Size of Septic Tank /fit s4LS C Type of S.A.S. Description of Soil G E T� r I Nature of Repairs or Alterations(Answer when applicable) lNs �l Nr.,.� s• , Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si "i •-� O -_ /� e Date '� / 0rj 9 Application Approved by /�y/,!f d /F Date ,� f v Application Di! 7 Date for the following reasons Permit No. '' Date Issued —————————————————————————————— . —r—r———————-- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Cert"ficate of Compliance THISJS TO'CERTI Y,tl3at t�On- 't�wage Disposal System Constructed ( ) Repaired ( � Upgraded ( ) Abandoned )t,lliy> � o� at /7 1—Dsor�'R(') has been constr•c d 'accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 dated J Installer ,,Ir , A 1S[gj �, � Designer 6 1 #bedrooms Approved desi gpd The issuance of this permit shuti be construed as a guarantee that the system w I func ioh as design d. Date Inspector y ———————— — — -- 1 ——————————— ——————— —— 3 No. � — —— \Fee by THE COMMONWEALTH OF MASSACHUSETTS , PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS lwigoar *y5tem Construction Permit Permission is hereby granted to Construct ( ) Repair ( I„-)''_Upgr d ( ban one( ) System located at i�v,✓iv �,✓ , 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: Const ct, us be completed within three years of the date of this pe Date Approved by M4 _1e� _ 06/02/2009 05:51 5084775313 ENGINEERING WORKS PAGE 01 Town of Barnstable RoWsWry, ►ervices Thomn F.GeMer,Director Pa 9 Red 1viden nmmm NWesu,.Direator MO Aafa-Shve4 Hyannis,MA.am loot: �QBa Feu: 508-790.63.04 i fie:. y `'�P 3ewa . .Permit# Asees®vr's ��2 MapwwceL -Ad :. �� (/u� �'71s 't�c� Address: ot yy �e,✓2/11 �P�1� 2�32 oa (9A`u7 "J J` 1L C, was issued.a.permit to insw a (isa�talier) sepc sys based on a design;&va by (address) dated a °� .� I._ :the,septic System referenced above was in$talled su. . to wt} ch:mad+ include mm' or approved chames such'as 1it of'Idle septic Milk, L, !4M the septic system referenced above was installed with for chmps (Le. .1.0 lateral relocation of the SAS or any vertical relocatiao.of.say so nent c s�►stea ) but in,accordance with State &Local Regolations. Plain ro v ijuv or ; •b .,by dcsipar to follow. � It1 OF 8fgs PETER T. McENTEE CIVIL 9p,No'35109 a Q- ESS/0 AL EN6 s ) (Affix Design . YAM) MALIN R201M Cm OF Q:�IeeltNaepli�/Da�elanor Cerfif"doe Form 3-26-04.doe Town,of Barnstable r# - S^ / Departmentlof Regulatory Services i > a i Public Health Division Hate. i`( s .. ibJq A�� 200 Main Street,Hyannis MA 02601' Date Scheduled (, (1 : Time' Fee i'd. T L t7 . w, Soil Suitability Assessment for Sewage-Disposal 'Performed:By _ U ti-�l�� `-��✓1.1--�-� ,� Witnessed By: 1 t/i� (�1�. `f�/lYll1.'/C LOCATION&_GENERAL INFORMATION Location Address - Owner's Name y It ITO- r Address Assessor's Map/Parcel c Engineer's Name NEW CONSTR U CTION REPAIR Telephone# C,,?F-7 3 6 Land Use "�i � rn"� Slopes(%) �'" U Surface Stones NQ+'� Distances from Open Water Body 1.50 ft Possible Wet Area ?C z1 'ft Drinking Water Well Drainage Way /11/ ft Property Line 30 - ' ft .-Other SKETCH:(Street name;dimensions ofaor_exact locations of test holes&perc tests,locate wetlands�n proximity to holes), evLtq Z H. Parent material(geologic) ��1 �� c`S ` ` Depth to Bedrock �/ I �"' 03 Depth to t3roundwater. Standing Water in Hole: ! Weeping from Pit Rpee CI:F Estimated Seasonal High.Groundwater 2` ? G�G 0 ►��-er^�cc1� �" DETERIVIINATION FOR.SEASONAL HIGH WATER TABL r Q► rn Method Used:" Depth Observed standing in obs.hole: 9 in, Depth to soil mottles: /J In. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well#�)-? Reading Date: AP42— Index Well level Adj,&ctoi . a A .C3roundwaier Level1-7 PERCOLATION TEST Date . Time,�� Observation Z Hole# / Time'at 9" Depth of Pere i' / M i,j t a Time at 6" Start Pre-soak Time® 1 0; ZO J�. 2n 11me(9"•6") End Pre-soak l :ZG' C� �0 '_SS Rate MinJ1nch C 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 u yo must first notify the, Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEFTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# 1 Depth from Soil Horizon Soil Texture. Soil Color: Soil Other Surface(in.) (USDA).. (Munsell) Mottling' (Structure;Stones;Boulders: Consi t v A L $ 3 l6 vL 8 S �'3 6 w 'C. M Samoa . to 2,S 6 DEEP"OBSERVATION HOLE LOG, Hole# Z Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones Boulders.. yc .6 Vic, l2Y/ t Y f ! �43 2 s Io DEEP OBSERVATION HOI:E'LOG Hole# Deptk from, Soil Horizon Soil Texture Soil Color Soil Other. Surface(iu.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. _ , Consistency. O3 _ DEEP OBSERVATION HOLE'LOG` Hole Depth from Soil Horizon Soil Texture Soil-Color Soil Other' Surface(in.) (USDA) (Munsell) Mottling (Structure,Sto ues,-Boulders. nsisto I Flood Insuranee:Rate Map 4 Above 500 year flood boundary No' Yes "Wtthin`SOU'year'boundary ~No" ;Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at ieasCfour'feet of naturally occurring pervious material exist:in all areas;observed throughouG.the area proposed for the soil:absorption system? S P 1?.;. F If not,what is the depth`of naturally occu 'in pervious material?,..... Certification I certlfy that on 1 l q17(date�,I have passed the soil evaluator exatninatton approved'by the; Department of Environmental Protection and that the above analysis was performed by me consistentwtth 1 } ' the required"tra' g;experttse and experience:descnaei in 31U CMR Signature Date3"I 'ASBPTIWSRCFORM:DOC t TOWN OF BARNSTABLE LOCATION /73 )wnti a SEWAGE# 9,00CI 13 5 VILLAGE ASSESSOR'S MAP&PARCEL 00 S'0Q INSTALLER'S NAME&PHONE NOO, C�c2�T3 � � , SEPTIC TANK CAPACITY 1000 ff f51'1.N33 0019 