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0011 GENERAL PATTON DRIVE - Health (2)
11 General Patton Dr / 292-102 Hyannis i 1 i I TOWN QE B 'TILE Lock (?N ' � at P/ r c%✓ SEWAGE # VU-LAGE—, ASSESSOR1 MAP&L�•c_ ,. ._�. . .� INSTAL.EIVS NAME&PHONE NO. SEPTIC TANK CAPACITY �.�. LEACHING FACIg.Fff: ( ) P� ._�(size) NO.-OFEEDROOMS. BUILDER OR OWNER. j PERMIT DATE: .—,COMPLIANCE DA`lT. ., __,m.... Sepaation Distance Between thoc MaximutmA.djust;d Groundwater Table dolltcBottoni()(I ac:hing , ility Private Water Supply Well mid Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) VAge of Wetland and l eaciung Facility(If any wetl:ads exist Within 300 feet f leac hi g f ali)�lr TA ® , v fob . i 71 i a W 9L) TOWN OF BARNSTABLE q LOCATION, ��SEWAGE VILLAGE ASSESSOR'S MAP&PARCEL �� 49 INSTALLER NAME&PHONE NO. SEPTIC TANK CAPACITY 0� LEACHING FACILITY:(typ /dim' ice✓ (size) NO.OF BEDROOMS OWNER PERMIT DATE: O COMPLIANCE DATE: t Separation Distance tween e: _ 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) c� y Feet FURNISHED BY � 1 H7 �� F No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co pu er: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpficatiou for bis saY stem (Construction permit p Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No �/)B, ei'/ Owner's Name,Address,and Tel.No.,i �,��Q�(j/� ' D Assessor's Map cel`� �- Insta�lle Name,Address,and Tel.Noav �IZ r- De ' ner's me,Address,and]Up No Al o �-� Type of Building: Dwelling No.of Bedrooms '� Lof Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) J Other Fixtures Design Flow(min.required) 93/- gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank ,�G'� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) d _-5' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Pie Date Application Approved by Date TT Application Disapproved by Date for the following reasons Permit No. J Date Issued ___��________.________------------------------ F ._ ... .;"--- "".--+ -.. ',�-*'ry^w�s""+.+++cipat,�•".-.p+.r.^ wxwv- .....•_� -^-'--- _...., ...y,..,a.n:ar=--..•d;•,.•ttir,w:-,... .. .,.-... �� No. " Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in compute— PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes I ftPhration for M1s osal Opstem (Construction Permit Application for a Permit to Construct( ) Repair)Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No Owner's Name,-Address,and Tel.No-�Q,fp ()Uj/JIJ o� Assessor s Map arcel Installer's Name,Address,and Tel. Desi ner's Name,Address, 1.No _ Type of Building: � - Dwelling No.of Bedrooms Lot Size � //690 sq.ft. Garbage Grinder( ) Other Type of Building �� Cj No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -j 1'9 gpd Design flow provided gpd Plan Date r Number of sheets Revision Date _ Title Size of Septic Tank� � �d1 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) d � Date last inspected: Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. •igned 4 � Date 2 l Application Approved by //Y/ f . i(/�. ._� Date Q . Application Disapproved by r / , Date for the following reasons Permit No. / (/ U/ Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliante THIS IS TO CE/R/TI'FY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded Abandoned( )by at ,/� ��/�,Q/ '� �o ,dy,�/�? has been constructed in acco4�fated ce �q /7/ ' with the provisions of T' le 5 end the or Disposal System Construction Permit No. Installer Designer #bedrooms Approved design flow A6 P r gpd The issuance of this permit shall not be construed as a guarantee that the system will nctiion as designed n/ Date (2 {11 ,) Inspector /r 1A,1 Al 1' } No. X���~L �' ---------- - ------ --------�--------- ---�-------•------------ ----=' Fee ..�_---- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION r BARNSTABLE,MASSACHUSETTS misposal *pstem Construction permit Permission is hereby granted to Construct( ) 7z�-I-i�,w2� airy( Upgrade( ) Abandon( ) System located at _Z -j1, ti 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 completed within three years of the date of this permit. ``/� Date � roved A b PP Y Town. of Barnstable Barlista d Regulatory Services Department A"meaica Gay BARNSCAHM p "`"Q_Q, i639' Public Health Division �� . 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO July 22, 2008 Premiere Asset Services c/o David Holt 1533 Falmouth Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 11 General Patton Drive, Hyannis,MA was last inspected on July 14, 2008,by Shawn Mcelroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Leach pit has clear signs of hydraulic failure with stain lines above inlet invert. Distribution box shows signs of effluent back-up. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH omas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 7576 Q:\SEPTIC\Letters Septic Inspection Failures\11 General Patton Drive.doc Town of Barnstable .°�"'E'' 1.� Regulatory Services Thomas F.Geiler, Director • MULN rest. q' Public Health Division ' Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 503-362--1644 Fax: 503-790-6304 Installer& Designer Certification Form Date: l 6 7 Sewage Permit# Assessor's iVIaplParce�� Designer: .��� l�r l� r' Installer: ` Gr <' Address: TO ?4,AC 1 / Address: On was issued a permit to install a (date) (installer) septic system at I ( -u. , PIALbased on a design drawn by address) dated (designer) �r I 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 Regulations. Plan revision or certified as-built by designer to follow. o. MRE R ` - ; (Installer's Signature) 11 0 t S4NITAO (Designers Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNST' LE 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. i I Q:Health/Septic/Designer Certification Form 3-26-04:doc Commonwealth of Massachusetts . Title 5 Official -inspection.. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 11 General Patton Dr r Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 every 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number s C= 0 B. Certification I certify that I have personally inspected the sewage disposal system at this adders and that the,,,- information reported below is true, accurate and complete as of the time of the inspection.T.Pe inspection was performed based on my training and experience in the proper function and Aiintenance of dn,site sewage disposal systems. 1 am a DEP approved system inspector pursuant to SectionJ5.340'of Title 5(310 CMR 15.000).The system: ` ry M ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-18-08 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. l t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 General Patton Dr Property Address Premiere Asset Services �. Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 every 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of.Board of Health): , ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 11 General Patton Dr ' ,t Property Address • :yc. Premiere Asset Services ' Owner Owner's Name information is Hyannis MA 02601 7-14-08 required for H y ` every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system,will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,'safety or the environment. 1: System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool*or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) ,determines that the system_ is functioning in a manner that protects the public health, safety'and environment: r r ❑ 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. F ❑ The system has-a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp-03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts _ W Title 5 Official .Inspection- Form Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments °w 11 General Patton Dr , Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis ., MA 02601 7-14-08 . every page. City/Town,. State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or ❑. ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 General Patton Dr , Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 x every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont): Yes No ❑ ® 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 " t, and chain of custody must be attached to this form.] ❑ Z. y The system is a cesspool serving a facility with a design flow of 2000gpd- I0,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure ` criteria exist as described in 310 CM 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 t Y ❑ ❑ 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. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official 'lnspection Form Subsurface Sewage Disposal System Form =Not for VoluntaryAssessments 11 General Patton Dr Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis ' MA 02601 7-14-08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No .. ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ' ❑. ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® , . ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected`for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? k 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 CM 15.302(5)] t5insp•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 General Patton Dr Property Address Premiere Asset Services Owner Owner's Name information is Hyannis MA 02601 7-14-08 required for H y ' every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? t ❑ Yes ® No Last date of occupancy: 5-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Ganons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? - ❑ Yes ❑ No I Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No _Water meter readings,`-if available: - Last date of occupancy/use: Date Other(describe): t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 11 General Patton Dr Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information .Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ - Innovative/Alternative technology.Attach a copyyofthe current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 General Patton Dr Property Address Premiere Asset Services ; Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 . . every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site planj: Depth below grade: 18 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): f Depth below grade: 12 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 12" Sludge depth: i' Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness. 