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HomeMy WebLinkAbout0017 FOREST GLEN ROAD - Health 17 Forest Glen Road Hyannis A= 290 - 023 7 TOWN OFB ANST LE ,OC"TION ! res f_-G CEv� SEWAGE LOT- LAG �y ct�n s'1 S � _ASSESSOR'S MAP& LOT p NSTALLJER.'5 NAME&PHONE NO. EpnC TANK CAPACITY EA.CMGJ FACILITY' (type) G¢�i �/.S (size)� S f OF B'SDROOMS �]]LDER OR OWNER. IER ITDA.TE, _.. ,._ _ C01� C,iMCE DATE: -- epamdon Distance Between the. Maximum Adjusted,Groundwater Table to(lie Bot}om of Leaching Facility Fie' Private.Water Supply'Well and Leaching Facility �any wells exist dyn site or�n dl n 200 feet of leaching facility)," -y--- t _ge oI Vtledand and Leaching Facility(If any �p(lands exist within 300 Feet of leaching facility) Feet urnishad b J Cn aw/1 ���a � � 1 4 © a 4 , � owe Commonwealth of Massachusetts _ ... . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M a 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. Cityffown• 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. A. General Information q C� 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address x E. Falmouth MA 02536 Cityrrown State „y Zip Code 5 1-508-495-0905 S13971 Telephone Number License Number - B. Certification MI I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority A01-40" Inspector's Signature Date The system.inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow,of 10,000 gpd or greater,the inspector and the system owner,shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner. and copies sent to.the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary'Assessments M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is y required for every H annis MA 02601 11-17-11 page. Cityrrown State Zip Code Date of Inspection -B. Certification (cont.) ' Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any'of the'fail"ure 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 i.n good working order with no sign of failure. 13) System Conditionally Passes: .❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass.- Check the box for"yes", "no"or"not determined" (Y, N, ND)for-the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ ' broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page, Cityfrown State Zip Code Date of Inspection B. Certification (cont.) , 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ , The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. . ❑ The system has a septic tank and SAS.and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 11 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 day flow t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts - a Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ '® "'Any portion of the SAS;cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion.of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either`yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ET ❑ 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 LtIms11/10regional office of the Department. 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11' page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual). 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form ,Not for Voluntary Assessments �M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11-2011 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) iF Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A 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) (f 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the,DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) ' Approximate age of all components, date installed (f known) and source of information: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee`or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today.Real.Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is H annis MA 02601 11-17-11 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis _ MA 02601 11-17-11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and empty at inspection with stain line at 12"from bottom of chamber. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration. Depth—top of liquid to inlet invert Depth of,solids layer Depth of scum layer Dimensions of cesspool . Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 __ Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form: Not for Voluntary Assessments M r 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. City/Town ' State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level'of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 3 3 E 00 -- s' B-F- 39 .r.. OCR ' t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. City[Town 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: 12 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . ,. y 17 Forest Glen Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-17-11 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 Town of Barnstable Regulatory Services ins Thomas F. Geiler, Director � •�� Public Health Division TFD MA'S A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April 