HomeMy WebLinkAbout0117 FOURTH AVENUE (HYANNIS) - Health 11�7FOLTRTHAVEy:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
`I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r�"1
P;1
117 4T'Ave
Property Address O
Jay Schofield "
Owner Owner's Name
information is West Hyannisport MA 02672 8-9-18 P+
required for every r.
page. City/Town State Zip Code Date of Inspection "t
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.
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Important:When filling out forms A. Inspector Information Sl#- 13,Q 3 3
on the computer,
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use only the tab James D.Sears AU.
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key to move your Name of Inspector
cursor- not Capewide Enterprises ' *'
use key.the return
urn Company Name
153 Commercial Street
VQ Company Address
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
az
8-10-18
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner.shall submit the.report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
J
Please note: 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.
15i1sp.doc-rev.7, W201 a Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 1 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
mSubsurface Sewage Disposal System Form •Not for Voluntary Assessments
117 4T"Ave
Property Address
Jay Schofield
Owner Owner's Name
information is required for every West Hyannisport MA 02672 8-9-18
page. CltylTown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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.Anyfailure criteria not evaluated are
indicated below.
Comments:
The system is a 1500 Gal Tank D Box and Two Chamber's.
2) 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, NO)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):
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y Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
117 4Th Ave
Property Address
Jay Schofield
Owner Owners Name
information is West Hyannisport MA 02672 8-9-18
required for every State Zip Code Date of Inspection
pegs City/Town
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 ❑ NO (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):
3) 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.
a. 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:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
117 4T"Ave
Property Address
Jay Schofield
Owner Owners Name
Information is West Hyannisport MA 02672 8-9-18
required for every State Zip Code Date of Inspection
page. City/Town
C. Inspection Summary (cont.)
❑ 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
b. 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.
ElThe 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 weir*.
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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
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Commonwealth of Massachusetts
- . Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
f
v 117 4T"Ave
Property Address
Jay Schofield - --
Owner Owner's Name
requir on is West Hyannisport MA 02672 8-9-18
requiredd for every
pass City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in is less than 6" below invert or available volume is less
El than YZdayflow =Eqe 1Nr,
❑ ® 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 water supply
well.
(3 ® 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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
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Commonwealth of Massachusetts
Title 5 official Inspection Form
NSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
` 117 4T"Ave
Property Address
Jay Schofield
Owner Owner's Name
information is required for every West Hyannisport MA 02672 8-9-18
page. City)Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat,or answered 'yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for aff inspections:
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 (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
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c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 4Th Ave
. Property Address
Jay Schofield
Owner Owner's Name
information is required for every West Hyannisport MA 02672 8-9-18
page City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
Description:
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: Date
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
117 4r"Ave
Property Address
Jay Schofield
Owner Owner's Name
information is required for every West Hyannisport MA 02672 8-9-18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercialllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203), Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.): -
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
117 4Th Ave
Property Address
J—ay Schofield
Owner Owner's Name
information is West H annis rt MA 02672 8-9-18
required for every State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
4. 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)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):
Approximate age of all components, date installed (if known)and source of information:
2001 Permit# 2001 477.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
40"
Depth below grade: 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.):
Pi in is 4" PVC SCH 40.
t6insp.doc-rev.7128/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
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f.
<n�, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
117 4Th Ave
Property Address
Jay Schofield
Owner Owners Name
Information is required for every West Hya nnisport MA 02672 8-9-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feeetet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal. Precast H-10
1°
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
29"
0„
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? age or over loading.
Sludge Judge _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank at working level. Tank and outlet cover at 30"w/inlet cover at 10". In and outlet Tee's. No
sign of leak age or over loading
15insp.doc•rev.72612016 Title 5 oft al inspecdon form:Subsurface Sewage Disposal System•Page 10 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
117 4T"Ave
Property Address
Jay Schofield
Owner Owner's Name
information is
required for every West Hyannisport MA 02672 8-9-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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 fast pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 4Th Ave
Property Address
Jay Schofield
Owner Owner's Name
equired foati fo Is
every
r West Hyannisport MA 02672 8-9-18
requir
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: �a�e
Comments (condition of alarm and float switches,etc.):
'Attach copy of current pumping contract(required), Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if.present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box Is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-40" Below grade. Box is clean and solid w/one line out. No sign of over loading or
solid carry over
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c�t�\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
117 4Th Ave
`J Property Address
Jay Schofield
Owner owners Name
Information is west Hyannisport MA 02672 8-9-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order,system is a conditional,pass.
11. Soll Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number:
2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 1174 T"Ave
Property Address
Jay Schofield
Owner Owners Name
Information is required for every West Hyannisport MA 02672 8-9-18
page, City/Town State Zip Code Date of Inspection
D. System Information (cont,)
11. Soil Absorption System (SAS)(cost.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two H-20 500 Gal. dry well chamber's. Chamber's at 40" below grade w/cover at 18". 2"
water in chambers w/no sign of over loading or solid carry over. No high stain line.
12. 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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
•- 15insp.doc•.ay.M612016 Title 5 Ofrwal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 4Th Ave
Property Address
Jay Schofield
Owner Owner's Name
information is West Hyannisport MA 02672 8-9-18
required for every
page- CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
a
. - 15lrisDdoe•rev.77262018 Title 5 ORidai inspection Form:Subsurface sewage Disposal system-Page 15 of 18
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c\ Commonwealth of Massachusetts
pp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
117 4T"Ave
Property Address
Jay Schofield
Owner Owner's Name
information
equireilo re West Hyannisport MA 02672 8-9-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
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A-r= 3s` 0 3 c
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15insp.doc-rev.7126@018
Title S Otfiaal Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
117 4T'Ave
Property Address
Jay Schofield
Owner Owner's Name
information Is Test Hyannisport MA 02672 8-9-18
required for every
page. City/Tom State Zip Code Date of Inspection
D. System Information (cost.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar `
I
❑ Shallow wells
Nd 10,
Estimated depth io iigh ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: 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:
Auger T.H. 10' no G.W.. Bottom of chamber's at 610'below grade. Bottom of chamber's at 4'-2"
above T H, Depth
f
A • rr+
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5>nsp.doc•rev.7!2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 o118
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c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
117 4T"Ave
Property Address
Jay Schofield
Owner owner's Name
information is West H annis ort MA 02672 8-9-18
required for every page City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form Inclusive of;
® A. Inspector Information: Complete all fields in this section.
® 13.Certification: Signed &Dated and 1,2, 3,or 4 checked
® C.Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Title 5 omciai Inspection forth:Subsurface sewage Disposal system•Page 18 of 18
151nsp.doq•rev.7/26J2f118 -
gE a6ed xed dH LEZZ 9I.0Z t l, find
TOWN OF BARNSTABLE �
LOCATION j 'f74 A01, SEWAGE #2-nil J'7 —7 /
VILLAGE ) iS ASSESSOR'S MAP & LOT Z4f -//
INSTALLER'S NAME&PHONE NO. '71)6"S%>6
SEPTIC TANK CAPACITY I`006
LEACHING FACILITY: (type) OP_n.,u%A( „1��(size) dW S4
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: L '� 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
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No. I Fee! 0.0 0 /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for iniopoal *proem Construction Permit
Application for a Permit to Construct( . )Repair(X)Upgrade( X,)Abandon( ) El Complete System El Individual Components
Location Address or Lot No. ' � s.an .No.
117 Fourth Ave -West Hyannisport &Mic� 0 Te
Assessor'sMap/Parcel , 69 Arboro Drive S haron Ma 02067
� f� / /Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Joseph P. Macomber & Son Inc Joseph P. Macomber' & Son Inc
Box 66 Centerville 775-3338 Box 66 Centerville 775-3338
i
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil,Loamy sand to medium to fine sand
Nature of Repairs or Alterations(Answer when applicable) Installing 1500 l 1 on tankf
Distribution box, 2-500 gallon leaching chambers —ZU
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss by oar f alth.
Signed y Date Z!7
Application Approved by Date
Application Disapprove or the following reasons
Permit No. ;;7,2_-VZe `7� Date Issued
+'r;�:�x`Kii't. 1°5�h.#:��a`3,>d.t .:�; � �t±.fr'a':�-.,. .ti n�:ly' t' •.�,y T -t'•� �`i�`'uf''�::� _ ,t �: z, ,._. .r r-�'r•.-i: -•�.. �ti,
` No. lr F/� �� �% Fee 5 O.O O /
THE COMMONWEALTH OF MASSACHUSETTS ,? t. 1 •Entered-ir computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
' 3ppfication for Mioaar 6pgtern Congtruction Permit
Application for a Permit to Construct( . )Repair(X)Upgrade( x)Abandon
( ) O Complete System O Individual Components
a Location Address or Lot No. jQ is(: am. L
Assessor's Map/Parcel 1 e 1Te�.No.
117 98urth Ave West Hy nisport 69„ �rboro Drive Sharon Ma 02067
{
Installer's Name,Address,and Tel.No.. 'Desi gner's m Nae,Address and Tel.No.
Joseph P. Macombe? & �30 - G>do Joseph P. Ma0ombft L& 4on Inc
Box 66 Centerville 775-3338 Box 66 Centerville 775-3338
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil:Loamy sued to medium to fine sand
Nature of Repairs or Alterations(Answer when applicable) Installin 1 500 allon tank
Distribution box, 2-500 gallon leaching chambers -l U
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 a • not to place the system in operation until a Certifi-
cate of Compliance has been issu d by RoarWfalth. / r�
f Signe s ,, Date Z!RS
Application Approved by /y _ U �� , V Date
Application Disapprove or the following reasons
4
Permit No.i:;7,/0/F^ Date Issued {
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance r�
THIS IS TO CERTIFY, that the On-site Sewage Disposal SystemiConstructed( )Repaired ()( )Upgraded(xa ).
Abandoned( )by Joseph P. Macomber & Son Inc
at 117 Fourth Ave West Hyannisport habeantcgnstructed in accordance A,
with the provisions of Title 5 and the for Disposal System Construction Permit Nve ook "C
Installer J.P. Macomber $ Son Inc DesignerJ.P. Macombedr& Son ,Inc
The issuance of this permit hall n t be construed as a guarantee that the syste un Z'addesigqe
Date Inspectorft
+
a
No./G0'�y,_ �7 Fees 0.0 0
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS �`j
�- �- - Migpogar *pMem Congtruction permit--, .
Permission is hereby granted to Construct( )Repair(x)Upgrade( x)Abandon( )
System located at! 17 Fourth Ave West Hyannisport
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:Constructio ust apcom �Iled, ithin three years of the date of this
Date: Approved by I
3
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAN
s
); Joseph P.Macomber Jr. hereby certify that the application for disposal works
construction permit signed by me dated 6/28/01 concerning the
property located at 1 1 7 Fourth Ave West Hyport meets all of the
following criteria:
• The failed system is connected to a,residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 .minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 fat of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust,the groundwater table,.using the Frimp(or
method when applicable)
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will W be located less than fourteen.(14) feet above the ma.-cimum adjusted
groundwater table elevation, 1
Please complete the following: `
A) Top of Ground Surface Elevation(using GIS information) lJ�
B) G.W. Elevation + the MAX. High'G.W. Adjustment 7 , G/
D=RENCE BETWEEN A and B lq 4-
A
W
SIGNED : DATE:6/28/01
(Sketc pr sed plan of system on back].
q:hW h roldv cent
Omitting Bathroom
pool
-} Omittin Kitchen pool
New 1500 gallon tank
2-500 gallon New Box.
leaching chambers. _
packed in 4 ' of 12"
stone. -25 'X1 3 'X2 '
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TOWN OF BARNSTABLE �
LOCATION ( � cf7� fa Vie SEWAGE # �'�"Ll-7�
i
VILLAGE_{ k1.c 3�,.5 ASSESSOR'S MAP &'LOT
INSTALLER'S NAME&PHONE NO._rq A Cd�v►
SEPTIC TANK CAPACITY I t;06 f
LEACHING FACILITY: (type) P.Y (size) 6W C4�
NO. OF BEDROOMS T -
BUILDER OR OWNER
.. ». ZiJ t n..w.-i+n:r - ,..:,, :. _ '':•'-::'s"� f;' pry �-
PERMITDATE Z. �.I COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well'and'Leachidg:Fkility (If any wells exist
on site or within 2'00 feet of leaching facility)' Feet-
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of teaching facility) Feet
Furnished by 4
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