0NOAAC A4 dwst— LEACHING FACILITY:(type)—�i � ��sacs (size) ►� ta 51 "Z NO.OF BEDROOMS OWNER g-v� PERMIT DATE: .i j« 05 COMPLIANCE DATE: Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching-Facility'(If`ny 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 ®4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION T W Z W � i d A F tT �T b � W ' b TITLE 5 EDIC IV OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSR SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM8 2002PART ACERTIFICATION ARNSTABLE H DEPT. Property Address: 173 DUNN POND RD HYANNIS, MA 02601 Z'�OOO SW� Owner's Name: FAVERO Owner's Address: 173 DUNNS POND RD HYANNIS,MA 02601 Date of Inspection: 11/19/02 copy Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS,���► Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 MAP Telephone Number: 508-564-6813 FAX 508-564-7270 PARCEL " Q®%®Q1 �. LOT ` 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: X Passes _ Conditionally sses _ Needs Furth valuation by the Local Approving Authority Fails Inspector's Signature: Date: 11/19/02 The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspecti n. 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 olf ice of the DL'P. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes condilions III the IIIIIe tsf Iu.al11,011111 111111 111111m Isle f11111111111114 fit Il.gf 111 111111 11114 inspection does not address how the system will perform in the future under the salve or dlffercul conditions of use. Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 173 DUNNS POND RD HYANNIS, MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. "not determined" lease explain. Answer yes, no or not determined(Y,N,ND) in the for the following statements. If p p n/a 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 173 DUNNS POND RD HYANNIS,MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 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 I5.303(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 n/a "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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 173 DUNNS POND RD HYANNIS,MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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.) (Yes/No)The system fait. 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 now of 10,000 gpd to 15,000 gpd. 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI 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 ttbilve the lilr�e$yF(em h�� failed: The mvner rn-nlif.1-gor of 011y Inr{'.e$y�tem rnnsirier�rl siEnificpni threat under Section E or failed under Section 1)shill upgrade the syslenl in ;1cconhilu:e Willi '110('Mlt 1 i,104 'I'liv ny1jIvIII iiIVllol. should contact (he appropria(c ri pional olliry ill Illy' I Woll1111rIII i Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 173 DUNNS POND RD HYANNIS, MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period ? X Have large volumes of water been introduced to the system recently or as part of this inspection '? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out" X _ Were all system components,excluding the SAS, located on site? X _ 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 ? X _ 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 X _ Existing information. For example,a plan at the Board of Health. X _ 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)J L Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 173 DUNNS POND RD HYANNIS,MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 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 r� Water meter readings, if available(last 2 years usage(gpd)): ram— V r �� 0 Sump pump(yes or no): NO 01—) Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CM 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons-- How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: 11990 IIV OWNER Were sewage odors delccicd wllcn ;II I lvlllp III IIII' allli l VI'II III 1111 l IVI Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD HYANNIS, MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD HYANNIS,MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Conunents(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: X(locate on site plan) Pumps in working order(yes or no): YES Alarms in working order(yes or no):YES Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): PUMP CHAMBER IS STRUCTURALLY SOUND. e Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD HYANNIS, MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a FLOW DIFFUSERS leaching chambers, number: 3 n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): DIFFUSERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a k Q Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD HYANNIS,MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 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. JJX cl L � (-00 m Ay belie AA JPILI+r �aGlq I?C 2;z np a n I Page I 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD HYANNIS, MA 02601 Owner: FAVERO Date of Inspection: 11/19/02 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+ FT. I I y� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.ST U S Governor Com :t ;onerr �9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A (j PART A �- CERTIFICATION � ,✓� Q `� Property Address: 173 DUNNS POND RD. HYANNIS MAP 270 LOT 4 3 Name of Owner LEONARD REIL r 1999 Address of Owner: SAMEto OF t" Date of Inspection: 2122/99 Name of Inspector:(Please Print)JOHN GRACI J3 I am a DEP approved system inspector pursuant to Secdon 15.340 of Title 5(310 CMR 15,000) E Z Company Name: John Graci Title V Septic Inspection Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 Telephone Number: (608)664-6813 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined In Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:2123199 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2/22/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any Information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. NO The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. N12 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced N12 The system required pumping more than four 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 I revised 9/2/98 Page 2 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2122199 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance W&(approximation not valid). 3) OTHER n& revised 9/2/98 Page 3 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2/22/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level In the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. . X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nla. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. r revised 9/2198 Page 4 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2/22/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been Introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2/22199 FLOW CONDITIONS RESIDENTIAL: Design flow:-Q g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):.1 Total DESIGN flow: .0 Number of current residents:2 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):JLQ Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): n/a Sump Pump(yes or no): NO Last date of occupancy: nla COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: Wa Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n& Last date of occupancy: Wa OTHER: (Describe) n& Last date of occupancy: n(a GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS PUMPED ONE YEAR AGO BY CANCO System pumped as part of inspection:(yes or no):YU If yes,volume pumped n(a_ gallons Reason for pumping: n1a TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM WAS INSTALLED IN 1990 COMPLIANCE ISSUED ON 10/24/90 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 L i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2/22/99 BUILDING SEWER: (Locate on site plan) Depth below grade: V 6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n& Comments: (condition of joints,venting,evidence of leakage,etc.) Wa SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ n& Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: E Distance from top of sludge to bottom of outlet tee or baffle: L" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: .1C How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING VERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:_i& Distance from bottom of scum to bottom of outlet tee or baffle ills Date of last pumping: nh Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nLa revised 9/2198 Page 7 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2/22/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nla Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nfa Dimensions: n& Capacity: WA gallons Design flow: nla gallons/day Alarm present: NQ Alarm level:j3L& Alarm in working order:Yes_No_: NO Date of previous pumping: ti& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: MQ (locate on site plan) Pumps in working order:(Yes or No): M Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) 1000 GALLON PUMP CHAMBER,CHAMBER WAS EMPTY AT THE TIME OF THE INSPECTION I revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2122/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: nta leaching chambers,number: 3 FLOW DIFFUSERS leaching galleries,number: jVa leaching trenches,number,length: n& leaching fields,number,dimensions: nLa overflow cesspool,number: n& Alternative system: n& Name of Technology: _uLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY PROBE WAS DRY.NO SIGNS OF FAILURE,SAS IS WORKING PROPERLY. CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: nLa Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) WA revised 9/2198 Page 9 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: V3 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2/22/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a �C �g I4 At iq A AD III o 0 6 Up 0 3 revised 9/2/98 Page 10 of 11 I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 173 DUNNS POND RD.HYANNIS MAP 270 LOT 4 Owner: LEONARD REIL Date of Inspection:2/22199 NRCS Report name: Wa Soil Type: Wa Typical depth to groundwater: Wa USGS Date website visited: Wa Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers _ Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) GROUNDWATER DETERMINED FROM HAND AUGER,10-NO WATER ENCOUNTERED. revised 9/2198 Page 11 of 11 ,- TOWN OF BARNSTABLE `LOCATION ,Q SEWAGE # VILLAGE ASSESSOR'S MAP & LOT y INSTALLER'S NAME & PHONE NO. j 1AIA) Q, kl,4sLjpc, SEPTIC TANK CAPACITY /goo CS r l /Oo® G 4 C-Li, 4� _ LEACHING FACILITY:(type) 3 LT-e4,diFl=y3cA, ' (size) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER --►'Aj saatr4 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Y) z o VARIANCE GRANTED: Yes No red Qvd <�e� „LI T-5- 0 �i -. No.. . ....I......DI Fmc.............................. THE COMMONWEALTH OF MASSACFYUSETTS BOARD OF H ALTH IV '77. .....OF_............................................................................ _t�AVVUraftvu for Vispviial lgork.6 Tow4rurtion ramit Ap; cation is hereby made for a Permit-to-Cons-tr-qqt. or Repair an Individual Sewage Disposal System at: MM�L...ac?.fA ...... ... .................................................................................................. are, Location-Address or Lot No. ......... ........... ............................... ................. ...............0......... .........................***........... lyC.................................... ..... To!t�.AuRajW....... ..... .!-.............. Installer Address U Type of Buildifig Size Lot............................Sq. feet Dwelling'—No. of BedroornsAf_Sx". ,J.....;!Wrr.\..Expansion Attic Garbage Grinder (IVO 114 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 04 Septic Tank—Liquid capacityIP2agallons Length................ Width..............__ Diameter__.._.__.._..._. Depth__._.___._..._.. Disposal Trench—No..................... Width.................... Total Length........._.......... Total leaching area....................sq. f t. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Other Distribution box Dosing tank ( ) ;a e75 Percolation Test Results Performed by..................................... .................................... Date............................................. Test Pit No. I................minutes per inch Depth of Test Pit....._.....___.___.. Depth to ground water________-____-__---__._. rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____._..........._..___. Ix ........ ........ .................................................................................................................................. 0 Description of Soil------------ ..... ...................................................................... .....................................................I.................... W U ........................................................................................................................................................................................................ W ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I T�TLE, 5 of the State Sanitary Code— The undersigned further agrees not to ace the system in operation until a Certificate of Compliance has is sued s led by th bo do of lieak;,;,A, C,*4�4� .... ........ Signed..... .... .............. ...................... ......�.l------ 7 Date .......................Application Approved By_..._._... ----•- ................................... ........................................ Date Application Disapproved for the following reasons:................................................................................................................ ..........................0.............................................................................................................................................................................. Permit No.._-w�.......t Issued--------- ....................................... ..................... ate No.t�............ .-,.. V FEs................................ r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .... . Apphration for Disposal Works Tonstrnrtinn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: •Lo y.....------ .k►:!! 's....PeA.....&4...... Location-Address or Lot No. r ° ..........-�r��� --.....�z r.: nraS................................ .........•---...........--•--......---•---•--•- .... ... Ow er Address ._ T> ,, �I,���atl:�--.'. ................ r .s.. ...... . ................................................... ._. .. :.. _, Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms-Rf sa".1..._3&m..,,,..Expansion Attic ( ) Garbage Grinder Wo Other—Type of Building No. of persons............................ Showers — Cafeteria QI Other fixtures ------------------------------ --• . W Design Flow...........................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityl,=O.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.........I........sq. ft. z Other Distribution box ("- ) Dosing tank ( ) '� f�-_i V---, 0.,-1 ' s, , Percolation Test Results Performed bY.......................................................................--- Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................mini}tes per inch Depth of Test Pit.................... Depth to ground water........................ a .. ODescription of Soil---------- . ... i -------------------------------•-•-•--••-----•----------------•-------- ---•- -•--------------------•-•-•--•----- x c, W ••------------- --•-------------•-•---•-•----••--•-----••----------•--•------•----•-•--•-•---------------------------•-----------•-----•-------------•-•-----•--•----•---------------------•-----•------ UNature of Repairs or Alterations—Answer when applicable............................................................................................... t Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLl 5 of the State Sanitary Code— The undersigned further agrees not to Cace the system in operation until a Certificate of Compliance has bom issued by th bo `d of hea th. G + Signed •. >a. - ------------------ -••------••----- •.••... 7!' Date Application Approved B ix." `r " PP PP Y `-�--=...............................M '-,�:::-----•------------------------------•- --•---------•--••--••-----•--•••-••...............................•---..Date--••--..... . Application Disapproved for the following reasons:................. . _ -•---•---------•------------------------•--------------------....:_•---••--•-------......--••-•-----••..........•--•----••--•---•--------•----•-•-----•----------•--------------•••......---•--......._. /� , a�te Permit No. :�v' - ------------- Issued--•---.:: "' - -- ...