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HomeMy WebLinkAbout0078 FERNWOOD AVENUE - Health 78 FERNWOOD AVE., HYANNIS A= 'I No. �(Gt Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Nplitation for Misposal 6p8tem Cunstruttion permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(k ❑Complete System ❑Individual Components Location Address or Lot No. fCp4jLLb b A VE Owner's Name,Address,and Tel.No. T"` P Assessor's Map/Parcel 2� g N�1��t`l l� 'l$ F��12 A-L1 t-0/6W t Installer's Name,Address,and Tel.No. Mpg—t f�Z��g�7 Designer's Name,Address,and Tel.No. Gi�i:C o� E 711C�2�S€S ��t�.t tkSl�P NIA Type of Building: /Dwelling No.of Bedrooms 1" Lot Size 13I !p, ..39-sq.ft. Garbage Grinder( ) Other Type of Building [� 1�#-�_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures IV A Design Flow(min.required) tT- gpd Design flow provided N 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) 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. Signed on Date 3 Application Approved by I Q> Date Application Disapproved by Date for the following reasons Permit No. ;tot y—691 Date Issued 3" 2 S— 1 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes , PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 4 Zipplication for disposal 6pstrut Construction Permit ' Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon)� 0 Complete System ❑Individual Components Location Address or Lot No. 7 S 56P�Q-bOD A V E Owner's Name,Address,and Tel.No. H ow.A-S PeKAe, Assessors Map/Parcel Q 2 9 1 D $ 7 9 FE'Wvk_-,00T;> A-U E 4\ANlv IS Installer's Name,Address,and Tel.No. 50ja_ tjj_2$,'7 Designer's Name,Address,and Tel.No. dApe crDS 61yT_ 5 KPk1. ILLC SH P NIA. Type of Building: Dwelling No.of Bedrooms /" Lot Size g 3 sq.ft. Garbage Grinder( ) Other Type of Building g�( 1Tl A-( - No.of Persons Showers( ) Cafeteria( ) Other Fixtures A IT- Design Flow(min.required) gpd Design flow provided Al 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) X,/(Sr 'tra 5`/S:ZX_ 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 r Compliance has been issued by this Board of Health. _ Signed Date Application Approved by Date `T Application Disapproved by Date i for the following reasons Permit No d2ot q —691 Date Issued 3' ' 5- fLf ---------------- =- - -- - _ _ - - - _- -- - - -- -THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO�CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded ( ( ) Abandoned(X)by _1 ADE( �� CIy 5P a (S� 4.4-Q- at 79 Fc-R0000b A-U E HAW)(s has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.o?0(H-091 dated 3 ''�Z S_ / C[ InstallereApulk)(DE Designer NJIA #bedrooms Approved design flow -; gpd s The issuance of this permit shall+not�b`e construed as a guarantee that the system will func tion as designed. Date . Inspector pector ,l. L l_ / ��� r4 •T,> f e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X) System located at 17!A 1=Ek10Wc<JN Auk t:6 i 1J4t C and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit.1___/ — Date �7 J - Lr Approved by v I a fi Public-Health Division_._ _ -_ . _ ._.._ _. _-- __ March March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need aiigi grinder pump for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.ma.us/cdb.a (under the"CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.bamstable.ma.us/PublicWorksTech/sewerinstallers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis—contractors,please call Dave Anderson at (508) 790-6244. F_.OR ANY..Q_UESTIONS./ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connecAUtters Stewart Creek Sewer Connects\MAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc Im Town of Barnstable Barnstable Regulatory Services Department jaicafty s 4xrrsrs I a)n Street, Hyannis MA vision 200 M MA 02601 2007 m _ � a Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -1360 March 28, 2013 THOMAS PECK 78 FERNWOOD AVE IMPORTANT NOTICE HYANNIS, MA 02601 Map & Parcel: 289- 098 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 78 Fernwood Avenue, Hyannis,MA, to public sewer on or before 4/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF TH BOARD OF HEALTH Thomas cKean, R.S., C.H.O. _ Agent of the_Board.of Health_.. Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MA1LING L.etA Sewer 2Pgs Merged 3-28-13 Yr2015.doc DATE: . 2/17/00 PROPERTY ADDRESS: 7$_ Fernwood—Ave -��----------- --- 02601---------------- above date I Inspected the septic stem at the abode address. On the ab e p p Y This system consists of the following: 1 . 1-1000 gallon septic tank . 2 . 1—Distribution box . 3 . 1-1000 gallon precast leaching pit . Based on my Inspectlon, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code ) 5 . The septic system is in proper working order at the present time . , 6 . Pumped septic tank at time of inspection . 