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0007 FRANKLIN AVENUE - Health
7 Franklin Avenue .� . Hyannis A= 292 —034 _..- f 1 - TOWN OF BARN TABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT I INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY �EACHING FACIL=: (type) (size) O. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 6.w o o � n 4ob rt .n ro i F FJ, Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LX«1 a 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name 11' infom;ation is W required for every Hyannis ✓ MA 02601 12-19-17 �5+ page. City/Town State Zip Code Date of Inspection .a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: n A. General Information Wh filling out forms /��� �a�aI I+++ on the computer, !! � O���`� �,SH�F Mgs��'O,, L5 use only the tab key to move your 1, Inspector:. yG cursor-do not '4! JAMES use the return James D.Sears key. Name of Inspectorla Ar � IdR� — Capewide Enterprises R�IF � Company Name �,,��•... . . �C 153 Commercial Street ��iryrgr51111MISlP",0��� Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1523 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs further Evaluatlon by the Local Approving Authority 12-26-17 I ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rey.6/16 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System-Page 1 of 17 ZWW VS 6Z a5ed xeJ dH 6911• 9 602 l,0 Uer Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information Is required for every Hyannis MA 02601 12-19-17 e page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and three chambers. 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.doc-rev.6116 Tille 5 0<Ycial Inspection Form:Subsurface Sewage Disposal Syslem-Page 2 of 17 ZZ a5ed xeJ dH 00:86 860Z 60 Uer Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name intormation is required for every Hyannis MA 02601 12-19-17 page. City/Town State Zip Code Dale of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection If(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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. I. 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 15ins.doc•rev.6116 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 £Z abed xed dH 00:91• 860Z l•0 Uef Commonwealth of Massachusetts Title 5 Official Inspection Form V; Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Y 7 Franklin Ave Property Address Nick Moscaritolo Owner Owners Narne information is reequiredquired for every Hyannis MA 02601 12-19-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 ❑ ® 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 4EMN is less than 6" below invert or available volume is less than '/2 day flo ellItIG l5ins.doc•rev.6116 Tills 5 Official hispection Form:Subsurface Sewage Disposal System•Page 4 of 17 bZ a5ed xeJ dH 00:86 8602 1.0 uer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 7 Franklin Ave Property Address Nick Moscarifolo Owner Owner's Name information is required for every Hyannis MA 02601 12-19-17 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. ® Any portion of cesspool or privy is within 100 feat 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 El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. r5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 g2 a5ed xeJ dH 60:86 8602 60 uer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foffn-Not for Voluntary Assessments 7 Franklin Ave Property Address Nick Moscaritok� Owner Owner's Name information is Hyannis MA 02601 12-19-17 required for every page. Citylrown 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 god x#of bedrooms): 330 t6ins.doc•rev.6116 Title 5 Otrtciai Inspection Form:Subsurface Sewage Disposal System•Pape 6 of 17 92 a5ed xeJ dH 60:9 6 9 60Z w Uer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information is required for every Hyannis MA 02601 12-19-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 Gal.Tank D Box and three chamber's. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 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: Gns.doc•rev.6116 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 7 of 17 LZ a5ed xed dH 20:86 81.0Z 60 Uef i c Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information is required for every Hyannis MA 02601 12-19-17 Page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and i maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6l16 Title 5 OfficW Inspection form:Subsurface Sewage Disposal System•Page 8 of 17 92 abed xed dH Z0:91. 9 60Z 60 Uer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.. 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information is Hyannis MA 02601 12-19-17 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2005 Permit # 2005- 199. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 14" 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.): Pipeing is 4" PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: 4 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. Precast H-10 Sludge depth: 0" 15ins.doc rev.6f16 Title 5 Offidal Inspection Form:Subsurfeos Sewage Disposal System-Page®or 17 6Z a5ed xed dH £0:91• 91.0Z 60 Uef Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v� 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information is required for every Hyannis MA 02601 12-19-17 page. Chyfrown 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 30" Scum thickness 011 Distance from top of scum to top of outlet tee or baffle t3 Distance from bottom of scum to bottom of outlet tee or baffle 18„ How were dimensions determined? Asbuilt-Plan-Tape + 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 cover's at 4"below grade. In and outlet tee's. No sign of leakage or over loading. 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 15ins.doc•rev.W16 Tine 5 OlGcial Impaction Form:Subsurface Sewage Disposal System•Page 10 of 17 OE abed Xed dH EO:9 6 9 ME 60 Uef Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments E 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information is required for every Hyannis MA 02601 12-19-17 page. CIIy/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.): i 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 l5ins.doc-rev.GAG Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 �£ abed xej dH £O:91, 960Z 60 Uer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information is required for every Hyannis MA 02601 12-19-17 for page. CilylTown 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.): D Box is 16"xl 6"A' below grade w/cover at 4". Box is clean and solid w/one line out. No sign of over loading or sot id carry over. I i 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. Soil Absorption System (SAS) (locate on site plan,excavation not required): ` If SAS not located, explain why: 15ins.doc•rev.6/16 Title S Officid Inspection Form:Subsurface Sewage Deposal System-Page 12 of 17 Z£ a5ed xed dH £H 6 81.0Z 1.0 Uer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments lveeltf7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name iquiredon is for every re Hyannis MA 02601 12-19-17 required page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): Leaching is three chanbers wl4' stone. Ck D Box and camera out line.Dry and clean. No sign of over loading. 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 tSlns.doc-ray.6016 ride 5 Official Inspection Form:Subsurfaos Sewage Disposal System-Page 13 o1 17 ££ a5ed xed dH t,0:8 6 9 L02 60 Uef Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information is required for every Hyannis MA 02601 12-19-17 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.): t5ms.doc•rev.6116 role 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 0117 b£ abed xe� dH b0:9 6 9 602 60 Uer Commonwealth of Massachusetts Title 5 Official Inspection Form a, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 7 Franklin Ave Property Address Nick Moscaritolo Owner Owners Name information Is MA 02601 12-19-17 required for every Hyannis page. City/Town State Zip Code Date of Inspedion 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 A-3 - 3 i 7: 39 A � o I . L t5ins.doc-rev.6116 T tle 5 Official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17 c,£ a5ed xeJ dH t,0:86 960Z 1,0 Uef . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7 Franklin Ave Property Address Nick Moscaritolo Owner Owner's Name information is required for every Hyannis MA 02601 12-19-17 page Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to igh 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 Ian reviewed: 4-18-05 p 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: T.H. on Design plan 4-18-05 12'+ no G.W.. Bottom of chamber's at T below grade. Bottom of chamber's at 9'above T.H. Depth. -- Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5lrte.doc rev.6116 Title 5 Otrrcial Inspection Form:SuDsudace sewage Disposal System-Page 16 of 17 g£ a5ed xed dH b0:9 I. 9 60Z 60 Uer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Franklin Ave Property Address Nick Moscaritolo Owner Owners Name information is Hyannis MA 02601 12-19-17 required for every State Zip Code Date of Inspection page Cityrrawn E. Report Completeness Checklist ® Inspection Summary: A, B, C, 0, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I5ins.do-rev.6116 Title S Official Inspection Form:Subsurface Sewage Oisposal Syclem•Pop 17 of 17 L£ a6ed xed dH 50:9 6 9 602 60 Uef C Town of Barnstable OF 1HE Tp� Regulatory Services Barnstable gyp'' o Thomas F. Geiler, Director ;mericaCity Public Health Division III BAMSrnac.e. 9 MASS. g Thomas McKean,Director 1639. `0 2007 iDrEG .(A 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 6, 2008 Commonwealth Investment Properties LLC 454 Trapelo Road Belmont, MA 01721 As of October 1, 2006 a new rental registration ordinance was put into affect requiring all property owners of rental units to register their rental units with the Town of Barnstable Health Division. According to our records, you own the rental property at 7 Franklin Avenue, Hyannis. Enclosed is an application and a copy of the ordinance. Please -use a separate application for each rental unit you own. Should you need more applications, they are available online at www.town.barnstable.ma.us. Go to the Health Division page by looking in the Department Menu: There is a link to the Rental Registration information on the Health Division page. You may print out as many as you need, and return them to the Health Division with the appropriate 2008 fees included. Failure to comply with this ordinance will result in the issuance of a non-criminal ticket citation in the amount of$100. Each day of non-compliance is considered a separate offense. Should you have any questions, please feel free to call 508-862-4644. Thank you in advance for your cooperation. • I Melissa Couto Division Assistant Health Division Direct#508-862-4072 I ' -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION 00 Fee TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: V� Owner's Name: , Owner's Address: Date of Inspection: 7 (,A Name of Inspector: (pl se p 'Ft) Company Name: , Mailing Addr s: qp ey z).A, jeleph.one Nu ber: :5na /al�g yc� co ,,CERrjFICA`T-JON.STATEMENT IYfg t ertihat I hap ersonally inspected the sewage disposal system at this address and that the information reported be')ow is-yrue,accurate and complete as of the time of the inspection.The inspection was performed based on my tRiningthd expedience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approv d system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: 0 0 Passes `" Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: a � 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. Notes and Continents ****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. 1 1 Page 2 of I I OFFICIAL, INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORD: PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 7 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: i I have not found any information which indicates that any of the failure criteria described in 310 CMIR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. stem Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced nr repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Ans er yes,no or not determined(Y,N,ND) in the for the following statements. If`bot determiners"phase expla' Th septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, xhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. 'A me septic tank will pass inspection if it isstructurally sound,not leaking and if a Certificate of Compliance indica ' g that the tank is less than 20 years old is available. ND xplain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or o structed pipe(s)or due to a broken,settled or uneven distribution box.System will passim if(with proval of Board of Health): broken pipe(s)are replaced obstruction is removed distributim box is leveled or replaced ND plain: The system required pumping more thin 4 times a year due to broken or obstructed pipe(s).The system will pass ' spection if(with approval of the Board.of ldeafth� broken pipe(s)are replaced obstruction is removed ND explain: - 2 Page 3 of I i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: rj� r. Owner: Date of Inspection: C. F her 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 i 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 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 I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frorn a private water supply well**.'Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3, ther: Page 4 of 11 J OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address Owner: — o Date of Inspection: D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: Yes No kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tic 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 '/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of tunes pumped '. ZAtty 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. , rAn y portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 certifted.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 /Jh� are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CNIR 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,Oftgpd to 15,000 gpd. You st indicate either"yes"or"no"to each of the following: (The ollowing criteria apply to large systems in addition to the criteria above) y no the system is within 400 feet of a surface drinking water supply -- _ — the system is within 200 feet of a tributary.to a snr5ce d�gwa�supply t e system is located in a nitrogen sensitive area(interim Weffbesd Protection'Afrra:—IWPA)or-a.mapped one II of a public water supply well If you ve answered"yes"to any question in Section E the system is considered'a significant threat,or answered "yes" ' Section D above the large system has failed.The owner or operator of any large system considered;a signifi t threat under Section E or failed under Secti mD shall upgrade the system in accordance with 310 CMR 15.304:The system owner should contact the appropriate regional office of the Department. 4 • j Page 5 of 11 OFFICIAL.INSPECTION:FORM-NUT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL:SYSTEM;INSPECTION FORM PART B 'CBECKLIST Property Address: _. . Owner: e C- ✓ Date of Inspection: .•7 ,7 Check if the following have been done.You.must indicate`yes"or"no"no"as to each of the following: Y�o 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)] • i 5 Page 6 of I'l OFFICIAL INSPECTION FORM-NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL JSY-SSTEMrINSPF;CTION FORM PANT C SYSTEM INFORMATION Property Address: U Owner: All& ov Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms.(design): Number of.bedrooms.(actual): DESIGN flow based on 3 10 CMR 15.203(for example: 110 gpd x#of bedrooms): '3 3 Number of current residents: Does residence have a garbage grinder(yes or no):L D Is'laundry on a separate sewage system(yes or no)��[if yes separate-inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):.eLl-&P . Last date of occupancy:. COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): r GENERAL INFORMATION Pumping Records Source of information: —� Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYTE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool y,... Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous intipection records,,if any) _Innovative/Altemative technology.Attach a copy.of the curieW.operation and maintenaa contract(w im- obtained from system owner) _Tight tank _Attach a copy of the DFP appmral _Other(describe): Approximate age of all components,date installed(if known)and soes ce of, formati i Were sewage odors detected when arriving at the site(yes or no)e® 6 Page 7 of 11, OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL•.SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5*1 `,'h Owner• _ Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade:�— Materials of construction:_cast iron ,&40 PVC_other(explain)-. Distance from private water supply well or suction line: Comments(on condition of joints, entmg,evidence of leakage;etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: ��X Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: c3 Scum.thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet fee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of.leakage,etc.): GREASE TRAP:&locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet.invert,evidence of leakage,etc.): 7 Page 8 of l 1 OFFICIAL.INSPECTION FORM_-NOT FOR VOL NTARY`ASSESSNiENTS SUBSURFACE SEWAGE"DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ < Owner: Date of Inspection: TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglazs_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage illt.0 or out of box,etc.): PUMP CHAMBER: (locate on site plan) Frumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurte^a^.ces,etc.): 8 ti r Page-9 of 1.1 OFFICIAL.NSPECZ-ION-FORM.. NOT,.FOR VOLUNTARY ASSESSMEN& SUBSURFACE SEWAGE DISPOSAL SYSTEM.�NSPEC"MI©N.FORM PART- SYSTEM INFORMATION,(continued) Property Address• (/ Owner: v Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located.explain why: Type leaching pits,number. c ambers,number.�-j 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.): AW 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 or no): 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,Ievel of ponding,condition,of vegetation,etc.): 9 Page 10 of'l €3F ., INSPE"CT-ION�-F —NOT FOR V�I LITatTAURY ASSESSMENTSSIBS�ACE SEWAGE`IZISPOSAL SYSTEM INSPECTION-FOR 1AiD-r r SYSTEM iNY'CJF'lcMT.R.3"IN"(continued) PPopetty Address: Owner• C Bate of nspection: 7 SKETCH OF SEWAGE]DISPOSAL SYSTEM ?rovide a sketch of the sewage disposal system including ties to at least two permanent reference L dsnarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. T I 10 Page 11 ofil I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: p Owner: v , Date of Inspection: .T SITE E�6 Slope Surface water Check cellar pv;f/ Shallow wells h e4.jep Estimated depth to ground water,Z-102 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole w'thin 150 feet of SAS) ecked with local Board of Health-explain- h Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: S ��IJ.S � 11 ��/� �C✓o� �i �I ' t TOWN OF BARNSTABLE 'LOCATION � , Ifyt1z1y �C�- SEWAGE# 1p 1p6 V13NLAGE 1 V aiiai,,� ASSESSOR'S MAP&LOT Z44 2'OJy INSTALLER'S NAME&PHONE NO. r .. r:g"PTIC TANK CAPACITY 11jca� LEACHING FACILITY:(type),3"/A/ri ftr:�-76 90,50'S (size) �S �O- NO.OF BEDROOMS �3; ,p 'LUILDER OR OWNER 1S ERMIT DATE: S �O ' D COMPLIANCE DATE: S-d-:5 O Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility (Ail Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A & B CANCO 350 Main Street ' AAA A-1C79 _ V •y/ Y n� "J ,OW4 NO"r WC� t No. 141 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for 30igpool *pgtem Construction Permit Application for a Permit to Construct( , )'Repair( 11-u--pg-rade( Abandon( ) El Complete System El Individual Components Location Address or Lot No. �k ner's Name,Address and Tel.No. Assessor's Map/Parcel alqa - o Installer's Name,Addres�a►&T1.1�sANCO Designer's Name,Address an el.No. 350 Main Street M-e ye,r Jn . Yarmouth MA 02673 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 .1"?1 - 4!�_ gallons per day. Calculated daily flow .3.3 O gallons. Plan Date - - Number of sheets Revision Date itl,/14 Title _ / Size of Septic Tank ATeb a ee:r gi Type of S.A.S. Description of Soil ��4h Nature of Repairs or Alterations(Answer when applicable) { Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this oar f H alth. P Y � �� Signed 1 Date Application Approved by Date Application Disapproved for the following reaso Permit No. Date Issued OPP N No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0.pprication for �Digogatbp5tem Co.maruction Permit Application for a Permit to Construct( )Repair( - pgrade( <Abandon( ) ❑Complete System ❑Individual Components n _ _ Location Address or Lot No. 7 O ner's Name,Address and Tel.No. Assessor's Map/Parcel _ PIS D Installer's Name,Address,and Tel.No. Designer's Name,Address an el.No. f'q,.-le r ��`� h Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Tyne of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ! Design Flow -33 1 - ,-5'- gallons per day. Calculated daily flow .33 O -'gallons. Plan Date y 1 ci) - .S Number of sheets Revision Date Title Jai /f-e — e<,/,ac, e. ! Size of Septic Tank /a b o Type of S.A.S. Description of Soil r /D�A h Nature of Repairs or Alterations(Answer when applicably) • � i II Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the�desm- bed ;site sewage disposal system in accordance with the provisions of Title 5 of the En ironmental Code andmt�ot to place the sy tem in operation until a Certifi- cate of Compliance has.been issued by t s, oar of Health. .�- �' ' +`�' ��-- Signed V � Date Soy Application Approved by ��/11 Date Application Disapproved for the following reason Permit No. '� Date Issued -- ---------------- --ti---- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( -<Pgraded Abandoned )by �/��l 0 at 7 IVY-4 i7 h 1 bas constructed in ace rda ce with the provisions of Title 5 an -t Oi,e Mfor Disposal System Construction Permit No. dated 5 Installer �� Designer The issuance of this permit shal of 'e cco true "Gas a guarantee that the syste will nc 'o as estgned. Date ( ,5 Inspector No. —�---- -------------------------Fee /(lo THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS MigosW *pgtem Com;truction 30ermit Permission is hereby,grante�to Con tru�t( )R pair(� r de(Abandon( ) System located at / / //�1 j 4 4yf� N iJ 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 ust b com meted within three years of the date of this =e t. j Date:_ / Approved by 9/16/03 Notice: This Form Is To Be Used For the Repair Of Famed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM M ,hereby certify that the engineered plan signed by me dated A -2c6•05 concerning the property located at -7 Pa'A-7�)PA r� AVe K)Ve meets. all .of the following criteria: • This 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. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • 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-be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: . A) Top of Ground Surface Elevation(using GIS information) Jr'I B) G.W.Elevation +adjustment for high G.W. V 2.0 �f DIFFERENCE BETWEEN A and B SIGNED :1 DATE: NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. 1 gASeptic\percexemp.doc TOWN OF BARNSTABLE LOCATION .t/� �GL SEWAGE# OZG�Cji�` 1 1� VILLA t i V"i�I�1I��S ASSESSOR'S MAP&LOT 21 INSTALLERiS NAME&PHONE INTO. SEPTIC TANK CAPACITY LEACHING FACILTFY-(type),/sA/ �12�7 •?7 +s (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: �' ID ` O� COMPLIANCE DATE:' Separation Distance Between.the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 'Per ?(n Feet Private Water Supply well and Leaching Facility (If any wells exist ,.J on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A R. R 350 Main Street I ( 35 I y ` I Y Town ®f Barnstable t"E'" Regulatory Services Thomas F. Geiler,Director BAMNSFABLE. - HASS. Public Health Division aTFDs Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: IMW Designer: n14"vVe"Ll1 V V 1�/ `�'I,� Installer: e R B CANNA 350 Main Street Address: , v . �,��C " I U Address: W_ Yarmnu1 ti yen nec73 '3A4 d yu On /6-OE- A� �? C t�) was issued a permit to install a (date) (installer) septic system at based on a design drawn by (address) �A06A datedA-Pyd z7j .-�� (designer) -1-•certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State &Local Re ns. Plan revisio r certified as-built by designer to follow.-C(UW - F GN I a . . l ' M R (Installers Signature) o. 1140 �GIsTS SANITAR�P� esigner's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO B TABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE,WINTER STREET BOSTON MA 02108(617)292-3500 a.R TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Address of Owner: 297 NORTH ST.HYANNIS MA/02601 ATT ARON BORNSTEIN Date of Inspection: 6/16100 t'JOHN GRACI Name of Inspector: � � � I am a DEP approved system Inspector pursuant to Section 15.340 of Tfle 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS o v� Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 608-664-6813 FAX 608-664-7270 o � CERTIFICATION STATEMENT Z2O 1 certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below is"true,accurate and complete as of the time of Inspection.The Inspection was performed based on my training and experience In the proper 6nrction'and maintenance of on-site sewage disposal[systems.The system: X Passes _ Conditionally Passes _ Needs Further Evalua By the Local Approving Authority Fails Inspector's Signature: Date:6/21/00 The System Inspector shall sub it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,If applicable,and the approving authority. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. S,R revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/16/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n(a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)Indicating that the tank was installed within twenty(20)years prior to the date of the Inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial Infiltration or exfiltration,or tank failure is imminent.The system will pass Inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. n/e Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced nta The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): _broken pipe(s)are replaced obstruction is removed ul I revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: . 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/16100 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS'BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within,50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonla nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n1a(approximation not valid). 3)• OTHER n/a I I revised 9/2/98 ; Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/16/00 D. SYSTEM FAILS: You must Indicate either"Yes"or'No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is Identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level In the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. - X Liquid depth in cesspool Is less than 6"below Invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. - X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy;is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or'No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the.environment because one or more of the following conditions exist: Yes No _ X the system is within 400 feet of a surface drinking water supply _ X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system,shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further Information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner: GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/16100 Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this Inspection. X As built plans have been obtained and examined.Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X ' - All system components,excluding the Sol[Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C.Is at issue,approximation of distance is unacceptable)1 5.302(3)(b)j X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. Slit revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/16/00 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:6 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIALIINDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of Inspection:(yes or no):NO . If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system(yes or no)(if yes.attach previous inspection records,if any) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: 1990 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2198 Page•6 of 11 }t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/16100 BUILDING SEWER:X (Locate on site plan) Depth below grade: 12" Material of construction: _ cast Iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: 4" Comments: (condition of joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 4" Material of construction: X concrete_metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2" 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: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal,, Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6116/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,Inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) THE DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _ (locate on site plan) h^ Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a {_t revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/15100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6 leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of Inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a e Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/16/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) AA Ab y Ap 3`I FA a°� A s ia` ; O° A Gcchk; R� revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 FRANKLIN AV HYANNIS, MA 02601 Name of Owner GLANDSTON LIMITED PARTNERSHIP Date of Inspection: 6/16/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet+ Please Indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET revised 9/2/98 Page 11 of 11 Sewer Permit No. Via- d5 Name Location a Insiiller's Name and Address �'��r -MA 00 nA-J,'`S ' Aif j R /)li RZV oEaci cSi9A.L7(�Ir /Z ri Builder's Name and Address J� Date Permit Issued: /7Z49 a Date Compliance Issued: tl Z T� / d t o1 f Wd ' e 7 Ft:s ...-7.17�_ THE COMMONWEALTH OF MASSACHUSETTS ni BOAR® OF HEALTH . 1 ...............OF..��` i..:ILG ................................... Appliratinn for Dispaii al Vnrks Cnnnitrnr#inn rnmit Application is hereby made . ._ ... .....?Lo.. • 24foraermt to Constuctsr � o epair oarn Individual ividual Sewage Disposal System at: -- ------.---.. ... ._ --_. .n-r . _ LaN .................•'. ---•-•_. ...----...... •----••----• ...... ..._..__ .. ...._._: ..... ..._.... Owner Address W Installer Address Type of Building Size Lot...... .......3........--Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures -------------------------------• . W Design Flow............./ .............._......gallons per person per day. Total daily flow......._.... v ...._.._._..___.._..gallons. WSeptic Tank—Liquid'capacity; OQ.•gallons Length/o��_y_ Width. � .'`._ Diameter..?091.._.. Depth....�.._. Disposal Trench—No.Al ge.... Width_.... .... Total Length............... Total leaching area....................sq. ft. Seepage Pit No-------- -........ Diameter....4............ Depth below inlet....?. ........... Total leaching area.,$.. '?sq. ft. Z Other Distribution box ( ) Dosing tank ( ) , Percolation Test Results, Performed b .. ___`........._-. �' '-�. .................. Date-. _-•---•- ...._..minutes er inch De th of Testwater 7- ,� Test Pit No. 1....� p � p � Pit........._e.._..... Depth to ground water.___._._____'_..__.. fs, Test Pit No. 2__.e't......minutes per inch Depth of Test Pit.1-�___..y.~ Depth to ground water..�v....... _... O Description of Soil... _. --.=�'�..... -�------------------ tiro Z�Z' ' x ----------------------------------------------------------------- ---,..--------•-----------------------------------------------------------------------------------------------....-- UNature of Repairs or Alterations—Answer when applicable_...:: .t �iLLi47T6N AND CERTIFY 1�1 ----••••----..n c'SYS`PEK•-WA'S"IN.S`•T'ALLED iN --- Agreement: . ^•t:ORDANGE T'OPLAM The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of IT •-• .l/'1 11E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the b rd of lth. ....... ... ••••• _._.. . �to . .......•Application Approved B � l TDa a Application Disapproved for the following reasons------------------------•------------------------------------------------------------------------------------•--- -•-••-•••••--•---••-•-•-•••........-••••••--•-•-----••••••-•••--••--•••••-•••-•-••-•-•....................••-•••••...•-••-•-•••••••••------•-•••---•---•--------••-••••------•--•-•-----••---•••......... Date Permit No.... ... ----• Issued------------ ----------- o�t A � ��: � • rri 1 - � .r�`ri�'� • � � '`r iJ t L p { -' r i I • � r �\ � � F V W �':1 �. c No��jj d.. -�'`h FEB................ THE COMMONWEALTH OF MASSACHUSETTS + '` BOARD OF HEALTH ......70.0, OF�', AVVIiration for MsVosaf Workii Tomitrurtiutt 'Prrutit Application is hereby made for a_-Yermit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: '" /�,�� Location-Arddress q or Lot N7 ........ •;�v:�GG%*Z L •. �// ✓y� s. l, ff� GiC W i Owner Address 0 __k G �. Installcr Address Type of Building Size Lot---- -- _ _..Sq. feet Dwelling—No.'of Bedrooms____.._....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building ........... No. of ersons____________________________ Showers a YP g ----------------- P ( ) — Cafeteria ( ) dOther fixtures ............................................................. ...................................... W Design Flow.............1r-.----.....................gallons per person per day. Total daily flow.............:__..._..:...------_-----•----gallons. WSeptic Tank—Liquid capac/ityZ�20_.gallons Length 4u��_"__ Width_�`_��.......__ Diameter_? ��.... Depth..!��......_. x Disposal Trench—No. .... Width................. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......'�._-_____. Diameter----�.... ------- Depth below inlet._1�........... Total leaching area_;.-��.E!sq. ft. Z Other Distribution box Dosing tank ( '-' Percolation Test Results Performed by., �r?°'��' '`�� �.. Date___: .. '.. a Test Pit No. 1___ �...._..minutes per inch Depth of Test Pit-��... .____.� Depth to ground water...�v............. fT4 Test Pit No. 2... .___..minutes per inch Depth of Test Pit_,_/�g........._.. Depth to ground water._ ?�G......_.: f,----------------------------------•-------•-----••--------------- �.---- - Description of U - -------------------------------------••----------------------•------------------------------........................................ W _ U Nature of Repairs or Alterations—Answer when applicable__._______' ,�tGkL'IIllla I�I\SGINE -_ii!/lS:�t- •;- ENGINE ------•.......................................................................=vS-ALLATIOIV AND__ CERREY p�4-,�,.:.::...._.. i HE SYS`E11VfWAS INSTALLED IN ...Agreement: r=RDAN('F TQ P1 p N The undersigned agrees to install the aforedescribed Individual Sewage-Disposal"System in accordance with f'1T+�1.I^ the provisions of '� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the b rd of bmlth. _..— - = - , -- f3(C, . z-'-Y'1 J-------••--- Date _---- Application Approved By.......... - ; ....... ..........' -�::; --•-----� 1 � ----- �--� /Dat Application Disapproved for the following reasons:---•----•------...-•-------•---•---------••------•-•---•---------•-•---•----------------•-•-----••-------------- ------------- _ _. ;. / Date ,f- Permit No.--- -_......�a. ..... Issued........... -------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH- .. ti1....:............OF... .,....-.:'.... t...................................... Trrtgfirat a of ToutVf aurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-------------------------------------------------------`---------�-;-w•------------•----••----------••---------------------.--•---------------------•------------------------------------------------ t ( ti Installer. - ' l at....... -------- -•........... — �'4=�"?------- 1 .. (fit nr�S has been installed in accordance with the provisions of ili� The State Sanitary Code a described in the application for Disposal Works Construction Permit �ro�4 ___f .%>; ...... dated......../_Z) THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F_"CT19.N SATISFACTORY. DATE..... ,� -•� -- --- •--•------------------------------•---- Inspector_...:- ----- ��:.11� Z>1GINING ENGINEER MUSi bceTHE COMMONWEALTH_OF MASSACHUSETTS NSFALLATION AND CERTIFY IN ,^." '1 HE SXSTEM WAS INS T BOARD OF HEALTH _,.. CE TO PLAN U OF............\r..... a /���a'4� �.4!�:::_''............. �/ NoT..� Q.. r FEE........................ Disposal "Pamit Permission is hereby granted............ • . •----- .---- --.....-`=`-='".-r^......-----••-------•---•--------------••-•-------...--•---..................... to Construct ( ) or Repair ( ) iduaI ewage Disposal System at No. = _:..:«._ ._``....._.�:_..G,h_N i . j as shown on the application for Disposal Works Construction P1 Fy it No r�"_frt!?3_.. D �_._..:. ....................... DATE. Board of Health -----------------_--- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS �`,- �,)f -. r-` / _1 f _. `1\ � , _ ',\ � � c _.,\ �� `'( �l. ' � , A} i1 �, (- 1 1 i ��� \ ``� � t � � ' �1_� t �� \� .: (� j L' r .rsa'c ,uV � .�Q I y 1 r P17- 'L V I 1 taTTACf:E�bQ / o , i t st Ic i IH OF F P- .:Y L. l t,l .N l..y � ROBERT yG BE a, w. P L,a Lk CM. woY _._ DAVIDSON �No. 24500 a rr_ STV �SStONAL IC CAiL:C0 LtATIp*s .C. 5.14s.c,U' 00 .50%Lr OeS.pITS AUp Pee4dLATI DOTE%- 'S-i4_�Etl.Z�.:.JUti:E:,:.19:6ES. vuiTaI:SSEG.:.BY...:-:=J6�2Y...D6�1tJr3te5b�.DR12.n�.StA3tE� fib. F��Ai.YF( .:::pcu r.o_RMED.:C-.Zyl :3Y2 Ff._..rs,A-TF- Zips "r :. AY. cacG G44&-.TAQK. �GME�=ST�Ioo�c::_:_:::g.:��tt-x.•.q.-10"nS_���.n�ep: CAC: �i:i:1G -p1'T-�EQA _.__5:1DE. EA:z ZRRCD)= 2(3..I4)Sx0x2-5= 62$ GPD I-Fra>aT�:La�EA .-(25. ..............:.:.:: .::7.. GPI PTS_C.::::s-Y S.—T. —E A�:v ::LCS' #_Z. E A ES .V�IA�( Rae -Ne:Ep:: :B�j_ lz:M:':D�aV tDS©i.7.�..C��,• 1 ' r o 401. t- 4�prca WV c�r rl \ j t ATTKCNcDD� W _ 01 d NI �....i.z._ . . t OF M,�, P-A'Q.V,-' L i 'hl r-\V C IN U E- 1 ROBERT c yc ?Q 3 t_t C M. a1®' �,v i t, DAVIDSON ca .p No. 24500 ASS/ANAL, �G CA.LCi_5 L./AT10A�S BA.SED'.0�j So%L. Pee4aubmDoTty' xAKE�1-_2.'!__.�tl►::.E:,.�3.e25- wt SSst t�E :.-- i.. .wfte! =. _DtatWMe, SA"bSTAZLE, M E1EALf4 : A CC TAtJ.K Qtr�'I7 :=: 3�.6itaGSx:C`-S: 4GJ5 6At-S. .-LJSE:::I doG>GAL-TAWKk Zf3-t4�Sx 0 x 2.5= 6 Z8 GPD W/-8'.:0.EFF :c>o:=;..... :.::::..... 7.9:-GPn TCiThIL�' MsiG�J R v.lj�:::.:: . .a.�:.-:-3.3a::<.:.:_.3 7 7:GPI (.....Sl: TIC:::.:sY:STEri%'�:.:.- �c�T :2:.UEAZ5ES:_WAS(. _. . "'Pr I -Dti'Tt~t.....���.:G;.I99ti 10 ,✓� v �- u, d VI N 1 ►� J V W 0 }� 0 (A (� 7 w m n� s A , _J • � , � � �� O `��gETTS b�� ZO o�q,�ay� C N J L > N U)i Z 0 a�V�y '• °° 00 / 32 o �Kl rg 46 lu 034. i -4 1 W /_C * 1 o� o i cow-low I � Z 'cc, t} ( 72'-' i wrrAcHevi .44 I o [ I H OF��s9 � y RO IBNERT_ y.C,' DAVIDSON &M. zasooa 01ST04'���c4' y� �SS�oNAL II •F•• �, SA.S.E.D.O►J SQ\l. OB5_PATS AUp PEP.�iDLATIDL���iT : . x'AY�Ea.:2_�._.)Ur:.t✓,_[9:Cy_ [Zti55S6�-�Y_=::.JE��Y..:.DdlNi to&,-,BA/LJ STAB LE bD. 1- EALA __:pER.F..o_rzMED 2�I1- Yy rT. rtATL° :. ..2M�p�tW.1— �I���Y. 3 8E.0.@-..110 SE:1dv0GAt..TAW K- {�cME;:_�T::.1000::�:...8-=�t��:x.•.¢- CiEA �iwlC�::.p1 :eEQp �..-SIDE-.ARCiA; ZR Q(D)=.2(3..14)Sx a x 2-5= 628 6�D -GPD _._...::...._ '*;2:=-UEAR�5E-6-'-IA�(.. A._ 5 ?67 �D o m ASSESSORS MAP : TEST HOLE LOGS NOTES: 3 �o PARCEL: 034 p 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOR :"/ eyt?� R S CSE THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF c � FLOOD ZONE : NON f1pZ�-� WITNESS : `NOT ��,QU1R,I✓l� , BOARD OF HEALTH REGULATIONS. 3Q S REFERENCE: �;Iy, DATE: Q.a 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, N Q tab PERCOLATION RA. I_: L M►N +ri SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO a 3 CLr�-SS r' �a_l t.5 ltA72.-0, t�9 Pd L INSTALLATION. 0 TH- I E(__&0.qo TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION a MARY '-" ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE _ n A (rO fkM w 1�3 DETERMINATION. y OR ?Ji ( ��m�1140 C�T P Lo BY n S 1 / O o +� l2 4� s E TT�._ _N1 N L __ -���0-�� ,L9 � �v (,p p�M 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "`1 (FOOT. (UNLESS ,g _ _ I��6' SPECIFIED OTHERWISE) LOCATION MAP C o �' n 5a�O � q � � 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A J ��' i GARBAGE DISPOSAL. KGD l U M 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) C I S",o Ai0,57 MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON `Ct 2..5`f A BASE OF 6"OF CRUSHED STONE. I /4 7) �v5VN4_ P+T To 6E pvM1°E,0, GRuSt+�Eo 4�- -3$.90 T►�V. c _ - l t6�,Mom, 5AW. No W R-� � �d a)Igo "ow4_Pju.�1k_i.LS w/ld I% or- PROP. CEO . SEPT I C: SYSTEM DES I GN T4Vri 4P Br S- ? FLOW ESTIMATE �J BEDROOMS AT <<� GAL/DAY/BEDROOM - 336 GAL/DAY TBM = TOP of SEPTIC `TANK WkTE*-4�A-'IE EL- Go. 81 GAL/DAY x 2 DAYS - G60 GAL U' Ax)mF_ USE l4iLO GALLON SEPT i C TANK eYIsnN� ��L,�_ wf/,sod G'a.ilarrl 56-P TIC T) V k tit Fr9-1 Lt p J 19+M+Cy tYj SOIL ABSORPTION SYSTEM aA_ w)t r._t t .o /Z•� Sox& S'I DE AREA: 2S� Z+�t�.�1 k Z k O,?y = t o q. 15� BOTTOM AREA: 25 x i -L u O. ?Y ; -ZZ Z Tit' I a I 331 .So GS�{9 � 33o ci` I r ►s'r1 N4 3 I'vt�, E 20 a, I SEPTIC SYSTEM SECTION o ,� 1 pt/ULLLIrJ4 l TO _)2 1i ¢ -� � cows Ta Et. Sv_ q- so.4 IN.} Z 8 I ,� N WII N G�10 f 'C7n►SGi Yat�f M� t 4��1 n5�,i nrf 6p, 232 �( S� 10 Insfatl 14 � ��" � wf a !, oi=�r�•le C 3� (,1as Baff!< � �•I� .����,9� b„ • o j �t)SnnIC� I - D-BOX � I,0wGAt..iod cop GAL Q��7 �Va{c/ et46 T�1LGBH Z N4 SEPTiC TANK ) 47 90 9�c,qo PIT Ex/snN�- D6-3 ( ILA,)Cooss ��� 1onl IV. Ts. 7.0 �-1 PJ �aske� "ZNOF—Mass a5 SITE AND SEWAGE PLAN o RR `y 24 3/"-� bovl►le LOCAT ION : /q/ENIJF lR\ N4711 . waskcd No. 140 50 47 Q�CISTE��O 12-16 PREPARED FOR : VE," _guz A4 8 Cq-fiCo SANI TAR\Pa F 2� PR'�s SCALE: �=?D DARREN M. MEYER, R.S. DATE: Z P.O. BOX 981 Z EAST SANDWICH, MA 02537 W DATE HEALTH AGENT Ph: (508) 362-2922 S�T..Lr 4�`•^7 V v' —��� -/ �-J ---/\�/1(7' l .J-•L/ / 1 0232 Sr ib I'v ,,,3TEJ ? 1'I�oF ;r_� y � �Z - /©D - -- — ;��.,� G C�nuTou G; �Pr� SuB�XL 22� �7�Fso t SNdso2'e -- COAkS Is \1 �SO.y, �i�ll 51A1 1 i •, GkA �� `e�'- v� i fCsr�6�.� � T� Ba�NO �P-SUMEo 'rr B E - > U � SAIUn �`� t/ L LA) IJ ( '� /N► � 50SL (�s}=RVAT''LGN PST T P � (7f�l✓�L t �f� t — W --- _ --- W \ A PERG TEST STT l E NO Uv P-TE l s VL . O �Pc� P zT - q'►Zvt��t�'u �. /� -Lace- Cam--XANI-Z&)A r Z=00 P45,Q PZJ-RA'1 F_=i� J GUUC' c,Q PI - /KR -r _ R - . F,RRy Ji�NNrNG , BP�'�i�BL>✓ I�ArcC O� NI-"A�..i1it - #� -� Gr S. 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