----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................I................OF..................................................................................... CIntifirate of T1111 prism • THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY................................................................................................................................................. .................................................. ''� // / Installer at---..W......I......... vnfis--•---.Ar'd_._ f-------------f'` G rA_ -----•-•--------••----•----------------•-................................................... has been installed in accordance with the provisions of Tll—"" S o#_.�'he State Sanitary C degas described in the application for Disposal Works Construction Permit No....< .� -��r------ dated----� -.1 07........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE 'S`YSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector......................................... .......................................... THE COMMONWEALTH OF MASSACHUSETTS �io BOARD ,OF HEALTH i C:-OF. +..:. .��`. ........_. �--.1�....._. �.. ....... . . No......................... FEE........:* Dispoll t1 Works (1-1111ntrnrtion rrntit Permission is hereby granted............................ •.---•••---....•-•-----•-----•---...•-----•---•-------•------•---•-••--•-•......-•-•--••---•..................... to Construct ( ) or Repair ( an Individual Sewage Disposal System at No.I.A 4----------- vnra:S..._._. .,�,. ............. C,rnf t:............. Street 7, •t a o P ------j Dated------- - --- � 1 L'S"`....... as shown on the application for Disposal Works Construction'Permit No-------- _ ........_ j ---....-•-•••- -•--••---•-------•----•--•----.' Board of Health DATE---------•---- -••.............•------••---------- FORM 1255 HOBBS & WARREN, IN._ PUBLISHERS fit Route 28 N LEGENDpd x e,uebef x' LOCUS -- 98-- EXISTING CONTOUR - r v o x ioo.sa EXISTING SPOT GRADE m L a ,_L -Wy EXISTING WATER SERVICE ' N U D -G EXISTING GAS •SERVICE West u o HIGH ao " EXISTING PUMP CHAMBER SCHOOL •% -eHW- EXISTING OVERHEAD WIRES (TO REMAIN) SEWER CONNECTION a Street o' TEST PIT TIE IN TO EXISTING FOR LINE, AT 97.77 - EXISTING SEPTIC TANK no BENCHMARK OR BELOW, EL.=99.40 TO REMAIN ( LOCUS MAP 1p ' TOP .OF TANK, EL.=96.93 NOT To SCALE 7NV.(OUT), EL.=95.60f X8967.98 o o S 54*42'10" E 1 I I 288.44'. ,89 LOT 4 ! fenc ockOde SH I 1 19.5' 28,730t S.F. O st ED Map 270 98;25 r .36 Parcel 05-0 11 02 DECK I ! .' !!i 98OQ.70N r_-RbP�. 98\29 x 97.52-A ! O r O W DECK � 1 4S a� ! I 0 98.72 I o o N CL CD /1' L91 1 x 99.76 EX/STING !! N o. ; HOUSE (#173) o 1 o I EXISTING S.A.S. I G 7.8 r^ TO BE ABANDONED %i U S�, I i G 64 LO Q w J to SOILS SHALL BE VERIFIED j 9 74 x-9 T n W 32 ��/ �X 99.2 PRIOR TO INSTALLATION 10 1.41 I bV G I STRIPOUT AS REQUIRED' TP-2 Paved (SEE NOTE 11) i. o Driveway �•� �l _ ` / x 9, 41 W 9.59 Zj TP-1 ' 99.50 _-_ I i O y i - 9,� i .g8'� ' I 100,00 i o Ben'chmork No. 1 - - ' ,00,08 SPIKE SET i` x 7 491 / 99.91 EL.=-99.50 (Assumed) 1 9moo° i / I x 96,60 k stockade fen ce . 286.2;� �- g -- -1-00 100.12 o OOg . 9&� � N 54*42'10" W�} 3 `------- S Benchmark No. 1 OWNER OF RECORD MAGNETIC NAIL SET GENERAL NOTES: 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. FURLAN, MARIA A EL.=100.00 (Assumed) 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. f 173 DUNN'S POND RD BOARD OF HEALTH AND THE DESIGN ENGINEER. 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS r �F M HYANNIS, MA 02601 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS AGREED UPON BY OWNER AND CONTRACTOR OR AS'OTHERWISE S OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DIRECTED BY THE APPROVING AUTHORITIES. LOCAL RULES AND REGULATIONS. PROPOSED SEPTIC SYSTEM UPGRADE PLAN 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY o PETER T. s TO INSPECTION AND APPROVAL 'BY' THE BOARD OF HEALTH AND THE THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING g McENTEE - DESIGN ENGINEER. CONSTRUCTION. w CIVIL N 173 DUNN S POND ROAD, HYANNIS MA 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS No. 35109 Prepared for: D. A. Brown, Inc., P.O. BOX 145, Centerville, MA 02632 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND ENGINEER BEFORE CONSTRUCTION CONTINUES. REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). Engineering by: SCALE DRAWN JOB. NO. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL I OF I.F Engineering Works Inc. 1"=20' P.T.M. 127-09 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY. / ( 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET N0. HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 14. SUBJECT SITE LIES WITHIN A GROUNDWATER RECHARGE AREA. C11 (508) 477-5313 5/9/09 P.T.M. 1 Of 2 r+ NOTE: TO PREVENT BREAKOUT, THE PROPOSED r� FINISH GRADE SHALL NOT BE < EL:100.5 fPROPOSED PUMP CHAMBER I; FOR A DISTANCE OF 15' AROUND THE • PROVIDE RISERS W/ SECURING FRAMES & COVERS PERIMETER OF THE S.A.S. PROPOSED D-BOX ' 6"- OVER EACH ACCESS MANHOLE AND SET TO FINISH PROPOSED S.A.S. " GRADE. MANHOLES BROUGHT TO GRADE SHALL BE INSTALL RISER & WATERTIGHT COVER INSTALL INSPECTION PORT OVER END UNIT OF 21" 6-4EAL. � " SECURED TO PREVENT UNAUTHORIZED ACCESS. SET TO 6" OF FINISH GRADE EACH ROW AND SET TO 3" OF FINISH GRADE 2" 2" t I y.• _ - . F.G. EL: 102.3f F.G. EL: 102.3-103.5(MAX.) ••'RIMS SET TO FINISH GRADERIMS SET TO FINISH GRADE MAINTAIN 27 GRADE (MIN.) OVER S.A.S.L = 9'(MAX.) N L 11'(MAX) �® S=19 (MIN.) ® S=1% (MIN.) 2' FILTER FABRICM SPLASH o4"SCH40 PVC 2" SCH 40 PVC 4"SCH40 PVCPAD UNDER EACH ROW 3". s" 6.5" TO 'o INVERT C�1 Top View Section INSTALL a D-BOX EFFLUENT EXISTING INV.=100.42 1NV.=100.25 EFFECTIVE LENGTH = 19.5' FILTER EXISTING zneFI OR eouAL> _ PUMP PROPOSED D-BOX INV.=100.14 5 ROWS OF 3 UNITS (18.8') + 1 CONTOURED WEDGES (0.7') INV.=95.60t EXISTING E S G EXISTING 5 OUTLETS (MIN.) EXISTING SEPTIC TANK EXISTING PUMP CHAMBER ESTABLISH VEGETATIVE COVER , TO REMAIN TO REMAIN BACKFILL WITH"'ftEAN NATIVE OR PERC SAND TO TOP OF CHAMBERS I EFFLUENT FILTER SHALL BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY ZABEL OR EQUAL. FILTER BREAKOUT EL.=TOP EL. ;.;: ' ' 75 . :: SHALL BE INSPECTED AND CLEANED ANNUALLY. TOP ELEV.=100.52 ':;' FILTER FABRIC INV. ELEV.=100.14 OVER UNITS (See Pump Detail, Sheet 3 of 3) ,. (RECOMMENDED) BOTTOM ELEV.= 99.60 � 2.83' � NOTES: 5' MIN. ABOVE BOTTOM OF 1 N- icmaffiz 1) D-BOX SHALL BE SET LEVEL AND TRUE TO T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 5 x 2.83' - 14.2' GRADE ON A MECHANICALLY COMPACTED SIX EXISTING SUITABLE _ INCH CRUSHED STONE BASE, AS SPECIFIED IN ADJUSTED GROUNDWATER EL.=94.6 s MATERIAL RO f 76 310 CMR 15.221(2). USE 5 WS OF 3-1 1" ADS BIODIFFUSER UNITS + 1 WEDGE. PROFILE 2) INSTALL INLET & OUTLET TEES AS REQUIRED. NO SEPARATION BETWEEN EACH ROW & NO STONE 3) MAXIMUM COVER OVER PUMP CHAMBER, D-BOX AND y S.A.S. SHALL BE 36". SEPTIC SYSTEM PROFILE TYPICAL SECTION T i1 N.T.a N.T.S. 6.4" . SOIL LOG 34" � DESIGN CRITERIA DATE: APRIL '23, 2009 (REF-P#12,541) SECTION END CAP SOIL EVALUATOR: PETER McENTEE (SE#1542) WITNESS: DAVID STANTON R.S. NUMBER OF BEDROOMS: 3 BEDROOMS HEALTH AGENT 11 STANDARD (H-10) 1310DIFFUSER UNIT SOIL TEXTURAL CLASS: CLASS I ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH DESIGN PERCOLATION RATE: 2 MIN. 20 SEC./IN. 100.1 011 100.2 0 MODEL 11" STD. A w A ' LENGTH 76" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT DAILY FLOW: 330 G.P.D. SANDY LOAM SANDY LOAM EFFECTIVE LENGTH 75" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY DESIGN FLOW: 330 G.P.D. 99 4 10YR 4/2 8„ 99.2 1 OYR 4/2 12„ DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. GARBAGE GRINDER: NO •_ g B SIDE WALL HEIGHT 6:4" SANDY LOAM a SANDY LOAM OVERALL HEIGHT 11" LEACHING AREA REQUIRED: (330) = 445.9 S.F. 10YR 5/8 10YR 5/8 - OVERALL WIDTH 34" 4640 TRUEMAN BLVD 74 97.1 36" 96.9 40 HILLIARD, OHIO 43026 EXISTING SEPTIC TANK: 1000 GALLON CAPACITY C1 , C1 9.2 CF • CAPACITY ADVANCED DRAINAGE SYSTEMS, INC. PROPOSED D-BOX:: 1 INLET, 5 OUTLET (MINIMUM), H-10 RATED MED. SAND MED. SAND PERC (68.8 GAL) 10YR 5/8 10YR 5/8 48"/60" USE 5 Rows OF 3 - 11 " (H-20) ADS BIODIFFUSER UNITS 2.5Y°6/4 y' •2.5Y°6/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN W/ NO STONE + ONE CONTOURED WEDGE (14.2 'x 19.5') 94.6 ADJUSTED .GW 94.6 ADJUSTED .GW 173 DUNN S POND ROAD, HYANNIS, MA SIDEWALL AREA: NOT APPLICABLE 91.9 STG.GW. 198" 91.9 STG.GW. 99" Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.7 SF/LF OF BIODIFFUSER) 90.1 T20" 90.2 120" Engineering by: SCALE DRAWN JOB. N0. 5 ROWS x 19.5 LF/ROW x 4.7 SF/LF = 458.3 SF - I Engineering Works, Inc. NTS P.T.M. 127-09 PERC RATE <2 MIN./INCH ("C" HORIZON) 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 x 458.3 = 339.1 GPD MIW-29, ZONE D, WATER LEVEL=7.3', APR 09, ADJ.=2.7' (508) 477-5313 5/9/09 P.T.M. 2 Of 2 _ t , I F 1 -P f t � ; W4-P►,l,�y'�', .,1 , Dur.Irhr.,lCy , ��_ g�as� p ;' C?.4` QUGusT -7 1 Jui.Y PA3 5, '7 T,5 Hae4 �4 Lon�4 Low Anl0 AKtD AIL M - 5ttr350U. ojpu iQ . :k Gail Art d� MErhu�l M.E�tuM , 4�tttw��u� Lrtp `i3 AK5t © 10 ` I, 17atuMC� = �� Y-r-),2 ust(Yn,�tr ltyc � � a _4 •__ 13e� Z9.3 i 4 � ,��,�. ;_ M D�tC�►.l Lt�,cat`1y ba..l✓t'2�c,�,ST U�l1TS � �o _ r CJ �pP k " _ 5, PIPE -lott.tTs �t- u: P� tom! �th"��2TtC�-4-E"f", ._.Vm.•---- --rv-.M ��� ►�a�-��• �N•u t��t M,�r�!��.� C:��C� 'CITc,E ST ' ' �(3 7LbqlFo2't'Pt 'C Ev Wbe4c->) LL` D col-�bLll.D 1 !?7 .. , 8. �HF�e jo PVc, 70 R�x-%H OUT I E I.�a f^ro Sc, ,�u SPTiC SYSTS►r'). • o 1 .a� -roe a,$: Nt_c.N�_v C2. rEIF- o N I NLEr , \ / T } �GAL. �. PuM ? 47.Glo l CC�y ,r V A, •LLB y, ..'�, ,,, �S 'a.. ,w p"'.�JOx �t� FP t" '� r.=::::... ice. r_=-=r-i.__'.c^- �:.—_C -•—_7�1 7`=..._R'X"' jJ q' Z HM1 ReZ W 17N _ tm . to ix�.aN1 ^ k� cwrr r , 1 Ixwr� MYM5 .5KM - - ZS" �"of q'1 ._ ruM f'�DrLQu�t�-� �tos�•�v sra�E •� \ , . .�. �' � Aow�-�p mkt c�. �7, n 50 - j M;. Z4 7 t5 � g►DE5'. )2xOA-/g,I CZ,S� 1-12 ,G M I ,oT..L coo y t au so e_.s kt tT44 7- ,�FI-IyAtelt�l 4 �a -ea, l_r.)` Q C: ZES 40 P : / �,rv��. �Ao..,� �- 1 CIVIL 6*L� 5 rcE�.> r � fGi5��� t �.;•►.lD sYo�`� ., ,�f . ,�r y p,A21.15`1AF3Ur ,,; t�P . : r III i l� i� No. O` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l/ • PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes RpPlifation for Mispo8al *pstrm Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(V Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.\7�> �� jn� Owner'sName,Address,and Tel.No. Assessor's Map/Parcel Z-1 —(.57— Installer's Name,Address,and Tel.No,- CX.) Designer's Name,Address,and Tel.No.� t - 7j5��5 Type of Building: _ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildings, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requir d—)7 �3 gpd Design flow provided gpd Plan Date 11�� (l.l Number of sheets 2— Revision Date TitleWoocy5a—k.xQ�sc 'umcc,. Size of Septic Tank Type of S.A.S. `1P_GC.k\ Description of Soil(5'_ r\ Nature of Repairs or Alterations(Answer when applicable)�eQ\G�00_, ( en& 0�—' 72) CxA\CN- \�-yC ��. bCJ1X X 1 lRjcM �. 3 N-�Q- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal h. Sign d Date Application Approved by Date r�,_ Application Disapproved by Date for the following reasons Permit No. "—C`j p Date Issued ----------------------------------- • No.