7 . Waste water is 59" below the invert pipe to the leaching pit . SIGNATURE:- Name:_,Z��11.ossake-r ,,Lr ------ Company: Joseeh_P;, Macomber & Son, Inc. Address:_ Box_66__ CentervilleL Ma- -02-._ 632-0066 ---------- -- - Phone: 508 775_3338_______ do THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MA COMBER & SON, INC. ` Tanks•Cesspools•LeichfIsIds Pumped & Instilled Town Sewer Connectlons P.O. box 66 Centerville, MA 02632-0066 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS y 1Vj EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-6600 TRUDY CC Secret ARGEO PAUL CELLUCCI DAVM B. STRU Governor Comm; is SUBSURFACE SEWAGE DISPOSAL SYSTUA•WSPECTION FORM PART A CERTIFICATION Pr,pwty Address:7 8 F e r n w o o d Ave Name of owner Thomas Peck Hyannis ,Mass . 02601 Address of Owner: Dieu of kupection: 2/17/0 0 ►lame of Inspector: (Ple-a Print) 1 o s P n h P_Ma r•o m b e r J r . I am a DEP approved syartsrn 4upector pursuant to Section 15.340 of Ttdo 6(310 CUR 15.000) corttparry Nam.: J. P.M a c o m b e r & S o n T n r _ UaarrgAddress: Box 66 f Pnrervill�., �ass. 92632 Telephorw Number: ;g g 7 7—.cr—�;3 8 — CFRWICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below is true, accurate and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal Iystems. The system: _Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails ��� �r M G� ,la%e*WK �, Data: �lLa�iV 44pector's::�The Systemall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)wwn thirty(30) days o completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspettor and the system ownr shall submit the report to the appropriate regional office of the Department cKnvironmentsd Protection. The original shouldt4,tent toVw system owner and copies tent to the buyer, If applicable, and the approving authority. . NOTES AND COMMENTS ti ' NA AR 6 2000 of B*jASj T0'"H ►V DEPT. LE ,v � . revised 9/2/98 Page IofII C0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION (condrwW) Property Address: 78 Fernwood Ave Hyannis ,Mass . Owner: Thomas Peck Diets of Inspection: 2/i 7/0 0 rispECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which Indicates that any of the failure conditions described in 310 CMR 1S.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: S. SYSTEM CONDITIONALLY PASSES: X,V One or more system components u described In the'Conditional Pass'section need to be replaced or repaired. The system,upon compJstion of the replacement or repair,as approved by the Board of Health,will pass. Indicste yes no, or not determined(Y. N, or NO). Describe basis of determination in all Instances. If 'not determined',explain why not. The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection; or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial Infiltration or exfiJtratlon, of tank failure is Imminent. The system will pass Inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. �d Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed plpe(s) or due to a broken, sanded or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(&)are replaced obstruction is removed distribution box Is levelled or replaced The system fsquired pumphiMore than•iourZfmes-a yeardue to broken or cbMcted pipe(s). The system w*psas-- Inspection If(with approval of the Board of Health): broken pips(s)are replaced obstruction is removed revised 9/2/98 Pset2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1� PART A CERTIFICATION(continued) Property Address: 78 Fernwood Ave Uyannis ,Mass . Owner: Thomas Peck Date of Inspection:2/1 7/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.YALL.PRQZECT THE PUBLIC HEALTH AND SAFETY AND THE EN=ONMENT: ,LPI Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water'supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance Al* (approximation not valid).- 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM IN SPECTION N FORM PART A CERTIFICATION(continued) Property Address: 78 Fernwood Ave Hyannis ,Mass . Owner: Thomas Peck Data of Inspection:2/17/0 0 D. SYSTEM FAILS: You ust indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No / Backup of towage into 4oci{ity"er-o"tom component-due%to an overkmded orcbggedSAS or-cesspool. 3— 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 he dis�utiort bo:�•,059 outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in�Is less than 66" 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—1. 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 withina Zone I of a public well. — X 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of s surface drinking water supply the system-irwitWn 200 feet of-a4411autery4o a surf60"Wbk4r►y-wa1W4UPPIY• --- _ _✓ the system is located In a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforpation. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 78 Fernwood Ave Hyannis ,Mass . Owrn.r: Thomas Peck Dot,of k-P—tl°"2/17/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: LAP g.p.d./bedro Number of bedrooms(�asl n Number of bedrooms(actual) Total DESIGN flow ;t �J Number of currant residents: Garbage grinder(yes or no):_ Laundry(sepwote system) LY-9s or�g:_ If yes, sapagatokupaction.requlred Laundry system Inspected 0y r no) Seasonal use(yes or no): Water meter readings,If av ble(last two year's usage(gpd): Sump Pump(yes or no): v � 1 Last date of occupancy:� � COMMERCIAL/WDUSTHLAL• Type of establishment: Design flow: ;i� ood ( Based on 16.203) Basis of design flow Grease trap present:(yes or no) industrial Waste Holding Tank present:(yes or no).,& Non•sonitary waste discharged to the Title 6 system:(yos or no):jr� _ Water meter readings,If available: Last date of occupancy:_ OTHER:(Describe) 1410 Last date of occupancy: ' GENERAL INFORMATION PUMPING RECFRD-S and source,ol.inform tion: System pumped as part of Inspection:(yes or no)-20 It yes,volume pumped: 41113d gallo a � J, Reason for pumping: ufH TYPE OF SYSTEM _Septic tank/distribution box/soil absorption system Single cesspool �jj Overflow cesspool Privy iL Shared system(yes or no) (if yes, attach previous Inspection records,If any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank U/Q Copy of DEP Approval Other /y APPROXIMATE AG&of all compwwnts, date Installed4d known)-and source of4ofermat(on: —^�^-1 1 t 2�f Sewage odors detected when arriving at the site:(yes or no) revised 9/2/98 Page 6of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:78 Fernwood Ave Hyannis ,Mass . owner: Thomas Peck Date of Inspection: 2/17/0 0 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the systemocompoiwtu wawbwrt praw►ped+fmatJeasi t+ivoaweelca aadtbe'aystem hasbaaovacaiaiwg VAMW liow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this Inspection. _ As 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. The system does not receive non-sanitary or Industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,JA/4xxcluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (15.302(3)(b)) _ The facility owner(and.occ11paaU,3f differwU from awner),ww&prmldad.wlth lnfarmatiomon the pcapar maintanane&0f SubSurface Disposal Systems. revised 9/2/98 Page 5orli i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION(continued) Property Address: 78 Fernwood Ave Hyannis ,Mass . Own*: Thomas Peck Date of 4spection: 2/1 7/0 0 BUILDING SEWER: (Locate on site plan) 1 Dept below grade, Material of construction: Cast Iron.3/40 PVC4R other(explain) Distance from?rivate water supply well or suction line 70 f Diameter 1P_ C mments: (condition of joints, venting,evidence of feakase,•otc.) - Joints appear tight . No evidence of leakage SEPTIC TANK !� (locate on site plan) A • Depth below grade- Material of construction: onerete meta( Fiberglass.✓d Polyethylene4&oter(expialn) If tank Is fnetal, list age-A�l 1s.age.confvmed by Certificate of Compliance IJ4(Yes/No) Dimensions: A>il W A If Sludge depth:- Distance from top of sludge to bottom of outlet tee or baffle. d Scum thickness:_ a Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outie tee or baffle: O How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles,depth of liquid level In relation to outlet invert, structuraHntegrity, evidence of leakage,etc.) Pump tank every 2-3 ypars _ Tn1Pt R nntlPt tees are i n n1 arp ThP --Ppti r seTti c task 'is structural —seti}s�� and- -Ahgws Re evidenee of GREASE TRAP: i- (locate on site plan) Depth below grade:A2 Material of construction W,4concretoA/4motal4�eFiberglass _Polyethylene_other(explain) Dimensions: k Scum thickness: Distance from top of scum to top of outlet tee or baffle:-AJ_ff Distance from bottom of squrn to bottom of outlet tee or baffle: Date of last pumping: /V Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural Integrity, evidence of leakage,etc.) Grease trap is not prpspnt revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Addro": 78 Fernwood Ave Hyannis ,Mass . Owe: Thomas Peck Date of Inspection: 2/17/00 TIGHT OR HOLDING TANK:N,wL (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:A/.4 Material of construction:A/Aconcrete jL)dmetaLfLFiberglass 4MPolyethylene.v.4other(explain) w)A Dimensions: 4A Capacity: A)4 gallons Design flow: Al gallons/day Alarm present Alarm level: Alarm in working order:Yes AlA No&/4 Date of previous pumping: A44 Comments: (condition of inlet tee, condition of alarm and float switches,etc.) T;�oht, or holding tanks. are_ not present'- DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) —Distribution box has one lateral . No evidence of solids carry over . Nn avi rianoa of 1 aakgga ipt() EIS Qut of th6 LQX PUMP CHAMBER:A.L)e, (locate on site plan) Pumps in working order:(Yes or"No) —i�/1 Alarms in working order(Yes or No) ,# Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) ump chamber is not present revised 9/2/98 Page8orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1, SYSTEM INFORMATION(continued) PmpertyAd&*": 78 Fernwood Ave Hyannis ,Mass . Owrw: Thomas Peck Dew of ir►sp.ction: 2/17/0 0 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan, if possible:excavation not required,location may be approximated by non4ntrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number: leeching galleries,number:_ leaching trenches,number, length: leaching fields, number,dim slons: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to boney sand to f; na sand - Nn g;_g` of h dyn1ji ; ,- ya; l