HomeMy WebLinkAbout0210 FAWCETT LANE - Health 210 FAWCETT LANE, HYANNIS
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TOWN OF_BARNSTABLE
LOCATION o�1d FibW C tTl SEWAGE#
VILLAGE 1y Y ASSESSOR'S MAP & LOT
J N S A£c?o,e r
LN35f-i�E'S NAME PHONE NO. A & B CANCO 775-6264
.SEPTIC TANK CAPACITY S
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 4 LF�'£b o
N 'S
DATE / D:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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Town of Barnstable P# �
Department of Regulatory Services
Public Health Division Date
9.�,6� 200 Main Street,Hyannis MA 02601
Date Scheduled e Time Fee Pd. J 0 0
Soil Suitability Assessment for Se Dis osal
Performed By: H( �� T i PYl G���l Z�, CS L' Witnessed By: (/lK A
LOCATION& GENERAL INFORMATION
Location Address I� � c e it Owner's Name VA,e K7 e5" "M A0t i'�,"t-
Address Z 1 O ��r J C cT7 L�J
Assessor's Map/Parcel: 2 l/ n _> it 3C- C� (tw &
7 b//3 7 Engineer's Name C r4-�1,�:��� �'t�� Y� 5 .
NEW CONSTRUCTION REPAIR Telephone# SIDq z Z 6 sob-.2-73--037 7
Land Use AueA�i) Slopes(R'o) 2- ✓X Surface Stones
Distances from Open Water Body ft Possible Wet Area ft Drinking Water Well _ ft
Drainage Way ft Property Line '7 1—0 ft Other ft
SKETCH:(Street name dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
S� alac(ntcl etc.,
Ev�aS�
Parent material(geologic). S Depth to Bedrock 7(26 6 S
Depth to Groundwater. Standing Water in Hole: t 20,ySs Weeping from Pit Face
Estimated Seasonal High Groundwater 120 �55.
DETERN UNATION FOR SEASONAL HIGH WATER TABLE
Method Used: D`rec k—0o uv gm
Depth Observed standing in obs.hole: ___ in. Depth to soil mottles: >12-0 in.
Depth to weeping from side of obs.hole: 20 in, Groundwater Adjustment A.
Index Well# Reading Date: — Index Well level Adj,fhetor AdJ.Groundwater Level
PERCOLATION TEST bate -5-3-100 inure. it AN
Observation
Hole# i - Time at 9" f/'3 S A)l
11
Depth of Perc 30 n y 8 Time at 6" 1 I
Start Pre-soak Time @ 1l: f 1 q _ Time(9"-6") �' (�15
' 32R tl
End Pre-soak 1 I
Rate Minibch
Site Suitability Assessment: Site Passed Y e-s Site Failed: "— Additional Testing Needed(Y/N) N U
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the. .
Barnstable Conservation Division at least one (1) week prior to beginning.
Q:\SEPTICIPERCFORM.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.
Consistency, ravel
/f7Yr3/2 -
o^30 -
30"120 C NS 2,rY114
DEEP OBSERVATION HOLE LOG Hole# 2-
Depth from Soil Horizon Soil Texture Soil Color Soil Other.
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
Fm
g-!a A-le LS /vYr 3/2
10 "30 13 �S /U�•�G
30-lug G h S 2,.5Y�A,
DEEP OBSERVATION HOLE LOG Hole#
Depth from . Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) .(USDA) (Munsell) Mottling (Structure,Stones,Boulders..
Consistency.%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consi ten
Flood Insurance Rate Map:
Above 500 year flood boundary No— Yes ._.
Within 500 year boundary No f Yes
Within 100 year flood boundary No,- Yes ,
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious in exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material? -
Certification
I certify that on 16-Z- "Y.9 (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 erience described in 3 10 CMR 15.017.
I.
Signature Date 5
Q:\SEPTICIPERCFORM.DOC .
Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: 11� I���,�z� I A-t�:)cA
BUSINESS LOCATION: iM � D2(co LINVENTORY
MAILING ADDRESS: S A AA t;- TOTAL AMOUNT:
TELEPHONE NUMBERI-505i. :2-7 B' 3 l 0 I
CONTACT PERSON: L-
EMERGENCY CONTACT TELEPHONE NUMBER: 0ftrkS46, i'✓I�+�► e-mil �87?MM15DS ON SITE?
