Loading...
HomeMy WebLinkAbout0040 FIRST AVENUE (HYANNIS) - Health 40 First Avenue Hyannis• P A = 267 026 µ 1 I' p d w v 6 u r p k I TOWN OF BARNSTABLEo LOCATION 1 0 FIRST 12V E SEWAGE# VIT,LAGE HYAOIS ASSESSOR'S MAP & LOT 2 d` INSTALLER'S NAME&PHONE NO. 6-kP-0 t-. W %usTi n/ 79/ 3 5' 73%9 SEPTIC TANK CAPACITY 1500 LEACHING FACILITY: (type) ::rNL�/L.�XaS lP-C%� sizes NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: ? 7 _0.S' COMPLIANCE DATE: Separation Distance Between the: t Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 000 0- $ Feet Private Water Supply Well and Leaching Facility (If any wells.exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C 2 - � �z Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.1 ,M 40 First Ave. ,, Property Address Olga Schulman Owner Owner's Names information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. Cityrrown State Zip Code Date of Inspection _ Inspection results must be submitted on this form. Inspection forms may not be altered ih%ny way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ' •� �of �� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. , Cape Septic Inspections VQ Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 Cityrrown State Zip Code 508-280-3356 S13938 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 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/12/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. 15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 41�K� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is y required for every West Hyannis Port Ma. 02672 10/11/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: This 3 bedroom home has a H-10 1500 gallon septic tank and a D-Box feeding two leaching trench with 8 infiltrators. At the time of the inspection there were no visible signs of past hydraulic failure. Note this is a Four bedroom septic system. 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): I '5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if + pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): I ❑ 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): I ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 1 , Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 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". i 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: t Yes No Backup of sewage into facility or system component due to overloaded or El ® 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 cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 e Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. City/Town 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 groundwater 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. Cityrrown 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? a ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has r been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 r DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): <440 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: k Number of current residents: 0 k Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedweekends 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.): i Grease trap present? ❑ Yes ❑ No k Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No t Water meter readings, if available: It5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. Cityrrown 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: 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) i ❑ Innovative/Alternative technology. Attach a copy of the current operation and t 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts N - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 03-07-2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 48"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.): Septic Tank(locate on site plan): Depth below grade: 36"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Standard H-10 1500 gallon septic Dimensions: tank Sludge depth: 1 t `5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 First Ave. G„M Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. 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 - i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r v I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4N ,•''� 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 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.): I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No li it5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. City/Town 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.): The D-Box had no visible signs of leakage or evidence of past hydraulic failure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* 1 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. i i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: Two with 8 infiltrators each ❑ 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.): At the time of the inspection there were no visible signs of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert i Depth of solids layer t Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. City/Town 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.): 4 t5ins.doc-rev.6/16 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 M 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks 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 I t 4 4 i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i TOWN OF BARNSTABLE (Av 7AA/U--7 LOCATION YU P—I RS T AV E SEWAGE# ZC'06- VILLAGE HYA10N ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. 9FQ o L W 40S7,d 7A/—.3 5/4 l3�9 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) TNFiGT�QATi7QS �2E�sou-)5 NO.OF BEDROOMS_ BUILDER OR OWNER Self JL.M g11 PERMITDATE: r7 U' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility alf 1z 5�d' 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 N VC-N 3ZS d0 I�?.fo ZS ofI VAI � /oy� SGR.tENEt7 � r Q 70QG�t Q I I Q LLt al y,I 1-5 - t QI\ t:1 Z ti� Or 001 00 ev 1500 t ►t, bpt- 533 c�3•e — D-god Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells Estimated depth to high ground water: 10 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole to ten feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 First Ave. Property Address Olga Schulman Owner Owner's Name information is required for every West Hyannis Port Ma. 02672 10/11/2017 page. City/Town 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 /o I I r t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t NO. THE COOMON"NEALTH OF MASSACHUSETTS FEE _ BOARD OF HEALTH OF APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( epair ( ) Upgrade ( ) Abandon ( ) - omplete System ❑Individual Components • ��' Location ne s Name �h r c'�fwcsL��/1A 9013 Map/Parcel# � `„ Address Lot 11 n / n" Telephone f"'t v 5%/N „vca✓�1,� �i yfi�; ��� Installer's Name 'Jest ner' ame Address � eley Telephone# Telephone ItType of Building: l Si4& Lot Size 1-3., -1 0 D Sq.feet Dwelling—No.of Bedrooms Garbage Grinder,-�- Other—Type of Building - No.of persons Showers-f-� Cafeteria-{—� Other fixtures — fL Design Flow(min.required) gpd Calculated design flow gpd Design flow provided gpd Plan: Date L / ' d ' Number of sheets 7 Revision Date e Title r 10, / n Description of S �'2,oil(s) — "'�1 c/ ed Ne J41 Soil Evaluator Form No. Name of Soil Evaluator.