pond; n-g . Sails are dr-y UasotatIOR 16 CESSPOOLS: ZOW (locate on site plan) �q Number and configuration: V Depth-top of liquid to inlet invert: _ Depth of solids layer: AIW Depth of scum layer: Dimenslotss of cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection) Cesspools are not nrecPnt _ Comments: (note condition of soil, signs of hydraulic failure,.level of ponding,condition of,vegetation, etc.) �•- esspoo s are not preGent _ PRIVY:16�41T- , (locate on site plan) Materjals of construction: Dimensions: Depth of solids:�� Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy is not present revised 9/2/98 Paee9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART C SYSTEM INFORMATION(con*wed) Property Address: 78 Fernwood Ave Hy.annis ,Mass . owner: Thomas Peck Date of 4"�: 2/1 7/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) O SOO revised 9/2/98 Page 10of11 4 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C t PART C SYSTEM INFORMATION(continued) Property Address: 78 Fernwood Ave Hyannis ,Mass . Owner: Thomas Peck Date of Inspection:2/17/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells 'l t Estimated Depth to Groundwater lb 0 Feet Please indicate all the methods used to determine High Groundwater Elevation: —JzObtained from Design Plans on record bserved.Site (Abutting property, bservation hole, basement sump etc.) determined from local conditions Checked with local Board of health Checked FEMA Maps _4Z,�hecked pumping records k4hecked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours Map . Gahrety & Miller Model 12/16/94 . Installed System. No water encountered at 14 ' I revised 9/2/98 Page 11of11 r+nr..-n t ram+-•.-r- rnrn+r nn+ns�erta�+ranart•.�•••++wn+n+s'mn nmstu n�rrsl u�+ rn-�-r-a-n-:......-.., � BOARD OF HEALTH '1'UHN UP Barnstable SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION T••t�T''.'::1—T./IT.�.�TT.TTf11'R.'fTITT1Cl1f R"RTI'�—.S'i TtlrR't 7A1'IR-"P•�RRAft 7 rm" ..J -TYPE OR PRINT CI.EARLY- PI?OPERTY INSPECTED STREET ADDRES$ 78 Fernwood Ave Hyannis Mass .ASSESSORS MAP, BLOCK AND PARCEL # &9N� OWNER' s NAME Thomas P.ed'k PART D - CERTIFICATION 1 NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J• P •Macomber & S@^K *Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Strevt Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 -3338 FAX ( 508 ) 790-1578 N CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate ) and omplete as of the time of .inspection - The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one ; System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failtire criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* \ The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 6 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 'One copy of this rt.ification must be provided to the OWNER, the BUYER where applicable ) and the 130ARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade - the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 . partd .doc TOWN OF BARNSTABLE LOCATION 7t F,,T V W,66l +v-e SEWAGE # VILLAGE H i/ ,q A1111 5' ASSESSOR'S MAP & LOT�67r INSTALLER'S NAME & PHONE NO. T P .A4 A C y,A4/ 0,1,' + S O -, SEPTIC TANK CAPACITY A ©o 0 LEACHING FACILITY:(type) P/ r (size) /.(,3�'�!1 NO. OF BEDROOMS ' PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: s * _ DATE COMPLIANCE ISSUED: ' ter. .` 916 VARIANCE GRANTED: Yes ��� No ��' 1�y� ~ la- \ _ _1a . f..+ No......�'' . 1, Fmc..................�..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Applirahatt for Diinpwml Work.6 C utuitrur$ion 11muff Application is hereby made for a Permit to Construct ( ) or Repair :(X)g an Individual Sewage Disposal_ „- System at: 78 Fernwo Aveyannis_________________________________ ................................................ ................................................................................................. Location-Address or Lot No. Ella Meleo Owner Address aJ-P-_Ma.CQA1,ber...Jr-.-------------------------------------------------- --------------------------------------------------•------------_....--•---------•----------------- Installer Address Type of Building Size Lot............................Sq. feet Dwelling-,,E No. of Bedrooms-_---_-----2------------------------------Expansion Attic ( ) Garbage Grinder (NO) '4 Other—Type of Building No. of persons---------------------------. Showers — Cafeteria Q' Other fixtures -------------------------------- - W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. 9 Septic 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 ( ) 0­1 Percolation Test Results Performed bY------------_-- -------------•-----------------------•------------------- Date...........................=•=.......... Test Pit No. I----------------minutes per inch Depth of Test Pit--.---...-.--.-.---- Depth to ground water----_----..... (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............•......... . --------------------------------------------•-•---••-------••--•• ............................................................................................ O Description of Soil......................................................................................-................................................................................ - V ....................S-and...&...Gray r e --------------------•:, W -------------------------- ------------------------- ----------------------------------------------------------------------------------------------------------------------------------------......... UNature of Repairs or Alterations Answer when applicable-------------emit__-Ce----pools.----Insta11----------•--•----. 17.10.0.0---gallon---tank-- 1---distribution-•box---1---1 000----gallon---leach---pit........................... Agreement-- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .-�� ------ .. . to ------------- Ap Appliai �--- Da[e Application Disapproved for the following reasons: .. .....-.... ........... ................................. ._........... . . .......... -----------------------------------------------------------.-...----------------------------------------------------------------------- -------------------------------------------- ---------------------------------------- Permit No. .... Issued ....... .—-- --- --------_~—----- .-----. Daze ,. _ �. .. 30 00 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diopo3al Works Tonotrurtion ramit - Application is hereby made for a Permit to Construct ( ) or Repair '(X). an Individual Sewage Disposal System at: .78........Fernwo..........•- --od...Ave Hyannis .... ....----- -----........... Location-Address or Lot No. Ella Mel .o Owner Address e.�—ma.c,am .be r...J .--------•......................................... ................................................................................................. Installer Address Type of Building Size Lot............................Sq. feet Dwelling„No. of Bedrooms-----------_?------------------------------Expansion Attic ( ) Garbage Grinder (NO aOther—Type of Building ---------------------------- No. of persons-----_--..-..------..-.----- Showers ( ) — Cafeteria ( ) a' Other fixtures ------ ------------------ - - W Design Flow-------------------------------------------- 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. 1----------------minutes per inch Depth of Test Pit---_-.--_-_------_ Depth to ground water........................ (i Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 --------•----•---------------•--•--•---•----•-•-----•-•---•--•--•-•••----•-•--•••••...........---••-......................................................... 0 Description of Soil........................................................................................................................................................................ xSand-- A-•-Gra.vel---••--•-•--•-•-•--•-•--•------•-•----•------•--••-•---------------•----•---•---•--•----•--•-•----------•-••-•••-•. V W VNature of Repairs or Alterations—Answer when applicable.............!Mi-t cesspools. Install 1 -1000 gallon tank 1 -distribution box 1 -100� gallon leach pit. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with fi the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. g /71/CGG7 /1 t---.- G��.. f 9`'......:...... _ �p Signed ---- - R ?_. Application.Approved B - ---- -------�1-- -- --------- �-' ... Dace Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------------------------------------------- ..............................................................._-----------------------------.--------------------------.....__-----------------------...------------------......._..... -- ------------ ---------------- ........ Dace Permit No. ---- ..��----------------- Issued -------- e..-�1----�-----------�''�J-------- Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �LErtifirate of V jampliana A- THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)r. by T A Mar+-nmber--..jr - Installer 7S Fernwood Ave Hyannis ----------------- --._...---------------------------------- has been installed in accordance with the provisions of TITLE 5 o�e State Environmental Code as described in the application for Disposal Works Construction Permit No. a `.b.��------. dated ....' .."_ . �j— THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r DATE----- -.. .....'-..- "`�.------------ Insp ctcar-,.... - -' , . - - - ----^'T—^--T,:---- --- ———— —— ——M——T— —-- ——i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE---...... ... 0..a.0 Bhiposiil Vorkii Tomitrudiolt van it Permissionis hereby granted----- ------------------------------------------------------------------------•-•--............. to Construct ( ) or Repair (KX) an Individual Sewage Disposal System at No... h7A P.dh?GCS? hF±r...:I? < 1 •-- '`rn � a '!. ............................................................ K.�St ee[`y Ciltl`ll�- Q as shown on the application for Disposal Works Construction Permit ------------------------ Cry x = "�' ' Board of Health DATE .r........... - `�s FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS