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Home My WebLink About0135 FIRST AVENUE (HYANNIS) - Health 135 First Avenue Hyannis F/R A = 266 023001 r" 1 r:yI�: '• TOWN OF BARNSTABLE - 0 0 LOCATION 3 SEWAGE # VILLAGE lr� i�sv'✓�1'P��T ASSESSOR'S MAP & LOTS 011 fad INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:-(type)/�� (size) �•�>t�oiYe2 NO.OF BEDROOMS _J_ BUILDER OR OWNER PERMITDATE: '2 S''�� COMPLIANCE^DATE: 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility / Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) „/ Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by a 0 e v- �r :, (✓ rw� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for �Digpogal *pgtem Congtruction Vermtt Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) Complete System O Individual Components Location Address or Lot No. * f jr— Owner's Name,Address and Tel.No. Assessor's Map/Parcel .7 3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms S" Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow d'9.x gallons per day. Calculated daily flow gallons. Plan Date 9 Q r o,X Number of sheets / Revision Date Title Size of Septic TankType of S.A.S. ;,-,P1YA -c c --,ee-7Y-" 41Ae,*,eeorx s Description of Soil 1 3X b 6 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed d Date 3 Application Approved by - Date Application Disapproved for the following reasons Permit No. Date Issued F No. ee THE,CCOMMONIIVEALTH OF MASSACHUSETTS ) Entered in computers Yes PUBLIC HEALTH DhV.ISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZppYicatidn for i Po aI *pgtem notruct on i3ermit Application for a Permit to Construct( )Repair:( )Upgrade( )Abandon( ) 25Complete System ❑Individual Components LocationAA(ddress or Lot No. l Owner's Name,Address and Tel.No. Assessois Map/Parcel 2�6/ O -J� O O� A ep �°/ �`saPG-`1'7' Sri �ryr�•►��rapo�T Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms S Lot Size sq.ft. Garbage Grinder( ) Other j� Type of Building �°e P- 'No.of Persons Showers( ) Cafeteria( ) Other Fixtures ! Design Flow gallons per/day. Calculated daily flow "� so gallons. F' Plan Date A a _P o� '" Number of sh ets ",f Revision Date Title Size of Septic Tank /Too�4,Ll. Type of S.A.S. ?'no 9A e. a o•�a•P�7Y C/l�Nis�l�.r r Description of Soil t 1 )(b 6 o'J) ' i Nature'of Repairs or Alterations(Answer when applicable) }`A C Date last inspected: E 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 Board of Health. J Signed Date Application Approved by W. //li Date Application Disapproved for the following reasons r✓� r " Permit No. � 1 Date Issued -----rr ------------------------- 1^1P ck� �11/�J T'HE COMMONWEALTH OF MASSACHUS a ETTS 3 i _b 'P cl�r„ BARNSTABLE, MASSACHUSETTS C7 Certificate of Compliance THIS IS TO CERTIFY, thaf"the On,site Sewage Disposal System Constructed Repaired( )Upgraded( ) Abandoned(. )by i .0 tcP e,4/ at ,*'.3 ---f Andt- has n constructed 'n accor nce with the provisions of Title 5 and the for Disposal System Construction Permit No. dated _Installer Designer .D ,ro 4'-r The issuance of this pe t sha f not be construed as a guarantee that the system w'1� sIdt ed. Z . Date �' S v 3 Inspector No.� � -----------------------Fee-�� f-2-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigozar *potem Construction Vermtt Permission is hereby granted to Construct)Repair( )Upgrade( )Abandon( ) System located at e!!rZAvP.r7• .40A.4, ,! is and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be complet d within three years of the date of thi qrmi . Date:_ Approved by i V F.V TOWN OF BARNSTABLE 1t LOCATION SEWAGE # VILLAGE L� �'�`Y" ' �T ASSESSOR'S MAP & LOT�6'e "-U I! INSTALLERS NAME&PHONE NO. ,.+, GEBoE'v/r 7,T�aZ"' . SEPTIC TANK CAPACITY LEACHING FACILITY: (type)F/c��a (size) �3 x�aXa2 NO.OF BEDROOMS J— BUILDER OR OWNER PERMIT DATE: oT COMPLIANCE DATE: �^ C) 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility / Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 1 I oN? OF //®�S'E Av 6s r No.- '�OU I � Fee `�'__'__' ---- BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVell CootructionAerm t Application is hereby made for a permit to Construct ( Alter ( ), or R pair ( )an individual Well at: Location — Address Assessors Map and Parcel -�1 _&I- ------- ---------- wner Address --------------------------- 5---- � �x - 30 °- _�� Installer — Driller Address- Type of Building Dwelling Other - Type of Building----------------------------------- No. of Persons-----------------------------— —- Type of Well---61U e -- - --- ---- Capacity---- f`S'--� -- --— Purpose of Well • ��!�v �L_ --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until ertifi ate .of ance has been issued by the Board of Health. x7A- Signed - - -- -------------- -------- ---- --- ---�-- t date Application Approved By - date Application Disapproved for the following reasons:------------------------------------------------------- ------------------- ----- -- ----------------- ----- - ------------------------------- ---date------_- Permit No.__——-------- - —--- Issued--- -- -- - - --- ---— ------------ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate (Of Compliance THIS IS TO CERTIFY, That the, �iividual Well Cso s cted ( Alte�e ), or epaired ( ) `` _ o by------------ - ---- - ------ -- - -- - - - -- -- --- Installer at------------ -------- ---------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -----------------------Dated--------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- --- - —--- --- ---- Inspector-------------------------------------—- - --- „ . i/._..t.. -'+,.Y"'.;� 's r � Y�-Y�t: -�'.v"'4 C�•rf i .I .. „•�y..l"'` ;:��.r: .�to lu�.ri�{ k,~`-'�"��ct f•�_ ♦yn.t.,'+4 6 +sp�h-�-^ti„r.^"Y"'y'+�`-� � -. ez� ` o0 f��! � �., . . No.----=`-:----------- - Fee------ - ------------ BOARD OF HEALTH TOWN OF BARNSTABLE zippCicat ion,for Iveell Construct ion permit . - Application is hereby made for permit'to Construct ( , Alter ( ), or R air ( )an individual Well at: _ PP Y P P 1.3- ----------- - - =----- - - - - Location - Address Assessors Map and Parcel 4 4/ - ----------- ----- wner� _ Address . . ” Installer - Driller Address s - ype-ofm.Building Dwelling--------- ----- -- ----_ ------- . .• - t. i Other - Type of Building-------------- ------------- 1 No. of Persons--------------.-- --------- I' Type of Well- --� f'-��_ - _---- - Capacity-------- -.��.'�----6-0�-- -- - =--— I Purpose of Well----• /-tr!�'Q �!L --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until.a--Certifica ;),MpJiance has been issued by the Board of Health. Signed - -- - -- - - 7/1- ------ - date l Application Approved By — =-�-- ---------- -- ---------- date Application Disapproved for the following reasons: =- ------------- --------------- ------- -- date —— -- - Issued---------------- Permit No. ------------------ - ----------------------_=-—------=------------ - date f�..��•,�..:®�.�•w.�..o,.-�...��.-,.�:�...o.�;...�.�,e...:....�',�...-....F�=.�=....d.... =...mow��...�..�.+�...... III. i BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of.Compliance THIS IS TO CERTIFY, That the ividual.Well Construct -d ( "A teed ), or ipaireof d ( ) Installer at- -- --- -------- -------------------------------------------------------------------------------- ---------------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ------------------------Dated---------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL ` SYSTEM WILL FUNCTION SATISFACTORY. DATE- ---- ------ -- - ---=- Inspector--------------_------------------------------ - ------------ BOARD OF HEALTH TOWN OF BARNSTABLE Yell Conorurt ion Permit No. f-�/_ Fee- --�=��-----� Permission is hereby granted-- -�rl�>li, to Construct (�' Alters ), or Repair ( ) an Individual Well at: No. --- --:) S-- --�� = —t--'�-?��"' iL`'`" -------- ------- Street as shown on the-application for a Well Construction Permit No t - -lam' 7.emu r-lv�" Dated----=- -- - - 717/V/ • --�--- — = - - ------=------ o Board of Health DATE---- --- ------- -- 7 r a Tb QF BARNSTABLE 1 ? : ��5: F1S� SEWAGE.# 'y N ,—. ` -• t �{ LOCATIO , f -' VILLAGE Ira:. WA '-sa ' ASSESSOR'S.MAP & LOT ; :"IN TALLER'S NAME&PHONE NO. s e_'d SEPTIC TANK CAPACITY 1" LEACHING FACILITY: (type) «5 (size). NO.OF BEDROOMS BUILDER OR OWNER ►" : z - ,fr 'S;;} r r j...:, r .,;;- '..• .,'...:. - Q �N crf tw csa.IL}4 t Ea;aw`,�ii°if1i PERIVITTDATE: NfR COMPL CE DATE +'N Sepaatron Distance.Between the u ' Feet° Maximum Adjusted Groundwater Table to the Bottom of Leachma Faeihty F Pnwate_Water Supply Weli and;Leachin'g-Facility y wells(If an exist � { : on site:.br within 200 feet'of leaching facility) Feet` Edge of Weiland and.Leaching Facility Of any wetlands exist within:300 feet.of.leacl;ipg facility) Feet Furr is,,ed by .t t� 1 t• e j!