�i �C ,� ; . Fee leg THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ..a PUBLIC HEALTH DIVISION - TOWNtOF BARNSTABLE, MASSACHUSETTS Yes , r application for Misposal stem Construction 3permit Application for a Permit to Construct( ) Repair(, ) ;Upgrad4e " Abandon( ) ❑Complete System ❑Individual Components, Location Address or Lot No. (�"j �� Owner's Name,Address,and Tel.No. p , Assessor's Map/Parcel ' 'l �j -(-� 1 s� .�Cl .•Sj( _`� 1 nti,-,� r,. Installer's Name,Address,and Tel.No.- Designer's Name,Address,and Tel.No 4-7-7-..55\5 c Luc,c�s\rc _ , Type of Building: Dwelling No.of Bedrooms I of Size Z45,� sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons' Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 5 gpd, Design flow provided x, ` gpd -7 -7 Plan Date \(A C 7 E _ Number of sheep's, Revision Date TitleAUUCY., C)\(-,rr C�c��.ti'�5�rac� a►.� ;�1 n�S Size of Septic Tank ,,()d) nns, ' ;,.,Type of S.A.S. �P�e(�t\ q-i e Description of Soil V ",� �1 C \CMG,, (`Ce, `�. -�-�(� G-C'"+ t \ Y vrn . LAC -`�. r ;� �-...�• hie:-' Nature-of Repairs or Alterations(Answer when applicable) P C'-ei' - P_K\ f )C- _7-y rs \ s-1` A \ 2 ) �CA-\ �66 Y. b y-�C �\ V:,). 2, ;,% Date last inspected: Agreement: The undersigned agrees to ensure the construction and mAhtoance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code•and not to'place the system in operation until a Certificate of Compliance has been issued by this Board of Health. /�. Signe<1'R' �.T/.ram" _ Date Application Approved by Date / / �- Application Disapproved by i Date . for the following reasons Permit No. � Date Issued - -- - -----_ - - - ----- ---•---•-- •-- -------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE;`MASSACHUSETTS _ Certificate of Compliance THIS IS TOO CERTIFY,that ftthe On-site Sewage Disposa system Constructed( ) Repaired`( ) Upgraded(V) Abandoned( �C_ at has been constructed in accordance / _ /c t with the provisions of Title 5 and the for Disposal System Construction Permit Now�l dated 1 Installer . AC1'l► 5 I�KL.L•-,��x,=�tG{\ Designer #bedrooms 7 Approved design flow -3 6 gpd # _ The issuance of this'permit shall not be construed as a guarantee that the system will function as designed. `.- Date #� ,- 3 a Inspector -------------------------------------------------------------------------------------------------- ------ ------ No. 7� V Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Misposal *pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade(�) Abandon( ) System located at\� \ 14IN( -Vif� 4-`e�(G,C,, and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ust be completed within three years of the date of this hermit. Date f �� -7/�-;-z" Approved y. ,— 1 e TOWN OF BARNSTABLE LOCATION Oln� Y)�, SEWAGE VILLAGE)�yGxww�a::) ASSESSOR'S MAP&PARCEL2,-10 -U�- INSTALLER'S N E&PHONE NO.� EPTIC T TANK CAP ITY �Gr tee LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER G PERMIT DATE: , Zi :L- COMPLIANCE DATE: 3— To -2,_ 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 CY `®�d� i c, �73 ���r t QumQ � I 1 (o { 3 �Y � Town of Barnstable OF THE rpm Regldlat®Ty SeI'VICS t Richard V.Scali,Interim`Director • BARNSfABt.E, , - �� i�; Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fat: 508-790-6304 Installer c&.Designer Certification Form Date: �l I22 Sewage Permit# 26Z2-�"'NAssessor's Map\Parcel Designer; GiC installer: .sen tSccafd' Address: 12 i>\Il s Address: /? 0 . 413dt Oil V'j W S G`�eay'ad, was Issued a permit to install a (date) (in stalle) septic system at /T7 , �v>,'.s � � r� . . based on a design drawn by (address) Cn9,'� Qer �tiarT Jk( dated :(designer) 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. Strip out .(if required).was inspected and the soils were found satisfactory,' I Geri � t fy that the septic.systern referenced above was installed with mayor.changes (�:e. greater than 10' lateral relocation of the SAS or any vertical elocation of any component: of the septic system)but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed"in with the terms of the IAA approval.letters(if applicable) 9 pelrrflk Coil (Installer's Signature) GV%L typ 35109 �O (Designer's Signature) (Affix:Design_ ere) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION, CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL,BOTH THIS'. FORIM AND AS- BUILT CARD ARE RECEIVED?BY'THE BARNSTABLE PUBLIC HE,ALTH DIVISION. THANK YOU. Q SepticDesigner Certification Form Rev 8-14=d3 doc Engineers note:This certification is Jimited to an as-built inspection of system components as installed prior to backfil.L The engineer did not supervise construction of the system.The installer assumes responsibility for all materials,workmanship,backlilling to.specified grades with proper compaction and set8ng risers/covers as shown on the design plan: I� >`� R oute 28 ——gg—— EXISTING CONTOUR f g,,bet N`11 Rd = LOCUS— 104 PROPOSED CONTOUR o X ,00sa EXISTING SPOT GRADE INSTALL A 40 MIL POLY LINER m 3 —W EXISTING WATER SERVICE TOP OF LINER, EL.=100.8 BOTTOM OF LINER, EL.=98.3 N I H o —G EXISTING GAS SERVICE EXISTING PUMP CHAMBER west Moip s SCHGOOL �¢ —eHb1h— EXISTING OVERHEAD WIRES SEWER CONNECTION (TO.REMAIN) trees o' TEST PIT TIE IN TO EXISTING FOR LINE, AT EXISTING SEPTIC TANK \,06 97,77 BENCHMARK OR BELOW, EL.=99.40 (TO REMAIN)LOCUNOT O SC AP ALE TOP OF TANK, EL.=96.93 INV.(OUT), EL.=95.60f \ �5 7.98 _o o S 54-42'10" l I 288.44' ,89 EXISTING S.A.S. I O ,-------l ���� TO BE 4BANDONE0 I ' FyRM£1? i x 9 8,6 0 \ LOT 4 ; I FEST. S.A.S. i \ 28,730f S.F. Q 1 1 I SHED ' O 102�.36 x I0 x 98,25 1\\ Mop 270 o , I oECK Parcel 05 02 9 8.7 0 EXIST. S.A.S. ' r 98, 9 x 97.52 r / OI L------ I ' it I 1 g O cV ! L-------' 1 I N ; 1 I O W DECK \ / E 1CLN o 101, 1 1 j Q I i 9 8.7 2 m x � o I ) 99,76 EX/STING i �''' �� o `� 4 ' i HOUSE (#173) �,� o PROPOSED S.A.S. O 1 G 7.86 o 113' x 35' LEACHING FIELD p I) W/2 DISTRIBUTION LINES 101,64 I d 1 I /�� 98,64 N w� W 32 i ° c L..i— j i BENCHMARK-1 97,63 �: W �x 99,2 I NAIL IN TREE Payed,; 1 J I I o EL.