� l-7i L1 JA Date of Evaluation Z 3 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu er agrees not to pi ce the s stem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed 'w `"" .to t FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Via':.,. .... //' ., ,. .. .f- �*, h» � .... r.,l„,. ...,•,',, "No. `� THE COF4 OALWEALTir** AF �ASSACHUSETTS FEE BOAR--AF—KEAL)TH a _ , Ckc� OF �Gra �f /P_ A APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( air ( ) Upgrade ( ) Abandon ( ) - v omplete System ❑Individual Components A Location yn� Na /,Z Map/Parc' #, 4� /3��� ®� Address / Lot (J S,T/ , r ,DQ✓�I/ ( //7 U /e' R/Z hone�.�� U 4- W Installer's Name r er , CCo S—t' J ��dr( T Address 04 ✓QV6la 21171'k Telephone# Telephone## Type of Building: 1, � �l 5)6 A CG Lot Size /3; Z O y Sq.feet Dwelling—No.of Bedrooms Garbage Grinder-(---)--^ Other—Type of Building No.of persons Showers-(-4, Cafeteria-(--�— Other fixtures Design Flow(min.req fired) 46 gpd Calculated design flow gpd Design flow provided 62—gpd Plan: Date Z- // U Number of sheets Z- Revision Date Title . ��►r, — f ry c�tr� / r V r► / Description of Soil(s) � ^,6 -So zva"I Z//�v 0/ �L " �U �eO S6n Soil Evaluator Form No..­ O�hS'"Name of Soil Evaluator lbo T;i i., n ..Date of Evaluation 1Z 3 0 DESCRIPTION OF REPAIRS;OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of �rl. TITLE 5 and fu er,a©grees not to p la �ce the sysr^sttem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ��1 /4 to /�5pec tion l.�f ✓( /��� a i / /17 v f` f FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 r i '� t'No.t�^_/ THE COMMONWEALTH OF MASSACHUSETTS FEE _ BOARD OF HEALTH - = CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System The undersigned.hereby certify that the/So vy�age.DXista�osa_ 1_,System Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) at j 1 i n ✓� _r �. has been installed in accordance with the provision of 31/0 CMR 15.00 (Title 5) and the approved desig plans/as-built plans relating t application,Nol�g-<31<f dated !! G/u S Approved Design Flow plans/as-built (gpd) Installer \JS Designer: 777A I.)`�'r Inspeetgr k Date t A lo S The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 r a No� THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT_ Permission is hereby granted to-Construct/�(�)-Repair ( ) Upgrade ( ) Abandon ( ) ari individual sewage disposal system at d ]'� -St- lit J%.t / / as described �`' in the application for Disposal System Construction Permit No. �ri/ ,dated I//�Dl U 5 I - Provided: Construction shall be completed within three years of the date o th`i-s-perm-t�111,dooc_al conditions must be met. Date �J 17�U '5Board of Health J3 --�.e__� FORM 2 — DSCP DEP APPROVED FORM 5/96 M 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON TOWN OF BARNSTABLE © LOCATION l RS f AVM SEWAGE 'm VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 5�1201- W /40ST,bi 7�I 3�{� L /9 SEPTIC TANK CAPACITY! % ®O ,(n S LEACHING FACILITY: (type) Si / G/c (/Gc� zee NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: �j COMPLIANCE,DATE: Separation Distance Between the: Maximum Adjusted Grou ndwater Table to the Bottom of Leaching Facility �(!� 'g t Feet Private Water Supply Well and Leaching Facility (If any wells.exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by 3 s' rA r I ® IO o aJ �bi2�i1 I g LZ.I al J r t 0- 2 001 ,s (Opt, f r Town df Barnstable �FTHE rp� Regulatory Services LULNSrnsLE, * Thomas F. Geiler,Director 9 MASS. q, 1659. ,. Public Health Division Thomas McKean,Director 200 Main Street Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 I, `'� � k t,( , a licensed Disposal Works Installer in the Town of Barnstable, authorizeG�ei��c_p-ate to act as my agent to obtain sewage permits certificates of compliance which I have signed for and to request sewage inspections. Telephone # -78( -344-1t3 tl� CC-EL. '7S1-LkC'g-96Ct0 Signature: 0. UJw Date: - [ _ 2�u Witnesse : 1 Date: 3//1 d i Agent.doc f Town of Barnstable �NE r° ; R.egulat6ry Services P a . 4 Thomas F.Geiler,Director Public Health Division c Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 0 £ice: 508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: Designer: CJ pV(O C- _UA L)UH PC- RiSInstaller: EP_zc -- t j Ao&TIr! Address: Z. L\ M\ Ll_ (Zoa o Address: Cg 8rock S%- E 1ST SK�o�O�tGI\ Slov697oA)_ IVA - OLO7Z On Cie20 t- t J A u s-rld was issued a permit to install.a (date) (installer) septic system at !�b A'/257- /qV based on a design drawn by (address) D A V,D C -C O O L.t Iy P .,RC-Sa dated b Ec, t l 1 Zoo4 (designer) I certify that-the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral.relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. qffislaller's Signature) ' (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTIII THIS FORM' A — .AS-, BUILT CARD ARE RECEIVER BY THE BARNSTABIE PUBLIC HEALTH DIVISION. THANK'YOU. Q. HedWSepticMesiper Certification Form f FROM David Thulin PE PAS FAX NO. : 5oe eee7259 Mar. ' 14 2005 10:53AM Pi i u u 11.Lvu•./ 1 L-i I i I �niu�._r i WDLL D1,HRJ VP MLHL I N . P. Town of Barnstable Regulatory Services, ' r Thom=F.Geller,Mrecter Public Health Divi qI&u, . - Thomas McKean,Director' 200 Main Street,$yennh,MA 03$01 Ot5=: 308.96;W" Fax; FII-790.6304 Tn®taller&Deefmtd Cert#fica n Borrn Date: ; 3 /-f &< Designer: 11 v«l L L vli.,,�� BLS IastaUen Address' .! , �_p. Addresa: n ice/ li .A�2537 on was ismed a permit to iza%U.a e septic system at O zseS� ys)rw c- based on a design drawn by(addrw . I certify t$at•the scoo'system referenced above was instal-led subemid.ally accarding to die design. which may include minor approved changes Qurh as 1atemI.reloc&on of the &stsibutioa b=and/or septic tank, I Cart*that the s+ept�c s t= reseed above was install�4 with major changes (i.e. greater ffiaa of thee W Or any vertical rdoaation of aY coatpanent of ttm aaptic**emn)but in aaoordanie with Stow&Local Re . Plan�'=n or coed w4uiit by de4 per to I*IIow. s�G , 614Ch �4t J�f1w a .�� CAVio o C. o 8 'rPULIN 9� CiVI O sMPFfecm D S Q:Heal"apetaMWIM ONMeaCea FOM f FROM David Thulin PE PLS FAX NO. 508 8887259 Mar. 14 2005 10:54AM P2 LOT 47 110.00' EAST FOOTING FOR PORCH 49.0' Lev L.LJ 1 "= DESIGN ELEVATION Z 23.0 Q O N Q N 31.0' 99.63 98.53* 0. tiR LL_ 4 4 43.0' fie- a Sao' 99.15 o j a 4.0' ` 98.028 N o z TBM PK NAIL Q ELEV=101.38 ASSUMED DATUM 29.0' 98.89 3a d 97.77• 98.69 .5 9 IP(FND) 98.50 yam, 97.40; I i I IVENT INSTALLED 98.39 97.253 WEST 110.00' O 2D 0 10 20 40 gD 0 Oco U7 04 ( IN FEET ) CB/DH (FND) vytN O.0 1 inch = 20 ft. _ � AS-BUILT PLAN ASSESSORS MAP 267 PARCEL 026 a TMULIN PLAN REF: PLAN BOOK 34 PAGE 23 v No.39403 V 40--FIRST I&VENUE PLAN DATE: AUGUST 1893 WEST HYANNISPORT, MASSACHUSETT DATE OF SURVEY: OCTOBER 14, 2004 su. COMBINED LOT AREA: 13,200tSF SCALE: 1' - 20' DATE: 3-14-05 FOUNDATION LOCATION DATES: MARCH 1 & 9, 2005 TOP FOUNDATION ELEVATION= 104.25 OFFSETS TO PROPERTY LINES FROM DAAD C. THULIN, PE, PLS NEW CONCRETE FOUNDATION 211 MILL ROAD EAST SANDWICH, MASSACHUSETTS 02537 PREP. FOR: SCHULMAN DRAWN BY: PST I CHKD BY. DCT .cos Not oa_osa Rev. SNEE7 1 OLGA PAGE 04 3e. . Jw � w le � F Z � d BATH .