13, 2006 Ms Barbara Cross 17 Forest Glen Road Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 The septic system owned by you located 17 Forest Glen Road, Hyannis, MA,was last inspected on March 17, 2006 by, James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: The liquid level in the D-Box was above outlet invert, backing up from the SAS You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HE TH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health COMMONWEALTH OF MASSACHUSETTS 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 CERTIFICATION Property Address: 17 Forest Glen Road Hyannis. MA 02601 Owner's Name: Barbara Cross Owner's Address: -!o- -rO/ Date of Inspection: March 17, 2006 Q Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 w Telephone Number: (508)862-9400 CERTIFICATION STATEMENT CD I certify that I have-personally inspected the sewage'disposal system at this address and that the information reported r below is true,accurate and complete as of the time of the inspection. The inspection was performed Based on m IM training and experience in the proper function and maintenance of on site sewage disposal systems. am a DEP ram,-, approved system inspector pursuant to Section 15.340 of Title 5(310 CAM 15.000). The system: Passes Conditionally.Passes Needs Further Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: March 20 2006 The system inspector shall.suA 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 ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5.Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Forest Glen Road _ Hvannis.MA Owner: Barbara Cross Date of Inspection: March 17, 2006 Inspection Summary: Check A,B,C,D'or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Forest Glen Road Hyannis, MA Owner: Barbara Cross Date of Inspection: March 17, 2006 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 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 coliforn 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 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Forest Glen Road _ Hyannis. MA Owner: Barbara Cross Date of Inspection: March 17, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"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.] Yes (Yes/No)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 System: 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(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question iri 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 Forest Glen Road Hyannis, MA Owner: Barbara Cross Date of Inspection: March 17 2006 Check if the following have been done: You must indicate" es"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? ✓ 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: Yes No ✓ _ Existing information. For example,a plan at the.Board of Health. ✓ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM P TART C SYSTEM INFORMATION Property Address: 17 Forest Glen Road H annis MA Owner: Barbara Cross Date of Inspection: March 17 2006 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 g d x#of bedrooms): 220 Number of current residents: I Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Curr?nLIX Occu ied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): —_gpd Basis of design flow(seats/persons/sqft,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): Pumping Records GENERAL INFORMATION Source of information: Pumped in 2004-per owner Was system pumped as part of the inspection(yes or no): 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 age of all components,date installed(if known)and source of information: Installed on 1121193-per as built card Were sewage odors detected when arriving at the site(yes or no No 6 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Forest Glen Road Hvannis. MA Owner: Barbara Cross Date of Inspection: March 17 2006 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: 16" 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: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3 Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet.tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not annonr to be any si ns of leaka e. Recommend riser be installed to bring cover within 6" )f aryde GREASE TRAP: None (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 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Forest Glen Road _Hvannis. MA Owner: Barbara Cross Date of Inspection: March 17 2006 TIGHT or HOLDING TANK: None (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: allons Design Flow: allons/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: 3.5" Above Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The li uid level in the D-box was above outlet invert backin u from the SAS PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Connnents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Forest Glen Road Hyannis. MA Owner: Barbara Cross Date of Inspection: March 17 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: _3-flow diffusors