(9t a IIIIIIf) s'. I _ II •: U n i� June 1, 2001 Glen Harrington Public Health Division 367 Main Street Hyannis, MA 02601 Dear Mr. Harrington: Per your conversation with my assistant,Heidi Matton, I have enclosed the Official Title 5 Inspection form completed on my recently purchased property at 135 First Street,Hyannisport. As she explained to you,the inspection was completed on the 26 h of April and we misplaced the forms, failing to file them during the 30 - day period as expected. I apologize for any inconvenience this has caused you or your department. Thank you for your acceptance of these forms outside of the filing period. I appreciate your assistance with this matter. Sincerely, Hamilton Shepley Opp r DIP C 216 Thornton Drive, Hyannis, MA 02601 — (508) 862 - 6261 �� COMMONWEALTH OF NL4.sSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A L CE�R,TIFICATION Property Address: Owner's Name:Owner's Address: Date of Inspection: ;,' /y41 o / Name of Inspector: (please rint) 1411 l Company Name: i /_1zA 1 T Mailing Address: 6 d E M7" Telephone Number: n l ;4�� dio CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F 'Is �J 1I Inspector's Signature: Date: 1 Z 1 The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. —_ Notes and Comments L � �. v c_i;Z, 0-0 ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not add[ess how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1/ iv�lL 5 / Owner: Date of Inspection: i Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D ZI Passes: e not found anv information which indicates that anv of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more gystem components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is 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. . ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed -- -.distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: _ rL "� Date of Inspection: <//rZ 6 / �+ / i 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 P P �'Y 5 5 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3 Other: 3 G Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEMMINSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner• Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _;k— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ K Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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 SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. �. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Tom__ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria r l are triggered.A copy of the analysis must be attached to this form.] V'' (YeslNo)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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) _= yes no the system is within 400 feet of a surface drinking water supply _ the system is within.200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(I.nterim 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. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / �� 5 T Owner: , I / i a7f Date of Inspection: ✓� �Z o�A Check if the following have been done. You must indicate`ves"or"no"as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health `( Were anv of the system components pumped out in the previous two weeks ? �< Has the system received-normal flows in the previous two week period? . Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? L _ Was the site inspected for signs of break out? Were all system components, exec"4' located on site ? _ _X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria_rlated to Part C is at issue approximation of distance is unacceptable) [310 CMR I5.302(3)(b)] 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION y Property Address: 7- Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):�J Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): > Number of current residents: L� Does residence have a garbage grinder(yes or Is laundry on a separate sewage system (yes or no _ (if yes separate inspection required] Laundry system inspected(yes or;'o _ Seasonal use:Cei_�s or no):Water meter rngs, if available(last 2 years usage(gpd)): Sump pump(yes or-O Last date of occupancy: l�rf�,� 5�9r•�,:n (�.. COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes o no If yes,volume pumped: gall'ons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Septic tank,distribution box, soil absorption system _ Single cesspool _..Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate a e of all components, date installed(if knownod4ource of information: ,-7 ►'(7U� Were sewage odors detected when arriving at the site(yes or _ 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): 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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 f Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . 3 5 r/ `' T Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspectton)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or nc.): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): N 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: "> >��/�-�' 7- Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Tyge , +T leaching pits.number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): V of' section locate on site plan) CESSPOOLS. (cesspool must be pumped as part top )( p ) Number and confisuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum laver: 4 Dimensions of cesspool: X Materials of construction: _5 2 + Indication of groundwater inflow(yes or, o Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): van �%�7, At 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.): { 9 Page 10 of 11 OFFICIAL INSPECTION FORM DISPOSAL SOY STEM INSPECTION FORM VOLUNTY ASSESSMENTS SUBSURFACE SEWAGE DISO PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM reference landmarks or sketch of the sewage disposal system including ties.to at least two permanent Provide a enters the building. benchmarks.Locate all wells within 100 feet. Locate where public water suppl y. en i 7 S J � j � \ 1 4 �A;1; 10 Page 11 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 1` Date of Inspection: H-'Zip//0,' / SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water Ll/ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting 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 ,c I1 - S • COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. y DEPARTMENT OF ENVIRONMENTAU PROTECTION Co 101 A� ' a � TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAI�SYSTEM FORM PART A CERTIFICATION Property Address: /� I � AZ' FAILED INSPECTION i Owner's Name: L'L i D/_ry _ _ alb Owner's Address: RECEIVED Date of Inspection: d 12,44 d l R! , 2"".. Name of Inspector: (please_ rint) kill WBM Company Name: �� W-47 TOWN OF BARNSTABLE Mailing Address: o ;Z HEALTH OEPT. e. ✓riy— Telephone Number: `�� I,f�,'� a)U CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:. Passes Conditionally Passes . Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 1.7,6/ The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or .DEP_)within 30 days of completing this inspection.If the system is a shared system,or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the -= DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,-and the approving authority. Notes and Comments 0 t` 5 iNC:� OM ****This report only describes conditions at the time of inspection and under the conditions of use at that i time.This inspection does not address how the system will perform in the future under the same or different i conditions of use. R i Title 5 Inspection Form 6/15/2000 page 1 r ' Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /l, L, CERTIFICATION (continued) - Property Address: l f /' ��L 5 / 2 Owner: GAT�"TJ Date of Inspection: Z-o Inspection Summary:'Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy m Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or ... obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed --- :— distribution box is leveled or replaced ND explain: ` The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 ti Page 3 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /CERTIFICATION(continued) Property Address: /L"r7T / Owner: Date of Inspection: (� C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a su_rface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 f — Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection 1241d D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z 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 SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (YesfNo)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• You must indicate either"yes"-or"no"to�each of the following: - The followingcriteria applyto la1 e s stems in addition to the criiena above - r — . yes no the system is within 400 feet of a surface drinking water supply the system is withir.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 11 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. 4 f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: & FV cy Date of Inspection: Z'd Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received-normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up i Was the site inspected for signs of break out? Were all system components,e- located on site ? _ _X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes n Existing information. For example,a plan at the Board of Health..- Determined in the field_(tf any of the failure cntena r lated to Part C is at issue approxtmatton.ofdistance is unacceptable)[310 CMR 15.302(3y(b)] _. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /47— Owner: Date of Inspection: 2 d FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): J 33� DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 1/) - Does residence have a garbage grinder(yes or&_ Is laundry on a separate sewage system(yes or o — [if yes separate inspection required) Laundry system inspected(yes oroo ..— Seasonal use: ye)or no):— Water meter re"adings, if available(last 2 years usage(gpd)): Sump pump(yes ory— Last date of occupancy: f.,, y-t- COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes o no If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool" _ - - .. =Overflow cesspool - _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank —Attach a copy of the DEP approval —Other(describe): Approximate a e of all components date installed(if known) d� cce f information: Were sewage odors detected when arriving at the site(yes or 6 Page 7.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �SYSTEM I,N�FORMATION(continued) Property Address: Owner: Date of Inspection: LG d 1 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,.evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:—concrete—metal_fiberglass polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: - How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage, etc.): GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: concrete metal—fiberglass_polyethylene_other _ Dimensions: Scum thickness: - Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /3 ! /- T Owner: 6Jvv� Date of Inspection: 2� 1 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): 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.): •-. ..-.�� .�..� _ sue. .. _ _ � _ 8 J L C Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C nn��SY,�S//TEM INFORMATION(continued) Property Address: / r//� Owner: L'Im' Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):Zoocate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): V CESSPOOLS: (cesspool must be pumped as part of mspection)(locate on site plan) Number and confieuration: d to inlet invert:Depth—top of liqui Depth of solids layer: Depth of scum laver: Dimensions of cesspool:_ X Materials of construction: t- h�1c Indication of groundwater inflow.(yes or o Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): TrL� f '79,— h � � •— 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.): ..9 Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /, Fz/ftr Owner: Date of Inspection: LG SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties-to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. a' J , e 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IIN/FORMATION(continued) Property Address: Owner: En Date of Inspection: 41,1U6 / SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting 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: -- RECEIVED ,_eUN 4 2001 TOWN OF BARNSTABLE HEALTH DEPT. June 1, 2001 Glen Harrington Public Health Division 367 Main Street Hyannis,MA 02601 Dear Mr. Harrington: Per your conversation with my assistant,Heidi Matton,I have enclosed the Official Title 5 Inspection form completed on my recently purchased property at 135 First Street,Hyannisport. As she explained to you,the inspection was completed on the 260' of April and we misplaced the forms, failing to file them during the 30 - day period as expected. I apologize for any inconvenience this has caused you or your department. Thank you for your acceptance of these forms outside of the filing period. I appreciate your assistance with this matter. Sincerely, Hamilton Shepley r 216 Thornton Drive, Hyannis,MA 02601 —(508) 862 - 6261 -LOCATION SEWAGE PERMIT NO. t7o�5 T VILLAGE 1_MSTA LLER' MA & ADDRESS - 11 R U I L D-rlt OR OWN ER DATE PER MIT~'VSSUE0 DATE OC MP-LlANCE ISSUED �. 1 � �� i �� N .BA. Fxs.....$..5.00 THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH ...................... .T.o.wn........ Barnstable.. ApplirFation for Uhip sal Works Tnnitrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: First Ave., West Hyannisport, MA 02672 ................___- ....----•--•-.................... ....- ..... .................-................................................................................ Location-A'ddress or Lot No. George C._Herst ._. . First Ave._,__West_Hyannisyort,_MA_ 02672 ............. .... .. Owner Address a A & B Cesspool.;Seryiee _128..BishoDs Terrace,,_Hyannis_,_ MA 02601 .. ....... ------ •-----•--- Installer Address Type of Building Size Lot.._ .........Sq. feet �-, Dwelling—No. of Bedrooms...............3..........................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of ersons._..-____._................ Showers YP g -------•-•----------•------- P ( ) — Cafeteria ( ) dOther fixtures ------------------------------------•-•---••--------------•--•---------------------............---------.....----• -•---- W Design Flow............................................gallons per person per day. Total daily flow............._..............................gallons. WSeptic Tank—Liquid'capacity......_.....gallons Length................ Width................ Diameter--.---_..___-__- Depth................ x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by............................................. ........................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ri Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -----------------------•--------------------------------•-•-----------......-••--••---••......•..-•......................................................... ODescription of Soil.........S44a..................................................................................................................................................... U •--••---•••........................•---------------....---•---•----•---•-•••.......--------•••------------------•-------------------•-•-•--- W U Nature of Repairs or Alterations—Answer when applicable...installation.--of--one...flmwdifussor--(pxe-. .cast)...stone-.pa.cked...wi h..extra--atone---(averlaw)-•--------------- --•---............................................................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T ITLL 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by.the board of h th. Sign I�l_ Date Application Approved By..... .--------•.••--- ............... vao--------- Application Disapproved for the following reasons:............................................... •---•--•--•-......--•......................Date ......••.... --•------•--•-•-------------------------------••••-•--------••--••--------•--•-•••--•---.......•--------•--•---------------------•-•---•-•••---...•-•----•----•-----•---------•--------•-•-•-----...... Date Permit No.........80- .... .. .... Issued.--------•--------61i?/80 Date �' 1 I ? THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............:-...._ .......OF.....B '.1St8b�A......--.-------------•---.........._.................._. Apptiration f ur Disposal Works Toustrurtiott 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: First Ave., Best Hy�isport, AA 02672 ................__...C._Herat • .._...........-------• ---------------------------.........----�-u-i--�-3•-�--O---i-'-t.....................--........................................... GeOr terstLocatio Addressor a First Ave.. West � ii- _ �lA 026Q'.2 Owner Address aA & B Cesspool3® vi�e 12 ..Iy . 26A1sf. ..... .... ... Installer Address Type of Building Size Lot.............................Sq. feet w Ing= o. of _._ ---•------:--________________ _______Expansion Attic ( )`'. Garbage Grinder ( ) Other—T e of Building, No. of persons Showers — , a Other fixtures.......................................... p 2 ( ) Cafeteria ( ) ..-- ................................................................. w Design Flow............................................gallons per person per day. Total daily flow..............................................gallons. WSeptic ,Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No...................... Width..................... Total Length...................: Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...................... frq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ DDescription of Soil.........� a---------------•-----••----------------------•--------•---•-------------------------------------•----•-------------------------------•-------•--•-•- x w U Nature of Repairs or Alterations Answer when applicable.__. t4 ls' $ �YL..Q :_QT3 ._. 11� � ---(itXV_.. ............................................................... Agreement The undersigned agrees to install'the aforedescribed Individual Sewage Disposal System in.accordance with the provisions of TITLZ 5 of the State Sanitary Code- The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issued by the board-of health L1, gn .�. . ..• ..�--�--"•-�-4r j----` ......6�17��®.--- q Application Approved By.... ---�----"•-•- ,Y-.-.---•------- ---------------------------------------- Date/$® Application Disapproved for the following reasons:............ --•-----•-----•--•--•----••••--•---•..............................••---•••••-•. .............. ---------------•----•-------------•--------•--••--•-•-------•--•--•----..........--•--••---••••-•--•--•••----•-•----•----•-•--••-•••----•--------------•-••--•--••-----••......-----•••--...-•-- Date 80 6/17/80 Permit No.. =.:....._ '...._..... _ Issued. --------•--• ' Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..:.......Towrt.............OF.............B�stable . . . ................................................. Tertifiratr of Toutplianrr TH lie TO Cg IF That end: idual ewa e Dis sal S ste ons ( red (X) A c�-B �esspoo ea i'Ce, fiy �lcshops �Ple s,' 1 bY- -- -•..... ........ .................. -- - First Ave. , Vest Hyannisport, KA 026721' George 0. Herbst at.---•---•------•-----------------------------------------•------------------------------------------------------------------------------- has been installed in accordance with the provisions of TIT 0 of tate Sanitary 91ig,��lescribed 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 FUNCTION SATISFACTORY. DATE....... .:..!.. °....................................... Inspector---•-- --••-• ,.. ....................................... } THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tom.........OF........Bmstable �0 �c'G ................................. ...........•--••........__.............••-••.............. $ 5.00 O ................... FEE........................ Disposal Works T. nnutr ion rruti# A H Cesspool Service, 128 B3, ops Terzace., Hyartmis, P.A 02601 Permission is hereby granted.................... to Con ct or R ai t a Indio u ei& s os S stem �rs� Are., �a nnnisporm, r �� P-Ve e 0. Herbst at No... eet _ /' 7/ as shown on the application for.Disposal Works Construction y3er it of . Dated.......................................... I .. - Board H-C� ..-----•------... th DATE-.......L .... ..................................................... f / FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS , F ASSESSORS MAP : ' TEST HOLE; L` 0GS C� �� ►2.1 PARCEL : OZ�j 1r._ NOTES; L OTC SOIL EVALUATOR: r 1 , f �5t]�� 0y FLOOD ZONE:-_�� WITNESS 121AUI A I1. The installation shall comply with Title V and Town of Barnstable BOH Reg's. /"� L P P , REFERENCE:� .__. �� __ \,c� DATE• 2. The installer shall verify the location of all utilities cess ools and inverts rior to PERCOLAT I N RATE;. 2-1 19 i 1 installation. y 3. This site design does not represent an structural or foundation design D�� P Y b e prepared considerations. Such to be re s. TH- i TH-2 p P y others. \ , ` 4. Zoning setbacks to be confirmed b owner/contractor/builder prior to .. g Y x �Awil construction. 5. All septic piping to be 4 inch schedule 40 PVC at 1/8"per foot. ,¢�, 5�, 6. Existing septic components to be pumped and filled per Title V Abandonment �D `` lb 2511� procedures. 7. Installation of utilities to comply with specific I p y t sp c c regulations and service provider LOCAT I ON MAP specifications. 8. At the time that the reserve septic area is required the water service and other ;o \ \ ✓1� ( G utilities to be relocated. f G `5 2 9. This plan shall not be utilized for property line determination. \� 2 �(D 10. Notification for staking foundation location shall be a minimum of 3 days prior to �g 11 << h�b 2.��.(� �. ► re h A'T 11. This plan does not represent approval for relocation of identified structure. I Approval by local code enforcement required. 12.All septic components must meet Title V specifications. I SEP:T I C SYSTEM DESIGN _,•,"DFLOW E)T I MATE �� ,,�f �,,• BE1JROOMS AT (� GAL/DAY/BEDROOM - 1 GAL/DAY SEPTIC} TANK .. / oiz G:;L/DAY x 2 DAYS - GAL 0 - -�. 0 SEPTIC TANK , N O GALL '.. USE � v i s/ SOIL t4.8SORPT ION SYSTEM _ f �� ro O 4 i 1 b V _ Uhl z ? m X : :--- 1 DE AREA. . c30TTOM AREA: - C� r ��QN I0 , f 0 = _ � 'C SYSTEM SECT •V . ,, /yam) 1 y �o?o� 15 zX r. ' r 1�5. ° - - Z 1� °� b� i GAL 1, ry f ,_ d / ( 2 � f i AD .00 SEP � y l,- r- SITE AND SEWAGE PLAN p LOCATION 1 �j, ��zo(,.�C' ZO '� l ► c�1t�- 'Y5 _ , r : PREPARED FOR : 'D .vrC� 1 •loll .rt r ~:% L�—� ,A�` r -- G L�-� — ✓�GTbo2 g C�tcJ(,,�, i g'tL,� " �0�/,5l ——j—� o \ / _ _ ' SCALE: ( - M � .: d: / �••� ), _Q2 .__.?J�r1��?�G�/�l bG�/,__D,��-_l�hl/�1�i . . �`n3__�}C�5 2 � � -�_)� �(LA -'�'� VID D B MASON,1� DATE: DZ _:.._l5 DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA W ` • l� DATE HEALTH AGENT j 3 _ / t508 ) 833- 2I77 W Z 5creen Porch Open Pori Ll iv, kv Li Li new steel beam O see engineering Outside:ohower O � O 5tora e Bedroom 1 S Down Up o� 0 window Seat I i it t cM^ lip—�11 I I ��h I I a.M Open Porch �I 1 N jrO lilt' 135 First Avenue Existing Ist Floor Hyannis, Massachusetts Lorraine & Hamilton Shepley Cottage May 3, 2005 scale 1/4" = 1' drawn by: jnb Bedroom 4 Bedroom 3 Bedroom 5 OBedroom 2 O O 0 0 0 Up 135 First Avenue Existing 2nd Floor Hyannis,i Massachusetts Lorraine & Hamilton Shepley Cottage June 4, 2005 scale 1/4" = 1' drawn by: jnb