TYPE OF BUSINESS: JL 9 rV SCPArQS
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous.waste:
Name of Hauler• Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes I or2- Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor &furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TOWN OF BARNSTABLE
LOCATION P 10 �'aw ct Lc.nA SEWAGE# ZO W — I-1 Z�,
VILLAGE \Au ✓tn S ASSESSOR'S MAP&PARCEL 9w - 13 y
INSTALLER'S NAME&PHONE NO. (T��� �'na,yndl SP 1 �/Zd3 (10af
SEPTIC TANK CAPACITY \00 O AA 1 U C v t5ki L l
LEACHING FACILITY:(type) \i20 3(o%to (size) (a) 3 Y (4 O
NO.OF BEDROOMS �F
OWNER
PERMIT DATE: .(o ' l S Zo l L, COMPLIANCE DATE: - Z U— 'Za t c-,
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility c) // Feet
Private Water Supply Well and Leaching Facility Of 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 eA 'k P1A0
r?J-e4 L LG
3> 3�
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No. CJ / Fee �v
THE COMMONWEALTH OF MASSACHUSETTS ' Entered in computer:
PUBLIC HeALTFI DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpfitation for Zisposal Opsteta (Construction Permit
Application for a Permit to Construct( ) Repair) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 24,0 c i'`�k C. Owner's Name,Address,and Tel.No. `
V/-��
Assessor's Map/Parcel 27 0 13y s
Installer's Name,Address,and el.No.Cp,g.;L(, �2/�i�l� Designer's Nanje,Address,.and Tel.No. �
4-7 04-
Type of Building: 2
Dwelling No.of Bedrooms l Lot Size 7 ��� sq.ft. Garbage Grinder( )
Other Type of Building q, No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date �_1 Number of sheets Revision Date
Title
Size of Septic Tank 0 Type of S.A.S.jZ) S S (r vt.(1 t,
Description of Soil See_ j2 Yih 30
Nature of Repairs or Alterations(Answer when applicable) •(1 l too !jKk 5c.0AL 7-)t l
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 b this Board of H It.
Sign Date (_1
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued ,
,
No. /CJ / x Fee / v /�"
THE`COMIVISIOMONWEALTH OF MASSACHUSETTS Entered in computer. Yes
PUBLIC HEALTT4 DN -TOWN OF BARNSTABLE,�MASSACHUSETTS
Rpplication for MispoBal 6pstem Construction Vrrmit
Application for a Permit to Construct( ) RepairV/) Upgrade( ) Abandon( .)a"❑Complete System ❑Individual Components
Location Address or Lot No. `_L0 Owner's Name,Address,and Tel.No.
Assessor'sMap/Parcel 'Z-70[(-3y
Installer's Name,Address,and Tel.No.ea!p.,,G(s �tJ�',r� Designer's Name,Address,and Tel.No.T
Type of Building: f_
Dwelling No.of Bedrooms �I Lot Size 13 10� sq.ft. Garbage Grinder( )
Other Type of Building j z CYY-r-, i No.of Persons Showers( ) Cafeteria( )
k
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan , Date Number of sheets ( Revision Date
Title 21O rr
Size of Septic Tank (D00 i51 Type of S.A.S. Z� S o yt,+t C.h<,
Description of Soil �J�i'p � �r P ?jo"
Nature
^of Repairs
,ror Alterations(Answer when applicable) L� ( a�—��_ /�t1�p �it�t /:)-,PA / Yi:5-/�
5 r
Date last inspected: / C o
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 H th.
Signe Date (- )t 3 Z-a' 0
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. '"` � - Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
CPrtifiratr of Compliancr
THIS IS TO CERTIFY,that the On-site S wage Disposal system Constructed( ) Repaired( ,) Upgraded( )
Abandoned( )by <—
at S I(D fk�,r_,e_kr� ` has been constructed in accordance
. h A/ 1/
with the provisions of Title 5 and the for Disposal System Construction Permit N cP—dated CG /1
Installer,) ul.P Q9 r l Designer .a C✓t t 1rL.�y-�.
#bedrooms l f Approved design flow gpd
The issuance of t is permit shall not be construed as a guarantee that the system will-f mot ry as designed��
Date
a 't .�y rr) Inspector.i.L.-• ' .�1 �' ,C. •�
-----------.---- - -------—---------- ----
No.r1(/ --- Fee /
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pBtem Construction VPrmit
Permission is hereby granted to Construct( ) Repair Y. Upgrade( ) Abandon( )
System located at
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 t erm t.
Date ( )! !.� f V Approved by
a
Town of Barnstable
Regulatory Services
ot
Thomas F.Geller, Director
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Officer 508-862-4644 Fax: 50S-74( •n+i;,.
Date: 2 7 1 Sewage Permit# Z 010- 11 Z Assessor's Map/I'areel ?'70/ (.;
Installer & Design.er.Gertification Form
Designer: ,�(; E 5L( ee(oc) , 'S'nc� Installer• pCL1eewicl �rtEer�cC�ea
Address: 11154 Cccx,berr Ik �r�w�, ^� Address: [ 0 %V- 1(-3
ea%k Wate.\nawl { A�_Ola3�`__ G2�v��ear ✓��t� tM�'
On,(v'��j2.o do c.Qc_ was issued a permit to install a
(date) (installer)
septic system at 2, 1 0 Fo C e}t e. based on a design drawn by
(✓n51��ce.ccr,�, dated May 12, 2 C' 1 0
(designer) —�
�•� I certify that the septic system referenced above was installed substantially according to
the design, which may include miner approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the sails
were found satisfactory.
l certify that the septic system referenced above was installed with major changes (i.c.
greater than I W lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State& Focal Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if required) cted and the Sails
were found satisfactory.
JOHN L.
J CHURCHILL
(inst er'sSignature ;�;L
Stec
estgner s Signature (Affix De gn Were)
P ASE RETURN TU` ARNSTABLE, PUBLIC H, 'AL D,IVV151d�I„ CER11FIC:ATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BO'Ud THTS 1NORIVI� D AS
BUILT CARD ARE RECEIVED BY'jgE, BARNST BLE PUP.LIC HFEALTH DIVISION.
THANK YOU.
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to-operate.) Business Certificates areavailable at the Town Clerk's Office, 1 FL., 367
Main Street;;Hyannis, MA 02601 (Town Hall)
DATE:17K, 6 C� Fill in please'
APPLICANT'S YOUR NAME/S &11, x �,_fo r /Z
« � y BUSINESS YOUR HOME ADDRESS: /� W e'er S
TELEPHONE # Home Telephone Number 50
NAME OF CORPORATION:
NAME OF NEW BUSINESS TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? � - YES' NO
ADDRESS OF BUSINESS l CJ 6a /IAP/PARCEL NUMBER " (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you,in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature** .
COMMENTS:
2. BOARD OF HEALTH t
This individual orm�the�it requirements that pertain to this type of business. MUST COMPLY WITH ALL
HAZARDOUS MATERIALS REGULATION';
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has beg in orm f, h li n in requirements that pertain to this type of business.
1 � X ,
Authorized Signature
COMMENTS:
01
TOWN OF BARNSTABLE Date:S /�( /
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: O arl C.�u 1 OeavijnOk
BUSINESS LOCATION: INVENTORY
i MAILING ADDRESS: d TOTAL AMOUNT:
TELEPHONE NUMBER: 5& t'oD . 1-75
CONTACT PERSON: 00-rf a y7a r I(,0a 1
EMERGENCY CONTACT T EPHONENUMBER: MSDS ON SITE?
TYPE OF BUSINESS: 10kgI V1 d 0
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous.waste:
Name of Hauler• Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the.General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
UST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor& furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers 11,W N ni
(including bleach)
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS..ON-SITE INVENTORY
NAME OF BUSINESS: w1dy
BUSINESS LOCATION:G10 F W 04f L 1 -� yo0V1I iVV INVENTORY
MAILING ADDRESS: �<� TOTAL AMOUNT:
TELEPHONE NUMBER: 5�� !�d -75 G
CONTACT PERSON: l(/ �(( �
EMERGENCY CONTACT TELEPHONE NUMBER' MSDS ON SITE?
TYPE OF BUSINESS: Vh 1j n
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous_waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes _ Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW. ,USED. Any other products with "poison".labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables `'�""hydfo-Ndric acid;other acids)
Floor & furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous(please list):
Laundry soil & stain removers
(including bleach) C Lc
Spet_re-movers &cleaning fluids ,
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash w.
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
i
r
f
1
COMMONWEALTH OF MASSACHUSI 'I"I'S
= j 'X E CUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
350 MAIN STREET D
WEST YARMotrrii,MA'
508-775-2800 (7"
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 210 FAWCETT LANE
f IYANNIS,MA 02601
Owner's Name: ALFREDO TAYLOR
O\NmerS Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Date of Inspection MAIZCH 23,2001
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street Mp►R
West Yarniouth,MA 02673 �NSj�,gt�E
Telephone Number: 508-775-2800 �pW HEPLgH pE�'
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 Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall Pubmit 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 now of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the
appropriate regional office of the DEP. Tile original should be sent to the system owner and copies sent tot
he buyer, if applicable,and the approving authority..