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 11 General Patton Dr Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition with all baffles in place. recommended pumping-for solids. 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 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: i ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 General Patton Dr Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 2" 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.): Box shows signs of effluent back-up. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- 11 General Patton Dr ' Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ® leaching pits number: 1 ❑ . leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit has clear signs of hydrolic failure with stain lines above inlet invert. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Dispcsal System-Page 12 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments + ,M 11 General Patton Dr , Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08. every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): i t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 16 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 11 General Patton Dr Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t. A L---- .ck-T—i 01' . t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 General Patton Dr Property Address Premiere Asset Services Owner Owner's Name information is required for Hyannis MA 02601 7-14-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope t, ❑ 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) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Town maps show groundwater at greater than 20'. t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF THE Tp� „ Regulatory Services MkRNSTABM Thomas F. Geiler,Director y MASS. i639. Public Health Division ATFD M1►�A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPT1C\Disc1aimer Private Septic Inspections.DOC J Town of Barnstable. P# °F Department of Resulatory Services t ublic Health Division Dare-- 1200 Main Street;Hyannis MA 02601 l Gf 'Time Fee Pd. I Date Scheduled i ,Soil' Srxitability Assessment for Sewtu e Dis osal . Performed By: i I I�i�E 2 � � G Witnessed . LOCATION & GENERAL INFORMATION _ �:J 1 Location Address i Owner's Name U v 8 �—�C /�c M.')P' CCNv PA ITC) DR, 42- W�n3vr S �� 7�' d D c IJ iJ k S• III\ Address C!N C t NJV !'ram O� Ayessor's Map/Pa ? / Q I Engineer's Name � /l p,� r/4 e Y�„� N$W CONSIRU('r7ON REPAIR X Telephone* o Land Use Res Slopes(%) (� Surface Stones Distances from: Open Water Body y"7-02 ft Possible Wee Area �(� ft. Drinking Water Wcli 7 1� ft i Drainage Way ft. Property Linci y �U ft Other ft SKETCH:(street name,dimensiods'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 1 L � 4 Existing Lea';(pit I {\ /� (Note 10) / 1 10 A,Ft r TH- r I \ rl rrl 6J u C. ).TH-2 / I ' E I .I�, -I- 1",4,Lv P I: �rl. I. i Parent material(geologic) � UfW JIIVS>!r( Depth to Badrock ' Depth to Groundwaldr. Standing Water in Hole' 114- Weeping from Pit Fpee / I Estimated Scasonal i jigh Groundwater 4I!q 1' DtTr&RMIN TION FOR SEASONAL HIGrIj WATER TABLE Method Used- Depth tll 10 sall mottles; In. Depth db¢ervcd standing in obs.hole: __ In. De P tt. Depth toiweeping from side of obs.hole: I in. Groundwater Adjustment ! ! A�.faetor.,._.�_ M.droundwater Level •.e Index Well# Reading Date: Index Well levdl PERCOLATION TEST Data Observation 1 I Time at 9" Hole# i Time at 6" . Depth of.Pere Start Pre-soak Time,@ Time(9"•G") 1�23 End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed X Site Failed; Additional Testing Needed(YIN) Original:.Public H41th Division Observation Hole Data To Be Completed on Back-r-------- ***If percola#On test is to be conducted within 100' of wetland,;you must first notify the r , lne'.ric:nn nt lPaat nne(1)wedk prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, o aver Ll „- � a-� 23w del A • SAVE DEI; OB SERVATION BSERVATION HOL E LOG Hole# • Depth from Soil Horizon Soil Texture Soil Color Soil Other - Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% —ravel) DEEP OBSERVATION HOLE LOG Hole# - Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.gb ravel DEEP OBSERVATION•HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) •(Munsell) Mottling (Structure,Stones,Boulders. Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No— Yes _/_�_ Within 500 year boundary No x Yes Within 100 year flood boundary No s Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas,observed.throughout the area proposed for the soil absorption system? S If not,what is the depth of naturally occurring pervious material? b Certifical!lon Q I certify that on -t (date)I have passed the soil evaluator examination<approved by the, be rtn;ient of Environmental Protection and that the above analysts was performed'by me consistent with the equire ini g,txpertise and experience described in 3.10 CMR 15.017.. Signature. 