-- 100.09 Drivewa W I 9;5'•9 TP 2/ X 9 — 2 4 •r'• '� x 99,50 - - — i O I � . t 9 SOILS �SHALL BE VERIFIED PRIOR TO INSTALLATION TP--1 1 ST IPOUT AS REQUIRED UIRED � � I •r', 0:17 8_ '•0 .(SEE NOTE 11) BENCHMARK-2 t 99.91 i 100.33.+ �i C❑R/RR TIE x 97,49i / % / I EL.=98,11 i I x 96,60 / t / stockade fence 286.25 1 o OQ 98�5 00 N 54*42'10 W g3 ---- ---- 100 100,12 I1 OWNER OF RECORD Benchmark No. 1 GENERAL NOTES: SCACE, RODMAN JR. MAGNETIC NAIL SET 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 1 SCACE, CHRISTINA RACINE EL.=100.00 (Assumed) 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. OF M 173 DUNN'S POND RD BOARD OF HEALTH AND THE DESIGN ENGINEER. �� Af 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS �, s9 HYANNIS, MA 02601 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DIRECTED BY THE APPROVING AUTHORITIES. p PETER T• LOCAL RULES AND REGULATIONS. J' PROPOSED SEPTIC SYSTEM UPGRADE PLAN �`, 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY MCENTEE N TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CIVIL 173 DUNN'S POND ROAD HYANNIS MA DESIGN ENGINEER. CONSTRUCTION. NO. 35109 , 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS O IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 'AEG/SIE Prepared for: Rodman SCaCe, 173 Dunn's Pond Rd, Hyannis, MA 02601 FROM THOSE SHOWN HEREON SHALL REPORTED TO THE DESIGN REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255 3 ENGINEER BEFORE CONSTRUCTION CONTINUES. � )• ` I ^ E� � Engineering by: SCALE DRAWN JOB. N0. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 1"=20' P.T.M. 264-21 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. Engineering f I'orky, Inc. t R. Z'� THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY. � ) _` 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 14. SUBJECT SITE LIES WITHIN A GROUNDWATER RECHARGE AREA. (508) 477-5313 1/19/22 P.T.M. 1 of 2 TO PREVENT BREAKOUT, CONTRACTOR �1' SHALL INSTALL A 40 MIL POLY LINER TOP OF LINER, EL.=100.8 EXISITNG TANK & PUMP CHAMBER BOTTOM OF LINER, EL.=98.3 PROVIDE RISERS W/ SECURING FRAMES & COVERS PROPOSED D-BOX OVER SEPTIC TANK OUTLET MANHOLE AND PUMP PROPOSED S.A.S. EXISTING CHAMBER ACCESS MANHOLE, SET TO FINISH GRADE. INSTALL WATERTIGHT RISER & MANHOLES BROUGHT TO GRADE SHALL BE SECURED COVER SET TO 6" OF GRADE INSTALL INSPECTION PORT OUTSIDE DRIVEWAY FOOTPRINT HOUSE (#173 TO PREVENT UNAUTHORIZED ACCESS. F.G. EL: 102.3t F.G. EL.=101.7(MIN.) to 101.9t RIM SET TO RIM SET TO MAINTAIN 2% GRADE (MIN.) OVER S.A.S. FINISH GRADE FINISH GRADE DECK \ L = 8'(MAX) 4" DIAM. INSPECTION PORT, F4."SCH40 9'(MAX.) ® s=t� (MIN. 13' x 35' LEACHING FIELD W/2-4" PERFORATED IN S.A.S., SOLID 1% (MIN.) ABOVE S.A.S., WITH SCREW CAP PVC 40 PVC 4"SCH40 PVC SET TORAD6„ ^ 2" SCHCAPPED ENDS3„ s" EFI.DEPTHINV. EL.=100.20(END) SHED SLOPE OF PERF. PIPE = 0.590XISTING INV.=100.63 35' EFFECTIVE LENGTH -' EFFLUENT EXISTING INV.=100.46 FILTER PUMP PROPOSED D-BOX SOIL ABSORPTION SYSTEM (PROFILE) (ZABEL OR EQUAL) INV.=95.60t EXISTING EXISTING 3 OUTLETS INV.=100.38 EXISTING SEPTIC TANK EXISTING PUMP CHAMBER TO REMAIN TO REMAIN ESTABLISH VEGETATIVE COVER— EFFLUENT FILTER SHALL BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY ZABEL OR EQUAL. FILTER FINISH GRADE � SHALL BE INSPECTED AND CLEANED ANNUALLY. EL.=101.7to 101.9t W STAKE APPROVED a? 4=_' •''' ` �• ;;;. FILTER FABRIC U' STAK BREAKOUT ELEV.=100.73 rn NOTES: 1) D-BOX SHALL BE SET LEVEL AND TRUE TO BOTTOM ELEV.=99.70 3/4"-1 1/2" DOUBLE �o N :.7 GRADE ON A MECHANICALLY COMPACTED STABLE BASE WASHED STONE OR 6" CRUSHED STONE BASE, AS SPECIFIED IN 310 5' MIN. SEPARATION TO G.W. 3.5' CMR 15.221(2)." AND 4' OF NATURALLY 13' EFFECTIVE WIDTH tK 2) INSTALL INLET & OUTLET TEES AS REQUIRED. OCCURRING PERVIOUS SOILS p� 1lb 3) MAXIMUM COVER OVER PUMP CHAMBER, D-BOX AND EST. HIGH G.W. EL.=94.6 _ SOIL ABSORPTION SYSTEM (SECTION) ' �,��� ��. S.A.S. SHALL BE 36". SEPTIC SYSTEM PROFILE ; PROPOSED S.A.S. T N.T.S. DESIGN CRITERIA SOIL LOG 35' NUMBER NUMBER OF BEDROOMS: 3 DATE: APRIL 23, 2009 (REF-P#12,541) SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: PETER McENTEE (SE#1542) DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DAVID STANTON R.S. HEALTH AGENT DAILY FLOW: 330 GPD ELEV. TP- 1 DEPTH ELEy. TP-2 DEPTH SEPTIC LAYOUT DESIGN FLOW: 330 GPD GARBAGE GRINDER: NO 100.1 A O 100.2 A 0" SANDY LOAM SANDY LOAM LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF 99.4 g" 99.2 10YR 4/2 10YR 4/2 .74 GPD/SF B B 12" EXISTING SEPTIC TANK: 1000 GALLON CAPACITY SANDY LOAM SANDY LOAM 10YR 5/8 10YR 5/8 PROPOSED PUMP CHAMBER: 1000 GALLON CAPACITY, H-10 97.1 Cl Cl 36" 96.9 40" PROPOSED D-BOX: 1 INLET; 3 OUTLET (MIN.), H-10 MED. SAND MED. SAND PERC 10YR 5/8 10YR 5/8 48"/60" TO 0 PROPOSED SEPTIC SYSTEM UPGRADE PLAN INSTALL AN 13' x 35' LEACH FIELD 2.5Y 6/4 2.5Y 6/4 94.6 ADJUSTED .GW 94.6 ADJUSTED .GW 173 DUNN'S POND ROAD, HYANNIS, MA SIDEWALL AREA: NOT APPLICABLE BOTTOM AREA: 13' x 35' = 455 S.F. 91.9 STG.GW. 98" 91.9 STG.GW. 99" Prepared for: Rodman Scace, 173 Dunn's Pond Rd, Hyannis, MA 02601 90.1 120" ' 90.2 120" Engineering by: SCALE DRAWN JOB. NO, TOTAL AREA:.....................................455 S.F. Engineering Works Inc. NTS P.T.M. 264-21 LEACHING CAPACITY = 0.74 GPD/SF x 455 SF = 336.7 GPD PERC RATE <2 MIN./INCH ("C" HORIZON) 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. MIW-29, ZONE D, WATER LEVEL=7.3', APR 09, ADJ.=2.7' (508) 477-5313 1/19/22 P.T.M. 2 of 2