HomeMy WebLinkAbout0015 FROST LANE - Health 15 FROST LANE, HyANNIS
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TOWN OF BARNSTABLE
LOCATION 8 ,2.0 ,�'L N SEWAGE# _.0 t6t 41,3
VILLAGE ASSESSOR'S MAP&PARCEL `
INSTALLER'S NAME i PHONE NO. 7'71-13:27:4-
SEPTIC TANK CAPACITY ks-A tr e t Mg�; ie-W8
.LEACHING FACILITY:(type) - -F 1�-N(Cl4t— (size) �-���ice•S DZ�-r
NO.OF BEDROOMS 3
OWNER
PERMIT DATE: COMPLIANCE DATE: 1
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- y wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
POW,
s
E70
(
tu a �,�� IA
? Fee G0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:J
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es
ftpliLation for Disposal 6pstem Construction 3pErmit
Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System [I dividual Components
Location Address or Lot No. /3" Fr-as- Lo-Y)e Owner's Name,Address,and Tel.No..0 - e 3
ly � �r�s�- ,o 1-119-2 is.:AZ6� Lr,
Assessor's Map/Parcel aaqLo/,g
Installe 's e,A ress, d Tel. o.sp - �,� o Desi er's Name Address,and Tel.No. G
--t 3
Apt
Type of Building:
Dwelling No.of Bedrooms Lot Size /ol-63 0 sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Q gpd Design flow provided 3 S gpd
Plan Date V� Number of sheets Revision Date
Titl , •� /Gt`u
Size of Septic Tank 4gx j� /660 q,,j-Q Type of S.A.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mainte of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environment ode a not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date /
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. co N fe'1 Date Issued ��
r
'V )�)
! No. Fee/C (%
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION 'TOWN OF BARNSTABLE, MASSACHUSETTS s
Zipplication for 30 sposal 6pstem Construction 3permit
Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon(.) ❑Complete System [r]Individual Components
Location Address or Lot No. /,S IcrOS� La r)e Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel U 9 1� Ci eSj-` t �S E fvS{ t(CE v1 t C g�
�.
Installer's Name,Address,and Tel.No..5- Designer's Name,Address,and Tel.No
&t4lo&LWAIgAA 41 CVv _
14� ,0-U. x �05� t- Sarroj fG /3�x 9&
Ile, 1,
Type of Building:
Dwelling No.of Bedrooms Lot Size /o `GS sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3 O gpd Design flow provided 3 S�� a S� gpd
Plan Date0c_� _,,Q Number of sheets Revision Date J
Title• .o �r��r � � �i 1�� , lc� f- / � � �i. : _;� l�f
Size of Septic Tank Type of S.A.S , S e a , ,
Description of Soil f
Nature of Repairs or Alterations(Answer when applicable)
ems"
Date last inspected:
Agreement: "^'� -_ _..
The undersigned agrees to ensure the construction and maintenaneg of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmenta de and fiot to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. /
Signed Date
Application Approved by ,6'i" Date
Application Disapproved by Date
for the following reasons
Permit No. l r 'T Date Issued
-----------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(,0 Upgraded( )
Abandoned( )by&
at has been constructed in accordance ---
with the provisions of!Title 5 and t e for Disposal System ConstructiorLPermit No / dated /,�.A,
Installer � 1�, � �v, �.�, - Designer 1 L
6�
#bedrooms Approved desj flow Z gpd
� 1
The issuance of this pe it sh 11 not be construed as a guarantee that the system will ctio a'si'designed. �..• ,,
Date �� (! Inspector V -9
----------------------------------------------------
Ilk ate.
No. "/ -"'/� Fee z4
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposai *pstrm Construction permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at �j �{'�, 1 �.h, „ ,.1.,a
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be complete within three years of the date of thi permit.