1 Date 12 O:\.SEPTICIPERCFORM.DOC COMMONWEALTH OF iv1ASSACHI:SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 8 CERTIFICATION �,l�J A Property Address: 116E�RAL P/9Tr0N DR, 7'Name of Owner T t I R�A) Address of Owner- S NDW l CV 0A Date of Inspection: 4 cr to ANx Name of Inspector:(Please Print)int) Cow gkoC: Boy'sF16to 2 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.0 p� 1> Company Name: A6VSF1Ee.0 r, ,j9 h Mailing Address: GVbo4 Avg S/�/U iJIC ry1/�, bd573 j `9<9 Telephone Number: 503 R$ Io 32 3 �-��/1 ` CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information report e o It e,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 _ Fails00 Inspector's Signature! t - 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 the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS /ODo GAtwfu SePric 'M'uK r �l?T(� SOLIDS,6000 6_01V,01P V 0 00 �RL i ol� 6 F60T C 640-1 01 r I DRY, A.M (.t X,1 D revised 9/2/98 Page Iof11 4 Printed on Recycled Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (,EN'�12�}� Aq?T-o AJ 0 P Owner: t". N� 1414N ' Date of Inspection:r_4-111q INSPECTION SUMMARY: Check(D B, C, or A A. SYSTEM PASSES: 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. 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. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "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(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. _ 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 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 revised 9/2/98 Page 2orn C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A j CERTIFICATION(continued) Property Address: ! GtNtQAL P/{TTorU OR Owner:—f, N YNAVV Date of Inspection 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 15.303(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 s61rabsorption 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 1 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). 3) OTHER s revised 9/2/98 Page 3of11 r DISPOSAL SYSTEM IN SUBSURFACE SEWAGE STEM INSPECTION S FORM • PART A CERTIFICATION(continued) Property Ad&w,: 11 G�N6-RAC SAT ToN Doi, Owner: 7./I V 1-141V Date of Inspection:q'U_'G q9 D. SYSTEM FAILS: 1 I 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 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—rg 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 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 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 or 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 Department for further information. revised 9/2/98 Page 4of11 r ; r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:.11 GENEROL. PArrC KJ O n r owner: 7.1V V H4VJ Date of Inspection:q Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No � y� �S A 60 t _ Pumping information was provided by the o�occupant,or Board of Health. j�J/$5 C Le►q �� I - 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. 4ME NO BECK &'1 P%Y S /C6 As built plans have been obtained and examined. Note if they are not available with N/A. ` _ The facility or dwelling was inspected for signs of sewage back-up. All The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. . _ All system components, 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.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [I 5.302(3)(b)] The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5of11 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM @. PART C j SYSTEM INFORMATION Property Address: 1 E1V& ,4L. P4,mfu Owner: Date of Ins on: '77 FLOW CONDITIONS RESIDENTIAL: Design flow: LIv g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow_ Number of current residents:Q Garbage grinder(yes or(R:10 Laundry(separate system) (yes or&):_kQ; If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or i6 Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or t�5 :-w Last date of occupancy:-APLIL COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: E GO System pumped as part of inspection: yes or If yes, volume pumped: gallons Reason for pumping: TYPE F SYSTEM Septic tank/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: j4DO�C)jC �©-��?2?5 Sewage odors detected when arriving at the site:(yes orpm revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Q, PART C SYSTEM INFORMATION(continued) Property Address: i I G-OWAL PoTTON Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK:y, (locate on site plan) Depth below grade:�lUG('{S Material of construction:1concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age— Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions:$i(.y Q( I'/0„#yx 5 I b Sludge depth:a 1AW4 S Distance from top of sludge to bottom of outlet tee or baffle: 3�re14) Scum thickness: r/VCA4 Distance from top of scum to top of outlet tee or baffle: if Cq5 Distance from bottom of scum to bottom of outlet tee-erbaffle: `/i How dimensions were determined: 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.) ,r 2G;CrJrA1 l9N 12UMi2106 1UGK7' VEAR 1, 60,1X12EZE RAFFLES, 0( t✓d10 AM Q V 1 LE— i'PE 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: (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.) revised 9/2/98 Page 7of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C rr 6E A SYSTEM INFORMATION(continued) Property Address}: l' IU€1v1'�. P#Mfj 0, Owner: � 1 H W Date of lnspection:9—,HI'n TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART C SYSTEM INFORMATION(continued) Property Address: 1I GENeRit. ?K11W DDT Owner: T, 1J j Belli Date of Inspection.9-9 -11 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;exc vation not required,location may be approximated by non-intrusive methods) If not located,explain: Type �� G R L LO-N leaching pits,number:�E Sly F QaT leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)- COIL DRY Am PDA,RtPj& E A10 Biagio (joy s+Ai5" PIT , G08D C0112,0rt-latV CESSPOOLS-_ (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 (cesspool must be pumped as part of inspection) 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.) revised 9/2/98 page 9orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1• PART C SYSTEM INFORMATION(continued) Property Address: t GDVG.QAL P&7". YU O2 , Owner: ,f j H Data 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) 9` 10 revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t, PART C SYSTEM INFORMATION(continued) Property Address: f 6 �11�RAL pfE�'1'arU2. Owner: T N H r J Date of Inspection: me NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 33 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 4 Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) MmR 6R&vn w47-EQ mA p� -6 Pr) 111 4to revised 9/2/98 P2ge11of11 q =- CO,Il1I0N-WEALTH OF 1 ASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION OATE WINTER STREET, BOSTON MA 02108 (617)292-5500 �lu g/q WE TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ,� Property Address: 1 6EAERA L RITrO,4 0Q Name of Owner T 7' rJ�j c fJ�(!► O Address of Owner- S k'DW i C vJ Date of Inspection: 9 4 (I pl�� Name of Inspector:(Please`Print) cow900C, 130u,506LO 1 am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.000) Company Name: Eow"o C, ©i! rEZa Mailing Address: (? w000 Ar/W _Ki91Udw r16 M?AA3 Telephone Number: 50 iS S'A C 3 2 3 CERTIFICATION STATEMENT 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 function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails u la Inspector's Signature: 0 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 the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS jo-OD CALWAJ SC-Pr(L TAW r L111- t-C SOL105,6000 601"'r(W j)Utz 6RLto>v 6 )rbpT &EAW (�iT r DRY, � A 9 o� N -1999 / Boa i revised 9/2/98 Page 1of.,l.4' i�!Printed on Recycled Paper � �� � ��� ��� �� � , �� ;�1w, � i 5+ � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i r CERTIFICATION(continued) Property Address: �1 G F,N`�R�} P/+TTD n! b R,r Owner: t. NVON Date of Inspection:�f INSPECTION SUMMARY: Chea An, B, C, or A A. SYSTEM PASSES: t, 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. 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. Indicate yes, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "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(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. _ 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 _ 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1l GtNCIQAL PI{T'TOPU OR Owner:-7, N Yf jAvV Date of Inspection: 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 15.303(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 s rabsorption 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). 3) OTHER revised 9/2/98 Page 3of11 �i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 6(IV RA L PATToiv pPQ, Owner: 7-/V V P141V Date of Inspection:q,q-'99 C D. SYSTEM FAILS: ' 1 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 . 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—tg 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 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 . 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 Protiction 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 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4orii { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address-H G606RRL. I'' ATrV Kl D 2 r Owner: T.If TNoj Date of Inspection:(t q,qgq Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No y �•� A60, _ Pumping information was provided by the owner,occupant,or Board of Health. j/[J�S LAN NED `f - 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. J�Me F/45 6EF' N g'MP%y S/AILC 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. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. . _ All system components, 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.H. _ 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)1 _ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 i '- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �. PART C `` SYSTEM INFORMATION Property Address: 1 6EIveFR41— P4MAJ A Owner. Date of Inspection:+�.'��� FLOW CONDITIONS RESIDENTIAL: Design flow: /1P g.p.d./bedroom. Number of bedrooms(design):, Number of bedrooms(actual):, Total DESIGN flow_ Number of current residents:Q Garbage grinder(yes or(r�'o :Jy Laundry(separate system) (yes or&):UO: If yes,separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or 49:& Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or(*-W Last date of occupancy:—Nar—IL COMMERCIAL/IN DUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: E 6 System pumped as part of inspection: yes or& V If yes, volume pumped: gallons Reasorl for pumping: TYP F SYSTEM Septic tank/oie 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: yn��?vx Sewage odors detected when arriving at the site: (yes orqpm revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Q, I PART C SYSTEM INFORMATION(continued) Property AddreAAs`�s�:/i 1 GeNCOAL PAT-TON DR, Owner. r,IV Date of Inspection:��j^�G�� BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK:X (locate on site plan) Depth below grade: 121NG45 Material of construction:11concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) i Dimensions:V, �-X l[�it/ � 5'6 I r 14. Sludge depth: Ian IA S Distance from top of sludge to bottom of outlet tee or baffle: 30IWJ4S Scum thickness:OL i/VC14 r Distance from top of scum to top of outlet tee or baffle:gimcko Distance from bottom of scum to bottom of outlet tee-or-baffle: 14 4t s -. How dimensions were determined: C�► o�5i1/Z�= Comments: (recommendation for pumping,�con dition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) -- C6AM i06 /VC T Q4 XR6! r L `0 Q n r U iLC i E 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: (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.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Ir^, e��tt n ' f qq SYSTEM INFORMATION(continued) Prop"Address}: �C'V€IL►T�,. PfFmrj OR, Owner: 1 Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8 of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ij. PART C SYSTEM INFORMATION(continued) Property Address: (1 (, NER��- WJjW Dp� Owner: zj ;Hiso Date of Ion. ,f,IpM SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;exc•vation not required,location may be approximated by non-intrusive methods) If not located,explain: Type to Cs R LL0?1N leaching pits,number:�E Sly F©bT t leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length- leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.)- �plt_ OR+I tib PDiu-pttj& L(G' oo (A;S1DG Pry, C,ODD CDC✓��tiv,�1 CESSPOOLS:_ (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 (cesspool must be pumped as part of inspection) 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.) i revised 9/2/98 Page 9of11 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1• PART C SYSTEM INFORMATION(continued) Property Address: I I (9EndE*A L P/+'M" 0 2 , Owner: -I, NW Date 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) C� �6F �39` 10 revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �•. PART C SYSTEM INFORMATION(continued) Property Address: l 66MFRAL P�F1'rOrtl io2, Owner: T, N HOrej Date of Inspection:� NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 33 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) MMR 6R&#vn.vuATEQ IY Ap` %b 0a /-4,410 revised 9/2/98 Page 11of11 0,C'AT10N SEWAGE PERMIT NO. V-ILLAGt , ice- i�,osf IMSTA LLER'S NAME A A0OIiESS 8 UILOF R OR OWNER DATE. PERMIT iSSYEO DAT E C 0 M P L I A N C E ISSUED .— _ ,1 F � ,. i /��' �l`s�i / / i i,�_ � '�.�, f/�,, � � . � �� � � � �, � � � � `� � \� '� � � \ �` ,� �� "------ I' ; . �! � s} l . _ ! � ... �! '�� .. <<,, }/j+ > 1' � ,I. J'� - 1+ � __ �I '! THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL Appliration for Disposal Works Toustraxr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair (1-4—an Individual Sewage Disposal System at* ocation dress t o ................... �, . , - ................................... a Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria a' Other fixtures ..............................'....................................................................................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width..._............ Diameter________________ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter_____.__.___.___..__ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ RS ------• ----- ------------- i j,,, f O Description of Soil.................e.�G-�Lvf �.j-f•�-u{-+�--------------- ------------------------------------------•-----•----••-- -----------------------------------------------------------------------------------------•----------------------------------------------------------- ------------ - - U Nature of Repairs or Alterations—Answer when applicable......... -� 711__ _. .0 '-�l-.....__.________. -----------------------------------------------------------•-------------------------...............--------------------...------•-•----•---------•-----------•---•----•--••------------....._....------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLZ 5 of the State Sanitary Code—The undersigned further agrees n to place the system in oerataon until a Certificat e to of Compliance has bee issued by the boa0oflth. gned- � _ ---�--- Application Approved By------- ---- �� .... ............................•---•-----------------------__•---- ----._...-•--- --•Date--------•----- Application Disapproved t following reasons-------------------------------------------------------------------------------------------------•---------.._.._ ....-----•-------------------•------•------------------------•---•--------••-------..._..--------------...--••-•--------------------------------•-•------------------------------------=---------......_ PermitNo......................................................... Issued............ (Ywif (J No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .l:f.................OF. r :r .1j Appliration for Diopooal Works Tonitrnrtion ranfit r Application is hereby made for a Permit to Construct ( ) or Repair (!--•3-•an Individual Sewage Disposal System at: _ f_ -_'._d_.._:.. ...1�1 . .......................... ...................... ......................................... Location Address r, or1 Lot.-No. .._.... .... l:J a.. .._ , ? /✓. /r• ...__.._... 1� '_�r i':�2?z"_+f_�`_?'..........-•---------•-•------•------------- ---•- �� Owner Address Installer Address UType of Building Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ .No. of persons............................ Showers ( ) — Cafeteria ( ) al Other fixtures .........................------ • -•-•••- W Design Flow...............................-----gallons per person per day. Total. daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width._.............. Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................................... W ,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G=., Test Pit No. 2................minutes per inch Depth. of Test Pit.................... Depth to ground water-_,_____--_-_-_-----___. P4 ` 0 Soil___________ .�_...�/.�.f ` Description of _________ ' ✓ W .. U Nature of Repairs or Alterations—Answer when applicable.........!_------__________,________,.. 1. r 1._!=--------=----�•?�-==�------'=-------•--- f ...............................••--.................._.......__.._.................................._............_.._.__.....---................_...........---._....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE, 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 li%�alth. j Application Approved By-•---- •. '.....•� / ---- J Date Application Disapproved t following reasons:.. .............••-----•----.....-•-•--•-------•------•-----•--•-----------------------•-----------...------'-••--------------•--•-----------•------•--------------------•----......------••--•-----••--•--- Date PermitNo........................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... .............. f.... . ..OF..... . ......� } 1�/ .f... .. . ......................... (9rrt f iratr of Tomplianrr THIS IS.. TO CERTIFY, TI'iat"the Individual Sewage Disposal.S,jstem constructed ( ) or Repaired by r �.... ''.........':.....:?.!�f ........,r`... - =..f -' - %.5:._.. .. ... _ Installer l / at................ .�......-�=-' `-.......................................' `. ' .................................' 1 �/�...!. -- ----......------------. ---.. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Co . ��scribed in the application for Disposal Works Construction Permit No.__.K__ __ _ ___________________ dated_, ._.___.....___...._...._.___.__._... THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONSTR E AS A GUARANTEE THAT THE SYSTEM MIIL . U CTION SATISFACTORY. DATE ...!"...I�� Inspector THE COMMONWEALTH OF MASSACHUSETTS BOAR_D OF HEALTH r r ? ._ .................................., r..... OF... J / J!; J No... ......... ....... FEE........................ 13iopooal Workii Tonntrnrtion Prrmit Permission is hereby granted = -.................................................. ........_.............................................................. to Construct ( - ) or Repair ( ') an Individual Sewage Disposal System Street. as shown on the application for Disposal Works Construction Permit No.. Date`� -.. .:................. r ' s ....�, Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS i I i C. TOWN CY BARNSTABLE SEWAGE 6 `'iLL�hEyc+ S ASSESSOR'S MAP& LOT ` INSTALLER'S NAME&PHONE NO. ' r •e � SEPTIC TANK CAPACITY V 5OO Se—;DT\C-- 't'ALI.V y LEACHING FACILITY: (type) (size)NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: ` 4 — 1] COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ....mow �'•.,; ��— �• � � 0 0 � l 1 . � . �.. ._ ., .r ,`�' . �7 n , O 4 1 J c� S NOTE:'TO PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:40.14 (FOR A DISTANCE OF 15' AROUND THE i PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. T.O.F. EL.=43.69 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER �ZN OF MAss OUTLET AND SET TO 6 OF FINISH GRADE SET TO 6 OF GRADE ONE. CHAMBER (MIN) AND SET TO 3" OF F.G. • F.G. EL.=42.80f D R E M r G F.G. EL=43.Ot F.G. EL: 43.5f -F.G. EL: 43.50(MAX.) VENT Y N . 11 9" MIN COVER/ L 10'"t L - 15' L = 10'(MAX) INSTALL11TWO INSPECTION PORTS (MIN.) �� 0 0 S_1x (MIN.) 36" MAX COVER, O S®1R (MIN.) 0 S�1X (MIN.) 4"SCH40 PVC 4"SCH40 PVC 4"SCH4o PVC NITAR�P� 10 14• a 11.3" TO •• INV.=40.66 .='4-48"LIOUIO INVERT LEVEL INV - .� i 4 GAS BAFFLE ' PRAiJO SED�`I ,=39.94 4 ROWS OF 4 UNITS AT 6.25'/UNIT = 25'/ROW INV.=39.75 SOIL ABSORPTION SYSTEM (PROFILE) INV.=40. 1 EXISTING 1.000 GALLON SEPTIC TANK RESTORE VEGETATIVE COVER EXISTING SEWER OUTLET BACKFILL WITH CLEAN PERC SAND 75" TO TOP OF CHAMBERS NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING ;, ,,: .;::•.;':• • .•: : ;•••,;; •: PIPE INVERTS PRIOR TO CONSTRUCTION ;'-; ' 2) D-BOX SHALL BE SET LEVELINV. ELEV.=AND TRUE TO BREAKOUT=TOP E . 5 39.75 GRADE ON A MECHANICALL COMPACTED SIX BOTTOM ELEV.= 38.81 INCH CRUSHED STONE BASE, AS SPECIFIED IN EXISTING SUITABLE 310 CMR 15.221(2) 2.83 MATERIAL 3) REPLACE EXISTING 1,000 GALLON SEPTIC 5' MIN. ABOVE BOTTOM OF EFFECTIVE WIDTH = 4 x 2.83' = 11.32 �• 76" _ TANK WITH 1500 GALLON SEPTIC TANK T.P. EXCAVATION OR G.W. IF FAILED, DAMAGED, OR UNDERSIZED. (6.31 PROVIDED) USE 4 ROWS OF 4-HIGH. CAPACITY PROFILE 4) INSTALL INLET & OUTLET TEES AS REQUIRED ADJ. GROUNDWATER EL.=32.50 = ADS 81001FFUSER UNITS-NO STONE SEPTIC SYSTEM PROFILE TYPICAL SECTION �- 16" N.T.S. Krs. 11.2" DESIGN CRITERIA , SOIL LOG P#: 12429 -�- j NUMBER OF BEDROOMS: 3 BEDROOMS DATE: DECEMBER 8, 2008 -� 34" +-I SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: o DARREN M. MEYER, R.S., CSE. SECTION END CAP WITNESS: DONNA MIORANDI, BARNS. BOH DESIGN PERCOLATION RATE: <2 MIN/IN 16"" HIGH. CAPACITY (H-20� BIODIFFUSER UNIT Elev. TP-1 Deptt, Elev. TP-2 Depth DAILY FLOW: 330 G.P.D. _ _ DESIGN FLOW: 330 G.P.D. 44.00 A LOAMY SAND 0"' 43.50 A LOAMY SAND 0" IOYR 3 2 r IOYR 3/2 " MODEL 16" HICAP GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) 43.50 6"� 43.00 6 LENGTH 76' B B � NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT- PROPOSED SEPTIC TANK: USE EXISTING 1,000 GALLON CAPACITY LOAMY SAND t LOAMY SAND TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 10YR 5/8 I 1oYR 5/6 EFFECTIVE LENGTH 75 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. LEACHHING-AREA=REQUIRED:--330 = 445.94 S.F. 28"" SIDE WALL HEIGHT 11.2" tea. 1 41.67 41.17 C 28" 7 c OVERALL HEIGHT 16" �Y DISTRIBUTION BOX: 5 OUTLETS (MINIMUM- OVERALL WIDTH 34" 4640 TRUEMAN BLVD HILLIARD, OHIO 43026 �P A S.A.S. MED. SAND PERC 37,0 MED. SAND 13.6 CF • USE 4 ROWS_OF 4=71T6�A BIODIFFUSER H-20 UNITS NO STONE 2.5Y 6/4 2.5Y 6/4 - CAPACITY (101.7 GAL) ADVANCED DmWE SYSTEMS, INC. BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.70 SF/LF OF BIODUFUSER) 33.00 132 32.50 132" PROPOSED SEPTIC SYSTEM SITE PLAN (BIODIFFUSERS) 16 UNITS x 6.25 LF x 4.70 SF/LF = 470 SF DESIGN FLOW PROVIDED: 0.74(470 GPD/SF) = 347.80 GPD > 330 GPD req'd PERC RATE 62 MIN/IN. ("C" HORIZON)NO GROJNDWATER OBSERVED 11 GENERAL PATTON DRIVE HYANNIS MA >t4 Prepared for: Mike Dedecko r.Q Engineering by: Surveying by: SCALE DRAWN JOB. NO. DARRENM.MEYER,R.S. Boo-Tech Bav/ronmente/ NTS D.M.M. i • I, Darren M. Meyer, R.S., CSE, hereby certify that 1 am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX 981 (508) 364-0894 CHECKED to conduct soil evaluations and that the above analysis h EAST SANDWICH,afA 02537 as been performed by me consistent with the DATE SHEET NO. 09OS requirements of 310 CMR 15.017. I further certify that 1 have passed the Soil Eval. Exam in October, 1989. ���sqc^2 - 12/ / D.M.M. 2 Of 2 �n p l t LEGEND }r PROPOSED CONTOUR ROVE 2e ® PROPOSED SPOT GRADE --g$ -- EXISTING CONTOUR + 96.52 EXISTING SPOT GRADE L' W— EXISTING WATER SERVICE SITE i TEST PIT F� t ~ 4 lrr ~� GEN. PATTON OR[ ! \ 43 LOCUS MAP N.T.S. 4s I - GENERAL NOTES: Inap• f �; Existing Lea c Pi (Note 10) r 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL ` _ BOARD OF HEALTH AND THE DESIGN ENGINEER. o I r 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS o % / OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE LOT 8 LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: r` 12 310 CMR 15.405 (1) (B): 1 AREA = 8400 S f +-1. / 1) A 0.36 FT. VARIANCE FROM 310CMR 15.221(7) TO ALLOW LEACHING TO BE ! I / ro <' r %% % 3.36 FT BELOW GRADE VS REQ'D 3 FT. (H20/VENT PROVIDED) % U I 0 r. Z t 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR l 0 ` L< l ! j TO INSPECTION AND APPROVAL BY THE BOARD .OF HEALTH AND THE _j M / / 42 ! DESIGN ENGINEER. /- /,%� 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN f/�' ENGINEER BEFORE CONSTRUCTION CONTINUES. I ` ' TH- � J .- / ! 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 41j, / o , 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF `4 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 45 , �44�_TH-2 1`�''�~�wf • �IN`,�(� I ( HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. = � 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 01v' t ! 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. BENCH MARK 43 _ �R%N I j` �--J! <� �`� 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE vq � THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING PAINT SPOT ON �20 35 \� / CONSTRUCTION. CONCRETE SLAB >t - J ! 10. EXISTING LEACHING PIT TO BE PUMPED, CRUSHED AND REMOVED. ELEVATION = 43,04 REPLACE WITH CLEAN MEDIUM SAND. BARNSTABLE CIS DATUM , °� ` . �-J 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION r 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY 14,2 AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. OF ,�q / �- 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. . ' ��- ssq�y r `fir 15. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPECIFIED) a DA E 16. INSTALLER TO FIELD VERIFY H2O CERTIFICATION PRIOR TO INSTALLATION. No. 1140 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 1 �NI 11 GENERAL PATTON DRIVE, HYANNIS, MA TAR�a� S �r0 MAP. 292 Prepared for: Mike Dedecko Engineering b Surveying b SCALE DRAWN JOB. NO. � LOT.'102 9' 9 Y� Y 9 Y� — SURVEY REFERENCE: 1 = DARRENM.MEYER,R.S. 8co—Teeb Bovironmenta! 20' DMM PLAN OF LAND BY CHARLES N. SAVERY, PLS 1 DEED BOOK 22352 PO BOX981 DATED: MARCH 28, 1968 J :. DEED PAGE.'001 E43TSANOwICH,MA 02537 (508) 364-0894 DATE CHECKED SHEET N0. 508-362=s922' 12/05/09 OMM 1 of 2