w/stone 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.): The flow diffusors were under water. A video camera was used for the inspection CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Cotmments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc): 9 i Page 10 of 11 OFFICIAL INSPECTI F RM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Forest Glen Road Hyannis, MA Owner: Barbara Cross Date of Inspection: March 17, 2006 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 V�rans 4� O 4 C;- o 0 i a9 cP 3 a 3� aY 3 qCo a� 10 Page 11 of 11 ,o OFFICIAL INSPECTION FORM'-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Forest Glen Road Hyannis..MA Owner: Barbara Cross Date of Inspection: March 17, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated ground to depth p g d 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 properly/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:_Topographic and water contours man Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground.water elevation: Using Barnstable Topographic and water contours snap Maps are showing approximately 12'+/ to groundwater. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 � x �`� A _ _____-----�-_ y I _e_._._.,�`�,_ f� � __-�-_ ,�` -� � _ -�-��-- -- } i ..�.., ) ��`� � (�' � I i i � 4 i � { { j i f ^—� � � � � � { .. _ 'ram �" �� � � � � � ��`•�-.ice_ r - \ ��_� ....,� ,� - , . �� '+ TOWN.OF BARNSTABLE LOCATION IV? i-oCe3r ONe', J4- SEWAGE# "LW6 r a2.7 t "I" ILLAGE ��.��g ASSESSOR'S MAP&PARCEL� INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 2 SLID (size) /,3 zfzio 2.,a NO. OF BEDROOMS �� OWNER - PERMIT DATE: 6 _/,.1--64 COMPLIANCE DATE: LI 17�/ 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 dZ— 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 T 1 T� �qq � 1 i V T -� f I� �p ��/ r:v ^t..y p t.. TOWN OF BARNSTABLE L'(iCATION r�-T G�� �• SEWAGE # VILLAGE ASSESSOR'S MAP & LOT�� Oa3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII.ITY: (type) US611 (size) NO.OF BEDROOMS 2L BUILDER OR OWNER �sS 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 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 facile Feet Furnished bynT� FO LA) � sw ❑ � 0 Q ' f W O I No. ���r p .— , to � / t Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplication for �Bi5po5a[ t M Con.5truction Verna Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. (°� !^e`S r �� �"� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel -4i 0 ,P Q Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type 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. Description of Soil Nature of Repairs or Alterations(Answer when applicable) gm& 1 f, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b 's Board of Healt Sig ed Date Application Approved by Date f qz Application Disapproved by: Date for the'following reasons Permit No. a t> )�4) Date Issued I a No. tD r d""/ '�!- ? - �° Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Dfgpogal *p.5tem Congtruction Permit Application fora Permit to Construct( ) Repair( ) Upgrade( ' Abandon( ) ❑ Complete System ❑Individual Components Location Address or,Lot No. 1 r) q-A Owner's Name,Address,and Tel.No. - JA Assessor's Map/Parcel tA S© O -� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. `�\Z �c7VJS� Type of Building: Dwelling No.of Bedrooms Lot Size _ sq. ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures i 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 t' Nature of Repairs or Alterations(Answer when applicable) g_eg Date last inspected: i Agreement: _. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued b A�iBoad of Health. Sig ed Date Application Approved by 1 Date Application Disapproved by: Date for the following reasons Permit No. C -�(0 �) �4 Date Issued (D THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance / THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by �A(0 4 r 004.1cd- at a .4- \C"_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. tZY(n � _ dated �O/. Installer 0 c c(c (� 0- Designer #bedrooms -3 Approved dc;�,6­:'�w (° gpd The issuance of this permit shall not be construed as a guarantee that the system will functi designed. --- Date Inspector -------------------------------------------- No. cam►—CIO(C> �- / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS lwfgpogal 6pgtem o gtruction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at I ) 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 completed within three years of the date o� this permit. Date (r,�� `a—1 Approved by i r Town of Barnstable ME T Regulatory Services Thomas F.Geiler,Director • sn�uvsr�s�e, Public Health Division ArFp � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Ime,13 Designer: �'� Installer: Address: . ®L 1�oy IV Address: 37 c� 4.�.. Z c ( was issued a permit to install a (date) r (installer) septic system at �.� r ® S 9 based on a design drawn by (address) F S-dated - 10 d 06 (designer) /�-certify that the septic system referenced above was installed—..