Notes and Comments
****"Phis report only describes conditions at the time of inspection and under the conditions of use at
that time. This inspection does not address how the system will perform in the future under the same
or different conditions of use.
Title 5 Inspection Form 6/1.5/2000 1 l
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
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:
B. System Conditionally Passes: N/A
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.
°O. 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 complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
C. Further Evaluation is Required by the Board of Health: N/A
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(l)(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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
** This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
I
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
D. System Failure Criteria applicable to all systems: N/A
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 pit 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
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow 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
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 H 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 is 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.
e
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
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)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(3xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 440
Number of current residents: 4
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): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 1999 475 CU.FT./2000 636 CU.FT
Sump pump(yes or no) NO
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CUR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 1995 BARNSTABLE PLANT
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
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 copy of the DEP approval
o Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 16"
Material of construction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 6"
Distance from top of sludge to the bottom of outlet tee or baffle: 13"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
TANK AT WORKING LEVEL.TANK AND COVERS 16"BELOW GRADE. OUTLET TEE,TANK NEEDS TO
BE PUMPED.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (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",20"BELOW GRADE.BOX IS SOLID AND LEVEL.ONE LINE IN,ONE LINE OUT.
locate on site plan)
PUMP CHAMBER: N/A ( P )
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
4
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
SOIL ABSORPTION SYSTEM(SAS)' X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER 27"BELOW GRADE. 3'6"WATER IN PIT.NO
HIGHER STAIN LINE.
CESSPOOLS' N/A (cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contnmed)
Property Address: 210 FAWCETT LANE
I-IYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
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.
V
a�
Title 5 Inspection Form 6/1.5/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 210 FAWCETT LANE
HYANNIS,MA 02601
Owner: TAYLOR,ALFREDO
Date of Inspection: MARCH 23,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 25.1 feet
e
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:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA: WELL AIW 230 AT 25.F
Title 5 Inspection Form 6/15/2000 11
OWN OF BARNSTABLE
LOCATION 4/d SEWAGE # q f- 3
r VILLAGE F/�Z a Hy/5 ASSESSOR'S MAP & LOT
INSTALLER'S.NAME & PRONE NO. A & B Q2 775-6264
SBPTIC,TANK;CAPA�CITY /cv® �sr
LEACHING FACILITY*ype)_,er-/- (size) 1000ac
NO. OF BEDROOMS PRIVATE WELT, OR PUBLIC WATER
BUILDER OR OWNERSQ0Je
DATE PERMIT ISSUED: '` Sr
DATE COMPLIANCE ISSUED: C�
VARIANCE GRANTED: Yes No '
I_
.�,�,
'�)J
4J
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s
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6y.,�\
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F No.. '�� �s....%ZC?.:..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.....i..e yl.............OF...... o,,.; . . L......-------•-•----------------------...................
AVp iration for RsVosal Works Tonstrurtion"T mit
Application is hereby made for a Permit to Construct ( ) or Repair (-4,1) an Individual Sewage Disposal
System at:
..9.... �'e... Ce.�,..o e..,... .2tn_`_a...............................
Location. ddress or Lot No..
rn ......... a�a '�w f�� n.. -------------------------I.........._.
Owner f Address
WJrC� Ll/11 �T
......................................... ................................
Q3t.w_
Installer Addr
Type of Building Size Lot............................Sq. feet
.. Dwelling=No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder
Other—TBuilding
( )
e� Other—Type of Buildiil g ............................ No. of persons..._.____....___._._..._.... Showers ( ) — Cafeteria ( )
d Other fixtures ...................•----._._.............................
-------•-••.....................•---.............._...-------•.._......
W Design Flow............................................gallons. per person per day. Total daily flow_._........................................_gallons.
xSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth_...............
Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area........._........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
�+ Percolation Test Results Performed by.......................................................................... Date........................................
a -
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
frq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ .---••••-•--------------•-•------••••--•--•-••••-•--------•-•-----•---•••......------.._..--•-----•-....................................
.....
-....
-----.--•--
0 Description of Soil........................................................................................................................................................................
U ••••--••-•-•••---•---------------••--•----•--•--•-------------------'-••-------------------••------•------•--------•••------------•----------------•-•--•---••--•-•---•---------...--•--•-•---•---•--•--
W
x -••--•-•-•-•-------------------------•-------------------------------------------------•--------------------------------------------------------------- - ----- -------.----------
U Na Lure of Repairs or Alterations—Answer when applicable._:T ...l�_CCa_ _�4�A�W_``��:�..�......
