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HomeMy WebLinkAbout0200 FAWCETT LANE - Health 200 FAWCETT LANE, HYANNIS A - i i i f e i j J 1 I tT Town of BarnstableHE •� Regulatory Services Department i r + IARNSfAB1E. ` � IIYY MASS. Health Division fc " 200 Main Street, Hyannis MA 02601 2007 Thomas F.Geiler,Director Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL # 7012 1010 0000 2850 9101 May 16, 2013 —Erica_F._Teixeria 485A Pine Street Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 200 Fawcett Lane, Hyannis, MA was last inspected on 4/29/2013, by James D. Sears, a certified septic inspector for the State of Massachusetts. • The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Inlet line to tank and tee needs to be replaced. Broken clay tee, need to replace tee. Need to replace outlet cover. Lower cover should be below grade. Inlet cover should be raised. You are ordered to repair or replace the septic system components within ninty (90) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in .future enforcement action. PER ORDER OF TH BOARD OF HEALTH Tho ' McKean R.S., CHO • Agent of the Board of Health QASEPTIC\conditionally passed\200 Fawcett Ln Hy May 2013.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=20140 TOyp (jamVz }ri i At G'i/(/J�fJ T � 76C2 Logged In As: Parcel Detail Wednesday, May 15 2013 Parcel Lookup Parcel Info Parcel ID 270-135 _ I DevelopeeLot r LOT 72 Location 1200 FAWCETT LANE Pri Frontage 1100 ' Sec Road Sec I Frontage Village IHYANNIS I Fire District(H NAY NIS Town sewer exists at this address o I Road Index 10526 Asbuilt Septic Scan: `` 270135 1 InteractiveRON Map 270135_2 Owner Info Owner TEIXEIRA, ERICA F , Co-Owner j � I Streets 1485A PINE STREET _I Street2 city[CENTERVILLE �WWµ- -� _I State iMA zip 02632 Country Land Info Acres j0 33 �J use Single Fam MDL-01 Zoning Nghbd�0104�J Topography Level I Road Paved Utilities S p c,Gas,Public Water Location Construction Info Building 1 of 1 Year 1968 I Roof Gable/Hip __ Wali Ex Wood Shingle ^� Built Struct Living 1004 1 Roof Asph/F GIs/Crop T AC INone Area{ 1 Cover ype — .— Bed Style Ranch Wal� Typical - ) Rooms 13 Bedrooms I T Model Residential Intl ical Bath 1 FIull-+ 1H Floor yp Rooms I °w �; Grade IA rev age Neat(Tyical �.l Total Rooms - Type p Rooms _. Stories 1 Story Heat Gas 1 FoundTyplcal �L Fuel 1 ation Gross 2 008 � Area Permit History http:Hissgl2/intranet/propdata/ParcelDetail.aspx?ID=20140 5/15/2013 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address. Erica Teixeira' Owner Owner's Name information is Hyannis MA 02601 4-29-13 _ required for every - page- City/Town State Zip Code Date of inspection inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Irnng out firms n A. General Information filling outfdmis on the computer, .FMRS use only the tab �.����'' S9C'': 1. Inspector: I key to move your o: G cursor-do'not Jalries D.Sears _ .JA M ES :m use the return Name of Inspector key. CapewideEnterprises,LLC Company Name 153 Commercial St. Company Address Mashpee MA 02649 city'rrown State Zip Code 508477-8877 S1623 Telephone Number Lioense Number B. Certification I certify that I have personally,inspected the sewage disposal system at this add and tha_t the information reported below is true, accurate and complete as of the time of the inspection. The Insattion was performed based on my training and experience in the proper function and rri'afintenanc-ei-Of or�lte sewage disposal systems. I am a DEP approved system inspector pursuant"toSection p'f3.34M Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ F ils ❑ Needs Further Evaluation.by the Local Approving Authority .� 4-29-13 ctors Signature \, Date The system inspector shall submitalcoPY of this inspection report to the A0proving Authority (Board ^4 IJnn11•6 nr MCI)) Zn Anyet incr a^+inn If+ho eve+-ri% is -� chornri cue+ern F%r has a design flow of 1 D,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. d 5 1 001 �(' 3 t5ins•3113 Titles Official Insaecoojtebsurface Sewage Disposal System Page 17 /'1NI L.7 IJ IV.J/i.l 1.1.L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira. Owner Owner's Narne infdrmation is required for every Hyannis MA 02601 4-29-13 page. Cityfrown State -Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ l have hot found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally Unsound, exhibits substantial infiltration or exffltration 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): I5ins•3113 Title 5 Official fnspection Form:Subsurfeoe Sewage Disposal System•Page 2 cf 17 Aprzy I3 Iu:3ip p.3 Commonwealth of Massachusetts - : - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Owners Name _ information is required for every Hyannis MA 02601 4-29"13 page. Citylrown State. Zip Code Date of Inspedion B. Certification (coat.)' Fj Pump Chamber pumps/alarms not operational.System will pass with Board of Health.approval if pumps/alarms are repaired. B) System Conditionally Passes (cunt.): ® 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 ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below)- Need to replace inlet line to tank and inlet tee. _ 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): 0 obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: v ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: {�' ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or'a salt marsh 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 ,yprty io iu:.sip p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner _ Owners Name information is Hyannis MA 02601 4-29-13_ . required for every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system,(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*R. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems_ You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in somiliM is less than 6"below invert or available volume is less than '/day flow X ei% G t5ins•3113 Title 5 Official Insoection Form:Subsurface Sewage bisposal System•Page 4 cF 1T Apr Ly,i:s -iu:mp p.c Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Y . ` 200 Fawcett Lane Property Address Erica Teixeira_ Owner Owner's Name information is Hyannis_ _ MA 02601 4-29"13 required for every -- page. CIty[Town State Zip Code. Date of Inspection B. Certification (cont.) Yes No 0 ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.-A copy of the analysis and chain of custody must be attached to this form.] Ej The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. o ® 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 systems owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes'to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ' t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 5 ad 17 i /11./1 G5 I J I V.JVi.J N.v Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Owner's Name information is required for every .Hyannis MA_ 02601 4-29-13 , page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health El ® 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? g 0 Were as built plans of the system obtained and examined? (if they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? a !. 