— P Y d substantially according to the design, which may include minor approved-changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater.than 10' lateral relocation of the SAS or any vertical relocation of any component of the.septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. E M (Installer's Signature) 0 Mt ER No. 1140 o p, � �GISTER� SANITAR\P� b � esi ers Signature)� ' (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF CONIPLIA.NCE WILL NUT BE ISSUED UNTIL BOTH -THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE.EA-RNSTABLE PUBLIC HEALTH`DIVISION. THANK YOU. Q:Health/Septic/DesignerCertification Form TOWN OF BARNSTABLEL`.• LOCATION CZzy /zp SEWAGE # Vi-LLAGE 11,�a&s ASSESSOR'S MAP & LOT ,;3& r 623 INSTALLER'S NAME & PHONE NO.,ELzi r /.3iZoS Ce.vfi SEPTIC TANK CAPACITY /doo LEACHING FACILITY:(type) FLo d.fusr_'s �3, (size) z1;t NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER vot-/ BUILDER OR OWNER 134,e,31.zg CkosS DATE PERMIT ISSUED: ^ ;- ?A Gj DATE COMPLIANCE ISSUED: 1 53 VARIANCE GRANTED: Yes No ' N a �J I 1 l' FI,:$............................. r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE A lire`#i> ,t f . �iri aii al Nurk,i Towitrurtiun rantit Application is hereby ma a I'ermlt istruct ( ) or Repair (V) an Individual Sewage Disposal Systjo � L --•;;� - ----------....... �G ........... ----- ----------- -------------------- - ._ ... :�oca on- dd - ? `� �c cr _ A dr ss YT Installer Address Type of Building Size Lot...........................*Sq. fee ., Dwelling—No. of Bedrooms.-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures _---------------------------- -- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 94 Septic Tank—Liquid capacity............gallons Length--------_------- Width................ Diameter................ Depth................ r Disposal Trench—No. .................... Width.................... 'Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 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........................ ...........................................•--...._.....---......-----•-----.................------.....----••-•--•-•-----•-------.........._..........------ 0 Description of Soil........................................................................................................................................................................ x W --•--------------------------------•----------------------------.................------•-----------------•----------------------------•.-------------- ...... UNature of Repairs r Alteratio Answer when plicable__ ___._._ �:....�,. .......a. _�._�. = . �.� -� c_� ............................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .. ..... ..."................ `....�..... . ...---."......--Dace�...._:..." Application Approved By ---------- .. ....Gt -•-;,,�............. ......... ... ..................................". ......./.n.g.C9...... /��3 Dace Application Disapproved for the following reasons: .......................... .... ..".................."................................".......-_.......................... ......... "... ............. ................".....................................""......------------...----------------------------............................_...--.............................................. ...------..-*. ....................... Permit No. """".."-""3"." ..--""7J..."l Issued Daze l No... '> _7,k X Flts............................ - THE COMMONWEALTH OF MASSACHUSETTS n� BOARD OF HEALTH TOWN OF BARNSTABLE J=. .� lirtttinn f>ur Dinpn'ttl Workii C o it rur finn 11rrmft, N Application is hereby mad for a Permit to- Goilstruct ( ) or Repair (L4 an Individual Sewage Disposal /ll r J Eooca ion \ddres-, A D.......... . ... .. �( __-•(__ .-?e........ . - ____ ., _. !_.. _ l!_.. �.� owner Address � __ -• - r... � Installer Address UType of Building Size Lot.................... ......Sq. feet Dwelling— No. of Bedrooms___________3.__________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons-_-.._--_---_________------- Showers ( ) — Cafeteria ( ) 04 Other fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. j 1:4 Septic Tank—Liquid capacity............gallons Length________________ Width................ Diameter---------------- Depth................ Disposal Trench--No. .................... Width.................... .Total Length.................... Total leaching area....................sq. ft. r Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... a Test Pit No. I................minutes per Inch Depth of Test Pit-_.______.__________ Depth to ground water........................ GX4 Test Pit No. 2................minutes per inch Depth of Test Pit.-...............__: Depth to ground water........................ 04, -•••-•-•••••.._...-•-•••••-•------••--•-•--••-••-•---•-•••-•---•••-••••-•---•-••--•---•-•--........•......................................................... ODescription, of Soil......................................................................................................................................................................... V .._..