�.. rAWft a \ v va ti1 �-� F-1 .. �99 MW � �� 8Z9It69895 $Z�SI �pBZlZL158 M m �p � r r r- x m r r r-4" - < IL W-e. _ r A h p zw . .. a R I SCREENED PORCH �. a�Ink �� to MASTER � ROOM � r` - BEDROOM LU o ► LliI min p KITCI3EN �". s�. '° k - auo it GARAGE i o m p4 co ROOM � LIT] [101 r---- --� r-----�---- H � 1 , ao�ano � 1 I I so WADE mm 1 `m Ly EV a, va I Lp ri FARMER'S PORCH CV am To faw Ln FIRST FLOOR PLAN RIDGE VENT ASPHALT SHINGLE ARCHITECTURAL STYLE 12 /A&N ASPHALT SHINGLES ARfxYlECR1RAL STYLE 12 ILEHI 1`V ALU NUM GUTTERS h DOWNSPOUTS AS PER M ALUMINUM GUTTERS R DOWNSPOUTS ASPHALT SHINGLES ARCHnU=URAL SAME s _ ; -_ _ - ❑ ❑ ❑ ❑ a ❑ ❑ ❑ ❑ ❑ ❑ ❑0 E:l _ ❑ ❑ ❑ ❑ --- ---— ---- TO — - -- — DIA. 0 El COLUMNS.TYP. ❑ LJ t_J ❑ ❑ U LJ ❑ - STEEL DMULATED EXTERIOR DOOR FRONT ELEVATION 2' 2' 3'-8' 2' 10' 2' 6' 2' 2'-4' • 7'-2' SD'-8' 18'-2' Sllaq j 22' N © C s°` © O © SCREENED PORCH o 20 PLumms WILL 1 N o iu 12 i 5'-6' j ___ 14'-6' ___ N � Ilk axlnaoll 0 1 I I 1 1 H j j SLOPED � 1 6'SLIDER I I 1 c,1,1'+c 1 PARRY „tDVE n I DININGBFOLD MASTER ROOM a 6 7'-4' 7'-r BAD t00M --------------------- ----- KITCHEN FIAT CM24 S/D'GYP.80.O wN,LS AW�CENf TD a COM BEIAw 111Nq ARFws II I I 1 P.T.tares II 1 C.) II ? 1 � 8'-6• � �� to ��----------------- �� GARAGE yp II II I 1 ° A II Ild I I O N ------------------------ 11 t.ItKi� - 11 j j M II amc .� II N II II o LIVING N E" r-- ---1 r———————— a 1 s ROOM 1 I I o rs �f S opm Coum I I I I I I I `n O E !77 , SFAT O c I I I I ' 9' DOOR I I 9'GAPA0E DOOR 2' 2' 6' 2' 2' m 14' 22• FARMER'S PORCH STEPS TO ORWE FIRST FLOOR PLAN 1483 SQ.FT. 1ST FLR LIVING AREA w 8'-8 1/4' 8'-11 1/2' 14'-4 1/4' + OZ7�� o Pew 1 F64 Me I I I I 14'-6' CLOSET to ease CLOSET 4' BIFOLD 4' BIFOLD ! 4' &FOLD _ 4' aIFOLD N 1 1 I I I I I I I N -- ----=-------------- ——— ——————— -------------------i HALLWAY TO UNFINISHED SPACE m VAULTED COLING VAULTED CEILING m BEDROOMm _ BEDROOM______ in i 114'\ 4' i 14'I �� K Q I I I 1 !! 8' ' HIGH W I 1 1 8'-4' HK#1 WALL 8'-4' H GH ALL I 1 —4' HKBi WALL 1 1 I I I 1 1 I I IQ Q I© 4'-4 1/4' 4'-3 1/2' T-2 1/2' 4'-3 1/2' T-2 1/2' 4'-3 1/2' 4'-4 1/4' 32' SECOND FLOOR PLAN 793 SQ.FT. 2ND FLR LIVING AREA f Town of Barnstable P# 10865 Department of Regulatory Services Public Health Division Date 12/1/04 �'OrFnt►`6�' 200 Main Street, Hyannis Ma 02601 Date Scheduled 12/3/04 Time 11:00AM Fee Pd.100S Soil Suitability Assessment for Sewage Disposal Performed By:David Thulin Witnessed By: David W. Stanton RS LOCATION & GENERAL INFORMATION Location Address: 40 First Ave,Hyannis Owner's Name: Alexander Schulman Address: 11 Plymouth Road Weston, Ma 02493 Assessor's Map/Parcel: 276-026 Eneineer's Name: David C. Thulin NEW CONSTRUCTION El REPAIR 0 Telephone# 508-888-7259 Land Use Residential Slopes(%) N/A Surface Stones N/A Distances from: Open Water Body >200 ft Possible Wet Area >200 ft Drinking Water Well >200 ft Drainage Way NA ft Property Line 20 ft Other NA ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) no.o' w o a d N H VI K 4 O O N 79.6' 2 ri N 110.0' Parent material(geol'ogic) Glacial Outwash Depth to Bedrock>20ft Depth to Ground water:Standing Water in Hole: NA Weeping from Pit FaceNA Estimated Seasonal High Groundwater >10' = - DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: NA Depth Observed standing in obs.hole:NA in. Depth to soil mottles:NA in. Depth to weeping from side of obs.hole: NA in. Groundwater Adjustment NA ft Index Well# NA Reading Date:NA Index Well level NA Adj.factor NA Adj.Groundwater Level NA PERCOLATION TEST Date >1/94 Time I 1 00AM Observation Hole# 1 Time at 9" Depth of Perc 6811 BOT. Time at 6" Start Pre-soak Time c 0:00 � Time at(9"-6") End Pre-soak 8:00 25 gal Rate Min./Inch, C5 Site Suitability Assesment: Site Passed F Site Failed: Additional Testing needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back rr* If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to the beginning. yr� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) 0-8" Ap i SANDY LOAM j 10YR5/6 N/A SOD - ORG. LOAM 8-32" B LOAMY SAND 10YR5/4 N/A SUBSOIL 32-116" Cl I COARSE SAND 10YR5/4 N/A LOOSE 116-124" C2 COARSE SAND 10YR6/4 N/A NO GROUND WATER I ' DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency.%Gravel) 0-8" Ap ; SANDY LOAM 10YR5/6 N/A SOD - ORG. LOAM 8-32" B i LOAMY SAND j 10YR5/4 N/A SUBSOIL i 32-68" ! CI COARSE SAND i 10YR5/4 N/A LOOSE DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) I , 1 I i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,%Gravel) i i t i I Flood Insurance Rate Maps Above 500 year flood boundary NoEl Yes❑ Within 500 year boundry No[] YesD Within 100 year flood bounda No❑ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system?YES If not, what is the depth of naturally occurring pervious material? Certification I certify that on 11/94 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience escribed in 0 CMR 15.017. Signature �� Date It Town of Barnstable P# 10865 Department of Regulatory Services ' WAM Public Health Division Date 12/1/04 �Ar 16T9.web$ 200 Main Street, Hyannis Ma 02601 eo r,Nt Date Scheduled 12/3/04 Time 11:OOAM Fee Pd.IOOS Soil Suitability Assessment for Sewage Disposal Performed By:David Thulin Witnessed By: David W. Stanton RS LOCATION & GENERAL INFORMATION Location Address: 40 First Ave,Hyannis Owner's Name: Alexander Schulman Address: 11 Plymouth Road Weston,Ma 02493 Assessor's Map/Parcel: 276-026 Engineer's Name: David C. Thulin NEW CONSTRUCTION ED REPAIR Telephone# 508-888-7259 Land Use Residential Slopes(%) N/A Surface Stones N/A Distances from: Open Water Body >200 ft Possible Wet Area >200 ft Drinking Water Well >200 ft Drainage Way NA ft Property Line 20 ft Other NA ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 110.0, t W I Z O 4� Q O N N d' C C N 79.6' 2 ri N 110.0 Parent material(geologic) Glacial Outwash Depth to Bedrock>20ft Depth to Ground water:Standing Water in Hole: NA Weeping from Pit FaceNA Estimated Seasonal High Groundwater >10, DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: NA Depth Observed standing in obs.hole:NA in. Depth to soil mottles:NA in. Depth to weeping from side of obs.hole: NA in. Groundwater Adjustment NA ft Index Well# NA Reading Date:NA Index Well level NA Adj.factor NA Adj.Groundwater Level NA PERCOLATION TEST Date 11/94 Time I1 00AM Observation Hole# l Time at 9` Depth of Perc 6811 BOT. Time at 6 7 Start Pre-soak Time @ 0:00 Time at(9"-6") End Pre-soak 8:00 25 gal Rate Min./Inch <5 Site Suitability Assesment: Site Passed = Site Failed: Additional Testing needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back *** If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to the beginning. Y DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistency,%Gravel) 0-8" Ap SANDY LOAM 1 10YR5/6 N/A SOD - ORG. LOAM 8-32" B LOAMY SAND 10YR5/4 N/A SUBSOIL 32-116" C1 I COARSE SAND 10YR5/4 N/A LOOSE 116-124" C2 COARSE SAND 10YR6/4 N/A NO GROUND WATER DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) 0-8" i AP i SANDY LOAM 10YR5/6 N/A SOD - ORG. LOAM 8-32" B LOAMY SAND 10YR5/4 N/A SUBSOIL 32-68" Cl COARSE SAND ',IOYR5/4 N/A LOOSE i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) i I i i i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) I i I i Flood Insurance Rate Man: Above 500 year flood boundary NZ Yes❑ Within 500 year boundry NoEl Yes -11 Within 100 year flood boundar No[j Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system?YES If not,what is the depth of naturally occurring pervious material? Certification I certify that on 11/94 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was perfonned by the consistent with the required training, expertise and experienc described in 310 CMR 15.017. Signature Date I�of COMMON"WEr�LTH OF ir�15Sr1CHi SETTS ZFFAIRS&,er EXECUTIVE OFFICE OF ENVIRONMENTAL IV DEPARTMENT OF ENVIRONMENTAL PROT_ECT1 i E9 ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 -C 8 ( 2 DO 4 TRUDY COXE Secretary. ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner AUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM K)N 15 >0 PART A CERTIFICATION Property Address: q0 F12s1 /9VE. Name of Owner E0, 60KOA SKY Al AP ;$71 L07-0,16 Address of Owner: Date of Inspection:7-/Y-00 Name of Inspector:(Please Print)(%A;A/LDC, BOLL IELO 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: 60WAR0 C &,u.SF/ELI Mailing Address: C—)� t n0 f) AUC 6A'V0w,C.4 M .0:)5 6 3 Telephone Number: 5_Q S M9(—_32 3 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: XPasses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ CCFails Inspector's Signature;,--7 + �" Date: 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 /$00 /14 LLON S c pi /C TAN K 1 0-130K 3 Cat TcX E/�Cl/iit,'l� C NA M 6E�S revised 9/2/98 Page Iof11 %J Printed on Recycled Paper 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: q 0 FIRST Owner: Go-ZONSIcy Date of Inspection: '7_N-00 INSPECTION SUMMARY: Check ®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: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. 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. 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 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 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: tt4 a F f RS I Au t Owner: &0-zCA 5i< Y Date of Inspection: -7_1 y-OO 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 (approximation not valid). 31 OTHER revised 9/2/98 Page 3or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM iNSPECTION FORM PART A r CERTIFICATION (continued) Property Address: t1 D FIRST AvE Owner: GCZ0NS K`r Date of Inspection: -7-I`1-� 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 Backup of sewage into facility or system component due to an 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 cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no 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 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 If 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 information. r revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: e40 FfkST A0 Owner: (,_C-ZCN S K Y Date of Inspection:.?_N-00 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 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 NIA. _ 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, 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 on the site has been determined based on: Existing information. For example, Plan at B.O.H. Y _ 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 occupants, if different from owner) were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5ofII 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: �j CZt31Us�t�{ Date of Inspection: -7,19.00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bed�om. Number of bedrooms(design):_ Number of bedrooms(actual):_ Total DESIGN flow 330 Number of current residents:_ Garbage grinder(yes or062D- Laundry(separate system) (yes or If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use k&or no): YES Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or 19: )1-0 Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow. Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or ri�o LLIV If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date Iinstalled(if known)and source of information: /NST�1CttO /`/�/� , �S Qu'�G.T Sewage odors detected when arriving at the site: (yes or revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C •+ SYSTEM INFORMATION(continued) Property A ress: L10 FIRST i41'r owner: U Z0A.;5K Y Date of Inspection: "7_1 tl-(Do BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction: cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade: "vcH S Material of construction:_'concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: to14.1 L Y5'8 W xsl" / Sludge depth: I iNG.H Distance from top of sludge to bottom of outlet tee or baffle:21 C14S Scum thickness: I rti 01 Distance from top of scum to top of outlet tee or baffle:81 nicnS Distance from bottom of scum to bottom of outlet tee or baffle: yrn,eNS How dimensions were determined:'-T-API` M64Suf?C 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.) TArvt< jS r,v ✓rRJ 6000 CV'L;0 T/ow, pLASTrL 1,t;e-6T /4.y+0 oLTf-C T"rFCS VEkY (-fr7 AF SONGS r2 SLiI>L-,L, I-eOu-0 uP 71) '(SeTteM OF OLT'(.CT 101P6 GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ''ll SYSTEM INFORMATION(continued) Property Address: qc FfRsr Owner: 6OZON Si1-Y Date of Inspection: 7_N_00 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:% (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids_carryover, evidence of leakage into or out of box, etc.) ONE P/00F /N r'kE 10,/0F OAT , fV l SLILI OS PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Pagc8orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 70 rrRST AV6 Owner: G0Z01VSI< Y Date of Inspection:."?-14-op SOIL ABSORPTION SYSTEM(SAS) (locate on site plan, if possible;excavation not required,location may be approximated by non intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries,number:_3 COLTEX CHAMBE2$ leaching trenches,number, length: leaching fields, number, dimensions: 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.) SGI� !S DKY I #VQ Stc4,S of f/!'DRA(.�C/C FAity2c� G�D (-A, f0�y CESSPOOLS:_ (locate on siteplan) 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 (cesspool must be pumped as part of inspection) 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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: C,le.ST qt C Owner: Gczolusge y Date of Inspection: 7-,+L,)o 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) a7' , 30 X7 revised 9/2/98 Page 10 of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C •� SYSTEM INFORMATION(continued) Property Address:-1{ FIRST AvC Owner: &0zoSK'( Date of Inspection; 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 Estimated Depth to Groundwater 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 x Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) M PCUND(.t;'-fek 1')AP/ 70PO M09P revised 9/2/98 Page11o011 < : A l /lit 026 ? TROY WILLIAMS Rr&FIEO SEPTIC INSPECTIONS wlgY - 2000 Certified by MA Department of Environmental ProtectionE ` V ir � Ae1� fit„ (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 � "��' b C o p� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: YO F,'rs4 I v e M v- Name of Owner 9 c/W. ., w►+ A I%r Address of Owner:_ /I E3 1 r✓ r r, A u Date of Inspection: $/S /bO P►'o v J •,c , Q�. v;L 90& Name of Inspector:(Please Print) Troy Nfilliams 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Troy Mfilliams So tin c Insnactions Mailing Address: __ 19 Hummel*Drive, So. Dennis, MA 02660 Telephone Number: (508) 385-1300 CER71RCATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: ' J it.at � i• Date: .5�S o 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 ttm system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS Although system meets the minimum requirements set forth by the Massachusetts Department of , Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Own": 40 First Avenue, West Hyannisport,MA Date of Inspecti.: Edwin&Dorothy Gozonsky May 5,2000 INSPECTION SUMMARY: Check A, B, C, of 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: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y. N. or ND). Describe basis of determination in all instances. If "not determined", explain why not. �( 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. N 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 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 40 N + o f - .., k -,4, A. wal �'�.H� +w, s.)