0 ❑ Was the site inspected for signs of break out? Z ❑ 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? 0 ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information 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 x !sins-3113 Title 5 Official Inspection Form:Subsurface Sexage Disposal System-Page 6 of 17 ,"Apr zy l o I U:'30p N. Commonwealth of Massachusetts �- . Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Owner's Name infomriatior is° requiredfor'every Hyannis MA 02601 4-29-13 page. Cityffown State Zip Code Date of Inspection D. System Information Description: The system is_a 1000 Gal.tank D Box and two 500 Gal, dry well chambers. Number of current residents: 0 -- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 2011-39,750Gals Water meter readings, if available (last 2 years usage (gpd)): 2012-24,000GaI's - Detail: Sump pump? ❑ Yes 0 No NA Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons perday(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present?- ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ INo Water meter readings, if available: 15ins-3113 Titre 5 Official Irspecllon Form:Subsurface Sewage Disposal System-Page 7 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Owner's Narne information Hyannis MA 02601 4-29-13 required for every y page- City[Town State Zip Code Date of Inspection D System Information (cont.) Last date of occupancy/user ' Date Other(describe below): General Information Pumping Records: 03/10 Source of information: - - - ---- Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons Now was quantity pumped determined? Reason for pumping`. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ InnovativelAlternative 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 VA system by system operator under contract [] Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Tide 5 Official Inspection Form:Subsuiface Savage Disposal System•Page 8 of 17 Hpr zy,i o i U:3yp p.y Commonwealth of Massachusetts ( Title 5 Official Inspection Form A r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Owner's Name information is required for every Hyannis MA 02601 4-29-13.. page. City,Town State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank 1998 permit#9831 D Box and leaching 2009 Permit #2009 -_278 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 28" Depth below grade:g feet Material of construction: ❑cast iron ®40 PVC ®other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage;etc.): Pipeing house to tank Cl and clay tank to Box 1 Box to chambers 4" PVC SCH 40. Note: Need to replace inlet line to tank and tee. Septic Tank(locate on site plan): 16" _ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No '^. Dimensions: 1000 Gal.Precast 1„ Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Sub—face Savage t7 aF—1 System•Page 0 of 17 Apr zaj J 6 1 u:syp p. i u Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Owner's Name - information is required for every Hyannis_ ,. _ _ MA 02601 4-29-13 page. cityrrown State Zip Code Date of Inspection D. System Information (cont_) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" o" Scum thickness Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 1811 How were dimensions determined? Asbuilt-Plan -Tape Sludge Judge Comments (an pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f Tank at working level. TAnk and inlet cover at 16" below grade w/out let cover, cement at grade, ' outlet tee. No sign of leakage or over loading. Inlet broken clay tee,need to replace tee.Need to replace oulet cover, Should lower cover, Just below grade. Should raise inlet cover Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ Other(eiplain): - ` 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 gins-3113 TRie 5 Offidal Inspection Forn;sutivaffaea Sewage Nwasai system•Page 10 of 17 Apr-zy j s 1 u:4up p. I I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 200 Fawcett Lane Property Address Erica Teixeira Owner Owner's Name information fo is Hyannis MA 02601 4-29-13 required for every page, cityrrown state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: r-1 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/}3 Title 5 Offrdal Inspection Fomt:Subsurface Sewage Disposal system•Page 11 of 17 ;MIJI Gy,IJ IV.L+up IJ. IG Commonweaith of Massachusetts -- Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica.Teixeira Owner Owner's Name information is required for every, Hyannis MA 02601 4-29-13 page. CitylTo,,vn State Zip Code _ Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-38" below grade wlcover at 12". Need to replace cover:. Box has two line's out. Box is clean and solid. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc:)-. *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Titls 5Official Inspedion Form:Subsurface Sewage Disposal System•Page 12 of 17 ryi G.7 1,J 1V.-tup Y. to Commonwealth of Massachusetts ^I y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Owner's Name information is' Hyannis MA 02601 4-29-13 required forevery page. Cityrrown Stale Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2_._ ❑ leaching galleries:. number.- El leaching trenches number, length.- leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leaching is two 500 Gal. dry well chamber's w/4'stone. Chambers are dry, wall's are clean like new. One cover raised at 8". Chambers are 32" below grade. No sign of over loading or solid carry over. 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 t5ins.3113 Title 5 Official Inspection Form:SubsuRaoe Sewage Disposal Systam Page 13 of 17 Hpf Ly I J I U:4 1 p P. 14F Commonwealth of Massachusetts r-� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessment's r .200 Fawcett Lane Property Address . Erica Teixeira Owner Owner's Name information is; required forevery` Hyannis, _ MA 02601 4-29-13_.. page. CityrTown State Zip Code Date of inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of p'onding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: - Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. I t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 d 17 Apr LJ.13 I UA I p P. I O 'Commonwealth of Massachusetts Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i , 200 Fawcett Lane Property Address Erica Teixeira Owner _ Owner's Name information's I Hyannis MA 02601 4-29-13 required for every y - - page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks cr benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately - R EAR a 14 -DECK !A�\t _3 a /c A I O � ❑ 3 IN=•3113 Title 5 Otfidal h3pocrion Fortrr.Stbsurface Sewage Dispcsal System Page 15 of 17 Apr zap i o -i u:4 i p p. i n Commonwealth of Massachusetts -- _M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Ownees Name information is - - - required for every . Hyannis MA 02601 4-29-13 page. CitylTown state Zip Code Date of Inspection D: System Information (cont.) Site Exam: ❑ Check Slope n ❑ Surface water El Check cellar El Shallow wells NJ 11' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 8-28-09 If checked, date of design plan reviewed: pate ❑ 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: T.H. Per Design plan 8-28-09 No G.W. at 11'. Bottom of chambers at 5'-6" Below Grade Bottom of chambers at 5'5"_above T.H. Depth Before filing this Inspection Report,please see Report Completeness Checklist an next page. IS:ns-3113 Title 5 0MCIal Inspection Fcrm:Suesurlace Sewage Disposal Syslern-Page 16 0117 rlpr cy i o i u;,+ p ' Commonwealth of Massachusetts Title 5 Official .Inspection Form N . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 200 Fawcett Lane Property Address Erica Teixeira Owner Owner's Name information is e required for Gv,ery Hyannis MA 02601 4-29-13 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C,.D, or E checked ® In Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal Systl in either drawn on page 15 or attached in separate file r� t5ns-3113 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page P of 17 0. No.,�PDl3 : ,51? Fee / 0/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftphratlon for Disposal *pstpm Construction 3pPrmit Application for a Permit to Construct( ) Repair 0/1�Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. a o0 FaWc.O.N' mVOwner's Name,Address,and Tel.No. � Cr ica� k Assessor'sMap/Parcel 00j-aw�� �R�.�— Installer's Name,Addressa and Tel.No. 5ab-7 77-1K 77 Designer's Name,Address,and Tel.No. c� Cr.�2ac'Ptr,Sa� Type of Building: Dwelling No.of Bedrooms Lot Size p 334 srf;:ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9!!j \ox_.e, wy W YeNc 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. Sign Date 5 / c Application Approved by Date t5ji Application Disapproved by Date for the following reasons Permit No. c� V Date Issued 0 3 No. 5 1 Fee V THE-COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION`S TOWN'OF BARNSTABLE, MASSACHUSETTS Zfpolirati6n for Mis oral stem Coneitrurtion Permit - Application for a Permit to Construct( ) Repair(V�Upgrade( ) Abandon( ) ❑Complete System, Individual Components j r Location Address or Lot No. 900 rtKcjej* Owner's Name,Address,and Tel.No. -�— ! f;a f C0. Z Assessor'sMap/Parcel V 3 goo j.,aw�Q Installer's Name,Address,and el.No. Svg.y�7- 3 7`7 Designer's Name,Address,and Tel.No. c� e�,AQ-&V�tzcPr�s2s 01A Type of Building: ( y Dwelling No.of Bedrooms Lot Size , 33 Q sg #. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil • , 1 ,..a Nature of Repairs or Alterations(Answer when applicable) 92 ac Q Qb ye",- C v,�f� i R Date last inspected: r, Agreement: i 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. i Date / LS Application Approved by !7 x Date J " Application Disapproved by r, Date for the following reasons Permit No. ('�/ Date Issued . ___ ________.______,__._.__-.__.__.-.__,f;4_,__.____.-------------------------- __.___.__._.__.___.___._____.__ -------------------------------------------- ' THE COMMONWEALTH OF MASSACHUSETTS ' BARNSTABLE MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V ) Upgraded( ) Abandgqoned( )by Co I �,� �i52 L.C.. at o�00 W has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No-,) — dated Installer`, 150-5 i U-�- Designer #bedrooms 1 - Approved design flow gpd e i The issuance of this pe it shall not be construed as a guarantee that the system will ion as designe Date Inspector f (�i V�✓, - ---- - ----- - -------------------- No.a Q/ 3 l 519 Fee� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at a a0 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 ingst becompleted within three years of the date of this Qb Date � `/ Approved i ' V TOWN OF BARNSTABLE LOCATION-2c,c,, /t'e.4V—, c el SEWAGE#� ,VVLLAGE ASSESSOR'S MAP&PARCELS?cs — 4 -jr` INSTALLER'S NAME&PHONE NO. r77�2 SEPTIC TANK CAPACITY/ 4 LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: —0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Botto of Leaching Facility Feet Private Water Supply Well and Leaching Facility f any wells exist on site or within 200 feet of leaching facilifi Feet Edge of Wetland and teaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ` . 1, � � M � � �, � � . 1 � � � �. � ! ���' � � �� K �1 a _ l V 6 /�� `� � 1 � .. . � b 6 ,,�.n a �: No. ` 'ag Fee �� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftPlication for Misposal 6pstrm Construction Vermit Application for a Permit to Construct( ) Repair(�q Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Lorca Addr06 ess or C t No. , cJ Owner's Name,Address, d�9 Tel No %!-` ,. k Assessor's Map/Parcel t9 7O -3 5 F \h LJ v%i5, Installer's Name,Address,and Tel.No.`j'0?1 — � ? (P Designer's Name,Address,and Tel.No.� �- M � ►rLSu�. Syr �+i� I Ca l �� 1 � R Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 O — gpd Design flow provided 3 3 6 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (15 � 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. 9 Q Signed c Date !, , , Application Approved by S Date — / Application Disapproved by Date for the following reasons Permit No. (966 ( ' g Date Issued L Fee N. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 100'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipp4ration for Misposal *pstrm Construction Vffmit _Application for a Permit to Construct Repair(>t) Upgrade Abandon( ) El complete System E]individual Components Locao n+A-Qd"rescs eo;r�LTo Owner's Name ddrn TN , Agssessor's Map/Parcel 9701 k"NL JA _ Installer's Name Address,and TeL No.15- Designer's Name,Address,and Tel.No5:D�---ir.0-1-0 Y'99 C_ L 90 �6( lo%q r-GV­1 V ke- ck—CAe, CA�_CA e C_&� Type of Building: j Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder eq Other Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures Design Flow(min.'required) 3 0 — gpd Design flow provided 3 3 6 • L4 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) e 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 s been issued by this Board of Health. I Signed ;��Z -01-- Date Application Approved by c S Date Application Disapproved by (7 Date for the following reasons Permit No. C9061- Date Issued 1- 1-01 --------7-­7�n­--i�._�M_-�­- -­­ �------------------------------------------------------------------------------- ------- CC THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS efftifirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired()4) Upgraded ti Abandoned( )by JjrA 'E— Sri_ S2d1L_ at cgC(D IF't3 LQUA� W,, Q_AN V)I 'has been constructed in accordance oq with the provisions of Title 5 an, he for Disposal stem Construction Permit No.;*0q-2 dated Installer F,, Designer 30- Y bedrooms — 3 Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will'fimct�ipn as designed. Date \.1 Inspector--___i,_!f�t ,1� No. C7 000? Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS C C Co-op, disposal 6pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair(X) Upgrade Abandon System located at 'FOLA-0CQ_�-4 La- - - \j 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 must be completed within three years of the date of this permit Date Approved by V Town of Barnstable °F1HE r°wti Regulatory Services Thomas F. Geiler, Director sa MASS.tom. Public Health Division 9^ 139. ATFOhM�A Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 --,, Fax: 508-790-6304 Date: Sewage Permit A"-3-fWAssessor's Map/Parcel 370 I35; Installer& Designer Certification Form Designer: (? ��-C��� Installer: ( MC Address: � ,I C��2C � Address: 1 C7 69 Con -V te� On E �(j�i n �S�- was issued a permit to install a (date) (installer) septic system at'900 �auxe,4 LjcLA-,-D_� iaNw\,,5 based on a design drawnby (address) � e1, dated S-o��6-09 t/ (designer) -t/ I certifythat the septic stem referenced above was installed'substantially_ P Y lly according to the design, which may include minor approved changes such as lateral relocation of the , distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. 3 I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. DAVID D. (Installer's Signature) - COUGHANOWIR y / No. 1093 TO S (Designer's Signature) (Affix De amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification form.doc AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATIONZc..-c.) ,A"4 Lv c f& �� SEWAGE#-C '� —'Z�J VILLAGE ASSESSOR'S MAP&PARCEL/74,�,— INSTALLER'S NAME&PHONE NO. �k�%—�' /wJG M- 17 S ?77 Z SEPTIC TANK CAPACITY LEACHING FACILITY(type)L' ` (size) /S—Z 4'— A NO.OF BEDROOMS 3 OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bott of Leaching Facility Feet Private Water Supply Well and Leaching Facility f any wells exist on site or within 200 feet of leaching facili Feet Edge of Wetland and Leaching Facility(If y wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY W 2 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=270135&seq=2 7/17/2014 Town of Barnstable Barnstable °4 Regulatory Services Department mgme'eac j * R&RNSTast-E, `0"9 i639. Public Health Division �� 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#70081830000205009816 8/18/2009 Carol A. Pinney 25 Benjamin Franklin Way Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 200 Fawcett Lane, Hyannis was last inspected on July 23, .2009,by Sean Jones, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PERYmas O ER OF THE BOARD OF HEALTH cKean, R.S.�C O Agent of the Board of Health COMMONWEALTH OF ASACH1SMS EAECUTrVE V C +o1 ENviRommYA L AFFAIRs - DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE S OFFICIAL INSPECTION FORM—NOT ►OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PAR TA CERTIFICATION Property Address:,qt?a F -�`'``�— Owner's Name: Ll" Owner's Address: Date of Inspection: "7&3 "bDS -� - Name of Inspector:(please print) Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville, 1A , "Telephone Number. (50f3) 775-877-6 CERTIFICATION STATEMENT I certify that I have personalty inspected the sewage disposal system at this address and that the information reported t 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 )Cam a DERV O approved system inspector pursuant to Section 15340 of Title 5(310 C111R I5.000)_ The systeii: Sµr Q Passes c - Z" c " itianalty Passes eds Further luation by the Local Approving Authoritt a __- t Inspector s Sigtiature: Date: -,— `n The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health-or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies'sent to the buyer,ifapplicable,and the appro.ving authority_ Notes and Comments ""This report only describes conditions at the time of inspection and tinder the conditions of use at that time_This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form Gli 52000 page 1 - e Page 2 of 11 OFFICIAL INSPECTION FORM—*NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: a040 '2,A-0Qi-9� L tA,\e_ 0 4\.("A5 Owner. CC__ CAP Date of Inspection: Inspection Summary: Check A,B,C,D or E J ALWAYS complete all of Section D A. System Passes: /\ j 1 gave 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. Y Comments: --r- - B. System Conditionally Passes: N IA One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If-not determined-please explain. The septic tank is in and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exflltmtion or tank failure is imminent.System will pa inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup • } ,•_� g ckup or break out or high static water level in the distribution box due twbroken or obstructed pipe(s)or due to a broken,settled or uneven distributi approval of Board of Health): on box.System will p vr@rass inspection if(v broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 bores a year due to broken Obstructed pipe(s) Pass inspection if(with approval of the Board of Health): The system will broken pipe(s)are replaced obstruction is srmotrcd ND explain: Page 3,of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: aZD0 �- ( n ►S Owner: C C- t"_ Date of inspection: C. Further Evaluation is Required by the Board of Health: ' , Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. 'System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the-public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within.100 feet of a surface water sitpply 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 front a 1 private water supply well— Method used to determine distance •`This system passes if the well water analysis,performed at a DEP certified laboratory, for colifortn bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 96)0 Owner: CC CO , Date of Inspection: "-2zluo_looi D. System Failure Criteria applicable to all systems: You must indicate`Yes"or"no"to each of the following for all inspections: Yes No - n,bt RYsc� h�Back-up of sewage into facility or system component due to overloaded or clogged SAS or cesspool C ' N Xjfi _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or C NZ*- Qresa.eN7 t /cesspool ,pw f lyiquid depth in cesspool is less than 6 below invert or available volume is less than%day flow ./Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Numbcr oftimes 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 t of a public well. ✓ .Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Kato supply well with no acceptable water quality analysis.(This system passes if lite well water analysis;;; . performed at a D£P certified laboratory,for coliform bacteria 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 S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.! Y . (Yes/No)The system fails.1 have determined that one or more ofthe above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Hoard of Health to determine what will be necessary to correct the failure. E. Large Systems: f To be considered a large system the sjstcm must sertie a faciii(y with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: Mie following criteria apply to large systems in addition to the criteria above) yes no _ ___ the system is within 400 feet of a surface drinking water supply _ _ the system is within 200 feet of a tributary to a surface drinking water supply - the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 1f of a public water supply well if you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes",in Section D above the large system has fined.The ov mcr or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact ltte appropriate regional office of the Department. 4 , Page 5 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner. C,C Date of Inspection: 7��3oS Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No ' ✓Pumping information was provided by the owner,occupant,or Board of Health ✓Were any of the system components pumped out in the previous two weeks 7 ✓/Has the system received normal flows in-the previous two week period? Y _ .,Z Have large volumes of water been introduced to the system recently or as part of this inspection 7- Were as built plans of the system obtained and examined?(If they were not-available note as NIA) + / 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? t y _ 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 7 _ I/Was the facility owner(and occupants if different from owner)provided with information on the proper,- maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: , Yes no _ _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any-of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CUR 15.302(3)(b)J r 5 Page 6 of i l s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION v Property Address: 'RDO �au3LC�.F-I- Owner: C . C Date of Inspection: 2 a o LOW CONDITIONS RESIDENTIAL _ Number of bedrooms(design):- 3 _ Number of bedrooms(actual): - - DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x Hof bedrooms): 37,z 4 PSI Number of current residents: C> Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):rs�- [if yes separate inspection required] Laundry system inspected(yes or no):wj Seasonal use:(yes or no):N� - Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):. BUD ? — (c)7 S�c� Last date of occupancy: Cv.'+t.�l �c oc.► ^ ` A6�- t cs r o1a r COMMERCIAL/INDUSTRIAL Type of establishment: /L-J Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no)._ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: + Last date of occupancy/user ' OTHER(describe): 3 GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): /w If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: 7E OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes;attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 1'agc 7 of 1 1 OFFICIAL INSPECTION F010•1—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L"Je cnt� - A� ' . C. Date of Inspection: /o;*oS BUILDING S£\VER(locate on site plan) Depth below grade: Materials of construction:_cast iron _✓40 PVC_other(explaut): Distance from private water supply well or suction lute: Comments(on condition of juints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓(locate on site plait) t Depth below grade: ) Material of construction:_✓concrete_metal_fiberglass_polyed,ylene _othcr(cxplain) If tank is metal list age:_ is age confinncd-by a Ceruficale of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /&�C' Sludge depth: Distance from top of sludge to bottom of outlet tee or bailie: —'" Scunt thickness: Distance from top of scum to top of outlet ice or bafTie: — Distance frorn bottom of scum to bosom of outlet ice or baflie: I low acre dimensions dctcnnincd: t�••e�s�+-.r..k :,, .ma_ Tg.'= Ace-Zf A 6e- C J-,,j Comments(on pumping rceonuncndations,inlet and outict(cc or bathe condition,structwal integrity,liquid levels as related to outlet invert,evidence of leakage,c(c.): -4 ba Hz.... �� wtic i i�t�,r.t- �•,v4r ! few r�kGfc Q z. 4z Sf+c r G f a�na Co"e- - GREAS£TRAP:_(tgcatc or s plan) Depth below grade: `J Material of construction:_concrete_metal_fiberglass____polyeiltylene_other (explain): Dimensions: Scum thickness: Distance fiotrt top of stunt to top of outlet(cc or baffie: Distance Gorr bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Conuncnts(on pumping reconuuendations,Wet and outlet ice or bailie eunditiu:t,structural integrity, liquid levels as related to outlet invert,cvidcncc of leakage,ctc.): 7 8ofII r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUIZ.FACE SEWAGE DISI'OSAL SYSTEM INSPECTION FOItNI PART C SYSTEM INFORMATION(continued) .icrty Address: Q c c.e. -! 1.. dam; �— icr: r of Inspection: -Z, +11T or HOLDING TANK: ,A) (1an1'c trust be pumped at time of inspection)(locate on site plan)- A below grade: crial of construction:_concrete metal fiberglass_polyethylene othcr(explaut): rcasions: ,acity: gallons ign Flow: gallons/day nu present(yes or no): nn level: Alarm in%votking order(ycs or no):_ c of last pumping: nrncrrls(condition of alarm and float switchcs,ctc.): STIUBUTION BOX: ` (if present must be opencd)(locate on site plan) ­ I. r, .pth of liquid level above outlet invert: U nunents(note of box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of kagc into or out of box,ctc.): �j , n..44-c- �tvz� ar a Loik,.s j2t A +4� eA jkojSehrij heg_ y4c.w f �yr •MG ✓�C. e s C. &P 614G K s uw� a� 04 i nr.��cc-*7 y T-(aG,4 �Ovs< Z+ws bet i.krJr, ,l��co butr oc L� jrt r JAIP CIIA61BEII: (�ca1c on site plan) _ imps in work ng order(yes or no):_ anus in worki,ag order(ycs or no): _ munenis(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page9ofil OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: elvce�-�- � . Owner: C. t� Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓(locate on site plan,excavation not required) If SAS not located explain why. Type leaching pits,number:_ ,,,"'leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): �;I ,.•-�.s �r nI, rvgG� ur e�-�.e..�. - t,..�„-kr 1.t4c/ ,.... e�- ��� !' �.�s 5AS lno.s b.c«cN a-y rloadcJ e-- Ast, CESSPOOLS:— (ce�ss[a pl must be pumped as part of inspectionxlocate on site plan) Number and configuration`::: �1 Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (lc�te on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) Property Address: f9OO �1� L9 CL,(\ Owner: C,C• _0 Date of Inspection: y 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. /3.1 LD 3 � � = A `3z- 33 " .3 3 lU Page It of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 36b i ce Ld""D - 5 Owner: C.C. 'd d Date.of Inspection: 7/2:3/229,� SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting propertylobservation 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: �•,-�; �,-ate— I c,�a tz�- �.-�-z A a Psi UaAal 11 ' Town of Barnstable P# 2�(P Department of Regulatory Services ` rR ` Public Health Division - atiwernace = _ _ Date~ �p t6 200 Main Street,Hyannis MA 02601 TfD MA't�' ' Date Scheduled D �._ { (� Time-� r Fee Pd. 100. 7I Soil Suitability Assessment for�Sewage'Disposal6!. o Performed By: __D RU1n ('00'H4 N 60 2 LSC Witnessed By: �d a �] - LOCATION& GENERAL INFORMATION LocTAddress Owner's Name Address :.D'ZeS 1��f1�C�+M rl.FQOL,-,Y k' Assessor's Map/Parcel: 7O I?j. , ��c,_*%v\t�j t 07 / S Engineer'�Vame NEW CONSTRUCTION REPAIR ✓ - Telephone# Land Use 1`'E+Sg�hC.�T.f� WdO�P� f Slopes(90) D Surface Stones lD0Distances from: .:Open Water Body ft. .Possible Wet Area ft 'Drinking Water,Well-ADO ft 1 Drainage Way -7� �' ft Property property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) N I rp2 70 GROUNDWATER ADJUSTMENT 1 EXISTING GROUNDWATER LEVEL BASED ON TOWN OF BARNSTABLE la GIS DEPARTMENT RECORDS. m � INDICATED GW 22.00 INDEX WELL AIW-230 1 m� � l� ZONE C f READING DATE DULY. 2009READING 23.0 ADJUSTMENT 3.3— — ADJUSTED GW 25.3 150.20 't . Parent material(geologic)4 0 (f/L!G O04 W9 S; Depth to Bedrock Depth to.Groundwater- Standing Water in Hole: Weeping from Pit Face e Estimated Seasonal High Groundwater See o bd V DETERMINATION FOR SEASONAL HIGH WATER TABLE ; Method Used: SLvF A bOiI¢ Depth Observed standing in obs.hole: in,4 Depth to soil mottles: in, Depth to weeping from side of obs.hole: in, Groundwater Adjustment .1 Index Well# Reading Date: Index Well level Adj,factor ®—Adj,C3roundwater Level , PERCOLATION TEST . Date 112-'1'01 Thne ti�AM Observation Hole# Time at 9" vtLq Depth of Pero V Time at 6" Start Pre-soak Time @ t 57 Time(9"•6 End Pre-soak L l �"U Rate MinJInch Z m P Site Suitability Assessment: Site Passed 1✓ Site Failed: Additional Testing Needed(YIN) original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 1001 of wetland,you must first notify the. Barnstable Conservation Division at least one (1)week prior to beginning. Q:\SEPTICNPERCFORM.DOC OF TEST: AUGUST 6. SOIL TEST L O S SOILE EVALUATOR: DAVID 0.2C000H9 ANOWR. R.S. WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. ' ,__--_--_ -PERC .NUMBER:--... - — 12687 = - 1 ! TEST PIT I - ! PARENT UMAATERIAL:- PROGLACA LD OUTWA SH s PERC AT 6B to - 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL_CDLOR -SOIL OTHER (INCHES) 'HORIZON - TEXTURE (MUNSELL) MOTTLING 1 43.15 0-4 O- - ,LOAM - j-- 1Z' YR 3%4 NONE- - -FRIABLE 4-8 _- -A LOAMY SAND -- 1Z-YR 4/6 NONE-- FRIABLE 6-28 B LOAMY SAND 7.5 YR 4/6 NONE FRIABLE I 40.62 - - __— _ _ -• . . . I '' 1 28-138 C— -.MEDIUM SAND — - —10 -YR 4/6 NONE­ �-- -LOOSE 31.65; T E S T� --PIT -2 NO GROUNDWATER ENCOUNTERED PARENT, MATERIALwPROGLACIAL OUTWASH j 1 2 MIN/INCH IN, C SOILS t ELEVATION DEPTH SOIL USDA "SOIL_ __ . SOIL COLOR SOIL-- OTHER 43.25 (INCHES) HORIZON TEXTURE (MUNSELLI MOTTLING � ' 0-4 - 'O LOAM 10 YR 3/4 NONE FRIABLE t 4-9 - _A -- - -- LOAMY SAND-- - -1Z-YR 4/4 NONE- FRIABLE ` 9-30 _B_ I LOAMY SAND 40.75 _ 1R-4/6 NONE. FRIABLE ! _ 0_.Y, 32.25 26-132 C MEDIUM SAND_ 10 YR 5/4 NONE LOOSE DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Otiier Surface(in.) — _ (USDA). _ .(Muusell). Mottling (Structure,Stones,Boulders. "Con i to _...So v - DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders" Cositn l Flood Insurance Rate Map: y _ Above 500 year flood boundary No_ Yes ._V__-_ Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? e 5 If not,what is the depth of naturally occurring pervious material? Certification I certify that on Vo J ��yS (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature `� lrS L 44 Date QAS.BPTl0PBRCF0RM.DOC TOWN OF BARNSTABLE Q LOCATION 2 6-2 4,6 SEWAGE # 3 VIIIAGE 6l J'v M A.i�a ASSESSOR'S MAP &LOT�Z 70 <357 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Z&A--6 LEACHING FACILITY: (type) 3 A/o-® )?Zo ioi 3 (size) /B 30 NO.OF BEDROOMS BUILDER OR OWNER .L.�z'' Y PERMTTDATE: �—� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 r s f { t \r ,tea i r r No. / •� Fee 5$ 0 . 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for �Digo.5ar 6pgtem Construction Vermit Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 200 Fawcett Ln Owner's Name,Address and Tel.No. 7 7 5—1 3 0 7 Assessor'sMap/Parcel Hyannis, MA Carol Pinney 200 Fawcett Ln `Z Hyannis, MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. WM E Robinson Septic Service PO Box 1089, Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Z7 5..k Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of 3 maximizers . t4,, 'D--13dhC 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 nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d b of Health. Signed V Date Application Approved by Date Application Disapproved for the following reasons ool Permit No. _3 Date Issued S 10" ��.....vim _, .. • a _ No. / t.. 1�-- •., Fee $5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Mitpaaf *pgtem Con.5truction Permit/ Application for a Permit to Construct( )Repair_( X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Locatign%Address or Lot No. 200 Fawcett Ln Owner's Name,Address and Tel.No. 7 7 5—1 3 0 7 Hyannis, MA Carol Pinney 200 Fawcett Ln Assessor's Map/Parcel Z xj t 3 ., Hyannis, MA Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. WM E Robinson Septic Service PO Box 1089, Centerville, MA 02642 Type of Building: - - Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / -- qq++ _ Design Flow gallons peg day.���alcul�ated aily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank t o\ B'w .-(co Type of S.A.S. l. .. : Description of4Soil sand •' - Nature of Repairs or Alterations(Answer when applicable) Title 5 Leachi+ag consisting of 3 maximizers. ill. -D-S30)< 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 nvironmental Code and not to place the system in operation until a Certifi- rate of Compliance has been iss d by of Health. / r Signed Date _ Application Approved by Date Application Disapproved for the following reasons Permit No. F-3 Date Issued J --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS AR:KSTABLEA1IASSACHUSETTS � ` Mica e of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired,(XX)Upgraded( ) Abandoned( )by at 200 Fawcett Ln, Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - 3 dated Installer Wm E Robinso'b Septic Sery Designer The issuance of this permits all not be.construed as a guarantee that the syst 'Will f �� s designed. Date /' Inspector / ►`' -"r --------------------------------------- No. /0 - 3/0 - 3 Fee $5 0.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Pinney � ]Di5potal *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(X)Upgrade( )Abandon( ) System located at 200 Fawcett Ln Hyannis, MA 02601 Installer: Wm E Robinson Sr Septic Service and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this I. Date: Approved by/�X TOWN OF BARNSTABLE LOCATION ujz"C l� �, .6 SEWAGE`# VILLAGE. ASSESSOR'S MAP&LOT �. INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY — :-.'LEACHING FACILITY: (type) f�o�-o lj?A X s (size) /d—.d o" NO.OF BE :::BUILDER OR OWNER PERMTTDATE:/— COMPLIANCE DATE: I Q :.Separation Distance Between the: Feet 'Mazimum Adjusted GroandwaterTle and Bottom of Leaching Facility ' 'Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) ;.:;Furnished by r r. NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 200 Fawcett Ln,Hyannis,MA, meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and/or change in use proposed * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) I01 SIGNED:vv DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). 