-•-••--•-•-•---•--------•...••-•-••----•---••-•---••--•---•••-••-•--•------•-••-•--•--•-•-------•••--••-••-•-•••---•---••---•--•-•••-•-..__._.._..••--•--'•-••----•--........._•-•-•-=------•••-••-•- W U Nature of Repairs or Alteratio —Answer when pplicable-_� PR....... _- /_ -------- :.: :. Agreement: / The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code.—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .......... ✓ .------", ... ......,.... ... .�._:.... f-- 2 13— Application Approved By ---------- -+ ...V1-.,fit-14- - ---..-------.......... ................................................ ....... ..-r�3 Application Disapproved for the following reasons: . - ... .................. . -- ............---...................................................I....--..... . ............... ........................................................ .............. ..... ................... ......--.....................................--.............. ........................................ Dare PermitNo. --------��....3....-.......3--/ ................... Issued .... ......--..................................................... Uare I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE- C�ertif rate of (111ompli2inre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired h,an.r -- /...--. /./ ... ..-... �...-.... at ........ .......................: ..7...... /..��. L:f._ i(/........ fit . .�-f - �L /L -=.<.. has been installed in accordance with th provisions of TIT I:E 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..---_ ........51............ dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... ..........._./...~.10..: 'S._.............................. - --------- Inspector .-----�_AD----------------------------------------- .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE NO. 9 ._-� 1...... FEE.--'`...©,--....... Ehop teal Workv Tanotru#i.oln 11rrmi# Permission is hereby granted !.. �� 5 =..-- --.......-t-'-•--=-----•-•--•........................ to Construct ( ) or Repair (VI-an Individual Sewage Disposal System � at No..................- -X7,61--- • ._ street as shown on the application for Disposal Works Construction Permit Nol_._'3 __. Dated........................................... ' - ---' -------•---------------------------------•------- ... Board of Health DATE.............. ...................... FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS I AssEssoRs MAP : : �v(Jvs Z�Ip TEST HOLE LOGS - NOTES 33 2 PARCEL : U2� — 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH Foes` \� SOIL EVALUATOR : i�- �' E �' R t? �6V� �� HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE : NUt� E�t�2R� _ E' f ��j a y� -� �i WITNESS : DUr1 Rt.l R944t` TA'BLI✓ BOARD OF HEALTH REGULATIONS. f REFERENCE : LCP f I7ZM DATE : /} ) M�IH �T '._._ + _31 37 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION RATE : L 2,M'N fKAI - J-w SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO WIF_0. INSTALLATION. l ci.A ;��i. a LITA-2=01 7 v .\i TH- I &L 'P� O F b"NO ( � f{72` ( }tA! �,ieU�("G�jQS U' .� 1D 2.10 v� TH-2 L_ 9j?j 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATIONl �l S � ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE A 3 I " y� `{ I DETERMINATION. �� (� IU+ 32•2� � - 4) .ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS I.0 `( / A (, f\AAL( / No SPECIFIED OTHERWISE) S Sh-N,p mi� 5lc knl�� LOCATION MAP(N ) q — _. To__g 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A 37, 0� GARBAGE DISPOSAL. C Zg 30.77 „ A ! L•5Ar10 3/ ! 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON y I I C � �o n ABASE OF 6"OF CRUSHED STONE. Z9, 14 �`� �} .Xl�al it CEf1C�-t PIT T� Ede- F 01Pt-:"(;7 G 'l 14L0 37 U�� O► S_ + I n�vvt� p�(L TI T'L. _\/, Wit" At wl G� �v1irC�. 1J _ SEPT ► C SYSTEM DES I GN _ �' �IU 'Ir�L�CNV FLOW ESTIMATE Iry O ) BED'IOOMS AT 00 GAL/DAY/BEDROOM - �WGAL/DAY 0� / SEPTIC TANK BENCH MARK TOP OF GAS GATE 3�O GA'_/DAY x 2 DAYS - L)�=vGAL ELEVATION - 3DAT W USE 0c''O GALLON SEPTC TANK --E�t TI BARNSTABLE GIS DATUM \ ' \�\ 1 �{,r„ I� ,�_[•r-�.Ir`•.��' SOIL ABSORPTION SYSTEM �2 ��-oi ekS� WATER GATE 30 L 28 �1 J ' 5l.c�) C��LC f� = - A, ,N26 C��I��Z► f-f �, .� L O�" P� Yo o\ 24 vi GATE ti' �'Fw,�y �� 22 �! I^ 2 0 7 , �� .A / \ SIDE AREA: �� �� 1 K 0 .S c '.� / �� BOTTOM AREA: 7L4 = Zcj U c7 / ELECTRIC IMETER 0 SEPTIC SYSTEM SECTION , L AGE 1 m � I _n CrIP t �tl ze p s �P�t2-t r CI Cv 41 pp TO _..._.__.. fs Fe R' EX� I c.3 C1YI571�1l Ns T Pt LL 1 SAP 6R' LUvbl WaSG�cG{ S �,e erg 4 I' D-BOX ' C] I_�4 `n 1 \ \ Uc)o GAL �� , ki D Udi --�® � fir-- 1/�d4i -Irs 1 \ AREA \ 3083255f1+- ' SEPTIC TANK le�� (n �S ��' ❑ ❑ __� L_I �?a 100.02 t y.7 30 '�__ ❑ SITE AND SEWAGE PLAN 28 �. —� LOCATION : I Z21 �(� i �L�n� ��y✓ [3A v114 0(�N , , o I '11 PREPARED FOR : �t� '_ fA-� C 'USS Nc. 10 sgrraa�P� n i DARREN M. MEYER, R.S. SCALE : I o DATE :dSIU � Z P.O. BOX 981 Z EAST SANDWICH, MA 02537 Z DATE HEALTH AGENT Ph: (508) 362-2922