—.A 4-1 Cc.-Sis�� S 7l-os4 Aa-"oA 1 �5 G.- GoNc <✓s. l�a � ccir. Ca�s � t �JyS 4•.al fapa.v�vysSt+4W. � Vie- &N-k T t .0 M+J S ✓'�-�o u•,/✓<- O N7 V 5 �-,, CJ�N c!' �IO 1� ` h�1 u iJ S.t -/!� /N /(( . V W C e- 1^ ' I I f t VJ, /7w3 s I M f,Jt C.. G revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 First Avenue, West Hyannisport,MA Owner: Edwin&Dorothy Gozonsky Date of Inspection: May 5, 2000 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. 11 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 W 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 (approximation not valid). 3) OTHER revised 9/2/98 Nge3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 40 First Avenue, West Hyannisport,MA Property Address: Edwin&Dorothy Gozonsky Owner: May 5, 2000 Date of Inspection: D. SYSTEM FAILS: Al 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 Backup of sewage into facility or system component due to an 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 cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ Any portion of the Soil Absorption System,,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 60 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: A//.9 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 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) 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 information. revised 9/2/98 Page 4oriI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 First Avenue, West Hyannisport,MA Owner: Edwin&Dorothy Gozonsky Date of Inspection: May 5, 2000 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye q No _ Pumping information was provided by the owner,occupant, or Board of Health. �C None of the system components have been pumped •foret least two weeks and-the system has been•receivhM normef flow �t rates during that period. Large volumes of water have not been introduced into the system recently or as part of this / inspection. Y _ 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. 1 _ The site was inspected for signs of breakout. 1Z _ All system components, excluding 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 on the 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 pproximation of distance is unacceptable) _ The facility owner(and occu ants,if different from owner) were.p w information on tha. rovided with pproper maintanaaceof Subsurface Disposal Systems. revised 9/2/98 Page 5ofII '' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: 40 First Avenue, West Hyannisport,MA Dace of Inspection: Edwin&Dorothy Gozonsky May 5, 2000 RESIDENTIAL: FLOW CONDITIONS Design flow: //d g,p,d./bedroom. Number of bedrooms(designi:- .Number of bedrooms(actual): 3 Total DESIGN flow 330 Number of current residents: y Garbage grinder(yes or no):,LE 5 Laundry(separate system) (yes or no):No; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no)- Y S Water meter readings,if available(last two year's usage(gpd):Y9 Sump Pump(yes or no):-6(0 ` ` ' °j a Pa •,s . Last date of occupancy: c.c o s / u5 c o. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_ opd (Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: _ Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped Ls part of inspection.(yes or no)A10 741 If yes,volume pumped: gallons Reason for pumping: TY 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of.DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: s Sews"odors detected when arriving at the/site:(yes or no) At* �/ 1 /�/O�c, Si.�/C i''` �w3 t.w cw.l. 1 S -f-".,A i H-io c�ry W c f l� 'Iti...�" �.�Lo,}�•..... r r/.. ✓l,'1 v 4", �+ + h N� n, STO r.' e.�� �v'OSIsr..S W:�. dvy G.Je l( rS kNOI./� Per QW+.Gr 6✓�' �' . a✓c�rw,�'�c,� oh / / �.l �'1/ n1 W�r11. act J/'/IIt,cr U/C c�✓'y NJs/I. �t �i'/���N�Acc.�/.cJ w� rz bA?- d: r /�.-.C�d� ar ✓ w��o�dt „ revised 9/2/98 Page 6of11 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 40 First Avenue, West Hyannisport,MA Date of Inspection: Edwin&Dorothy Gozonsky BUILDING SEWER: May 5, 2000 (Locate on site plan) Depth below grade: /8" Material of construction:-31—/.ast iron Z40 PVC other(explain) Distance from private water supply well or suction line Diameter C/ Comments:(condition o/fI--joints, venting, evidence of leakage,etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:-�/-oncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions:_ � ,��x �jh�G ' S"d any C'1/6 r^ Sludge depth:_ Distance from top of sludge to bottom of outlet tee or baffle: -3 Scum thickness: A10A1 Distance from top of scum to top of outlet tee or baffle:A10 5 c-J v� Distance from bottom of scum to bottom of outlet tee or baffle: ^!o s c- J&4% How dimensions were determined: loe%d -i- Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structuralintegrity, evidence of leakage,etc.) t/ L ;, I ( ,� u�r� J J, c,i o✓ -�L t W h o ' i h GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) 71 revised 9/2/98 Page 7of11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 40 First Avenue, West Hyannisport,MA Date of Inspection: Edwin&Dorothy Gozonsky May 5,2000 TIGHT OR HOLDING TANK: il�(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in.working order:Yes No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: _ Comments: (note•ff level and distribution is equal,evidences of solids carryover, evidence of leakage into or out of box,etc.)—'a- PUMP CHAMBER: k (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8oru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 40 First Avenue, West Hyannisport,MA Date of Inspection: Edwin&Dorothy Gozonsky May 5, 2000 SOIL ABSORPTION SYSTEM(SAS):-3e/ (locate on site plan,if possible; excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number:_ leaching chambers,number. Z - CG 1 4-yC leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of sal, signs of hydraulic failure,ley I of ponding, damp soil,condition of vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) PRIVY:-A/✓,, (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding; condition of vegetation, etc.) revised 9/2/98 Page 9or11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM pVSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 40 First Avenue, West Hyannisport,MA Dace of I"spectia": Edwin&Dorothy Gozonsky May 5, 2000 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) M�.J rs—o�y'Lila" �—wk- revised 9/2/98 Page 10of it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirxmd) Property Address: Owner: 40 First Avenue, West Hyannisport,MA Date of kapecdon: Edwin&Dorothy Gozonsky May 5, 2000 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 . Estimated Depth to Groundwater N 4-Feet Please indicate all the methods used to determine High Groundwater Elevation: VObtained from Design Plans on record VObserved Site lAbutting 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 V/ Used USGS Data Describe how you established the High Groundwater Elevation. (Must/be completed) 4-tS Sh l„✓t.J� kp w.. �t� 0. 4 /Q • O LO `7/�J1++ C1) /tU L ,H� W S 5 v A k. 1jw) vl4 + Ia a 1-tcA t6% %Lt h � C nJI w t revised 9/2/98 Par 11 of11 , No. �� Fee 40 .00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for 30igaal *pgtem Construction Vermtt Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 40 1st Ave W. Hyannisport Mr Gozonski Assessor's Map/Parcel Instal':Nalnee i�Z re s,and T e o.t i c S 2 r V Designer's Name,Address and Tel.No. P.O, box 1089 Centerville Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(no Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) install a 1 , 500 g a 1 tank, d-box and 3 high capcity stonepacked infiltrators. 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 Certifi- cate of Compliance has been issued by this B ordef ILealth. Signed Date Application Approved b Date Application Disapproved for the following reasons Permit No., %�— �7` ✓ _ Date Issued P. No. Fee 4 0.0 0 � � `-'� ; THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Miopool *pgtem Congtruction Permit f Application is hereby made for a Permit to Construct( )or Repair(x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 40 1st Ave W. Hyannisport Mr Gozonski Assessor's Map/Parcel lVa! .Nqg&bldTrel Oann4 TteptiC Sery Designer's Name,Address and Tel.No. P.O. box 1089 Centerville 775-8776 Type of Building: . r Dwelling No.of Bedrooms 3 Garbage Grinder(ncy Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) r Other Fixtures " 1� Design Flow gallons per day. Calculated daily flow gallons. 'flan Date Number of sheets Revision Date Title - Description of Soil ! sand J_ ' Nature of Repairs or Alterations(Answer when applicable) install a 1 ,500 gal tank, d-box "and 3 high capcity stonepacked infiltrators. Date last inspected: Agreement: : z, 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 Certifi- "> cate of Complian5p has been issued by this Bo d Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 9tY-- Date Issued —— ————— ———————————————————————— ——— - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(x)on by Installer W.E. Robinson Septic Sery at40 1st Ave W. Hyanni sport has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constructio rmit No. datedd Date Inspecto THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAff THE SYS- TEM WILL FUNCTION SATISFACTORY. _ —f N. �—--�------------------f�—------�— /Fee• 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mtgoal *p5tem Construction Permit Permission ishereby granted to W.E. Robinson Septic Sery , to construct( )repair(x)an On-site Sewage System located at No.# 40 1st Ave W. Hyannisport Street and as described in the above Application for Disposal System Construction Permit.V,.4 No. Da The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. i All construction must be completed within three years of the date below. t Date: M %� Approved y ' Board of Health 1 S CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I W.E. Robinson Sr , hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at 40 1st Ave W. Hyannisport meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. ` SIGNED: I DATE: L� LICENSED SEPTIC-SYS`I'EM INSTALLER IN-I"ME-TON"Or BAIL*ISTABt::':I+IUNI..ER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. Qy r. P� 46 LOCATION SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S NAME & ADDRESS c Z- O UlLDER ��" Nip ER V e��r� DATE PERMIT ISSUED �2L Z)?v DATE COMPLIANCE ISSUED !� h �` � � !� '..a y'- 3d Lf-d No................ Fins............................. ° THE COMMONWEALTH OF MASSACHUSETTS BOAR® !-IEA Ti-I .................... .................OF............Q�J/1^t. ..... .. tr-_---.-_---_-...-- Appliration for Di ipaaal Works Tow3trurti n runfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Ieati�Address or Lot No. ..... .......... .—.......................................................................... ----------•••--------.........................._............._......_........._............-----•. W GOwner Address .............. '..�...--- = e.4- - -- ----------------------------------------- Instal r Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.....?...................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Pa Other fixtures ..--••-••.................•••••. - W Design Flow............................................gallons per person per day. Total daily flow.......................-....................gallons. WSeptic Tank—Liquid capacity............gallons Length--------_----- Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area-_-____--_--------sq. ft. Seepage Pit No--------------------- Diameter-_.-___--__--------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil... ( Yl c` l - - -- - -- -.................... .. .. . .... ........ . .... ................... x U ----•-•-•••-•-••-••------••-----•-•---••----••------------•--••-----2.4 --- ..••-•--•----...----••---•-•-----•-••-----•--•-••---------•--•-•------•-••-•----••......•---••............... UW --------------------------------------------------------------------------------------------------- --------- ------------------••---•-••-•--•---•--••--............ Nature of Repairs or Alteratipns— er en appli bl ,: - -- 4 d d ........................� ------------------- �--- -- _ �v_ .---------. .......-- Agreement: G ~L l�i►� The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions o£ii T'p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bfn issued y the board of health. Sl = .�...� O Date Application Approved By---•- J- �y __ Date Application Disapproved for the following reasons:............ _.................................._...._..........._ Date Permit No. --------------- Issued.., - �-------------•----- Date No........................ Fxs... ................. . THE COMMONWEALTH OF MASSACHUSETTS BOARD,.,OF• HEA TH .... � ..................OF.. P9f.'` .r. e�'��' ........................ Allpfira#ion for Dispersal Works Tomitrurtton rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: a L cation-Address r or Lot No. A . _ �' .............................................. ................................... _.._........__......_......._.....__.......__. ------- - ------ W Owner . -----..Address a .....-------•-------•------- ins er Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----------•-------------------------------------------•••---••••-••••••---•.........-------•--•-----•-•----- W Design Flow............................................gallons per person per day. Total daily flow.............................._.............gallons. WSeptic Tank—Liquid capacity—_........gallons Length................ Width................ Diameter_------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No.___-_-_-_-.-____.- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ' 1 Percolation Test Results Performed by-------------------------------------------------------------------------- Date...................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch, Depth of Test Pit.................... Depth to ground water_-- .................... r- •-••••••--- ••--•- ODescription of Soil ' s` __._ +.�..2j ?�"e_..............................................................-•---•-----••-••-•----•-........................................... x V •--•-•--••••••••••-•-•--•---•••---•-••.....-•-•-••------•--•••----' ---...................................-------------------------------- ------------------------------------•-•-•••-•••--•-•--•-- UW •--•••••-•----------•-------•-••-------------•••------•••---------••--•-•••......------•--•••..... Nature of Repairs or Alterations� swer hen applicable ., 'h � -- ------ 4 --�`":-a----------.. i Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the isionsrov of TITLE, p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until,'a Certificate of Compliance ha en issuepy the board of health. Si : ed-•--•- ......................... --------------•---------------•--•---•--- -- � � Date Application Approved By------ ----- _,__ ............................. Date Application Disapproved for the following reasons_________________________ _ _______...__._ ---•-----------------------------------------------------------------•---••------•--------------------------•-•--••••-•-••---•••----•-••------••••......••••-•--•••••----•------•...---------••--------- Date 4 Permit No......................................................... Issued_--= ! Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ....................... " ::............ � Tntif iratr of Tomplittnrr TIkkrS IS TO 17ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired c In 1 ! - - -•----- ----•-------------------•--------------- has been installed in accordance with the provisions of TI:L:; j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No________________•_•_-___:....__..___._... dated__..___._....._______..___..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL UNC ION SATISFACTORY. .DATE... - Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT .... ............OF......� �........................................... �................. No._........ ...... FEE... ................... �iapap or ,, TaniAr ion rr ti Permission is hereby granted._.. _--- ---------' ' .,! ` to Construct ( or Re air. 'an .ndividual Sewage. _isposal System ..� ......................... Street as shown on the application for Disposal Works Construction P i N _ Dated------- _f r ----- .,-e94 - �. .z.. -,--------------------------- Board of Health DATE... _3 FORM 1?55 HOBBS & WARREN. INC., PUBLISHERS r 75- � - Ur`, 1500 GALLON J �^ BSMT SEPTIC TANK N m W S 0 N (EFFECTIVE LENGTH) ZOf U t\ 75.. GARAGE O LJJ v> 00 a w NO BSMT CL.'(n O w 00 L m SAS RESERVE �w - `n zo SEE SHEET 1 Z = o LjjCV - � Of - Q INSPECTION PORT STANDARD INFILTRATOR CHAMBER w .DISTRIBUTION BOX D N Q MOUND FOR PROPER DRAINAGE ESTABLISH VEGETATIVE LOVER Q Ln < L� In Ld TOPSOIL TOPSOIL �/ 6' MIN., NpN-TRAFFIC AREAS tl ( * o 12' MIN., H-10,LOAD AREAS � Z NATIVE UNDISTURBED I N NATIVE SO.O' W J 00 Q BACKFILL EARTH BACKFILL CoIn co 102' MIN. O ~ [Y Qcn 6' � 0_ Q �-- R6L s' TWO STD. INFILTRATOR 1 5 9 N w o0 INFILTRATOR STANDARD DETAIL TRENCES - 8 INFILTRATORS PER TRENCH, NO STONE v NOT TO SCALE PROPERTY LINE SEPTIC SYSTEM DESIGN DATA SEPTIC SYSTEM DIMENSION DETAIL SEWAGE FLOW ESTIMATE GENERAL NOTES SOURCE UNITS GPD/UNIT QTY GPD COMMENT SINGLE FAMILY RESIDENCE BEDROOM 110 4 440 310 CMR 15.02 (13) 1. ALL MATERIALS AND CONSTRUCTION METHODS SHALL 4. THE LOCATIONS OF UNDERGROUND UTILITIES SHOWN 6. IF RIZONSNTERED. REMOVE ALL UNSUITABLE SOIL, S & B CONFORM TO THE PROVISIONS OF THE COMMONWEALTH ON THIS PLAN ARE APPROXIMATE, AT LEAST 72 HORIZONS FROM BELOW THE SAS PROPOSED ELEVATIONS TOTAL ESTIMATED PEAK DAY FLOW 440 GPD - NO GARBAGE GRINDER OF MASSACHUSETTS ENVIRONMENTAL CODE TITLE V. HOURS PRIOR TO ANY EXCAVATION FOR THIS AND WITHIN 5 FEET IT THE PROPOSED LEACHING SEPTIC TANK PROJECT WORK, THE CONTRACTOR SHALL MAKE THE SYSTEM. `REPLACE WITH CLEAN SAND FILL MEETING 2. EXCEPT AS OTHERWISE NOTED, ALL PROPOSED REQUIRED NOTIFICATION TO DIG SAFE (1-800-322- SHE REQUIREMENTS OF 310CMR 15.255. SEPTIC SYSTEM PIPING SHALL BE 4" ' SCH40 4844). AND THE BARNSTABLE WATER COMPANY FOR VERIFICATION OF LOCATIONS. TOTAL FLOW X DET. TIME = 440 GPD X 2.0 DAYS = 880 JUSE 1500 GALLON TANK PVC SET TO THE LINE AND INVERT ELEVATIONS 7. WATER SUPPLY FOR THIS LOT IS PUBLIC WATER RE-POSITION EXISTING 1500 GALLON TANK SHOWN. THE MINIMUM PITCH OF-PIPES CARRYING 5. CONSTRUCTION OF THE SEPTIC SYSTEM'SHOWN ON CONNECTED AT THE STREET:LINE IN THE APPROXIMATE N SOIL ABSORPTION SYSTEM SEWAGE OR SEPTIC TANK EFFLUENT SHALL BE 1/8TH THIS PLAN IS SUBJECT TO THE INSPECTION OF THE LOCATION SHOWN_ THE PROPOSED SEPTIC SYSTEM SOIL ZO INCH PER FOOT IF NOT OTHERWISE NOTED. TOWN OF BARNSTABLE HEALTH DEPARTMENT AND ABSORPTION SYSTEM IS'NOT TO BE LOCATED WITHIN 150' OF N PROPOSED 4 BEDROOM SYSTEM = 440 GPD SYSTEM DESIGNER. NO PART OF THE SEPTIC SYSTEM AN'EXISTING PUBLIC OR PRIVATE_WATER SUPPLY. j PERC RATE = 2 MIN/INCH (CLASS I TYPE SOIL = 0.74 GPD/SF) 3. PRIOR TO CONSTRUCTION OF THE SEPTIC SYSTEM SHALL BE BACKFILLED OR MADE INACCESSIBLE UNTIL .74 GPD/SF = 594.59 SF REQUIRED DEPICTED ON THIS PLAN, THE CONTRACTOR SHALL INSPECTED AND APPROVED BY BOTH. THE 440 GPD a 0.74 GPD 594.59 SF - LF (CHAMBER REDUCTION RATING) = 91:05 LF REQUIRED OBTAIN A DISPOSAL WORKS CONSTRUCTION PERMIT CONTRACTOR SHALL-SCHEDULE INSPECTIONS AS FORM THE TOWN OF BARNSTABLE BOARD OF'HEALTH. REQUIRED. 91.05 LF =. 6.25 LF (CHAMBER LENGTH) = 14.56 CHAMBERS OR 15 CHAMBERS TOTAL W NOTE: FOR NEW CONSTRUCTION, NO SYSTEM SHALL BE CONSTRUCTED WITH A SOIL ABSORPTION SYSTEM AREA OF LESS THAN 400 SF OF ACTUAL CHAMBER BOTTOM AND SIDE WALL AREA. O p o Z o w 15 CHAMBERS x 25 SF/CHAMBER(4 SF/LF x 6.25(CHAMBER LENGTH)) = 375 SF OF SYSTEM SOIL TEST DATA „1 (N LtJ AREA < 400 SF ¢ - _ 400 SF _ 25 SF/CHAMBER = 16 CHAMBERS REQUIRED = 100 LF OR 2 ROWS OF 50 LF (8 DATE: 1.Z�3�04 - P108'65 Li m Z w _r U) CHAMBERS.PER ROW) EXCAVATOR: HAND EXCAVATION a Y N a ci o L 1 B.O.H. AGENT: 'D. STANTON (BARNSTABLE) o 2: o 0 o 105 _....... .... .._...... . _. . ._...... .... ._...... __ .................. ..... ........... .... ........................ ... ....... ENGINEER: D. THULIN TOP FOUNDATION 103.00, RES. RISER TO WITHIN 6' OF FIN. GRADEI = TI - T r7 j F FINISH`GRADE EXISTING LIOCA ON' TP 1 LOCATION: TP2 N } i 2'l LEVEL PIPE ;SECTION E£Ev. DEPTH EIEV. DEPTH N w V) i ( _ 101.2 0.0 Ap - SOD, ORG. LOAM 101.2 0.0 Ap - SOD, ORG. LOAM F 100.5 0.7 100.5 0.7 100 98 53 - ••- B LOAMY SAND B - LOAMY SAND wV) Q 97.77 98.5 2.7 98.5 2.7 O UZZ - I ( TOP EFF. DEPTH 97.25 Cl - COARSE SAND C7 - COARSE SAND W Q Q W j a-vvcOf V) V>O s-o.ozo 98.02 I a vvc V) N Z s-o.o�o a °� 97 25 I DEPTH g 95 5 5 7 PERC <5 MIN. IN Q O 3 a vw S-o.oio ( EFF DE H / V) 95 F... .. ........ .. . ........ ...._ s 000a -... .... ... z ....... .. I _.. ....... BOTTOM N U U 97.57 t. B T 671 DO I NO GROUNDWATER O�- i �s DIST. B X T INFILTRATORS o ¢ a a 16 S € NOTE: O U J W j INLF�� rEE 1500-:GALLON r ( IN TiNO TRENCHES - NO STONE C2 - COARSE SAND INSTALLER TO CONFIRM SOIL AND N of Q< I 10 DELOW .r.ti•. SEPTI¢',„TANK OUTLET ,TEE ^f�, 91:5 s.7 W/O,'TLET t 1'4 ,BELOW Noa'� A I 90.9 10.3 GROUNDWATER CONDITONS TO 5' MIN. BELOW I _ LIQUIDi LE=GEL _ € BOTTOM PROPOSED SOIL ABSORPTION SYSTEM PRIOR Z x O op GAS BAFFLE - _ „,„ _ „, _„ _ �,_ TO INSTALLATION. Z so _ __ ._._ _ LIQUID LEVEU _. _ LL a o\� .._._. t i _ _ _ _ __€ NO GROUNDWATER QLli >-Lf_ U 0 25.6 y .r. ` �: 20.4: 14.8 50.0' ? I w N Ir / i i ! l' .f tI . ... . ..... .... N 0 85 _......... .. . ...... y..._...... � , 0 10 20 30 40 50 60 70 80 90 100 110 120 130 00 SECTION THRU SEPTIC SYSTEM 04-084 SHEET 2 OF 2 I O (V L0 p (V 1\ (S W [n I 00 Ly) G a_ F~- � C\ 3 Lv LOT 47 W m Z = O LOT 46 ROAD Existin a g house OUTLINE OF PROPOSED HOUSE BEp U J FF=/0.3.9 ' CRAIGML V) Q 1017 �fo be remo�ed� QL1 0 o LOCUS 110.00' CYD R W < o m Q U 102.S 6'Pic fence W o ro 1 '0 10>.3 uj z: N Roi/ fence can 00 L6 12"OAK F- 00 1019 1 "OAK Q Q .. w / x SAS RESERVE CENTERVILLE 0 N W O HARBORLO LOT 44 D 101 ;EXISTING, / Lown N z ��HOUSE ' ' i ls, �' LOT 45 RELOCATE EXISTING (� c `wJ SEPTIC TANK Lawn ; Y Concre wo/kw 10"OAK USGS — HYANNIS QUAD O ! ' ! ' 100. 101.2 2000 0 1000 2000 4000 102.>i/ _... /► ON j mm' SCALE IN FEET /r �/ RELOCATED jI SEPTIC TANK ! q ASSESSORS MAP 267 PARCEL 026 _._.c_-. - cP PLAN REF: PLAN BOOK 34 PAGE 23 Edge of,oa11emen 2 t X k %% ` ' "o K LOT-43A cii F. ,' PLAN DATE: AUGUST 1893 Z 102.4 - �,✓� S E 6' Chain /ink fence O __ , O DATE OF SURVEY: OCTOBER 14, 2004 ._ .: o N MAPLE WAY j�� I �' 100.6 COMBINED LOT AREA: 13,200tSFLLJ I ,8-OAK LEGEND a GAR: /� �� DISTIRIBUTION BOX v vo v z o EXISTING CONTOUR N w �� # 5 w m a PROPOSED CONTOUR o J 101.6...................._...._.. Q Y (n Q i o K NAIL Concrete P fi%rbor 4"OAK TBM P Shed X SO.O EXISTING SPOT ELEVATION o o o TBM 01.38 F/og00% 2 , [50.0] PROPOSED SPOT ELEVATION LO LOT 42 ASSUMED DATUM NOTE: Ta o EXCAVATE AND REMOVE EXISTING SAS TEST PIT LOCATION o Cobb/esfone w0/kw0� z I- 1 100.3 CHAMBERS. ABANDON STONE IN PLACE O D F- L i/ac hedge Q w Cobb/estone apron o Z = w U Z Z Stone drMewoy co own ZONING ww> w m w o N LOT 43 DISTRICT RF-1 cn J cn z 10>.6 100.6 1007 16 STANDARD INFILTRATORS o Q Q Z)0 a IN TWO TRENCHES FRONT SETBACK 30 FT N m v v N SIDE/REAR SETBACK 15 FT o C) � 110.00' 6'Pvc fence' o CL o a a w J LOT 40 LOT 41 PXStAOFMAS rjrjN0. NQFtij,1aOf N p of o 101.3 - y>`� `s9�, AVIDz a _ DAVID s� C L ao�QfLOCATION OF SEPTIC SYSTEM FROM TFiC. ULIN r av INSPECTION REPORT MAY, 5 200� No.39403 2997g y a 9 CIVIL - 1-- o uj 20 0 10 20 40 80 '� .o S7EQ �FwQ N 3 0 ( IN FEET ) 00 1 inch = 20 ft. 04-084 SHEET 1 OF 2' _ - 20 9 ' (n 75" i>; a. _ I J 1500 GALLON - BSMT SEF7IC TANK CL N 0) _ O (EFFECTIVE LENGTH) U 75" -' GARAGE (If � w to 00 r w NO BSMT w Co O w °�° Of W o SAS RESERVE cn SEE SHEET 1 Z = o r N -f U in LliINSPECTION PORT STANDARD INFILTRATOR CHAMBER X � N W DISTRIBUTION BOX Q MOUND FOR PROPER DRAINAGE ESTABLISH VEGETATIVE COVER Q L0 Q L` i Lc) O W vL vl. cn 00 Z • p U Off TOPSOIL TOPSOIL 6' MIN., NON-TRAFFIC AREAS LL ), } U 0 12' MIN., H-10 LOAD AREAS f- J ZZ N NATIVE UNDISTURBED NATIVE00 50.0' w S J � .. O BACKFILL EARTH BACKFILL 1 0- g S• :: }p '• 102- MIN. "• OfQ U) "6 •5' TWO STD. INFILTRATOR �+ �j c�' a cal w o INFILTRATNR STANDARD DETAIL TRENCES - 8 INFILTRATORS 4 PER TRENCH, NO STONE x `� NOT TO SCALE PROPERTY LINE I SEPTIC SYSTEM DIMENSION DETAIL SYSTEM DESIGN DATA SEPTIC_ i SEWAGE FLOW ESTIMATE GENERAL NOTES SOURCE UNITS GPD/UNIT CITY GPD -,COMMENT AL " 4. THE LOCATIONS OF UNDERGROUND UTILITIES SHOWN 6. IF ENCOURNTERED;REMOVE ALL UNSUITABLE SOIL, Ap & B _ SINGLE FAMILY RESIDENCE BEDROOM 110 4 440 1. ALL MATERIALS AND CONSTRUCTION METHODS SHALL 310 CMR 15.02 (13) CONFORM TO THE PROVISIONS OF THE HODS WL'OI ON THIS PLAN ARE APPROXIMATE AT LEAST 72 HORIZONS FROM BELOW THE SAS INVERT ELEVATIONS HOURS PRIOR TO ANY EXCAVATION FOR THIS AND WITHIN 5 FEET OF THE PROPOSED LEACHING TOTAL ESTIMATED PEAK DAY FLOW 440 GPD - NO GARBAGE GRINDER OF MASSACHUSETTS ENVIRONMENTAL CODE TITLE V. SEPTIC TANK PROJECT WORK, THE CONTRACTOR SHALL MAKE THE SYSTEM. REPLACE WITH CLEAN SAND FILL MEETING r REQUIRED NOTIFICATION TO DIG SAFE (1-800-322- THE REQUIREMENTS OF 31OCMR 15.255. 2. EXCEPT AS OTHERWSE NOTED, ALL PROPOSED 4844), AND THE BARNSTABLE WATER COMPANY SEPTIC SYSTEM PIPING.SHALL BE 4- 'SCH40 j FOR VERIFICATION OF LOCATIONS. . 7_ WATER SUPPLY FOR THIS LOT IS PUBLIC WATER TOTAL FLOW X DET. TIME = 440 GPD X 2.0 DAYS 880 USE 1500 GALLON TANK PVC SET TO THE LINE AND INVERT ELEVATIONS SHOWN. THE MINIMUM PITCH OF PIPES CARRYING . I 6. CONSTRUCTION OF THE SEPTIC SYSTEM SHOWN ON CONNECTED AT THE STREET LINE D THE APPROXIMATE Z SOIL ABSORPTION SYSTEM RE-POSITION EXISTING 1500 GALLON TANK LOCATION SHOWN. THE PROPOSED SEPTIC SYSTEM SOIL .SEWAGE OR SEPTIC TANK EFFLUENT SHALL BE 1/8TH THIS PLAN IS SUBJECT TO THE INSPECTION OF THE � INCH PER FOOT IF NOT OTHERWISE NOTED. TOWN OF BARNSTABLE HEALTH DEPARTMENT AND ABSORPTION SYSTEM IS NOT TO BE LOCATED WITHIN 150' OF N PROPOSED 4 BEDROOM SYSTEM = 440 GPD -SYSTEM DESIGNER. NO PART OF THE SEPTIC SYSTEM AN EXISTING PUBLIC OR PRIVATE WATER SUPPLY. 5 ti PERC RATE = 2 MIN/INCH (CLASS 1 TYPE SOIL = 0.74 GPD/SF) 3. PRIOR TO CONSTRUCTION OF THE SEPTIC SYSTEM SHALL BE BACKFILLED OR MADE INACCESSIBLE UNTIL W 440 GPD _ 0.74 GPD/SF = 594.59 SF REQUIRED DEPICTED ON THIS PLAN, THE CONTRACTOR SHALL INSPECTED AND APPROVED BY BOTH. THE 594.59 SF - 6.53 SF/LF (CHAMBER REDUCTION RATING) = 91.05 LF REQUIRED OBTAIN THE T S AL AR CONSTRUCTIONKS PERMIT CONTRACTOR SHALL SCHEDULE INSPECTIONS AS TOWN OF BARNSTABLE BOARD OF HEALTH.` R OUIRED. 91.05 LF a 6.25 LF (CHAMBER LENGTH) = 14.56 CHAMBERS OR 15 CHAMBERS TOTAL w " NOTE: FOR NEW CONSTRUCTION, NO SYSTEM SHALL BE CONSTRUCTED WITH A SOIL ABSORPTION SYSTEM AREA OF LESS THAN 400 SF OF ACTUAL CHAMBER BOTTOM AND SIDE WALL AREA. p 0 p Z o Ij «^ 15 CHAMBERS x 25 SF/CHAMBfR(4 SF/LF x 6.25(CHAMBER LENGTH)) = 375 SF OF SYSTEM SOIL TEST DATA „) 04 w AREA < 400 SIF } N 400 SF _ 25 SF/CHAMBER = 16 CHAMBERS REQUIRED = 100 LF OR 2 ROWS OF 50 LF (8 DATE: 12/3/04 - P10865 W o LLI J CHAMBERS PER ROW) EXCAVATOR: HAND EXCAVATION a Y N a ci o ' B.O.H. AGENT: D. STANTON (BARNSTABLE) o o coil o ......._.._..._............................_........_..........._.._..........................._._..............._..........._........._........._............._.........,._..............................._._._......................._................................._...:......................................._._........._..............._..........._.._._..................._............................_.................. 105 - 1. t ] ; ENGINEER. D. THULIN TOP FOL NDATION 103 00 RES. RISEF{ TO WITHIN 6' ..OF FIN. GRADE ( € N }j s s IFINISH GRADE = EXISTING CiOCATION: TP-1 LOCATION: TP2 2' LEVEL PIPE :SECTION € Ap - SOD, ORG. LOAM Ap - SOD, ORG. LOAM Z o E EV. DEPTH ELEV. DEPTH 101.2 0.0 101.2 0.0 O H Q { 100.5 0.7. 100.5 0.7 F=J w � _. J I k • E I - L� NLOAMY SAND ;z100 98.53 B - LOAMY SANG B L) =�.40 07.77 .5 2.7 98.5 2.7 Z98 U Z Z - TO EFF. DEPTH 97.25 Cl - COARSE SAND Cl - COARSE SAND w`` Q Q ILL, IY/ V)gN € ePVC t t : - y I�J�Z S-0.020 98.d2 Ld s�-oo,0 97.57 4^PK 97€125 F I 95.5 5.7 PERC <5'MIN./IN Q _ I 4 Pvc' s-o.oio _......_... __BOT EFF. DEPTH 96.71 1 ( -o.000 ! BOTTOM U U H ............._.._.......... ....:......... 95 - __.._.......__................_....._..._......................................._..........._.,..................._....._ .............._....................................._................_..................................._.............._e. { I NO GROUNDWATER Q Q i I DIST. BOX 16 STD. INFILTRATORS I ,!� € U V) o U J w IN TWO TRENCHES - NO STONE C2 - COARSE SAND INSTALLER TO CONFIRM SOIL AND Q NOTE: Of N JO<Q INLET TEE 1500 GALLON - OUTLET TEE g 91.5 9.7 GROUNDWATER CONDITONS TO 5' MIN. BELOW Z Q 10" BELOW SEPTIC TANK € 90.9 10.3 1 W/OUTLET 14" BELOW I BOTTOM PROPOSED SOIL ABSORPTION SYSTEM PRIOR ZQ O�� LIQUID LEiVL GAS BAFFLE -_ _ ___ b. ----. TO INSTALLATION. Z - } _ L101tt1 13EVELL _ _� _.._- _ _ L, U w 90 ; __ ¢ __ ) -._ I _ f NO GROUNDWATER J = I ( d t O O p ( ; 25 6 20.4' 14.8 50.0' ! l uj_ w o t 8s -........ I :,. .. ....... .... .. .._. . . ........... . . . . ... . ..... ....: .._. cn o 3 00 p 10 20 30 40 50 60 70 80 90 100 110 120 130 SEC-T��`ON TH RU SEPTIC SYSTEM o4-084 SHEET 2 OF 2 7