1 3 � �Q6 3 , o � w J' ' A O/ lYJ Commonwealth of Massachusetts Executive Office of Environmental Affairs RECEIV:B1 Department of DEC 5 1Environmental ProtectionH�r�oEPwllllam F.weld TOW1d OF BARNS Governor Trudy Coxe Sxretary,EOEA David S.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 0 C) PART A �` rl CERTIFICATION Property Address: Address of Owner: 4C G A(_ G 7 Date of Inspection: (If different) t -7 7 0 Name of Inspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson Septic Service 1 . P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT ' �7 7 1 certify that I have personally inspected the sewage di pbs l—s�sYerh t 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-siteZsewa disposal systems. The system: Pa55e5, + -- _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails x Inspector's Signature:. A01 ; ✓ Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.,tne system owner and copies sent to the buyer, if applicable and the approy;ing authority. , INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITItQNALLY PASSES: One or more syst m components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. i Indicate yes, no or notdeter ined (Y, N,or ND). Describe basis of determination in all instances. If"not determined", explain why rtotj , _ 'The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is 1 imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95)+ 1 r One Winter Street • . Boston,Massachusetts 02108 • FAX(617)566-1049 • Telephone(617)29240M �,- k. Printed on Recycled Paper s � . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: G'el �,,4lU� Owner: FtJSA'- f 4/ Date of Inspection: jj,_3, Ac3 B]SYST CONDITIONALLY PASSES (continued) _ 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 _ Th system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass ins ection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVA ATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions xist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, afety and the environment. 1) SYSTEM WILL PA S UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PR TECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or rivy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL U LESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUN TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The cvstem has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water pply. _ The sN-stem has septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a ptic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system ha> a s tic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fr m that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the s stem violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identi i below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into fa ility or system component due to an overloaded or dogged 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. 'eo 2 (revised 8/15/95) !9 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: G O �� �'� 1-�-17e"' Owner: Date of Inspection: / 1i-.3 0 D] SYSTEM ILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no Iceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for co form bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E]LARGE SYSTEM FAI S: s The followi criteria apply to large systems in addition to the criteria above: The design flow •f system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environ ent because one or more of the following conditions exist: the sy tern is within 400 feet of a surface drinking water supply the tem is within 200 feet of a tributary to a surface drinking water supply the sys m 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 e - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: j_ 0 Check if the following have been done: _humping information was requested of the owner, occupant, and Board of Health. 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. VAs built plans have been obtained and examined. .Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. tfhe system does not receive non-sanitary or industrial waste flow %Ahe site was inspected for signs of breakout. L/AII.system components, excluding the Soil Absorption System, have been located on the site. Vfhe 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. I/fhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _Vhe facility owner (and occupants, if,different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. z 4 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 O ® /7 Owner: J +o9 Date of Inspection: 3 ,o'qS1 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 Gallons Number of bedrooms: Number of current residents:111) Garbage grinder(yes or no):_,6::f- a Laundry connected to system (yes or no): Seasonal use (yes or no): Y Water meter readings, if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_gallons/daY „ Grease trap present: (yes or.no) Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no)_" Water meter readings, if available: v Last date of occupancy. OTHER: (Describe)' Last date of occupancy: GENERAL INFORMATION ' - e PUMPING RECORDS and ource of information: e4 AOJ System pumped as pan of:inspection: (yes or no)6t/ If yes, volume pumped Rallons Reason for pumping: TYPE QF SYSTEM 1, 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)Ael, '> g (revised 8/15/95) - Y - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ; ®© WC,C17, I'An e-- Owner: C �B�%/° f Date of Inspection: _ 4 S ir SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: !®concrete _metal FRP—other(explain) Dimensions: a "� Sludge depth: (? -- °' ► o , , Distance from top of sludge to bottom of outlet tee or baffle3 — VO Scum thickness: u Distance from top of scum to top-of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, conditions of inlet'and outlet tees or baffles, depth of,liquiddllevel in relation to outlet invert, structural integrity, evidence of leakage, etc.) .®�- ti /'<' / 1 ( i..a GREASE P:_ (locate on sit plan) Depth below gra Material of constru ion: _concrete _metal _FRP—other(explain) Dimensions: Scum thickness: Distance from top of cum to top of outlet tee or baffle: Distance from botto. of arum tn.t)ottom of outlet tee or baffie: Comments: (recommendation for pump g, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage• etc.) (revised 8/15195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C)_� r/�wGe 7 Owner: Date of Inspection: TIGHT.OR HOLDING TANK:_ (locate o site plan) Depth belo grade: Material of co struction: _concrete_metal _FRP_other(explain). Dimensions: Capacity: al Ions Design flow: allons/day Alarm level: Comments: (condition of inl t tee, condition of alarm and float switches, etc.) DISTRIBUTION OX:_ (locate on site pl ) Depth of liquid level above outlet invert: Comments: (note if level and dis ributior, is equal, evidence of solids carry,o•.er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:( es or no) Comments: (note condition of pum amber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) d2oo FAwC,e � ��C ':9-n�i�S Property Address: Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):�✓ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs,of hydraulic failure, level of ponding, condition of vegetation,etc.) 17 CESSPOOLS: _ (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: ISI cs c,ieS Indication of groundwater: 4-0 inflow (cesspool must be pumped as part of inspection)—QA l 1 '4' �- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of/hraulic failure, level of ponding, condition of vegetation, etc.) Irevised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (1 Y i i 20 I I Ft� r DEPTH TO GROUNDWATER Depth to groundwater: l9 f feet method of determination or approximation: 1 Oy� 60 t (revised 8/15/95) 9 . O � a 23 ri7��as cam,`Li ALL PIPE SECIFIED ARE ATIONS E L O V V PROFILE EXPRESSED INV DEC IMAL FEET NOT FEET AND INVERT I CHES.TIONS z� RAISE COVERS TO WITHIN SIX INCHES OF FINAL GRADE TOP OF FOUNDATION ONE INSPECTION RISER FOR LEACHING GALLERY TO EL 45.79+- WITHIN 3 INCHES OF FINAL GRADE AS INSPECTION PORT. 43.25 3 FL Q v ALL PIPE TO BE D-BOX MAX SCHEDULE 40 PVC 3" DROP, AND TO PITCH AT -FLOW LINE I I i i 41.00 1/8 to/Ft MIN. 14 46 GAs� PRECAST BAFFLE DRYWELL 6 in BOTTOM OF 41.13 +- STONELEACHING EXISTING \40.38 LEACHING GALLERY EXISTING EXISTING 40.55 BASEGALLERY EXISTING 1000 GALLON 40.25 (END VIEW) 38.25 5.00 ft + SEPTIC TANK II/ SEE DETAIL ON REVERSE EXISTING 11 A K 24 f t of 5 ft 12.58 f t bl 12 ft , ADJUSTED SEASONAL P 25.30 HIGH GROUNDWATER Mcorn n M Al r O W Z < Z cr) y rn z y n (n end / N / \ ' 4l -�i / �} / A cn m o W + m m N \ F Q I X Z N N� �p m \ I Np Fq 3m / 3 ul (D ccoXf \ ®N \ a 0 Z m oz \ -0 420 m 5 coM�,p --S) z v o a -n Sli'� �tl •j cnmocn-i L LTJ >� �Z of / �0 o»�= @ n w ozo�z ci)w =z m ® Omrn \ �OAK F- � �� y���I` G . cznom� �l r c 0 � O�� cm��m 13rn Ul Z n rn- -''o oz e C) CD ED �(n� �� �Iym N O �� �� =o>roo �� �� rn: '' Z > >oCOz m rn o m ° N m 0 � f�l ����- ~ o o � M ( m rn o zz -jO -1 c rrn cnmrn cnmo�� o C -I M � o �� �m m -� mx m x --1 n -9 G) 3 D -<7 "1 O rn � � cn GI � �� Rl O -1 cncno-0z C a > � U� --1 3 rA C ~ Z� ~Oti 3 �omn0� N W > O (� fTl � _ p Co 3mm 000O Z n),Z ����� -� Z N M Z� 0 0 X O Cy1 y� s��b C 'I �O y f C) Z Q 2 z O�ooC cl M Z(-) O U) = a O -i y�' C O cn rn3�m N (� '-'M O r N r m m 3 r Z O v l I MVO �3 0 o- m m Ul M Z . O r m y 3Nd, 1133 ocrncn> —i > urn.) o z yo mZ I ' I o y rnz - r�mmo o N N � 3 � o � rn o Z m; m� � 0 00 Z 0 F < m �f l z o mi m Rl n �- ytd 0 2 m cn z (D N M F- 3 n -,m O >C O O - 3 k vM can Z � c�cn Zcil Z r pi or�-� m ❑ Fl <�ccnm 1 Ul M Z �'� Z mzO�z p r O;Uzimo z y 3 ol Tr Z SOIL TEST LOG SOIL TEST: DAVID 28. 2009 . DESIGN CALCULATIONS SOIL EV`LUA�TOR: DAVID D. COUGHANOWR. R.S. , WITNESSED BY: DONNA MIORANDI. HEALTH DEPT. PERC NUMBER: 12687 DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD TEST PIT 1 NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS PARENT MATERIAL: PROGLACIAL OUTWASH USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL PERC AT 66 in - 2 MIN/INCH IN C SOILS CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DISTRIBUTION BOX: USE 3 OUTLET D-BOX. MINIMUM INSIDE DIMENSION = 12 in. (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING MINIMUM SUMP = 6 in. 43.15 0-4 O LOAM 10 YR 3/4 NONE FRIABLE SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 Ft x 2 Ft LEACHING GALLERY CAN LEACH 4-6 A LOAMY SAND 10 YR 4/6 NONE FRIABLE A = ( 24 x 12.5 ) = 300 sf Asdw = [ 24 + 24 + 12.5 + 12.5 ) x 2 = 146 sf 8-26 B LOAMY SAND 7.5 YR 4/6 NONE FRIABLE Atot = 446 sf 40.82 Vt 0.74 x 446 = 330.04 GPD 28-138 C MEDIUM SAND 10 YR 4/6 NONE LOOSE 31.65 USE A 24 Ft- x 12.5 ft x 2 Ft- GALLERY. Vt = 330.04 GPD > 330 GPD REQUIRED TEST PIT 2 NO GROUNDWATER ENCOUNTERED LEACHING GALLERY 1000 GALLON SEPTIC TANK PARENT MATERIAL: PROGLACIAL OUTWASH DIMENSIONS AND DETAIL NOT TO USE SHOREY PRECAST 500 GALLON NOT TO 2 MIN/INCH IN C SOILS LEACHING DRYWELL (H-10 LOADING) SCALE USE EXISTING H-le UNIT SCALE ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SEPTIC TANK IS TO BE PUMPED DRY (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING CONSTRUCTION DETAIL AT TIME OF INSTALLATION AND IS TO 43.25 BE EXAMINED FOR STRUCTURAL 0-4 O LOAM 10 YR 3/4 NONE FRIABLE DRYWELL UNIT STONE INTEGRITY. INSTALL NEW PVC OUTLET TEE EOUIPPED WITH A GAS BAFFLE. 4-9 A LOAMY SAND 10 YR 4/4 NONE FRIABLE 2 4.0 ft 40.75 9-30 B LOAMY SAND 10 YR 4/6 NONE FRIABLE m- 43 TAPER 26-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE � c4 32.25 Lo 4 N �� ® C (V O 0 I m�' o �] GROUNDWATER ADJUSTMENT m ` (4- Lo EXISTING GROUNDWATER LEVEL 3.5 t B.5 f t 6.5 f t .5 t t BASED ON TOWN OF BARNSTABLE 24.0 ft GIS DEPARTMENT RECORDS. 10 INDICATED GW 22.00 INDEX WELL A1W-230 500 GALLON DRYWELL ZONE C DIMENSIONS AND DETAIL INLET ET OUTLET READING DATE DULY. 2009 READING 23.0 USE H-10 UNIT ADJUSTMENT 3.3 3 IN DROP ADJUSTED GW 25.3 INSTALL ONE INSPECTION —. RISER TO WITHIN THREE —> lol FLOW LINE INCHES OF FINAL GRADE FROM a AND INDICATE LOCATION BUILDING IB to 14 r TO ON AS-BUILT PLAN in J D-BOX 48 to LIOUID GAS LEVEL BAFFLE 00 33 NOTES - oo�000 coo OOOO� In 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. ��o�o�0000�oo OOO CROSS SECTION VIEW 000 0 i� 2) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED �g FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. 10z 1n 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). CROSS SECTION VIEW 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTIL_.I=TIE_ S,- BEFORE EXCAVATING FOR SYSTEM. •',-ti; '•,. •; 2 to PE/iSTONE 2 in PEASTONE SEWAGE DISPOSAL SYSTEM PLAN 5) EXISTING LEACH PIT TO BE PUMPED, COLLAPSED AND--FILLED: o 0 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF,IRON�i`FINES AND DUST IN PLACE. 28 s/4 To EFFECTIVE a u ro [3� -TO SERVE EXISTING DWELLING Z) ECO-TECH ENVIRONMENTAL RECOMMENDS T E' h-NS;TNLL'ATION OF LOW FLOW FIXTURES -iiz,ncAVB DEPTHi-vz� GRAVEL n AND APPLIANCES. AND BIANNUAL PUMPING, ,OF THE SEPTIC TANK. In CAPE COD COOPERATIVE BANK 6) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR- LO- DING. DO 'NOT 46 In 58 In 46 In 200 FAWCETT LANE HYANNIS. MA A ' PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM.. 150 In 9) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND`TRUE TO GRADE -ON A LEVEL INSTALLER MAY SUBSTITUTE AN APPROVED GEOTEXTILE ECO-TECH ENVIRONMENTAL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED. AND ON TO WHICH FABRIC IN PLACE OF THE 2 in. PEASTONE LAYER SPECIFIED. 43 TRIANGLE CIRCLE SANDWICH MA 02563 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO.. MINIMIZE UNEVEN: SETTLING. ETE-3215 AUGUST 28, 2009 2/2