Date (� Approved b ^'r"
FEB-20-2020 05:02 From: To:15087906304 Pase:1/1
Town of Barnstable
Rogulatory Services
Richard V.Scali;Interim Director
$ � Public HeSlth Division
.ago Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
'Office: 5.09-8624644 Fax: 508-790-6304
Installer&Desi er Certification Form
q/,51
Date: ��� Sewage Permit#,;t0�9- y13 Assessor's Map\Parcel 1
Designer: n 6 Installer:
Address: /3 Address: t!S/1;' A,.4 ru PJ
• � � M�crs(-ten .>nR,'llg o�y8'
On r' ��Xas issued a permit to install a
(date) (instal er .
septic system.at S CJ S� Lam. t AN.)§ased on a design drawn by
—Taftess) 0 [ C�
M e. dated I 1
designer)
X I certi, that . sep c system referenced above was installed substantiallyy according to
the design, which may include minor approved changes such as lateral'relocation of the
distribution box and/or septic tank. Strap out (if required) was inspected and the soils
-were found satisfactory.
I certify tbat the septic system referenced above was installed with major changes,(i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State& Local Regulations. Plan revision or
ceRified as-built by designer to follow, Strip out(if required)was inspected and the soils
were found satisfactory.
1 certify that he system referenced above was constructed in compliance with the erms
df
vaIletters(if applicable)
a of
(1 er s Signature)
r
q 140�
/
(-- signer's ignature) ere
PLEASE RETURN TO BARNS. L•E PUBLIC HEALT N.• . ERTIFICA. E
OF CoMpLL ,NCE. MILL•NOT BE ISSUED •UNTIL. BOTH THIS.FORM AND AS-
BUILT CARD ARE RECEIVER BY THE ARNSTABLE`PU•BLIC HEALTH:DMSIO .
THANK YOU.
Q:�Sepdc\Des�a Cenification Form Rcv t8 14-13.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:when filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: 314 Wq�
key to move your
cursor-do not Sean M Jones
use the return Name of Inspector
key.
S M Jones Title V Septic Inspection
1�1 Company Name
74 Beldan Ln.
Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com SI4522
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. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000).The system:
® Passes ❑ Conditionally Passes ❑ -a1 sl�
;I
❑ Needs Further Evaluation by the Local Approving Authority
SEP 2 1 REC D
9/1/2010
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of�completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
v
t5ins•08/08 Title 6 Official Inspection Form:Subsurface Sewage Di I Syslem•P ge I 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. Citylrown 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:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N,ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or 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•09/l18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 at 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ 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):
El obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,.
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins-09/08 Title 6 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owners Name
information is required for every Hyannis Ma 02601 9/1/2010
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•09/08 Tide 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
_
page. Cityrrown 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 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
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.
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
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 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.
® El Determined in the field (if any of the failure criteria related to Part.C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd
t5ins-09108 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/industrial 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:
t5ins-09108 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Fora
A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 p Y rY
�< 15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. City/Town State Zip Code Date of Inspedion
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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
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):
Lt5in. 09108 TiBe 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is Y required for every Hyannis Ma 02601 9/1/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank d-box and 1 leach pit original, 1974, Leach pit added 1988
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
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.):
Joints ok, vented through roof
Septic Tank(locate on site plan):
Depth below grade: 1.5
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 Gallons
Sludge depth:
3"
t5ins 09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
VjSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge'to bottom of outlet tee or baffle
3'
2"Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers and took
measurements
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 was structurally sound,water level was at bottom of outlet invert. Tank was recently cleaned but
should be done again within 2 years and every 2 years as maintenance. Covers on riser.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal []'fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. CityrFown 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 was found to be functioning as intended.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of:pumps and appurtenances,etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
lugTitle 5 -Official Inspection :Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
leaching galleries number:
El leaching trenches number, length:
leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit#2 had 3'of available leaching and a stain line approx. 2" higher. Vegetation was normal.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 17
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
_
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.):
Privylocate on site plan):
( P )
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 114 of 17
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
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'l 3
e
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. -1 2�
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t5ins•09MB Us 5 Official Inspection Form Subsurface Sewage Disposal System•Page 15 of 17
egt
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20+/
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)
El Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Town of Barnstable topography map shows groundwater @ 22'
}
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-0901 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Officia Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
15 Frost Ln.
Property Address
John Powers&Marilyn East
Owner Owner's Name
information is required for every Hyannis Ma 02601 9/1/2010
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 17
. f
CO'.MION- EALTH OF MASSACHi;SETTS
_ EXECLTINrE OFFICE OF EN-MON-MENTAL. AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WLN M STREET.BOSTON A 0210r 1617 1 292-JJIIV
y
J
TRl DT COL
Secre;a-ry
ARGEO PAtiL CELLtiCCI DAVID B STP-HS
Govern: Cotnntiss:one-
SUBSURFACE SEWAGE DISPOSAL SYSTBN NtSPECTION FORM
PART A
CERTIFICATION
ProPertyAddress: 15 Frost Lane Namsofowner Dennis Lajoie
Hyannis Address of Owner:
Date of Inspection: J(> bL
Name of Inspector:(Please PrinK)WIII. E. Robinson Sr.
I asru a DEP approved s erq inspector to Section 15.340 0l Title fa(370 CMR 15.000)
CompanyN,me: Wm• E. Robinson septic Service
MaaingAddress: PO Box 10 9. Centerville MA
Tolep xm Number:
CERTIFICATION STATEMENT
I certify that 1 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 function and
maintenance of on-site sewage disposal systems. The system:
!/Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: -
Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority!Board of Health or DEP)within 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 lute
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
- 14k
r 0
VT
rep se3 5/2/9E pave iorii
t: -•--red o-Rec.,c-wd Parr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Nop"Address: 15 Frost Lane, Hyannis
.)weer: L a j o i e
Date of Inspection:
INSPECTION SUMMARY: Check (9 B, C, or D:
A. SYSTEM PASSES:
L/1 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.
COMMENTS:
B. S STEM 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 es,no. or not determined(Y. N,or NO). Describe basis of determination.in all instances. N "not determined'.explain why not.
_ 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 120)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.
_ 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 Iwith approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
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
Yevisec 9/2/96 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION Icorrtinued)
Property Address: 15 Frost Lane, Hyannis
annis
Owner: La oie
Date of inspection: 6
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 W ACCORDANCE WITH 310 CMR 15.303 f1)(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) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING 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 ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
31 OTHER
i
'P�` 'sc' 9/2 98 P2ge3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 15 Frost Lane, Hyannis
Owner: TT�aa�
Date of Inspka l O 1 e
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
d termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct,the failure.
Yes N
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool. -
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. 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 YSTEM FAILS:
You must ind cate 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
he th and safety and the environment because one or more of the following conditions exist:
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)
The owner o operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the apartment for further information.
re'IT iBeQ 9j 2/98 Pagc4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
PropenyAddress: 15 Frost Lane, Hyannis
owner: Laj ole
Date of Inspectr_:�
Check if the following have been done: You must indicate either "Yes- or "No" as to each of the following:
Yes No
Pumping information was provided by the owner,occupant, or Board of Health.
_ 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.
_ As built plans have been obtained and examined. Note if they are not available with NIA.
_ The facility or dwelling was inspected for signs of sewage back-up.
-dam _ The system does not receive non-sanitary or industrial•waste flow.
1/ _ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_ 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:
_ Existing information. For example, Plan at B.O.N.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
/ (15.302(3)(b)) . .
_✓ - _ The facility owner (and occupants,if different from owner) were provided with information on the propermaintananrAik-0f
SubSurface Disposal Systems.
_evil seC
Pair 5 of I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address: 15 Frost Lane, Hyannis
Owner: LaJoie
Date of Inspecti .1.6—a-T'�
FLOW CONDITIONS
RESIDENTIAL:
Design flow:or-C O g,p.d./bedroom.
Number of bedrooms(design): 3 Number of bedrooms lactual):3-
Total DESIGN flow (, ! y
Number of current residents:-2--
Garbage grinder(yes or no):1Jc0
Laundry Iseperate system) Ives or no);/&0; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use Ives or no):,fi 6
Water meter readings, if available (last two year's usage (gpd): 9 9-0 0 58, 5 Q U gal
Sump Pump(yes or no): A/O
Lest date of occupancy: �-S 98-99 1 �2, 0�0 gal.
3
COMMER IAUINDUSTRIAL:
Type of est lishment:
Design flow: d ( Based on 15.2031
Basis of desi n flow
Grease trap resent: (yes or no)_
Industrial W ste Holding Tank present: (yes or no)_
Non-sanitar waste discharged to the Title 5 system: (yes or no)_
Water mete readings. if available:
Last date o occupancy:
OTHER:( scribe)
Last date f ccupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
�g94
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM
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
APPROXIMATE AGE of all components, date installed(if known) and source of information: 44 &-Z7 !✓ r�
Sewage odors detected when arriving at the site: (yes or no)
�el'lseu 9 2 Page 6(if II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued►
'roperty Address: 15 Frost,„Lane, Hyannis
Owner: La]_Qle
Date of Inspection:
BUILD G SEWER:
(Locate n site plan)
Depth be ow grade:_
Material f construction: cast iron 40 PVC other (explain)
Distan from private water supply well or suction line
Diamete
Commen : (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan) �sf,
Depth below grade: d—+
Material of construction: oncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_ (Yes/No)
G
Dimensions: � �`•
Sludge depth:
:2 g'
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness: /-� 1
Distance from top of scum to top of outlet tee or baffle:_ j 6 ,
Distance from bottom of scum to bottom, J outlet tee or baffle:
Wow dimensions were determined: 0 I,✓
comments:
Irecommendation for pumping, condition of inlet and outlet.tees or baffles,.de t of liquid level in relation to utlet invert. structural integrity,
evidence of leakage, etc.) &$
GRE ,S RAP:
(locate on ite plan)
Depth belo grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain)
Dimension
Scum thick ess:
Distance fr m top of scum to top of outlet tee or baffle:
Distance f m bottom of scum to bottom of outlet tee or baffle:
Date of la pumping:
Commen
Irecomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evident of leakage, etc.)
Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(eortt mwd)
l,rope"Address: 15 Frost Lane, HYANNIS
Owner: Lai oie
Date of Inspection:
TIG R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(iocete o site plant
Depth belo grade:_
Material of onstruction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow gallons day
Alarm prese ii
Alarm level: Alarm in working order: Yes_ No_
Date of pre ious pumping:
Comments:
(condition f inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: (/
(locate on site plan)
q
Depth of liquid level above outlet invert: (75
P
Comments:
(note if level and distribution is equal, evidence,of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CRAM ER:
(locate on site plan;
Pumps in wor ing order: (Yes or No)
Alarms in wo king order(Yes or No)
Comments:
(note conditi n of pump chamber, condition of pumps and appurtenances, etc.)
rev1sed. S/L/SC Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: 15 Frost Lane, Hyannis
Owner: Laj oie
Date of Inspection:/o,,,X
SOIL ABSORPTION SYSTEM(SAS):_v
(locate on site plan, if possible;excavation not required,location may be approximated by non intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions.
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condi ion of soil, signs of hydraulic failure, level of ponding, damp soil, conditiop f vege ation_, �tc.) n
�s G
CESSP OLS._
(locate o site plan)
Number a d configuration:
Depth-top f liquid to inlet invert:
Depth of sods layer:
Jiepth of sc m layer.
Dimensions f cesspool:
Materials of onstruction:
Indication of roundwater.
infl w (cesspool must be pumped as part of inspection)
Comments:
(note cond tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on sit plan)
Materials of c nstruction:
Depth of soli s: Dimensions:
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
rt
` Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icon immd)
"IropertyAddress: 15 Frost Lane, Hyannis
.)wnef: Laj oie
ante of Inspection:
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)
' 1
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ILI 1�`'vYz
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S
1
Yes sec G;'2/�� Page 10ofII
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C
SYSTEM INFORMATION(con*WWI
mp"Address: 15 Frost Lane, Hyannis
Owner: Laj oie
Date of kupedbon:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked Deep
Groundwater depth: Shallow Moderate
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells N
Estimated Depth to Groundwater Ig 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
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
y
rc-visec 9/2/9b PaFc11of11
0
TOWN OF BARNSTABI_E
s
C)CATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. CO
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)
NO. OF BEDROOMS�PRIVATE WELL OR PUBLIC WATER_
BUI1:DER OR OWNER e:�A-1Qf L d f
DATE PERMIT ISSUED: 9 a2
DATE COMPLIANCE ISSUED -x ' z
VARIANCE GRANTED: Yes No
4
O
Q
N
N ,
N.
ti
LOCATION SEWAGE PERMIT NO.
-77
VILLAGE -- '
_cc:
INSTALLER'S WAME&�pA�DDRESS
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
r _
i
I
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF .HEALTH
0
Fe:.:]Z iV.S7 6 a le,
' 'Appliration I for Disposal Morks Tonstrurtion Prrmit
• Application is hereby made for a Permit to.Construct,(, ),or-Repair ( an Individual Sewage Disposal
System at
ocat on-- -«ess ..._ .. -qo.•
• ' o~ r Lot N
...::...............................................
ner �w ddress ._. A
--
M Installer Address r
Type of Building , ' Size"Lot..............................Sq. feet
Dwelling—*No..of Bedrooms..... ...............................Expansion Attic ( ` ) Garbage Grinder ( ' )
per,, Other—Type of Building ...........:............... No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures................................................................................... '
Design Flow.............................:.............'.gallons per person per day. Total daily flow-:..........................................gallons.
WSeptic Tank--Liquid capacity___.._..___gallons Length:............... Width.............._._ Diameter................. Depth................
Disposal Trench—No..................... Width....... ______ Total Length......;_............. Total leaching area.. sq. ft.
Seepage Pit No.....t-------------- Diamete'4.::rf---__-__ Depth below inlet.... ........... Total leaching area.. ..sq. ft.
Z Other.Distribution box Dosing tank
aPercolation Test Results Performed by...........................---•--•--••......--•_______--•--------•-•----•-• 'Date.........................................
,.a Test•Pit�No. 1................minutes per inch Depth of Test Pit:.....................'Depth to ground water.................-......
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... s
y r
Descriptionof Soil............-•-•-•---...•-•-•....................••...................................................................................................................._
-- = '
-U Nature of Irs o lt�r n —Answ,�r � ,a,Pphcable---.t---.......... ../----------------------------------------------------------------------
J . ,( Wes"
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ITi U 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
Z.,tUe board
J,0 health.
- � Signed.......------•---....--•--�------------------------`--•------•--------••---•-----••-- •-----•-•----•---•• ,
Date
Application Approved By........... "•- ---- —�
Date
Application Disapproved for the following reasons__________________________________________________________________________________________________________«.... ,
-------------------................................................................................................ ...........-.......••••-............................
Date
c
Permit No....... ........... Issue&.......................................................
Daft
NogF-_Y72 ~
0 Fins2......................
THE COMMONWEALTH OF MASSACHUSE17S
BOARD OF HEALTH
. ... .........A).............I..................................................
..................... ............. . . ...... ....
Appliration for Dispasal Works Tonstrurtion "amit
Application is hereby made for a Permit, to Construct or Repair ( t-ran Individual Sewage Disposal
System at:
r-9 o A.............................. ..................................................................................................
Location-Address 14 or Lot No.
fIVAJ)S J A Q 0 1
.................. ....... ............... ... ................................
Co /Address
.......... .........
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling-No. of Bedrooms..... ................................Expansion Attic Garbage Grinder ( )
Other-Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Pa
Other fixtures ..........................................WW ............................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank-Liquid capacity............gallons Length................ Width................ Diameter..._............ Depth................
Disposal Trench-No..................... Width.................... Total Length.........._........_ Total leaching area....................sq. f t.
Seepage Pit No----/--------------- Diameter4.: _/.'--. Depth below inlet.........._..... Total leaching area.33.�t.sq. ft.
Other Distribution box (, ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit...........--....... Depth to ground water.._.....................
Test Pit No. 2................minutes per inch Depth of Test Pit.__..........._..._. Depth to ground water........................
------------------------------------------------------------".....*-------------*----------------------*.........."-----------------------------------**"*"'
0 Description of Soil.........................................................................................................................................................................
-----------------------------------------------*---------------------------*--------*-------------------------------------**------------------I---------I------------------------*,----* --------
................................................................................................................ I---101.1....... ........
U Nature of Re airs or Alterations-Answer yv Jien applicable....... ......... ................... ......... ....................................................
5
....................Q--- �_:7 -
---------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T 1Z- 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 by the board of health
Signed.._.._.�� ? -.2g,er
................................................................... ..........................
Date
Application Approved By............ ...... ........
0 Q Date
Application Disapproved for the following reasons:.....................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo.- . ......................�/----------------------- Issiied_.......................................................
Date
-————————————————————————————————————————————————————
THE COMMONWEALTH OF.MASSACHUSETTS —
BOARD OF HEALTH
..........................................OF;poe/v_r7r�
.........................................................................
THIS IS TOC-W-R, IF ThatTertifiratr of Tompfiaurr
,the Individual Sewage Disposal System constructed or Repaired
by...............................------------------ C;;�-----------------------------------------------------------------------------------------------------------------------
Installer... .......i�.� .............
at..... ......................... ? CNN! ---------------
has 7------------------------------
been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..........�.5.......5 7�....... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....................J 0 - 5 -
.......................................................... Inspector....................................................................................
---- ---------------- ------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................ ./e....................................
No...... FEE�q...............
7
Permissionis hereby granted... .........4...�f K....... ....................................................................................
to Construct or Repair O an Individual Sewage Disposal System
00
at No.---..4. ......................... ... . Aj40V1_S�
..................................................................................................
Street '7e-
as shown on the application for Disposal Works Construction Permit No./.,-,------ Dated..........................................
.................................... .................................................
.............Y- Board of Health
DATE:._... ..........................................................
� '
No. - ----- - - ----- � Fee-------L:5 el"a--------------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applicat ion *rVell Congtruction3permit
Application is hereby made for a permit to Construct (Alter ( ), or Repair an individual Well at:
�l a 7 S.
_ ------------------
- - --- - --
Location — Address Ass ssors Map Ind Parcel
Ow/neer�
• — —- Address
¢ d _z eX -- - _--—/?--J, J—Cn-S h
----- ---
Installer — Driller Address
Type of Building
Dwelling -—— ---------------------— --- —
Other - Type of Building ----------- No. of Persons--------------------------------------------------
Type of Well— �� ----- - ------ ------ -__--- -=--------------
YP --------------------------- Capacity---------
of Well----L,�/
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed—� --��C"�-----------
/Y/-LS------
date
Application Approved By-- --
date
Application Disapproved for the following reasons:
--- - — -- -- - —- - — -- — - -- - — --- --- ---------------------___ - ---- — ---
date
Permit No.—�`� —`��- � 4:> -- — - Issued---- — -
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
` Certifitate ®f Compliance
THIS IS TO ERTIFY, That the Individual Well Constructed (-I, Altered ( ), or Repaired ( )
bY-----�� __CUB
Installer
Lam' .
has been installed in.accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
4 �, _ �-
Regulation as described in the application for Well Construction Permit✓�i�6• --- ------------�P'•�--Dated=-------'��----_J_�'•5
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----------— - --- - — ------------ Inspector---— ----- --— — ------------------------
No.--------------------' Fee--------------------
BOARD OF HEALTH
TOWN - OF BARNSTABLE
Applitation orlVerr Cootruction Permit
Application is hereby made for a permit to Construct (Alter ( ), or-Repair ( )anq individual Well at:
S f 0 0 S 1� /-.a �f yCa"' " L�_ -------
Location — Address Assessors Mip and Parcel
------------------------------------------------------------------------------------------
Owner Address
- X0 if
/ram
Installer — Driller Address
Type of Building
Dwelling-------------------------------------------------------------
Other - Type of Building--------------------------------- No. of Persons-------------_--_----_---:---- -____--
Type of Well-- — ---- — - - -=---------------- Capacity-------- _—
Purpose of Well_I 1r `� `f��-``=---------- -
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate off Compliance has been issued by the Board of Health.
Signed -
date
Application Approved By----.------ _
date
Application Disapproved for the following reasons:----------------
------------------------------—__— -- -- --- -- - - - -- ------------------------
date
' Permit No.- - � `'" ---- - Issued------ -- - - ate d ------ -----------------
date
l�
BOARD OF HEALTH
TOWN OF BARNSTABLE
- . -; Certtficate Of Comptiance.
THIS IS TO CERTIFY, That the Individual Well Constructed (�'), Altered ( ), or Repaired ( )
- -------------------------------------------------------------------------------------------------------
Installer
at
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit�I� � ---��Pr�--Dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE— -- --- -- - ---------------------------------- Inspector -----------
BOARD OF HEALTH
TOWN OF BARNSTABLE
Veil Con5truct ion Permit
No. -----------��----- r Fee----- 7J
Permisslon is hereby grantedto Construct ( "), Alter ( ), or�R/epair ( ) an Individual Well at: f
No. _/5 = / /05 7- IA.) ��-/_V,, �r -M '�trees -------------------------- -----------------------------
-—-------------------------
Street
as shown
on the application for
(a�Well Construction Permit _
No.- =— -�—�! - -- Dated-- --C- - vim— - --
Board of Health
DATE------------------------------------------------------------
w„
WrT-
I LEGEND HYANNIS
PROPOSED CONTOUR
® PROPOSED SPOT GRADE WEST MAIN ST.
b EXISTING CONTOUR
+ 96.52 EXISTING SPOT GRADE
,f { W— EXISTING WATER SERVICE Most W m
TEST PIT LOCUS N
FROST LANE
2 5 i S�JO
24 �
O 82.16' w
26
LOCUS MAP
LOT 1 — 3 Q �' BENCH MARK
1 AREA = 12,080 sf+—/ / � i i ; //,�� TOP OF FOUNDATION LOCUS INFORMATION
PARCEL ID: MAP 289 PAR. 019
BARNSTAB�E GGIS DOATU TITLE REF: 24977/340
PLAN REF: 183/019
Ljj 1 / / FLOOD ZONE: PROPERTY NOT IN FLOOD ZONE
> PROPERTY IS WITHIN A NITROGEN SESITIVE AREA
Y SEPTIC SYSTEM
REPAIR PLAN
LOCATED AT:
I
EXISTING 15 FROST LANE
II DWELLING 1
HYANNIS, MA
11 TOP OF FNDN PREPARED FOR
I r
O EL = 26.50+ 1 FORREST THORPE
OCTOBER 9, 2019
ILL TP-1 I I
TP-2 I I
1 BECK J�� or
'
0
m ` I DA C WREN ,° 0 I I EJ
1 EXIST./ 1,000G 0V1
25.0 1 SEPTIC TANK i it �P�G�STE��
i
$4NITAR\'
120.0'
24 I
25 26
27 MEYER & SONS, INC.
P.O. BOX 981
EAST SANDWICH, MA. 02537
PH: (508)360-3311
FAX: (774)413-9468
meyerandsonstitle5@gmail.com
SHEET 1 OF 2 J 1894
� I
ELEV. TOP I
DROP FND. NOTE:' PLACE MAGNETIC MARKING TAPE OVER ALL COVERS
} (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (24.0-23.0)
= 26.50�• �F.G.EL: 53.30 F.G.EL: 24.50 F.G. EL: 24.0
s MAINTAIN 2% MIN SLOPE OVER LEACHING AREA
A
" F.G.EL: 23.75 j 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2"
.• . ; STONE OR FILTER FABRIC DOUBLE WASHED STONE
4 6" w
" 4" SCH 40 PVC
;a 10"I 14 s NWEME30M
®®®®�®®®®®
® S= 1 MIN.)
A' TEE'S ARE TO BE ( , E3E3 ®®E
_ 4" SCH 4o PVC INV. 21 .50 2 EFF. DEPTH ®®®®®®
INV.22.45 INV. 21 .30
GAS _ 4' 2 X 8.5' 4'
EXISTING BAFFLE PROPOSED DB 3
DISTRIBUTION BOX EFFECTIVE LENGTH = 25'
INV. 22.70 - (1-120) INV. ELEV.= 20.0
EXISTING 1,000 GALLON SEPTIC TANK
GAS BAFFLE TO BE INSTALLED ON ��VN OF sJ9 BREAKOUT
OUTLET TEE AS MANUFACTURED BY �`� �y
NOTES: TUF-TITE, ZABEL, OR EQUAL D1� R TOP CONC. ELEV.= 21 .0 ELEV.= 21 .0
1) CONTRACTOR SHALL VERIFY ALL EXISTING v0 H - •®®f ®®
PIPE INVERTS PRIOR TO CONSTRUCTION INV. ELEV.- 20.0 E38
2) D-BOX SHALL BE SET LEVEL AND TRUE TO � ®®1EEM3f3®®
GRADE ON A MECHANICALLY COMPACTED SIX ° 130®®®®®
INCH CRUSHED STONE BASE, AS SPECIFIED IN �NITAR�a� BOTTOM EL.= 18.0 3.75' ®®5 FT®® 3.75'
310 CMR 15.221(2) I b vy l \
3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK WITH 1500 GALLON SEPTIC TANK IF FAILED, SEPARATION 5.50 FT. EFFECTIVE WIDTH = 12.5'
DAMAGED LE UNDERSIZED. SEPTIC SYSTEM PROFILE SOIL ABSORPTION SYSTEM SECTION)
4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 12.50 (SECTION
BAFFLE AS REQUIRED (500 GALLON H-20 LEACH CHAMBER)
GENERAL NOTES: DESIGN CRITERIA
I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL LOGS TPT: 19-178
BOARD OF HEALTH AND THE DESIGN ENGINEER.
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: OCTOBER3, 2019 NUMBER BEDROOMS: 3 BEDROOM DESIGN
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF)
LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: DESIGN PERCOLATION RATE: <2 MIN/IN
- 310 CMR 15.405 (1) (B): WITNESS: DAVE STANTON, BARNSTABLE HEALTH DEPT. DAILY FLOW: 110 G.P.D. X 3 BR = 330 G.P.D.
1) A 5 FT. VARIANCE FROM 310CMR15.211 TO ALLOW LEACHING
TO BE 15 FT FROM DWELLING VS REWD 20 Fr Elev. TP-1 Depth Elev. TP-2 Depth GARBAGE GRINDER: NO (not designed for garbage grinder)
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 23.5 0" 23.55 0" SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXIST. 1,000 GAL SEPTIC TANK
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE FILL A LOAMY SAND DESIGN ENGINEER. 21.68 A 22" 10YR 3/2 LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F.
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING LOAMY SAND 22.37 14"
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN IGYR 3/2 " B LOAMY SAND
ENGINEER BEFORE CONSTRUCTION CONTINUES. 21.08 29 1OYR 5/8 USE TWO (2) 500 GALLON H-20 PRECAST LEACH CHAMBERS W/ 4'
5. ALL ELEVATIONS BASED ON ASSUMED DATUM. B LOAMY SOYR AND ND 20.55 C 36" STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D
S. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 20.0 C 42" BOTTOM AREA 25 x 12.5 = 312.5 SF
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. PERC TEST MEDIUM SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. O EL 48.80 SAND
8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED MEDIUM 2.5Y 7/4 TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D
To A CONDITION AGREED uaoN BETWEEN OWNER AND CONTRACTOR. SAND DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE 2.5Y 7/4
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
CONSTRUCTION.
10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND REMOVED PER TITLE 5. 12.50 132" 12.55 132"APPROX. LOCATION. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
s
11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION PERC RATE <2 MIN/IN. (C" HORIZON) 15 FROST LANE, HYAN N IS, MA
12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY NO GROUNDWATER OBSERVED
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY Prepared for: Thorpe
13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. Design and Site Plan by: SCALE DRAWN DATE
14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. • 1, Darren M. Meyer. R.S., CSE, hereby MEYER&SONS,INC. N.T.S. DMM 10 09 19
eye y certify that I am currently approved by MADEP pursuant to 310 CMR 15.017
15. ALL PIPING TO BE 4" SCH 40 O 1/8-/FT (UNLESS SPECIFIED) to conduct eon evaluations and that the above analysis hoe been performed by me consistent with the PO BOX981 REV DATE CHECKED SHEET NO.
requirements of 310 CMR 15.017. 1 further eerft that 1 have passed the Son Eval. Exam in October, 1999. EAST SANDWICH,MA 02537
508-362 2922 DMM 2 of 2