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HomeMy WebLinkAbout0046 FISHER ROAD - Health 4 hbf Road . Iy � .�� +, + ��� ,+ .���*tip �1 1 • ann� 0 Lam, TOWN OF BARNSTABLE LOCATION (`P/ J DES er !� SEWAGE#e�Olq VILLAGE {y�/aiU/UI,S yy ASSEESSOR'S MAP&,LO-T130ed INSTALLER'S NAME&PHONE NO. �I�rF� -)ASV SEPTIC TANK CAPACITY 15C� LEACHING FACILITY:(type) (��9C I 1 d?t'r (size) NO.OF BEDROOMS BUILDER OR OWNER e- L Li PERMIT DATE: Lo /I 1 Ll COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by p a QP W Iq/' airy /✓' S 51LO k$�Yv No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYitation for Misposar *pstem Construction permit Application for a Permit to Construct( ) Repair(64upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. del Fs ¢�' r Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /p _Zgr Installer's Name Addressand Tel.No / ✓�'�¢�'``� Designer's Name,Address,and Tel.No. V-s—d Q, -Y,-_ Lev-`Q ..r.+�at6 4__e "73 Sod-7 s --?d�o?D Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in s accordance with the probisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Signed �%` Date ene/& j Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 716 Date Issued 42 ([f Fee A ( D .� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes r 0(ppYic-ation for.3pisposal Epstein Construction 3permit Application for a Permit to Construct( ) Repair((lTUpgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. g/( S�o�' /� Owner's Name,Address,and Tel.No. /-/_4-0aV d Assessor's Map/Parcel p _.7�S— 1/6 Fi.s/r Z .S< d S Sob-Li-E - L YQ' Installer's Name,Address,and Tel.No/g4/ . Designer's Name,Address,and Tel.No. TI pe of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. r' Description of Soil Nature of Repairs or Alterations(Answer when applicable) /YPl�1Gl�� r r f/o.0f>�o hPj 1 i�eo/ a� 7—, Ls yti� /7/13— 3 /J do k - 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 proAsions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of e;Co}npliance has been issued by this Board of Health. / Signed 1��,•--"' �i-�'' � Date ,�' i� Application Approved by Date / Application Disapproved by x F Datef r for the following reasons Permit No. zz� Date Issued --------------------------------------------------------------------.-- ----- ---------------------------------- - TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by at 418 s�p� ,r�.� f/yo•����- has been cons�Mw cc with the provisions o 'tle 5 and the for Disposal System Construction Permit No. Installer �s�i� ""� Designer #bedrooms Approved design flow gpd The issuance of this permit shall nrot/be(construed as a guarantee that the system wi'It-function as-designed. Date (fi!) -�� //�/ Inspector ------------------------a------------ -------------------------------- ----------------------------------------------- -------------- - No. � Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS 30isposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair( 4_� Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with t Title 5 and the following local provisions or special conditions. /! Provided:Construc ion st be mpl ted within three years of the date of this permit. 1 Date Approved by r /\// TOWN OF BARNSTABLE LOCATION SEWAGE tl VILLAGE I NL f} ASSESSOR'S MAP&LOT-1 10=2US' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist c n 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) J nJ p Feet Furnished by tin lcrta,.t n Q.2wtiy- D U i Commonwealth of Massachusetts • s Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe Owner Owner's Name ratan is Hyannis Ma. 02601 5-29-14 required for every Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:v1"ren A. General Information filfng out forums 't on the computer, use o*the tab 1. Inspector. U/ key to move your cursor-do not David J."Burnie use the return Name of Ivor key. Neighborhood Waste Water Service 1�1 Comte Name 350 Main St. Company Address West Yarmouth Ma. 02673 C'tyfrmn State Tap Cade 508-775-2802 S1386 Telephone Number License Number B. Certification \ I certify that I have personalty 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 5-29-14 Inspecto's SignatufaDate The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *"This report only describes conditions at the time of inspection and under the conditions of use ` at that time.This inspection does not address how the system will perform in the future under f - die same or different conditions of use. !Sins•3r13 Title 5 oftw inspection subsiaface Sewage M troeww System•e 1 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe owner Owner's Name t1fOffriatim is Hyannis Ma. 02601 5-29-14 required for every page. CityylTown State 7jp Code Date of kispection B. Certification (cost.) Inspection Summary,. Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 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: System is a conditional pass 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 extiltration 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 Certificated Compliance indicating that the tank is less than 20 years old is available. r ❑ Y ❑ N ❑ ND(Explain below): The system is a 6x6 cesspool ,and a precast leaching pit. The cesspool is falling apart and is unsafe. The cesspool should be removed and a new 1500 gallon septic tank be installed. 1SR� 3f13 Title 5 official tr w Form:Subsurface Sewage D Sy�n'Pap of 17 E Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe - owner Owner's Name infomradon is Hyannis Ma. 02601 5-29-14 required for every cityfrmn State Zip Code Date of lrqmcbon B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired. B) System Conditionally Passes(cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): One new h101500 gallon septic tank needs to be installed, new PVC pipe to be connected to cast stub at outside of foundation Install new d box and connect to existing leaching pit ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment 1: System will pass unless Board of Health determines in accordance with 310 CMR 16.303(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 15ins•3113 Till Pap Offidsl Inspection Forth:S�urfaae Sewage Disposal System• 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe owner Owner's Name rn�n is Hyannis Ma. 02601 5-29-14 required far every Pap- CigdTown State Zip Code Date of inspection B. Certification (cont.) 2. System will fail unless the Board of Healy(and Public Water Supplier,if any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or dogged 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 lever in the distribution box above outlet invert due to an overloaded or dogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Mrs-T13 'title 5 Official hispecbw Forth:Sucsiew Sewage Mposal SYsWm.Page 4 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 fisher ProperWAddooss Beverly McAuliffe owner Owners Name inf0"nation is Hyannis Ma. 02601 5-29-14 required for every page. cityrrown state ZipCode pate of lrgn w B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes If the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria e)dst 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 one 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—NUAA)or a mapped Zone.1I 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. `t5hs-M3 Title 5 Official bsPaction Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface sewage Dposat System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe -- Owner Owner's Name iftffn ir�is requir Hyannis Ma. 02601 5-29-14 med for every cayrrown S zip Code Date of Ingmcfiw C. Checklist Check if the following have been done.You must indicate"yes'or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ❑ ® Were as built plans of the system obtained and examined?(if they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ❑ ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. El ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: unknown 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): unknown t5ft•3113 Title 5 o(5a W kmpecbon Forth:Subwrf"Sewage Disposal SYstem'Pap 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe owner owner's Name infomra6on is Hyannis Ma. 02601 5-29-14 required fbr every Pap- cityRo, State Zap Code Date of inspection D. System Information Description: 16x6 cesspool, no distribution box and 164 leaching pit with stone 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, d available(last 2 years usage(gpd)): Yes Detail: 2013 2200 sq'x7 5=16500 by 365=46gpd 2014 2800sq'x 7.5=21000 by 365=58 gpd. Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gauons per day(go) Basis of design flow(seats/personslsq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑.Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3M3 Title 5 official ftMection Farm:Subsurface Sewage DisQosaf SyMm'Pap 7 of 17 f Common wealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe Owner Owner's Name information is Hyannis Ma. 02601 5-29-14 reWired for eery City/Town State Zip code Date of tnspeaion D. System Information (cont.) Last date of occupancy/use: current Date Other(describe below): System is a cesspool and a 6x6leaching pit. General Information Pumping Records: Source of information: Cesspool pumped one year ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Aftemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Cesspool with a 6x6 precast leaching pit t5ins•313 Tttie 6 official hspeetion Forth:SubsuRace Sewage Disposal System Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher PrWrty Addrs Beverly McAuliffe Owner Owners Name Irdbrequired m Hyannis Ma. 02601 5-29-14 ired for every page. Cityfrown state Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed(if known)and source of information: unknown, no permit on file Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 24" Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 10 plus town water line feet Comments(on condition of joints, venting,evidence of leakage, etc.): Main line is PVC. Septic Tank(locate on site plan): No septic tank, cesspool working as Depth below grade: septic tank. Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) Cesspool being used as Septic tank,with precast leaching pit If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions. Sludge depth: t5ft•3N3 Title 5 official hwec im Form:Stturtaw Sewage Disposal System-Page 9 or 17 Commonwealth of!Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposat System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe Owner Owner's Name informaWn is Hyannis Ma. 02601 5-29-14 required for every Cityfrown State Zip Code Date of Inspection Pap- D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle Cesspool 1/4 full 3"' Scum thickness Distance from top of scum to top of outlet tee or baffle 30" Distance from bottom of scum to bottom of outlet tee or baffle 0' How were dimensions determined? Tape and estimated Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Cesspool Blocks have moved and the cesspool is in danger of collapsing. Grease Trap(locate on site plan): -Depth below grade: feet Material of constriction: ❑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 t5ir s•3113 Title 5 Official hpection Force SWM face Sewage Disposal Sysem•Page 10 of 17 CommonweaM of Massachusetts Title 5 Official Inspection Form Subsurface Swags Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe Owner Owner's Marne m(onnabon is Hyannis Ma. 02601 5-29-14 rr3quired for every Dom• c4frown State Zip Code Date of Inspewon 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: 9aRms Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No &%•W Title 5 OftW won Fom SWMff ce SMW Deposed System-Pap 11 OW Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe owner Owner's Name infomwation is required Hyannis Ma. 02601 5-29-14 required Far every ice- Cityrrown Stag Zip Code e of inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No distribution box. 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.): No distribution box. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): *If pumps or alarms are not in wonting order,system is a conditional pass. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: Located and found dry f5ire•3H3 Tilt 5 Ofrk hspec ion Forth:Subsurface Sewage Dial System'Fg 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property address Beverly McAuliffe Owner Owners Name information isHyannis Ma. 02601 5-29-14 requited for every Pap. Cityrrown state Zip Code Date of Irspedion D. System Information (cunt.) Type: ® leaching pits number: 1.6x6 precast ❑ leaching chambers number. ❑ leaching galleries number. ❑ teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativelaftemative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): Dry, no standing water. Cesspools(cesspool must be pumped as part of inspection)(Date on site plan): 1 cesspool,6x6? Number and configuration 1/4 full Depth—top of liquid to inlet invert 8" Depth of solids layer Y Depth of scum layer � Dimensions of cesspool UP Cesspool block Materials of construction Indication of groundwater inflow ❑ Yes ® No t5im 3113 Title 5 OffoW kWecbon Form Stbwuface Sewagg D'LVow System Page 13 of 17 Commonwealth of'Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe Owner Owner's Name IMOffnat10°is Hyannis Ma. 02601 5-29-14 required for every page- Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Blocks loose and out of line Privy(bate 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.): t5hs-W 3 Title 6 OlfiCiW won Fame Subsurface Sewege Disposal System•Pap 14 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe Owner Owner's Name 'nfOffnation is Hyannis Ma. 02601 5-29-14 requkned for every City/Town State Zip Code Date of Inspection per- D. System tnfarmation (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 t5irrs•3113 Title 5 OMCIW kupetlion Forrrr Subsurface Sewage Disposal Syst-•pap 16 of 17 AsBuilt . Page 1 of 1. TOWN OtF�BARNSTABLE LOCATION 7 fd 1`"�51� SEWAGE# VIL LAGS ,r: :.1n T NL. } ASSESSOR'S MAP tit LOT: . INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private.Water Supply Well and Leaching Facility (If any wells exist c n site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) p Furnished by t t_rt ll.r vul n _�- Q R:+t-tV,2� 6lt q& T 0sSi b . r— ` 01 - 3� Sie. . o� .._ 4 http-//issgl2/intranet/propdata/prebuilt.aspx?mappar=310285&seq=1 5/29/2014 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher PropeftyAddress Beverly McAuliffe Owner Owner's Name "dbrrnation is required Hyannis Ma. 02601 5-29-14 regqained for r every CdyRown 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 13'6"Plus....hand auger found dry 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: Hand auger dry to 13'6". Bottom of leaching pit 8.6'below grade. 13.6'less 8.6'=5'seperation. Test well AM zone D level 21.35- 1 1'adjustment 5 less 1 1=3 9'to dry auger hole. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5irn•3N3 Title 5 official trispection Fam S Sewage Disposal System-Page 16 of V Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 Fisher Property Address Beverly McAuliffe Owner Owner's Name k*ffnafion is Hyannis Ma. 02601 5-29-14 Pap. ity/a CTaMm State Zip Code Date of Irapedion age• 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 i t5ns,3N3 Title 5 offkW lesp9ebon Fomr Substafew Sewage Disposal System•Page 17 of 17, /I TOWN OF BARNSTABL_E LOCATION 7 S1 SEWAGE # VILLAGE <nll ASSESSOR'S MAP & LOT l® INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO..OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) .:Feet Edge of Wetland and Leaching Facility(If any wetlands exist within'300 feet of leaching facility) Feet Furnished by (A-rk 1Ce�uua ri _.- CZl'c 1� �� �oS- T©�gi '1 QC�'� , . d. �i _ __LDCQT_ION. _SEWp_,C,E PERMIT UO, VILL4GE INSTALL R 5 ►.l_&MF- ADDRESS _ bUILDER S 1 &VA.E ADDRESS_Cz D4TE PER" T 15SUED D D.TE COMPLI &MCE ISSUED : r C0 f 11 w 1 L t _ No.------f�� .. FRiz .... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ... ..... ............OF..................................... ................................................... Appliration -for Uiipoott1 Works Totuitrurtiou Vrrmit Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 4 .