---t- 1rj--------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
-- Signed. ....................................... fit:_ `j..............
Date
Application Approved By..................
. /I-- s-J? ._..
Date
Application Disapproved for the following reasons:_....-•------------------------------------------------•------..._______._........_..___.. ...._........._.....
...............................•----------------•-•-••---•--•---•----------------•-•----••----------•-•-------••••--•••------------•---••---•---------•-----------------•-•--•------•-•----•-•---•-•.---
�j Date
PermitNo.-- '� -----------•----•--- Issued-.......................................................
Date
f
Fxs....::�.��._.....
...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
,
f c:... OF, r... `+ ,
J
Appliration for Disposal Works Tonstrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (-iQ an Individual Sewage Disposal
System at:
Location-Address _ y1 i' or,Lot No.
IJC:S. . if--.ri: -�•-� �_t:.c,
.........:....`fr- •Owner.... ........ ...,...... .........................{ (y----/•'Address ...------•--•-•........................••-
W tl , l ti� )
. i :t..
................................................................................................. ...T...............................................`............................................
a Installer t� Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'04 4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
a' Other fixtures ................................. .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth____-__---__-_--
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(L4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 •---•-•--------------•----•---•--••-----•-•----•-•-•----•-•--------------------•---.........................................................................
0 Description of Soil........................................................................................................................................................................
x
V .............................................................-....................t......................................................................................................................
W
-------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- ----•-
U Nature of Repairs or Alterations—Answer when applicable__--_-:_-_'`:_`_ i --+ .................% �� cr� L)
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TTTLE� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed. - (rI
1 - Da
Application Approved By-•••--•-•--•. ( ..................... // �"
Date
Application Disapproved for the following reasons-----------------------------------------•---- ............................................................
.......................................................•-------•-----•---••-•--•----------•-•----•--•----•••--••-----•--------•----••••----••----•••••--•-•----••--•---------------•••--••-•--•--•.....
Date
PermitNo....0..�..... .................................. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
;�
OpIntifirtt#.t of Tompliatta
THIS IS TO,.CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired O
Inst,�ller
at............� -Q•---...F -------....----- ` 'Ec ,z ------------------------------------------------------------•---------------
has been installed in accordance with the provisions of "' 5 of e State Sanitary Code as described in the
application for Disposal Works Construction Permit No._-_.YJ _3)_XS -._- dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU TION ATISFACTORY.
DATE........ 4 ....-••...............•.. Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�( 9NotJ �r� � =—w`-,;r���'- alc;-..................................................... FEE...-•---.................
Disposal Workii 0nnitr inn rrnti#
Permission is hereby granted.......... 1._.- .=?-.--_ _1 ..........................
to Construct ( or Rrair ( ,�_axl�Individual Sewage Disposal System
atNo. ••-•...........................................•... x�. _�-._-.----........---------...
Street
as shown on the application for Disposal Works Construction Permit.No_ -___._ �Dated
-----------------------------------------
................................ -'....................................................
r/ �../
DATE..............R.... ...................................... Board of Health
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
TOWN OF BARNSTABLE
LOCATION to c cTl SEWAGE #
VILLAGE Y ASSESSOR'S MAP & LOT
j a
S NAME 6z PHONE NO. A & B CANCO 775-6264
-SEPTIC TANK CAPACITY /A,,S,P f c 7/—,.v
LEACHING FACILITY:(type) (sue) .
NO.-OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNE LFiE'£ Ole
DATE D: 3 a
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
• 3
i
i
s• '
0
TOWN OF BARNSTABLE
LOCATION s�/C0_ SEWAGE#
70
VILLAGE iS ASSESU.?
'S MAP&LOT�G,O�Q
cKS90 ME _ /` a NA &PHONE NO. U -��
SEPTIC TANK CAPACITY/OOO Gb/ � � �lSpZOX
LEACHING FACILITY: (type) (size) 1060 /V•
NO.OF BEDR
BUII.ISER•0 OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: /
• Maximum Adjusted GroundwateF Table and Bottom of Leaching Facility f Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 206 feet o eaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of ea chin cili ) Feet
Furnished by /P j
00� _.off/i
o04 '
0
OWN OF BARNSTABLE
LOCATION /� ` L� SE WAGE #
VILLAGE . 6/ a a N t S ASSESSOR'S MAP 6i LOT
jNSTA XER'4 NAME Cz PHONE NO. A & B CANCO 775-6264
"=—t-VA CAPACITY /C?-'10 Clle
LE,�C TG F�9�,CILITY:(type) _ (size) /000 0-4.
NO, OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNERSZAVC c4r
DATE PERMIT ISSUED: - t'
DATE COMPLIANC ISSUED: =� .C� 'dp;
VARIANCE GRANTED: Yes No
I
TOWN OF BARNSTABLE
LOCATION �' /�� ei: 2,1 /i C SEWAGE #
VILLAGE iS AS70
SESSM
MAP&LOTT c.0�_D
71YS 9OR' Ica
p/� �•�NAME&PHONE NO. /` `,TL70 �y To�CO
SEPTIC TANK CAPACITY/OOO col a.Sat ' OY,
LEACHING FACILITY: (type) i (size) /O�C���S'
NO.OF BEDR
BUILDER O OWNER '
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 leachincili, ) /� Feet
Furnished by lP
o
_ >
� . Q
�.
�.
� w
r , ,TOWN OF BARNSTABLE _
LOCATION v� ��vSl SEWAGE # f/Z� ��
VILLAGE ASSESSOR'S dMAP &1L30'P L-7 1
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY (coo
LEACHING FACELITY: (type.) _ (size)
NO. OF BEDROOMS ( j x.((0 4. ,nod'14
1
BUILDER OR OWNER �.
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
•c>or c� Qy t ns c.�a� n �a �
ate'6�-� -- � ..,r�;•�
A
s*
�h
T.O.F. EL.= 46.5�± PROVIDE EXTENSION RISER FINISH GRADE OVER D-BOX= 44.0'+- GENERAL
WITH COVER OVER INLET& 4"SCHEDULE 40 PVC MIN. SLOPE 1% FINISHED GRADE OVER BIODIFFUSERS= 44,0' - 45,4.'
OUTLET TO WITHIN 6"OF F.G. SLOPE @ 2% MIN. 1. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
INSPECTION PORT WITH ACCESS BOX TO METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL
FINISH GRADE t REMOVABLE WATER-TIGHT COVER OVER WITHIN 3"OF F.G. (ONE PER TRENCH)
@ FND. EL.= 44'•7± FINISHED GRADE OVER TANK EL. = 4.4.,j± RISER TO WITHIN 6"OF FINISHED GRADE
CODE AND ANY APPLICABLE LOCAL RULES.
2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER.
EXISTING 4" _
PROPOSED 4" 4"TEE 9„MIN• 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL
OUTLET PIPE PVC SEWER PIPE 36 MAX "DIA. OUTLET(S) SEE 61 MAX.21 TOP OF SAS/B.O. = 40,33'
SYSTEM UNLESS OTHERWISE NOTED.
"
.� 6" 3" 3 DROP MAX 3° 9„ �+ PROVIDE WATERTIGHT (L�1 ,18 ) 4. TO PREVENT BREAKOUT,THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
------.-.-.--- 2"DROP MIN nn1N.s�OPE @ 1% �- - $- JOINTS(TYP.) ELEVATION =41.18' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A
10" _ E4"PVC IN FROM CLEAN SAND 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF
" * ' EPTIC TANK 4"PVC OUT TO 1.33' THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION.
14 41 . ± nliTYP
6 TYP
O LEACHING FACILITY 0.90, (TYP-) 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM.
(41 .95 ) 12" s"
CONTRACTOR SHALL CONTRACTOR SHALL 41 ,2Q' MIN. 41 ,Q3' (4O.8rj') I 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL.
VERIFY SIZE AND 48" VERIFY CONDITION OF OUTLET TEE 39,9Q' 39.00' (LAID FLAT) (39.85') 2.875'(34.5")--+------5.75'� 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK
CONDITION OF EXIST. EXISTING TEES (41 .071) 6"CRUSHED STONE (T�'P) FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS
SEPTIC TANK AND REPLACE AS GAS BAFFLE OVER MECHANICALLY (40.75 ) 5.0
NECESSARY COMPACTED BASE (TYP.) 4'MIN. 11.50' NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH
AND DESIGN ENGINEER.
5 OUTLET DISTRIBUTION BOX 40.0'(TYP FOR BOTH TRENCHES) 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 44.00'ESTABLISHED
TO BE INSTALLED ON A LEVEL STABLE ON A NAIL SET IN PAVEMENT AS SHOWN ON PLAN.
BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV= < 33.30' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
EXISTING 1,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT
CROSS SECTION VIEW BIODIFFUSER (PROFILE) BIODIFFUSER (END VIEW) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES
SEPTIC TA PROFILE 1 C 36HC 6BIODIFFUSERS - ® TO THE DESIGN ENGINEER.
*CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR DISTRIBUTION O TAIL ( �.7 ) ( } 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC.STRUCTURES SHALL BE MADE WATERTIGHT.
TO ANY WORK & NOTIFY ENGINEER IF DIFFERENT. "` NOT TO SCALE NOT TO SCALE NOT TO SCALE
ffi �C � I 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING
AS-BUILT SWING-TIES C DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM
r
r z :
HG1 HG2 " ` PERC NO. 12909 APPROPRIATE AUTHORITY.
DESCRIPTION w, x�r �r
► INSPECTOR: David W.Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
SEPTIC COVER OUT(1) 22.7' 17.4' • + f ` "w EVALUATOR: Michael Pimentel E.I.T. LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
re THEY SHALL WITHSTAND H-20 LOADING.
DISTRIBUTION BOX(2) 26.2' 23.0' C.S.E.APPROVAL DATE: Oct.27, 1999
`� 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES.
/ INSPECTION PORT(3) 61.3' 54.5' z r MO
DATE: May 3,201E
y � . . ' TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE
MAP 270 INSPECTION PORT(4) 59.5' 57.7' �, , , .. ;: ,� = MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY.
+� Y +► $ r ELEV TOP 43.3E
PARCEL 133 REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY,
* �33.3E FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3).
ELEV WATER= '
Wi-
w», " 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
ZONE 2( PERC RATE= 2 min./inch
SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
Benchmark#1 x'h n_ S77°4T2p" � ,� ,"" �� , .. �� DEPTH OF PERC= 30"-48" 16. PROPOSED PROJECT IS LOCATED WITHIN:
Nail Set in Pavem't4 _ _
Elev. =44.00' 6 ��- �" - TEXTURAL CLASS: 1 ASSESSOR'S MAP 270 PARCEL 134
Approx. M.S.L. X X-X X II Env
X " � x OWNER OF RECORD: LEONARDO R. &DARKYS MARICHAL
x-x-x_XENCEc1NE LOCUS 3
X-X- ,��� ADDRESS: 210 FAWCETT LANE
/ MAP 270 X X X-X-X-X-X- � k. 0" 43.30' HYANNIS,MA 02601
X r 3 Fill
PARCEL 134 PATIp �X X-X-X 8" Loamy Sand 42.63'
t 13,668 S.F. k �'
�. 7 �� �
s �- x.
" 1 0"A/ 10Yr 3/2 42,47 FEMA FLOOD ZONE C
1
B Loamy Sand
COMMUNITY PANEL# 250001 0005 C
S
a / . 10Yr 5/8 17. DEED REFERENCE: LAND COURT CERTIFICATE 161340
N ty k r r sm 4p ,
lam► W l BIT x N , 30 .� 40.8E 18 PLAN REFERENCE: LAND COURT PLAN NO.22825-P
H. QRIVE r Perc -
/ /� / !f,
LU x o Z 39.30' 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
V o Tn ! to N Z r r
f �
q yF r 04 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY
CO
Medium Sand FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANYLIABILITY
`r•., ` SL,�A ' % o • C 2.5Y 6/6 FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURP6S9.
m p o (5-10%gravel)
a ` � ► ` 21. IN ACCORDANCE WITH 310 CMR 15.401 -15.405,THE FOLLOWING LOCAL UPGRADE
APPROVAL WAS REQUESTED FROM 310 CMR 15.221 (7):
j (1.) A 2.07'WAIVER(3.0-5.07')FOR THE MAXIMUM COVER OVER THE LEACHING FACILITY.
i x US L C PLAN
z � ,� O
U ~ k SCALE: 1"= 1000'
W 120" 33.30'
/ W x Benchmark#2
cl, to - ' / Stake and Tack No Mottling, Standing or Weeping Observed
/ M o
' HC-2 Elev. =44.83
Approx. M.S.L. TEST I T DATA
A
LEGEND
W
#210 PERC NO. 12909
EXISTING
-_ x INSPECTOR: David W.�Stanton, R.S.
P 50x0 EXISTING SPOT GRADE
4-BEDROOM � �
DWELLING / NUMBER OF BEDROOMS(DESIGN) 4 - -
\ k � _ EVALUATOR: Michael Pimentel, E.I.T.
TOF =46.5'± C,o �Q o �
0) 10 DESIGN FLOW GAUDAY/BEDROOM C.S.E.APPROVAL DATE: Oct.
^ TOTAL DESIGN FLOW 440 GAUDAY
iH t�' W cU l / DATE: May 3, 2010 27, 1999 50 5b ` - EXISTING CONTOUR
PROPOSED CONTOUR
W Q 0 ' x co DESIGN FLOW X 200 % = 880 GAUDAY
\ / AS_BUILT TOTAL 16 ARC 36HC TEST PIT#: 2 ❑/H/W EXISTING OVERHEAD UTILITIES
GAS giy�I✓ V W 2 / 2) / k H-20 BIODIFFUSERS (8
TP 2\ USE EXISTING 1,00E GALLON SEPTIC TANK
J 44.0' \ BIODIFFUSERS EACH TRENCH) ELEV TOP= 44.00' TELE EXISTING TELEPHONE UTILITY
/ I G1S\ to / 1) y� 1 /I GAS ELEV WATER= <34.00' W W EXISTING WATER LINE
GAS HCA ,��� 0.0f ' PERC RATE= GAS EXISTING GAS LINE
INSTALL 16 -ARC 36HC (#3616BD) BIODIFFUSERS (H-20) DEPTH OF PERC= TEST PIT LOCATION
I � � TP 1 r� /
STONE 4 T QS 3 95 2' J SYSTEM CAPACITY TEXTURAL CLASS: 1 EXISTING 1,00E GALLON SEPTIC TANK
TELE\-' \ F "AS-BUILT" INSPECTION PORT WITH (TOTAL L.F.OF BIODIFFUSERS)(7.8 SF/LF)(0.74 GPD/SQ.FT.)= GPD "AS-BUILT"4"SOLID SCHEDULE 40 PVC PIPE
/ TELE - �44` i / ACCESS BOX TO GRADE (TYP OF 2) (80.0')(7.8 SF/LF)(0.74 GAUSQ.FT.)= 461.8 GAL. LEACHING/DAY " O Fill 44.00' "
43.33' AS-BUILT"DISTRIBUTION 80X
8 Loamy Sand TOTALS: A/�" 10Yr 3/2 43.17` U -AS-BUILT-
ARC 36HC'(#3616BD)$IODIFFUSER(H-20)
/ , y TOTAL NUMBER OF BIODIFFUSERS: 16 B Loamy Sand (96.87') ACTUAL ELEVATION"AS-BUILT"
TOTAL NUMBER OF COUPLINGS: 0 10Yr 5/8
\ EXISTING 1,000 GALLON SEPTIC TANK TO S77°48'20" a >c Q' 4 TOTAL LEACHING AREA: 624.0 SQ.FT. 30" 41.60'
BY
E N l Lu - TOTAL LEACHING CAPACITY: 461.8 GAL./DAY Rom• DATE APPD. DESCRIPTION
�E UTILIZED AS PART OF THIS DESIGN 139•04, ,_ "AS-BUILT" SEPTIC SYSTEM
x
ti
"AS-BUILT" DISTRIBUTION BOX
PREPARED FOR:
NOTE: ING AREA OF 7.80 SF/LF OBTAINED FROM THE c 2.5Y 6/6 Medium SandEFFECT CAPEWIDE ENTERPRISES
MAP 270 ! DEPARTMENT VE LEAC OFHENVIRONMENTAL PROTECTION APPROVAL LETTER (5-10%gravel)
PARCEL 135 X-,X` "MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO LOCATED AT
NOTES: ADVANCED DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003(LAST 210 FAWCETT LANE
MODIFIED FEBRUARY 18,2010). TRANSMITTAL NUMBER=W000052. HYANNIS, MA 02601
1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP k''k
EDGE OF EACH SEPTIC SYSTEM COMPONENT, 120" 34.00' SCALE: 1 INCH = 10 FT. DATE: SEPTEMBER 27,201E
0 5 10 20 - 40 FEET
No Mottling, Standing or Weeping Observed i�OF MASS
2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION �Za`�� AcGr PREPARED BY:
NNOW
OF THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY RESERVED FOR BOARD OF HEALTH usE � �o" '
WITH TEST PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER 11 11 o cvWR ►i_�.: R• P- JC ENGINEERING, INC.
AS-BUILT "'� 7 2854 CRANBERRY HIGHWAY
AND LOCAL BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH N .41807
TEST PIT DATA. A��F GIs r EAST WAREHAM, MA 02538
P APPROVED z 2. I SITE PLAN PLAN D ' N 5os.273.0377
3.) ENTIRE PROPERTY IS LOCATED WITHIN A DEONE SCALE: 1"= 10' Drawn By: MCP Designed By:MCP Checked By:JLC JOB No.1817