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HomeMy WebLinkAbout0079 FIDDLERS CIRCLE - Health 79 Fiddlers Circle Hyannis P A 288 157 � o II WN OF BARNSTABLE A LOCATION �OIG �. G�� SEWAGE # 3_ VIL,LAGE_ UL �ASSESSOR'S MAP & LOT � 7 INSTALLER'S NAME&PHONE NO. (� SEPTIC TANK CAPACITY �1 l c ' LEACHING FACILITY: (type) L_ (size) 2C 1 NO.OF BEDROOMS _ BUILDER OR OWNER PERMIT DATE: L ~ '' COMPLIANCE DATE: ILZIO Separation Distance Between the: Maximum Adjusted Groutidwaier 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>;y , . O. � 1 'o g d r � i� I � t '� + •-� � �� �T�' tH � ' �i' .� - `, -- � No. A9 Fee �'J' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4-4 Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS f 1plication for Disposal stem Construction permit p Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon V) ❑Complete System ❑Individual Components Location Address or Lot No. �1 r1 F d `lam Ct Owner's Name,Address,and Tel.No. Assessor's Map/Parcel S' ` 1 \t v i t i G A Installer's Name Address,and Tel.No. Designer's Name,Address,and Tel.No. 6 IJ C_rMu-4" Type of uilding: -- Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures )q� Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) i v L c ,\, lk c-ri G, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the.afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ) �/ Si Date Application Approved by Application Disapproved by Date for the following reasons Permit No.AA 313 Date Issued .� ''.'?���..,ro�: ,..s..a....,.:i,,.i...�`! - -.-,,,�;••;.,,� ......., r,.a,.. �.,,.Z„ ,."w"` .,.y_r' l''a-',�- .• wR< :s.-.�._ r ,..w..,k°-Tti: +T ...ry,�.fi+�..''}.ry ..:.*n;.•'?�F:s`�"9"",�i�,. '-aa`'3 .'� a No. J(J�V Feed THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for Misposal *pstem (Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon()() ❑Complete System ❑Individual Components Location Address or Lot No. 1 9 1r dr'S C f Owner's Name,Address,and,•Tel.No. N e,,tip% S Assessor's Map/Parcel �► '' t 1 �} c Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. rcn ! t t Z u y kr nno Type of Building: 'L Dwelling No.of Bedrooms J) 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided /V 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)r C 14\ St Alt C, �c�V aA- ` p (/ e CC f, A �C-C � �r f l r J C 4 tl� l dQ k \J!P Date last inspected: 7 f 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. J Signed ? Date / 401 Application Approved by Date Application Disapproved by� Date v for the following reasons Permit No.,;aS- 313 Date Issued t 1?w 001 t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(/)by ( r A -— at ')� !��d'.r 5- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2b9 dated Installer S t t'��"� Designer #bedrooms Approved design flow JU J+ gpd _. The issuance of this permitshall not be construed as a guarantee that the system will function\ades;gned. Date C� ! �S' Inspector - ----------- --.--- - ------_----------------------------- -------------------------------------------------- - -------------- No. �U ^ Fee rT,?2�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -Misposal *pstpm Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon System located at �i P 1 J d b u s ' H v k rt,, l,_ and as described in the above Application for Disposal System Construction Permit.,The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: /Construction must be completed within three years of the date of this permit. Date /Z g 2 0/ Approved by I Commonwealth of Massachusetts 157 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is Hyannis required for every MA 02601 9-16-13 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ,:•`��N OF I Nly����i' on the computer, MgSS9 use only the tab 1. Inspector: �'' ciG key to move your t: ,N z cursor-do not �{ 2 ,y J�MES use the return James D.Sears (J �J—) us SEARS u Name of Inspector Y• 411�� CapewideEnterpdses,LLC = ;''°F °:' SP "ICI Company Name RINSP� �o��` 153 Commercial St. oluuua�`��� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 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 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-16-13 spectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Offidel In Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page_ Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired. B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'( 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in swap&is less than 6°below invert or available volume is less than %day flow oL f.4r1111vG t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is Y required for every Hyannis MA 02601 9-16-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owners Name information is required for every Hyannis MA 02601 9-16-13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.tank D Box and five infiltrators. Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page S of 17 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 79 Fiddlers Cir. Property Address Brian McCarthy Owner Owner's Name information is y required for every Hyannis MA 02601 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known)and source of information: 2003 Permit#2003-615 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast Sludge depth: 1" I' t5ins•3/13 Title 5 Official Inspection Forth:Subsurtace Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8t' Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape- Plan Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level. Tank and cover's at 1' below grade. In and outlet tees. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °< 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owners Name information is y required for every Hyannis MA 02601 9-16-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-42"below grade w/cover at 28". Box is clean and solid w/2 lines out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 79 Fiddler's Cir. Property Address Brian McCarthy Owner owner's Name information is required for every Hyannis MA 02601 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number. ® leaching chambers number: 5 ❑ 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.): Leaching is five infiltrator's w/4'stone. Ck. D Box and camera out lines to chamber's. Clean w/no sign of over loading or solid cant'over. No sign of holding water. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 official Inspection Form:Subsurface Sawage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately s s o6_�-� � i elf 3 � t t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is Hyannis MA 02601 9-16-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells /v0 Estimated depth torgh ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12-8-03 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design Plan 12-8-03. No G.W.at 12'. Bottom of leaching around 5'-6". Bottom of leaching around 6'-6"Above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Fiddler's Cir. Property Address Brian McCarthy Owner Owner's Name information is required for every Hyannis MA 02601 9-16-13 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3113 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. t r r ' FEECOMMON Of MASSACHUSETTS WjM5)6kO� y v Board of Healt j—e MA. APPLICATION FOR DISPOSAL SYSHM CONSTRUCTION PERMIT Application�,r P rmit to Construct( ) Repair( ) Upgrade( Abandon( ) - Complete System ❑Individual Components Location' ' v�s Cy Owner's Name Map/Parcel# Address PME Lot# 8A-- Telephone# Installer's Name S Designer's Name �I+A Sv Address et Address Telephone# _ Telephone# ,®_S _� qip bJ�� C)ASal" Type of Building Lot Size (nehf� sq.ft. Dwelling-No.of Bedrooms VP-9 (2;) Garbage grinder (AA Other-Type of Building IQONE No.of persons a Showers (yYCafeteria V) Other Fixtures LiaVa-my-Y+ kkmLAea,-J Saplb-, LAuaVrpy Design Flow (min.required) gpd Calculated design flow^3?--,O Design flow provided -&Ai o P gpd Plan: Date I f ©`-) Number of sheets Revision Date `-- Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator aevlc4.3 SWAY Date of Evaluation__I z4 a l t7� 3 DESCRIPTION OF REPAIRS OR ALTERATIONS sac -J,- "I The unde igned a ees to ins a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr to lac t ration until a Certificate of Comaliance has been issued by the Board of Health. Signed Date �!J ® G Z'�''`. a''m ' "o.+.�•r'h....... .. ^.`-v•.:. ��r a�, �r ti.�.•». .r-X'�'r m -R re ,,,�}.��+J„v a— e !rr ' '�r. � FEE Board of Health, �1�. MA. ; APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT � Application igr P rmit.to Construct( ) Repair( ) Upgrade( Abandon( - Complete System ❑Individual Components k Location � a (29 ax. (u n pt-ok Owner's Name =Y.n C`y On Map/Parcel# Z�g ' �. 1 J Address 5 RME Lot# 3 !�2 Telephone# Installer's Name 't1_41;tar*rS t5E t G ^JC7 r,E Designer's Name Address S TRH T�`r► S .. r �(� Address�-c)a '6cx �2} �� `m CJ�`�:J.t-,. MR Telephone# n _, 6,4�'5 i\b Telephone# 509_54 C�-e _p-+ ©;,S 3(.:, 1 I Type of Building ��St�Et\\T►A� Lot Size 1 D.(Y�f� sq.ft. Dwelling-No.of Bedtrooms '—V)r\VeP_ Co:�;) Garbage grinder (J /6 Other-Type of Building NbNE No.of persons CR Showers (KCafeteria V) Other Fixtures t LeyATOi_Y, K%TC.V\ErJ irJk. LAuNrORV Design Flow (min.required) 3 D gpd Calculated design flow _273Q Design flow provided 3_-M.PQ gpd -Plan: Date 11 � Q,X� Number of sheets � Revision Date Title \\ Dv ^C 5 A.,-Aam cr Ae Description of Soil(s) 1 _)�o lzzr Ag, ►7\CSl //11 Soil Evaluator Form No. Name of Soil Evaluator l._A Qt e'l SMIA-Y Date of Evaluation I ZJ,9103 DESCRIPTION OF REPAIRS OR ALTERATIONS CA\CCFV& —0\QA--, The unde'�signed agrees to install theabove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t ntTo/ttjopllac th/e�W)MO ration until a Certificate of Compliancce has been issued by the Board of Health. Signed W/ �C.,.fA Date ;N ) " No.C �== FEE C®MMONWhALT14 ®F MA ACHU SETT �/} SS Board of Health, Y ! (iL '(_..�^ , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) Xcomplete System The undersigned hereby certify that the Sewage Disposal System;/Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: K bl rs/L 15,St0h4(_ atP.�/"ard 14r1`76 0r has been installed in accordance with the provisi . Design Flow ons of.110 CMR 15.00 (Title 5) and.the approved design plans/as-built plans relating to application o. QU03'-Wy dated J�J l dd? Approved Desi (gpd) Installer lo(AI l 1�l�� it./ r l n lrN, r 1 Designer: Inspector: Y— k� -0 -Date: v •�•v l r The issuance of this permit shall not be construed as a guarante that the system function as designed. No. FEE C®MMONWEALT14 ®F MASSAC14USETTS Board of Health, �� r,5 J p .i, MA. ,. .. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is ereby granted to; Construct( ). Repair( ) Upgr de(V Abandon( ) an individual sewage disposal system at ! dir'lo o 6 as described in the application for Disposal System Construction Permit NJO,�' 114 57,dated r Provided: Construction shall be completed within three years of the date of this per "it:ill local conditions must be met. �b � / t Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date I� Board of Health I 03/31/2014 02:53 FAX _ 16 002/002 CARMEN E. SHAY };�os -54M796 k.. ENVIRONMENTAL SERV'ICES,INC. P.O.Box 627, East Falmouth,MA 02536 January 2, 2004 RE: Certification of Title V Septic System Installation: Residential Property—79 Fiddlers Circle,Hyannisport, MA Dear Sir or Madam: r On December 26, 2003, Roger Roberts, Inc. was issued a permit to install a Title 'V Septic System at 79 Fiddlers Circle, Hyanisport, MA, based on a design drawn by Shay Environmental Services on December 3, 2003. XX I Certify That The Septic System Referenced Was Installed Substantially According to the Plan I Certify That the Referenced Above Septic System Was Installed With Changes but in Y Accordance'With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is Required. If you have any questions, please do not hesitate to call the undersigned at(508)-548-0796. I Sincerely, CARATENE.SH'Ar ENVIRONMENTAL SERVICES,INC. ttt OF M4, CARMEN eye E. S 'AY a. 1181 ry Carmen E. Shay,R.S., C.S. �° a �.P President G;S T S4A%1TkR��`ha"' G JRN-2-2004 FRI 02:33PM ID: PAGE:2 1 I VVN OF BA.RNSTABLE LOCATION i� �G SEWAGE #2—� VILLAGE Y- ASSESSOR'S MAP &LOT, /5 7 INSTALLER'S NAME&PHONE NO, SEPTIC TANK CAPACITY t ' o LEACHING FACILITY: (type) �--" (siie) �� ® 1 NO.OF BEDROOMS ` BUILDER OR OWNER PERMITDATE: l zl- / '' COMPLIANCE DATE: 2 O ,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 it 0 000 /� Sep - 20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 N • �� srzs;oi \ )TICE: This Form Is To BeUsed For tlse Repair Of Failed Septic Systems Only. PERCOLATION 'TEST AND SOIL EVALUATION EXEMPTION FORM :. Y hereby certifythat the engineered ian si�*sec by me � P o• , clatec 1 Z Yl concerning the property located at meets all of the trl:owin; c:ntena: • This failed syseem is connected to a residential dwelling o,nJy. There are no :ornmercIa.! or business uses associated with the dwelling, 'F•e soil is class;fed as CLASS I and the percolation rave is less than or equal to -rr:nutes per inch. The applicant may use histoncal data to conclude this fac: or may :onduc:t pre!irnw.ar,% tests at the site without a health agent present • There :s no increase in flow and/or change in use proposed • Therc are :to variances requested or needed, The bottom of (he proposed leaching facility will not be located less than fourteen I,) fee: aoove the maximum adjusted groundwater table elevation. fAdiusc the nunc!.yater cable using the Fnmptor method when applicable) Please complete the following: �.I Top of Grouno Surface Elevation (using GIS information) B` G W E;evat:cn. _ •1- ad;us(men( for 'nigh G.W. RTAEN( F.. BETWEEN .\ and B c;'QED DAT1=: [ 3asec i-ori t^z aGove r.fornacion, a repair permit wil! be issued for bedreom..s `,% :dd uonal bedrooms ate authorized to Ehe future without en;tneerec plans. �. 1c:nn!CAa �<i cc.tm9 • ,, 1 14 Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: q(A' V�&A\,PcS Cee.L-E MA Lot No. -Ji- Owner: T&A,j w A k1l 1_5 pA Address: cjsa tH� Contractor: �u%qySAddress:'70•—rSesx La2 P JZ )+mo A visa G Notes: -TA ye Vr STEP 1 Measure depth to water table to nearest 1/10 fit. ................. 5 ............................................................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... Mtw OBWater-level range zone .......................................... ) STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... J3 , mont /year STEP 4 Using Table of Water level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ............................................... ... ...................... 3............ 1; Figure 13.—Reproducible computation form. . 15 4 F ITOWN OFF B^ARNSTABLE LOCATION d ����'`—� SEWAGE # VILLAGE m(Ni p ASSESSOR'S MhO IOT( INSTALLER'S NAME&P NO. SEPTIC TANK CAPACITY t aI .-O` b6UC. 1 LEACHING FACILITY: (t ) () 4 ��(3 p® � l NO. OF BEDROOMS {� BUILDER OR OWNER \ ` '� a_`)( ie 611w 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 PLI r+�; r � -S j V 1 �-� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 79 FIDDLER CIRCLE HYANNIS Name of Owner MRS SCHAEFFER Address of Owner: 430 HARTFORD AV.BELLINGHAM MA.02019 8 Date of Inspection: 611/99 Name of Inspector:(Please Print)JOHN GRACI l am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) �E,j+jVr# ,�►� Company Name: n/a J Mailing Address: n/a UN 2 1999 Telephone Number: n/a to Of IIE4TMD CERTIFICATION STATEMENT A / I certify that I have personally inspected the sewage disposal system at this address and that the information reported belo 1 tr e, - ra 6% and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper functi n maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V _ Conditionally Pass s code 316 CMR 15.303.My findings are of how the system is Needs Further E lu ion By the Local Approving Authority performing at the time of the inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: �f Date:6/2199 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN MAINTAINING EVERY YEAR.THE SYSTEM CONSISTS OF TWO 6'X6'BLOCK CESSPOOLS. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6/1/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n1a One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _ broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced Wa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced _ obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6/1/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n(a_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6/1199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6/1/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)J X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6/1/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):.a Total DESIGN flow: 3M Number of current residents:11 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):AQ Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: nta gpd(Based on 15.203) Basis of design flow: Wit Grease trap present:(yes or no):JNIQ Industrial Waste Holding Tank present:(yes or no): 1`1Q Non-sanitary waste discharged to the Title 5 system:(yes or no):No Water meter readings.if available:Wit Last date of occupancy: WA OTHER: (Describe) nta Last date of occupancy: nLa GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):M If yes,volume pumped 101111 gallons Reason for pumping: MAINTENANCE TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: Wit APPROXIMATE AGE of all components,date installed(if known)and source of information: 1962 Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6/1199 BUILDING SEWER: (Locate on site plan) Depth below grade: 1 Material of construction:_ cast iron _40 PVC X other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ nta Dimensions: V X V BLOCK CESSPOOL Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 3C Scum thickness: 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: 1E How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) MAIN CESSPOOL AND ALL COMPONENT ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY YEAR GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:iVa Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: Wa 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.) n(a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:611/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Wa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n/a Dimensions: Wa Capacity: n(a gallons Design flow: Wa gallons/day Alarm present: MQ Alarm level:jiLa- Alarm in working order:Yes_No_ MO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nla DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) IILa PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6/1/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: n& leaching chambers,number: _nLa leaching galleries,number: 11La leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: 6'X6'CESSPOOL Alternative system: nfa Name of Technology: jVa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE OVERFLOW CESSPOOL IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION.NEVER MORE CESSPOOLS: - (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: Wa Depth of solids layer: n& Depth of scum layer. nLa Dimensions of cesspool: nfa Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)WA Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) DLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:nla Depth of solids: Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wd revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6/1/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a 13 4A ��Z �r �7 0A revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 FIDDLER CIRCLE HYANNIS Owner: MRS SCHAEFFER Date of Inspection:6l1/99 NRCS Report name: nta Soil Type: nta Typical depth to groundwater: n1a USGS Date website visited: nLa Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation. Must be completed) Y 9 ( P 1 USGS MAPS AND CHARTS-10+FEET revised 9/2198 Page 11 of 11 r , _ - SECTION.A A P.V.C.. ALL W1LET PIPES FROM THE r �---10 min, from ( NOTE. ALL PIPES ARE TO BE 4 SCHEDULE 40 In VENT PIPE O Least 24 chas tailADDITION . : ) A' 0> ACHING SYSTEM dsTRisuTKtN cox SHALL BE �• < PLOFILF, VIE OF T LE Existing Foundation 1 house to septic took Schedule 46 PVC w Charcoal Odor Filter 12 CONCRETE COVER eP `, J . . .' SET LEVEL FOR AT LEAST 2 FT. t took covers must be - W p 3 at 1 8 1 2 Washed eastone N N - ELEV. 00.00 Assumed J /TOP OF FOU RATIO E EV 1 ) . within B In. of finished grade'. ,_� - - 1 ,Washed shed Stone _ - 5 WTLET ., ..3J4 to 1. J2Crushed K aba A ' Grade aver.Septic Tank 99.00 Grade over D-Box 99.007 over SAS 99.00 to 98.Ck. ._. '•*.- F rtr++ .z'ao . KNOCKOUTS !1..:..., a,-.. .. lar�, . , a , I OUTLET _ Fac4 , S 0 - _ 043 02 - 3HOLEH 10 _ OIST. box 3 ►aximum care. Top Load Ebv.'ffi9t1.00 m,,. Top Of SAS- Elar =95.50 : r •` -wa t1V • .. .'t eJ-.w Yii'l 0 10 NEW s 0.01 ar Greoter NEV PIPE u1 1.500 GAL.; 1s.5' o S= 0.ot'per foot ♦ 4' SCH. 40 T t.75. FROM EXIST, FOUNDATION r SEPTIC TANK rn 10 � 10•'�EHective Oeptn - p " ',' a r' of rD : r&. ...? H 10 s Units a �,zs 3o PAN TIOCROSS-SECTION ,. , � a L SEC N O mt b J1 CONCRETE FUU_ FiDUNMTION-' 31 a, 0.83,(10'inches) v a. 3L25 3i _ X 3 HOLE H 10 DISTRIBUTION - 6 h.ot 3J4-1 1/2 II 37.25I; SYSTEM 'PROFILE t CdT1POCted 8tarle JLength c > u u rn Effective ` NOT TO SCALE. ar Not to Scale ♦ .'� - , > 4 -- 4 u SAIL ABSORPTION SYSTEM (SAS) R N t o INFILTATRDR HIGH CAPACITY .(H 10 LOADING)/ GEDRGE D B IE GENERAL NOTES 8 in.of 3J4 1 i/Y � - d oeted stone Effective Vktth �w Not to Scale w R E DIVALENT » (0 0 ) 1. Contractor is responsible for Di -safe notification - - NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN fi BELOW GRADE �- = o P 9 d Bottom of Test.Hale 1 Elev.=87.00 m NOTE. OVERALL HEIGHT OF INFILTRATOR IS 18' FECTIVE HEIGHT IS 10' and rotectlon Of all underground utilities and pipes. No Q•amdwoter Observed o 144• P 9 P P _ 2. The septic stank and distribution box shall be set I level on 6 of 3/4 -1 1/2 stone. , 3. Backfill should be clean sand or gravel with no stones over 3" in Size. i e o'inspection 'durn Installation 4:'This system s subJ ct tduring - b 'Carmen E. Shay Environmental Services, Inc. Y it install his system in accordance 5.. The contractor sha costa I t v Ian with Title V of the Massachusetts state code, the approved p PERCOLATION TEST and Local Regulations. i encounters an 6. If, during' installation the contractory 1 . . _ O • Date of Percolation est: ECEMB R $ 2003 soil conditions or 'site-conditions that are different tT 0 E e Performed B . CARMEN E SHAY R. ' C.S.E. r r :design T st P orm y C LOT #41 : from those shown on the soil log a In our e . ,WAIVER per Barnstable B.O.H. _ . Results Witnessed BY, VEf� P r ) Installation must halt & Immediate notification be WI , R INC. „ SHAY ENVIRONMENTAL SE VICES, C .. P e: s Than: MPI 4 „ 4 PVC made to Carmen E. Shay - ,Environmental Services, inc. ercoiation Rat Les 2 8 VENT PIPE 7. No vehicle or heavy machine shall drive over the 't3 _ Y machinery , 0 •- septic stem unless noted as H-20 septic components. cP I cD P system P R d' cfl cr, - s ' nail outlet tee ends. ,> 8. Install Tuf fite `gas _baffles or equal o O � Failed �. t� \ ! L 4 NSF PVC pipes. � 9. AFI Distribution, Lines shall be 4 -diameter'Schedu e, 0 S C p p 0 111 79d 40 10 E � Cesspool , r r 4 diameter 10. All solid piping, tees & fittings shall a dla e r � 1 10.00 PP 9, g b ` Test Hole I -Schedule 40 'NSF PVCpipes :with water tight ants. , \ , 1 9 1 7 5 \ t :N 1 ► o. T Residence and Abutting \ i 11. Municipal Water is Connected to ALL OF , he es ce 9 DEPTH SOILS ELEV. , : ,.•..,...,: 8.5 1 ...PROJECT BENCH MARK � > . ,., .� - •. . .► i Properties .Within 150 Feet. -_. _.-...._,µ.-., � Shed s,*�:�. •., f t ..;-�._ I > W I . \ p 0 99.00 TOP OF FOUNDATION , THE PROPERTY :LINES ARE APPROXIMATE AND Loamy ELEV. - 100.00 (Assumed) -Sand ., °�` .•,•.t- �:. I r t COMPILED FROM THE SURVEY PLAN GENERATED BY O TEST HOLE 1 I t ► O WHITNEY &'BASSET OF HYANNIS, MA ELEV. 99.00 D Box I t o SUBDIVISION N F LAND IN YANNISPORT MA o -12 A. sa.00 1 op t ENTITLED SUBD SON PLAN 0 H , h • DATED JANUARY,, 1951 � 2 .5 1 Loamy 0 0 1 , , / AND`IS NOT INTENDED TO BE A SURVEY PLOT PLAN f Sand 22.5 \. 1 t IT SHOULD B USED FOR NO 'PURPOSE OTHER THAN I 10 rx s/b I ` 1500 ai. \ I �,,, I t � S D E , . t , g I I O THE SEPTIC SYSTEM INSTALLATION. 1 a g 97.00 Septic Tank t 1 2 - 24 e ' I I ► �i Medium Sand Q �� I i I EXISTING CESSPOOLS TO BE PUMPED OUT AND Y a t I f REMOVED 70 FACILITATE NEW SEPTIC SYSTEM INSTALLATION 25 7/ 7.00 A-MAL�GAS--LINE- y- I ► t 24' 144 LOT' 43 L,.. I r # EXISTING NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE � 0 TE - ASPHALT A r r ► r o 3 'BEDROOM FROM THE EXISTING CESSPOOLS 7Q BE DISPOSED ' DRIVEWAY O - z e Deck r ►D c \ -0F AS PER BOARD OF: HEALTH SPECIFICATIONS. O r HOUSE r i r i R ESE. WI-THIN -.H , ^. '--0; v.,.,r• PROPERTY A i�1- 1Nh iiJ z00 vr , i c PrwrcrcTY : ► O I _wtfLAivOS r<E PRC E i H n { I f r t _ y IkP ASSESSORS MAP 2 8 :PARCEL 157 O r ► AS S $ i I \ I , r I I 6- 0 i f7. LEGEND , Perc #1 0 1 ► I I n » Depth to`Perc. 38 to 56 P r ► 1 I 1 Perc Rate- Less Tha 2 MPI I ASPHALT r 1 I 'LOT 42 : I 1 I DENOTES PROPOSED Groundwater Not Observed . c 1 # ► t DRIVEWAY r r ► 104X 1 I : I , I SPOT GRADE No Observed ESHWT 1 I I f0,000 Square Feet ADJUSTED H2O Elev. _ None I r t cD 1 I ,� ,, , ► DENOTES EXISTING.. r I X 104.46 SPOT GRADE � Ir r i PL I 85.00 , PROPERTY LINE i 1 ------------- , ` I 98 S 79d 40 f 0 A' � , ..: \ _,.. � 96P PROPOSED CONTOUR - - - - - - 7 EXISTING CONTOUR ----------- -- DEEP TEST HOLE f S E 3c24 pAN.:ACCESS MANHOLES I i �j ', b� y PERCOLATION TEST,"LOCATION' .,. .• . . -:. . .. .,� . . FLU Z7 L �'R S" CIR CL.� 6 FOOT STOCKADE `FENCE ,< ._....�.-mac •-3-•-i...=-. --`-, to 40 FOOT RIGHT,'OF WAY riET ou yi. N THE ACCESS COVERS FOR THE SEPTIC TANK, P LOT P LAN .. ..� DISTRIBUTION BOX AND LEACHING COMPONENT t SHALL BE RAISED TO WITHIN 6 OF . . .� FiN1SHEDGRADE. D SEPTIC SYSTEM UPGRADE STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EOUALS A OF PROPOSE ON ALL OUTLET TEE ENDS ,r PLAN VIEW GI,IrG PREPARED FOR INSTAL �NGIAIE E�y3U� 3-24- REMOVABLE COVERS T� S T TION AN® T s J OA N N A J 0 H N S O N . I �r� . .,, 'I WA SI FYIN �`��� �,,,.., .. SST , , AT 'r T)LP'1 r' ED IN re� l ;r #79 ` FIDDLERS CIRCLE �, 3 min. clearance .. t3, � � sN.ET a mh}�2_mh:filet to outlet 6. ;' T - ` OUTLET - TO' . - ,r :� , _ HYANISPORT MA 4'-0'-min. . . : , 0.owe. Desl n Calculation PREPARED BY. . ... _ PEP ED o 330' ai. a 330 .Gal./Day'Min. per Title V ,.. .. „ Number of Bedroorfis. 3 ;;Equivalent t G fD Y ( P ) r- , z ,� ,: • . .�.. �. .. .. .--.�. -. ,. . _ .. .... � Garbage Grinder; No � h •. �' ,;. to•..:o-' 5' -a• Leaching Capacity Proposed: 330 Gat./Day Minimum (Min. Per Title V) � , CARMEN SH1 Y 9 T M A : Septic Tan .` .. E r, . Septic lank _ 3 x 330 Gol. Da 660 USE 1,500 CAL Se c k P / Y. P , ENVIRONMENTAL SERVICES, INC. N S TIO 0 20 40' E D EC N 5C� ,CROSS SECTION i percolation rate of <2 min. inch SOIL ABSORPTION ..AREA. Using p / ,/ Bottom sArea. , 0.74gal/sq. ft, x .370 s ft. 273.8 gallons r ,. q g P.O. `BOX 627 ' � ' / :. t 7 -s : ft. 58 gallons � , Sltlewall Area. :0.74, al. s f . X 8 ST , 9 q q 9 .�--� . . EAST FALMOUTH MA 02536 ; TYPICAL 1 00 GALLON SE TIC TANK , C L 5 LL i 3 .$ gallons Provid n 3 1 0 P i - 9 uITAR ...... ..;<.a _ .,. 4 6 T F : 50 $ Ors „ EL AX 8 5 l NOT TO SCALE _. NI N INCHES) :DEPTH .SCALE 1 2 Use. 5 INFILTRATOR HIGH CAPACITY_H 10 UNITS HAVING A 083 10 CHES , _ CA E. ] . 20 DRAWN- BY< :,CES ' ' DATE. DEC _1 2003 H 10 OARING f �. \\ s W 1 T U 4 0 OF WASHED TONE ON THE.SIDES, :AND 3• _ t)F• .ASHED'STONE 0 BE USED WITH . . S S , ., N, P W H 1 OF l :'ON, THE ENDS. No sTorlE u DER PROJECT SD507 � - FILENAME. 5D507 P.D G S EET i4