-� / rA -------------------------�--^•-•---•••.............�------�-------•-------•............. ..................S Location-Addres or Lot N --•--•. ----------- ----- /' w er a Address y Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms________________________________ _Expansion Attic ( ) Garbage Grinder ( ) pa., Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures --•------- -------------------------------------------------------•---------------------------------------------•----- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ xDisposal 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. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..___.-._____.______-. LT, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water._.__._..__.__-.____-. - 9 ----•---------------------------- -------------•------------------............---••---------._••--•-......................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x V .------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Al tions— swer when licable...... �_a-'_`�.:_ _ � -C Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss d by th;e board of health. Sign C" `i=-�4 !1 6 '� -- ------- ---- Date,� .� Application Approved BY :... .. ....�_....,---------------- Date Application Disapproved for the following reasons---------------•---•-----•-- ------ ----------------------------•••-•----------------------••--------- •....................•----------•---------------------------------------------•-------------•----••-----.-------------•----•-----....._..--•--------_.......--------------.-_._...._•------------------- Date PermitNo......................................................... Issued,.:................ ----------------.......----------= Date No.......� /._. ........... ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _. ._.. ._ .................OF................................................................. .......----- XpVliratiun -fur Di,gVuual Workfi Tunutrnrtiun Vautit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ Location•Address ��/ or Lot No .............../l�Y__ .fir. �"�• .... G E - - - - -...-------- Ow;{er / Address rjC 1. �v!+ O a..y o I�U� f......•••. ------- •--Inst --••-----• ----✓-------------•---• -•----•-.----- ---• ---......... Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) pa,, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4 d 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........-•----------•-•---------•----- ,4 Test Pit No. 1................minutes per inch Depth of Test Pit.---------------.--- Depth to ground water.-.-----.--------.------ f� Test Pit No. 2----------------minutes per inch Depth of Test Pit...----............. Depth to ground water-...-------_---_----.._. P4 ---------------------------•-----------------------------------•--•------------•-------•-•-•-------•--------••--------•-----------------------••------••--- ODescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------- x U ----------------------------------------------------.-.....-.............--•-------------••-----------......-..--•-•-------------------------------------------------•---•--•-----•------..-------------- -----------------------------------------------------------•---•-•-••------...-...-•-•----•---•----•----•-•--------------------------------------------------••-----..... ---....-. .- Nature of Re Itrs or Alt 'ons—Answer when a icable.------ `' ° � �- --- U P` --------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss Jd by the board of health. Signed. .. - r i-- ._. •-•-.,"' . --- -•--•--------- Date ApplicationApproved By........................................................I--•............................... ----------------------- -------- ------- Date Application Disapproved for the following reasons:---•-•-•---•--......----••------••-----------••.........-•----------------------------------•--•-•.........----- --••----•--....-..-•--------•---•--------•-------------------••---•--------------------•-•-----•-------..............----------------•---•--•---•-•-•-------•-------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (Iertif iratle of Tontlilianrr THI IS TO CERTIFY, hat t e Individual Sewage Disposal System constructed ( ) or Repaired (IK by........- = `-'`'".S?./-�... '� '- ` ' ` S-•----- -----------------•••----••••-•--••---•-...----------------...............-•-••-•--••--•••------•-•••. �l Installer atr / �!.. .. ... N ......-•/" --------------�� a .................`-•.. -- ---� ...................................... has been installed in accordance with the provisions of Article XI 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 &GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------A ld" --••-•••••------------------------------ Inspector . -------------------------------- THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF EALTH / J) /� ..........OF........... :... .... ._...................................... FEE ------------- DinVu,ial urk �un�trnrtiun rrntif Permission is hereby granted---- - !^-' ....i v o to Construct ( ) or Repair ( an Individual Sewage Di osallSS stem at No.---- A /` 'I4� .............••••-�`=-' --'.. = -� /f � >7?d Street as shown on the application for Disposal Works Construction P rffil-it No.... ... .......... Dated--------....------.---------------------- f / Board of Health DATE------ .................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS