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HomeMy WebLinkAbout0012 GENERAL PATTON DRIVE - Health 12 General Patton Drive Hyannis P A = 292 126 N I K M Commonwealth of Massachusetts Title 5 Official Inspection Form >q Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments 12 General Patton Dr � Property Address Fannie Mae Owner Owner's Name information is required forHyannis MA 02601 7-22-08 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: s ' Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr C= Company Address -= E. Falmouth MA 0253r6; , City/Town State C S Zip Code r E 508-495-0905 S13971 Telephone Number License Number W � B. Certification N I certify that I have personally inspected the sewage disposal system at this addre s and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ;. ,❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority l/ 7-24-08 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. ' t5insp•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 F Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 7-22-08 every page. CitytTown 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: ® 1 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: System is in good working order with no sign of failure. 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 Vol unta ryAssessm ents 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name n information is Hyannis MA 02601. 7-22-08- required for y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) W e 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."Sy'tem'willfail 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 -; •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. . t5insp•03f08 - ti;; - Title 5 Official inspection Form:Subsurface Sewage Disposal System.-,.Page 3 of.15 Commonwealth of Massachusetts t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 7-22-08 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 i,acteria 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: • . 4 _ Yes No L ` ❑ ® 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 I , ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1h 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. El ® 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 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 7-22-08 _ 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 - 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. El ❑ 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 ❑ ❑ " the system is within 400 feet of a surface drinking water supply L -❑ ❑ 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 16.304. 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 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments M 'y 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 7-22-08 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? w ❑, ® 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? ❑ r ❑ Vvere 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: r ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 General Patton Dr - Property Address Fannie Mae Owner Owner's Name information is required forHyannis MA. 0260.1 7-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: , Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 0 Number of current residents: , Does residence have a garbage grinder? r ❑ 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? ❑ Yes ® No Last date of occupancy: 5-08 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: . Last date of occupancy/use: Date 14, Other(describe): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of15 Commonwealth of Massachusetts W Title 5 Official Inspection -Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 7-22-08 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? r 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): Approximate age of all components, date installed (if known) and source of information: 2003 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 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 0260.1- 7-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 22 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet- Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): • Depth below grade: 16"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)i, ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: Distance from top of sludge to bottomof outlet tee or baffle 20" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1-3" 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 12 General Patton Dr Property Address Fannie Mae ' Owner Owner's Name information is required for Hyannis MA 02601 7-22-08 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 is 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: z ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp-03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal`System Form -Not for Voluntary Assessments wM 12 General Patton Dr 1 Property Address Fannie Mae Owner Owner's Name information is Hyannis MA 02601 7-22-08 required for. y 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 ❑ Na 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site`plan): Pumps in working order: • ❑„Yes,r ❑ No Alarms in working order: ❑ Yes + ❑ No t5insp'•'03/08 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 .. - •i . .. Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is Hyannis MA 02601 7-22-08 required for y 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: - ® leaching chambers number: 5-infiltrators .0 -leaching galleries. number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool r 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.): Infiltrators in good condition with no sign of back up. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is Hyannis MA 0260t' 7-22-08- required for y _ every page. City/Town 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.): 4 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.): t5insp-03/08 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page,13 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 12 General Patton Dr Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 7-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (coat) 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. v` - I t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 General Patton Dr Property Address Fannie Mae Owner. Owner's Name information is required forHyannis MA 02601- 7-22-08- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record ff checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no water at 12'. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 THE Town of Barnstable Tp� ,P` o Regulatory Services BARNSTABLE, Thomas F. Geiler, Director y MASS. i639. Public Health Division ATED MA'S 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. QASEPTIC\Disclaimer Private Septic Inspections.DOC' TOWN OF BARNSTABLE LOCATION pjj��: pa SEWAGE # Z04) 41 VII .AGE. n,,3 171th ASSESSOR'S MAPS& LOT 2q 2—12(p INSTALLER'S N &PHONE NO. � 2,eeo SEPTIC TANK CAPACITY LEACHING FACILITY: (type) `� Lr ' (size) NO.OF BEDROOMS BUILDER OR OWNER 'PERMIT DATE: 7 5 u 3 COMPLIANCE DATE: —1—0 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet . Furnished by 1 a 4 f�Jq �+� �_i W (/�} F A Q —__►�_ � .. C�'74 � � o, W � �h No. lie _ FEE S Board of Health, CC f1Sb12. MA. APPLICATION FOR DISPOSAL SYSHM CONSTRUCTION PERMIT Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( omplete System ❑Individual Components Location t2 `�Q, Owner's Name Map/Parcel# ACC 2 Address Lot# 3 ' 2 Telephone# Installer's Name Designer's Name Address 4::VU M�,t S ;� Addressi:5n)4 Telephone# SC _2LI(,-aemTelephone# S Type of Building Lot Size 9 sq.ft. • Dwelling-No.of Bedrooms �t'l,-1� CXCS�i _ �C1�'Q�2 ^l��t� Garbage grinder Other-Type of Building ncNo No.of persons Showers (VrCafeteria (yY Other Fixtures L A v n,� -�-nhe r� S1(1�C �_13tN7C�lc�i Design Flow (min.required) gpd Calculated design flow , Design flow provided gpd Plan: Date 4\8�� Number of sheets Revision Date Title Des,S,QA Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator 'Vate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Q �C3i1 The undersigned agees to instdll above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to ', o plac system in o eration until a Certificate of Compliance has been issued by the Board of Health. Signed Date lee Inspections COMMONWEALTH OF MASSAC14USETTS Board of Health, �1 gn')S�Ve MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - Complete System ❑Individual Components Location `2S2.f�`a n j Owner's Name Map/Parcel# Address P 'S Lot# -'47 37 Telephone# , Installer's Name Designer's Name ' �C\M, ham �J Apo? ��c-a n c J�ICsS• Address �A v 4f42W NCH , O�1�4� Address rJo ��, F, Telephone# 5 _2 y`- Telephone# $U \, Type of Building , ,Z,�n-i c\ C-1 I - Lot Size , �Y� sq.ft. Dwelling-No.of Bedrooms tal O Garbage grinder , `-'Other-Type of Building nn p G No.of persons 'Showers (1(Cafeteria (01 Other Fixtures L.R v q y Design Flow(min.required) ;r:;O gpd Calculated design flow O�O`-' 3 Design ow provided 3?S4k•48gpd v Plan: Date 4 810 Number of sheets 1 \ ✓ Revision Date t ` Title r i R-u De"5 zc\ C 17� Description of Soils) -,cre G G C G�PCx Soil Evaluator Form No. \ c� Name of Soil Evaluator( 0) A\A PP,3 S"ODate of Evaluation 4 DESCRIPTION OF REPAIRS OR ALTERATIONS �Q.A ��C3f`�• + The undersigned aees to ee aabove described Individual Sewage Disposal System in accordance with the provisions of TITLE and, further agrees to AWt io place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed /A Date Inspections > ___ ,.._,x_�.�• r• ter._.;.,. ,�....�. w_..,..�:.r,�,-..._.-•W.:-�� .. �„<...�y.,.. ....r..--, __: >�-z;,�-- __. _>r...-�. , ,- t`:.,.,->-�%--M----�-.-�-.�_.,.�-�._ ' No. )U� -f X FEE — COMMONWEALTH Of MASSACHUSETTS Board of Health, hr/'N.1 +�� MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The and igned he eby cer�15 that t e Sewage Disposal System; Constructed ( ),Repaired ( ,Upgraded ( ),Abandoned ( ) by: h6 JJ /P at 'J t7 en P,J 7�n d+✓�st�f has been installed in accordan e with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 9 U 0,1—/t/9 , dated t-1 4/o X Approved Design Flow 110,17 (gpd) Installer �,/�j Designer: Inspector: Date: -f/7 63>1 The issuance of this permit shall not be construed as a guarantee that the system will function as designed. h• 7 /q•No. 2003 �C( / FEE } � x COMMO WEALT14 OF MASSACHUSETTS Board of Health, 1�t^r�f �V MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at /j �? P/-,,/ ) G+ /1 Ait /�.,/n,n/!r f as described in the application for Disposal System Construction/Permit No.of 0031i/y , dated 47 k/4.2 . Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. � V/Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date i Board of Health F TOWN O�F� � By,ARNSTABLE ] LOCATION 1�_ C�� gg_ '�✓_[�. Me- SEWAGE 0 2-0()3 ��7 VILLAG Atl- ASSESSOR'S MAP & L,OT 2Q 2-1 Z� INSTALLER'S N A Mt&PHONE NO. 2 � * (-n SEPTIC TANK CAPACITY �bt� LEACHING FACILITY: (type) _ �� 0-d (size) .. NO. OF BEDROOMS BUILDER OR OWNER, ®1b53 c ,c PERMTTDATE: 7 " COMPLIANCE DATE: "" '0 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands-exist within 300 feet of leaching facility) Feet . Furnished by i r`73 3 Sep-•20-01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 P . 02 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION? TEST AND SOIL EVALUATION EXEMPTION FORM 1, P,Ac,,1 kAt4l? , hereby certify that the engineered plan signed by me dated �J concerning the property located at �Srrieets all of the following criteria: v • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is ciass.fied as.CLASS I and the percolation rate is less than or equal to , unuces per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in Flow and/or change in use proposed • There are no vanances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen ;IY) feet above the maximum adjusted groundwater cable elevation. ,Adjust the ounGwater cable using the Frimptor method when applicable) Please complete the following: Al Top of Ground Surface Elevation (using GIS information) g) G.W. Elevator, .F a.d;uscment for high G.W.. DITFERENCE EETWEEN A and B I S•lD0 SIGNED _ DATE: Basec upon the above information, a repair permit will be issued for bedrooms na .imum. yr acditinnal bedrooms are authorized in the future without engineerec Lepuc system plans. u:litzlhh lr:dcr.pucczmp Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: * (Z C, Lot No. Owner: 765f, � 20('1t�{'G— Address: Q�r}- ACc,��1��Zc�• . •�k�slo�tME) Contractor: 'd=7)%:kA`2 &%Arnmr iCN!;� Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. Date f o3 s..................................................... mon h/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: AIU3 OA Appropriate index well.................................................... o2 OB Water-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to 3 water level for index well mo th/Year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water level zone (STEP 2B) • /' determine water-level adjustment ........................................................................................... �T STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water ^ levelat site (STEP 1) ............................................................................................................. 1; Figure 13.--Reproducible computation form. 15 Cape Cod Commission: USGS Well Data - March 2003 Page 1 of 2 United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells neasured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the last column in the table and the footnotes below. For further information, please contact Hydrologist Gabrielle Belfit at the Commission offices (508-362- 3828). March 2003 t`S(;S Site Water Record Record Departure from Number"*'-" Location Well No. Level* High* Low* Average** (links to l!SGS Monthly Overall national water-lei el database) Barnstable A�� �2.3 20.5 26.6 0.8 1.4 4139560701.64301_ Barnstable A4W �4.8 20.5 28.6 -0.5 -0.2 414154070.165001_ Brewster BMW 21 1 1.6 6.9 13.6 -1.4 -1.4 414518070020301 Chatham CGW 138 22.6 20.9 26.6 1.0 1.4 4141.0007001 l 101_ Mashpee M1 W ?9 7.I �.6 ]0.0 0.9 1.4 41352)070291904 Sandwich S��W 46.8 45.9 48.2 0.3 0.5 4.1441.8070241601_ SDW Sandwich �J3 >2.1 45.8 55.1 -2.1 -2.0 41.412_4070265901 Truro TSW 89 1 l.3 10.2 13.0 0.4 0.8 420206070045901 Wellfleet WNW 17 9.7 7.3 12.8 0.4 0.7 415353069585401 http://\.v\vw.capecodcommission.org/wells.htm 4/3/200_ 04/09/2003 16:43 15085399343 VPGI PAGE 02 a ut�H��tv���i7aemsSl�1 @ pasgepOD ig 7oel����avaers�t�,i I•.. L�'te7(� ll'0l9DdCut ��� � I • Jauvwut paap -vM mQpeagdde os 9upe(s s sued��pw}oo/s�agd�l�P Pa $ds a�peas i9�t+1L1 00'Si iq�i/�=87?s aqt qtF++ uepaeaae•vc peRessuF taasq■ 4 • to ( ) P—oP--RV'( )own'( )Pa+(dam`( )paiattasueo 44—ag leiodsLa 29--"alp%up Apax—6gaa&q i+ouj%-aapurt eKt. -wMft h Jib. I* ( —�G1 I i 13 npgKje as M .ice► ✓U.MD 'VACFew ',Fm mfo SIT l � r-��'r�' ^� mid ul � �H3A&IKOi�KO:) I , 1 Y 1 j ZO 'd b t 861 z98L6 'ON XVA 30VOINOW AA I Wd 9Z:Z 1 AHI £00Z-0 I-MV a - D DECEIVED U f DATE:4/18 03�� 2-7 2003 PROPERTY ADDRESS: 12 General-Patton-Drive TOWN OFBARNSTABLE HEALTH DEPT. Hyannis,Mass. ' 02601 p ------------------------ �� III On the above date, I inspected the septic system at the above address. . This system consists of the following: 1 . 1 -1 000 gallon septic tank. FAILED INSPECTION 2. 1 -Distribution box. 3. 1 -1000 gallon precast leaching pit. Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. (78Code) 5. The septic system is in hydraulic failure. 6 . A New Leaching area needs to be installed. 7 . The system should be pumped. 8. Waste water is less than 6" below the invert pipe of the leaching pit. SIGNATURE: Name:-J.P. Macomber Jr_______ Company: Joseph-P. Macomber_& Son , Inc . Address: Box 66 Centerville , Ma . 02632-0066 Phone:- 508-775-3338 -------------------- THIS CERTIFICATION DOES NOT CONSTITUTES A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 -\ COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ,i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 12 General Patton Drive H annis Mass Owner's Namemaria Deo izera Owner's Address: 31 Arcadia Drive Marstons Mills Mass. 02649 ( Israel DaSilva Date of Inspection:4 18 0 3 Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name:J.P.Macomber & Son Inc. Mailing Add ress:Box 66 Centerville,Mass. 02632 Telephone Number: 5 0 8—7 7 5—3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP appr6ved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionallv Passes �eeds Further Evaluation by the Local Approving Authority Y Fails Inspector's Signature: Date: L/—% --D The system inspector shall s mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2_ of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 General Patton Drive Hyannis,Mass. 02601 Owner: Maria Deolizera Date of Inspection: 4 18 03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: file I have not fed any info�i=which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in hydraulic failure A new leaching area_needs to be installed 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. -06 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: NO Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box,.,System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 General Patton Drive Marstons Mills .Mass. Owner: Maria peolizera Date of Inspection: 4 11 R/o-1 C. Further Evaluation is Required by the Board of Health: A 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 envirorunent. 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: 4)6 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. �d 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 y00 feet b 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 General Patton Drive Hyannis,Mass. Owner: Maria Deolizera Date of Inspection: 4/1 8/0 3 D. System Failure Criteria applicable to all systems: You must indicate yes"or"no"to each of the following for all inspections: Yes No _ 0ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool / ischarge or ponding of efl]uent to the surface of the ground or surface waters due to an overloaded or Static clogged SAS or cesspool liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or f cesspool i—AA—lq06 LTLiquid depth in is less than 6"below invert or available volume is less than 14 day flow D Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Ax 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. _ 3;Any Any portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma �S (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. i E. Large Systems: To be considered a large system the system must serve a facility with a design flow of]0,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply a system is within 200 feet of a tributary to a surface drinking water supply _ he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone it 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. 4 i Page 5 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 General Patton Drive Hyannis,Mass. Owner:Maria Deolizera Date of Inspection: 4 18 03 Check if the following have been done.You must indicate`yes"or"no"as to each of the followin 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 ? 411— Has the system received normal flows in the previous two week period ? V 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? iW d Were all system components,eenluding the SAS, located on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no v Existing information. For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddress12 General Patton Drive yannis, ass. Owner Maria Deo izera Date of Inspection: 4 1 8 0 RESIDENTIAL FLOW CONDITIONS l Number of bedrooms(design): 'gJ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):'9X//4 Number of current residents:A Does residence have a garbage grinder(yes or no):ye.f Is laundry on a separate sewage system (;ees or no): ZUb[if yes separate inspection required] Laundry system inspected(yes or no):fi,5 Seasonal use: (yes or no): 4)0 Water meter readings, if available(last 2 years usage(gpd)):Augus t 2 0 0 2=5 9, 2 5 0 gallons=1 6 2 . 3 3 GPD Sump pump(yes or no): VP `P, April 2003=104, 250 gallona=285. 62 GPD Last date of occupancy:Ad 41- COMMERCIAL/INDUSTRIAL Type of establishment: AM Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sqft,etc.): ti Grease trap present(yes or no): Industrial waste holding tank present(yes or no):,4W Non-sanitary waste discharged to the Title 5 system (yes or no):4LO Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of informationNone available Was system pumped as part of the inspection(yes or no):�Q If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TPSOF SYSTEM �/Septic tank,distribution box,soil absorption system w Single cesspool Overflow cesspool 167 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) 4!;P Tight tank W11 Attach a copy of the DEP approval 41 e)Other(describe): Approximate age of all com onents,date installed(if known)and source of information: �o �,� Were sewage odors detected when arriving at the site(yes or no): 't'0 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 12 General Patton Drive Hyannis,Mass_ Owner:Mari a D -ol i .e a Date of Inspection: 4/1 $/o'i BUILDING SEWER(locate on site plan) / 4" Lite wieght PVC Depth below grade: e29--/ pipe & fittings through out Materials of construction cast iron,VD 40 PVCzther(explain7:the system. Distance from private water supply well or suction line: /O 7L Comments(on condition of joints, venting, evidence of leakage,etc.): Joints appear tight-No evidence of leakage-The system is vented thro h the 'house vents. SEPTIC TANK: Y (locate on site plan) 11�wov�-5 Depth below grade: Material of construction: TI"ConcreteWd meta IXh9fiberglass polyethylene rUd other(explain) AljP If tank is metal list age: is age confirmed by a Certificate of Compliance(yes or no):.41�(attach a copy of certificate) /x -A0 Dimensions: ����/� �� 4; Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: .: Scum thickness: / , Distance from top of scum to top of outlet tee or baffle: &PCA) Distance from bottom of scum to bottom of outlet to or baffle: f How were dimensions determined: ✓} 6490/&( Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Once the septic system is upgraded.Pump the septic tank annually.Garbage disposal is oresent. Inlet & outlet tees are in place.The tank is structurally sound. and shows no evidence of leakage. ������"' GREASE TRAP(/,W e(locate on site plan) Depth below grade: (J1 Material of construction:A0 concrete VOmetaWIO ftberglass��oIyethyIene e)Xother (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 40 Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: _ Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Crease trap is not present 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 General Patton Drive Hyannis,Mass. Owner:Maria Deolizera Date of Inspection: 4 f 1 8/0 i TIGHT or HOLDING TAN)Ukt, (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: IVA Material of construction:M concrete.,64 metal Ah fiberglass ILO_polyethylenet/4 other(explain): Dimensions: Capacity: allons Design Flow: W11191 gallons/day Alarm present(yes or no): Alarm level: �e Alarm in working order(yes or no):_.4 Date of last pumping:_� . Comments(condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOX: Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): Distribution box has one lateral.There is evidence of solids narry_ nver_Nn evir3Pnre of leakage into or out of the box PUMP CHAMBER ,N/G(locate on site plan) Pumps in working order(yes or no): dJ14 Alarms in working order(yes or no):� Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamber is not present 8 l I i Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 General Patton Drive Owner: Maria Deolizeraass. a Date of Inspection: 4 1 8 0 3 SOIL ABSORPTION SYSTEM (SAS):Z(locate on site plan,excavation not required) 1 -1000 gallon precast leaching pit. If SAS not located explain why: Located• See page 10 Type 01 leaching pits,number: / leaching chambers,number: O leaching galleries,number:—Q Afd leaching trenches,number, length: d bleaching fields,number,dimensions: overflow cesspool,number: a r innovative/altemative system Type/name of technology: ��e' �20 Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy sand to medium fine sand The leaching pit is in hydraulic failure. wastes water is less than 5" hplow the invert pipe of the leaching pit. A new leaching area needs to be installed. CESSPOOLS"esspool 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: A Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Ces-spools are not p s nt PRIVY/ (locate on site plan) Materials of construction' /o Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is not present 9 Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 General Patton Drive Hyannis,Mass. Owner: Maria Deoli_7 ra Date of Inspection: 4/1 R/n-i 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. J i' 10 Page 11 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 General Patton Drive Hyannis,Mass. 02601 Owner: Maria Maria Deolizera Date of Inspection: 4/1 8/0 3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 'yd feet Please indicate check all methods used to determine the high ground water elevation: No Obtained from system design plans on record-If checked,date of design plan reviewed: NA YESObserved site(abutting property/observation hole within 150 feet of SAS) NQ_Checked with local Board of Health-explain: NA YFS Checked with local excavators, installers-(attach documentation) Yp,q Accessed USGS database-explain:http: //town,barns table.ma.us. You must describe how you established the high ground water elevation: Used: Gahretv & Miller Model. 12/16/94 Grniind water elevations ahnvP -,Pa level. Used: US_GS_- OhsPrva ion Well data- ,Time 1 992 Used: JIgM;-TPrhni nal hnl l ati n 92_nnn-1 Plat-t- #9 Annual rancles nf qrniinrl water e ey3 danLtarT1992 Leaching Pit ;eet Groundwater: Feet Below Bottom of pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is feet. 11 f : 1 ya•rrnrn.-n.•r►T.Tr:rnrmr•nmrv-.n:e+rrerni:•s.-.e.•mr:+n-s*mn nr�-�a++a�+v.rre+ �.. 1 TOWN OF Barnstable �' r •F BOARD OF HEALTH 0 r••. •.•.-_"' SUUSURFACE SEWAGE DISPOSAL SYSTEM INNSPECTION FORM - PART D •- CERTIFICATION I -TYPL OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 12 General Patton Drive Hyannis,Mass. 02601 ' ASSESSORS MAP, BLOCK AND PARCEL # 292-126 OWNER' s NAME Marie Deolizera PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc'.:o' COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Strvvt Town or City State Lip COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 5 0 8 ) 790 - 1578 R CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system nt this address and that the information reported is true , accurate , and omplete as of the time of �inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 3031 Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con 0cted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . t- Inspector Signature Date One copy of this rt.ification must be provided to the OWNER, the BUYER where applicable ) and the 130ARD OF HEAL1'I1. * It the inspection FAILED, the owner or..'.operrator shall upgrade ' within one year of the date of the inspection, unless allowed ortre system otherwise as provided in 3.10 CMR 15 . 305 . equired partd .doc f .... ... .......... COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 12 GENERAL PATON DR. HYANNIS D C, — �o�Lp , �, �.• Name of Owner MIKE BAKER 14 Address of Owner: 130 DUDDLEY RD.OXFORD MA.01540 N"�`�.'.� s Date of Inspection: 12/22/99E�c��t Name of Inspector:(Please Print)JOHN GRACI IiEr� 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) n Company Name: n/a 4,7 DEC 2 8 1999 Mailing Address: n/a Telephone Number: n/a , TOWty0FgARNSTABLE ' HEALTH DEPT , d r CERTIFICATION STATEMENT 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 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: X Passes The inpection is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: isubmit Date:12/22/99 The System Inspector sha a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this Inspection.If the system is a shared system or has a design Flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ;NOTES AND COMMENTS ',THE SYSTEM PASSESTITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM USEFULL LIFE: revised 9/2198 Page 1 of 11 x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 INSPECTION SUMMARY: Check A, B, C, or D: 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: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wa 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. nta 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. n1a 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 n/a 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 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 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 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 ilia_(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION('continued) Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Wa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11v. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X 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 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 GENERAL PAT ON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 FLOW CONDITIONS RESIDENTIAL: Design flowAill g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: = Number of current residents:Q Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): n(a Sump Pump(yes or no): NQ Last date of occupancy: n& COM M ERCIAL/INDUSTRIAL Type of establishment: n& Design flow: nLa gpd(Based on 15.203) Basis of design flow: E& Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:n/a Last date of occupancy: xi& OTHER: (Describe) D& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: Dia System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nta_ gallons Reason for pumping: n& TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS APPROXIMATELY 15 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 BUILDING SEWER: (Locate on site plan) Depth below grade: V 6" Material of construction:_ cast iron _40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ nLa Dimensions: L 9'6"H 5'7"W 4'10" Sludge depth: 1"" Distance from top of sludge to bottom of outlet tee or baffle: 3E Scum thickness:-Q Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: A How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Wa Dimensions: nta Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:l]La Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n& 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.) nLa revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/A Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) Wa Dimensions: nta Capacity: nta gallons Design flow: n(a gallons/day Alarm present: NO Alarm level:jiLa- Alarm in working order:Yes—No—: NQ Date of previous pumping: n(a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n& DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:n& Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2198 ` Page'8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION('continued) Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nla Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: .uld leaching galleries,number: _nla leaching trenches,number,length: Wa leaching fields,number,dimensions: nla overflow cesspool,number: nla Alternative system: NA Name of Technology: .nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY_THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: nla Depth of solids layer: nla Depth of scum layer. nla Dimensions of cesspool: Wa Materials of construction: WA Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection)n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) I" PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:nla Depth of solids: nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 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) n/a iA v (� a3 a3 revised 9/2198 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 GENERAL PATON DR.HYANNIS Owner: MIKE BAKER Date of Inspection:12/22/99 NRCS Report name: nLa Soil Type: nta Typical depth to groundwater: nLa USGS Date website visited: nLa Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of health Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS F i revised 9/2/98 Page 11 of 11 y x , commonweo►th of Mos=hU$ettS John Grad ExecutNe Office of EmAronniento{ Affairs D.E.P. Title V Septic Inspector P.O. Box 2119 Department of Teaticket,MA 02536 Environmental Protection (508 564-6813 8 e ro SUBSURFACE SEWAGE DISPOSAL A YSTEM INSPECTION FORM m ft 141 E0 CERTIFICATION MAY 3 0 1997 D Hyannis Address of Owner: TOWN OF 12 General Patton y Y cv Property Address: (If different) HEALTH Date of inspection:5119197 DIClocclo Name of Inspector:John Gracl ,` Company Name,Address and Telephone Number: E ti CERTIFICATION STATEMENT I certify that I have personally inspected the sewage was performed based on my training and experience in the proper function and age disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. TheP maintenance of on-site sewage disposal systems. The system: This inspection Is based on criteria defined in Title v X Passes code 310 CMR 15.303.My findinns are of how the system is Conditionally Pa55 5 performing at the time of the Inspection.My inspection does Needs Finer luation By the Local Approving Authority not septic system and any or Ky any warranty or s omponenttsarantee of ruseful Idev of the Fails �f �i Date: 5119197 Inspector's Signature: of this inspection report to the Approving Authority within thirty(30)days of completing this The System Inspector shall submit a copy d or greater,the inspector and the system owner shall submit m or has a inspections. If the system eg onal office of the Department odesign lf Environmental ow of 0yr, applicable ppl cable and the approving authority. the report to the appropriate The original should be sent to the system owner and-copies sent to the buyer,if app INSPECTION SUMMARY: Check A,B,C,or D: A] SYSTEM PASSES: X I have not found any C of mationwhic failure indicates that the not system lusted aaee indicated beloa criteria below MR 15.303. defined as in 310 B] SYSTEM CONDITIONALLY PASSES, _One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,pa sses inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If "notexf Itrationtlortan ikfoiain lure is t) _ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or roved imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as app by the Board of Health. (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 1 k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 General Patton Way Hyannis Owner: Dlclocclo Date of Inspection:5119107 _ Sewage backup or breakout or high static water level observed in the distribution box is 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 leveled 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 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. NES THAT THE SYSTEM 1) NOT FUNCTIONING IN ALMANNER WHICH WILL PROTECTESS BOARD OF HEALTH THE IS SYSTEM WILL PASS HE PUBLIC HEALTH AND 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 LESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)THAT HEILL SYSTEIM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAF TY AND THE DETERMINES ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage in 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 2 , t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) -P ro pe rty Address: 12 General Patton Way Hyannis Owner: DlciocclD Date of Inspection:5119/97 D] SYSTEM FAILS(continued) _ 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). Numbers 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 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. 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: The following criteria apply to large systems in addition to the criteria: 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: 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. it (revised 11115195) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 12 General Patton Way Hyannis Owner: Dlclocclo Date of inspection:5f19197 Check if the following have been done: X Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the 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. n1aAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. G (revised 11115195) • 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 General Patton Way Hyannis Owner: Dlciocclo Date of Inspection:5H9197 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 gallons Number of bedrooms:2 Number of current residents: a Garbage grinder(yes or no): No Laundry connected to system(yes or no): No Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: 4 months ago COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:U gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: n1a Last date of occupancy. Na OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection:(yes or no)Yes If yes,volume pumped: loon gallons Reason for pumping: Maintenance. TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: n1a SewaIge odors detected when arriving at the site:(yes or no) No t (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 General Patton Way Hyannis Owner: Dlclocclo Date of Inspection:5119197 SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 8'8"H 5'7"W 4'10- Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness:1" Distance from top of scum to top of outlet tee or baffle:V Distance form bottom of scum to bottom of outlet tee or baffle: 17' 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.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) nla (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 General Patton Way myannls Owner: Dlclocclo Date of Inspection:5119197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nia Material of construction:_concrete_metal_FRP_other(explain) Dimensions: Na Capacity: n1a gallons Design flow: n►a gallons/day Alarm level: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Na DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:-!!La- Comments:' (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) Na PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Na (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 General Patton Way Hyannis Owner: Diclocclo Date of Inspection:5119197 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Na Type: leaching pits,number: 1,000 Gallon leach pit leaching chambers,number:n1a leaching galleries,number: nla leaching trenches,number,length: n1a leaching fields,number,dimensions:n1a overflow cesspool,number:nia Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) The overflow was empty at the time of the Inspection it Is structurally sound.It has not been more than 112 full. CESSPOOLS:_ (locate on site plan) Number and configuration: nia Depth-top of liquid to inlet invert: n1a Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nia PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: n1a Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) n1a (revised 11115195) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address' 12 General Patton Way Hyannis Owner: Dlclocclo Date of Inspection:5119197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' YJ�CI� Al U o A D � AC �5 �A i DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts ,(revised 11115195) Town of Barnstable A Regulatory Services 9O?Ea � Thomas F. Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 October 23, 2003 Mr. David Masse 28 Redwood Circle Mashpee, MA 02649 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND ARTICLE 51 OF THE TOWN RENTAL ORDINANCE. The property owned by you located at 12 General Patton Drive, Hyannis, was inspected on October 20, 2003 by David Stanton R.S., Health Inspector for the Town of Barnstable, because of a complaint. The following violations of the State Sanitary Code were observed: 105 CMR 410.200(A): Heating Facilities Required: The old oil furnace is in disrepair, with some of the parts are cracked and potentially leaking carbon monoxide according to the recent inspection by your HVAC repair company. It is noted that the room temperature observed during the inspection was at 68 degrees Fahrenheit. 105 CMR 410.351(A): Owner's Installation and Maintenance Responsibilities: The kitchen light fixture was observed missing during the inspection. The tenant claims you removed it to repair it several weeks ago, and you still have not replaced the light fixture. 105 CMR 410.351(A): Owner's Installation and Maintenance Responsibilities: The warning light on the stove remains lit up saying the surface is hot, even though the stove surface was not hot. 105 CMR 410.351(B): Owner's Installation and Maintenance Responsibilities: The ceiling fan in the rear bedroom is out of balance (wobbles) making a grinding noise and creates an accident hazard when it is turned on. You are directed to correct the violations listed above within Fourteen (14) days of your receipt of this notice, by repairing or replacing the furnace, replacing the kitchen light fixture, correcting the false light on the stove and by repairing or replacing the ceiling fan that is out of balance. [Note: Per our phone conversations, Keyspan has been to the property to look at converting the oil furnace to a new,gas furnace, and a plumber has been contracted Q:Health/Order letters/Housing violations/12 General Patton.doc to install the new furnace on Tuesday October 28th, 2003. It is noted that you have provided the tenant with an electric heater in the meantime, and can provide more heaters if needed. At the time of the inspection, the room temperature of 68 degrees met the housing code criteria. Should the temperatures drop down lower and the electric heater(s) cannot maintain a safe temperature in the home, you may need to provide another adequate shelter for the tenant.] You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance could result in a fine of up to $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER LOFHEOARD OF HEALTH Thomas A. McKean, R.S. Director of Public Health Town of Barnstable Q:Health/Order letters/Housing violations/12 General Patton.doc Health Complaints 20-Oct-03 Time: 4:19:00 PM Date: 10/17/2003 Complaint Number: 17134 Referred To: DAVID STANTON Taken By: DENISE WITTER Complaint Type: CHAPTER II HOUSING Article X Detail: PRODUCT INTEGRITY Business Name: Number: 12 Street: GENERAL PATTON DRIVE Village: HYANNIS Assessors Map_Parcel: Complaint Description: MR. NELSON STATES THAT HIS HEATER IS GIVING OFF OIL FUMES AND THAT HE IS WITHOUT HEAT. WE HAVE ALERTED DAVID S. TO THIS PROBLEM AND HE IS INVESTIGATING. HE HAS NOTIFIED THE LANDLORDS TO THE PROBLEM AND THEY WILL BE SWITCHING FROM OIL TO GAS HEAT ON TUESDAY. to Actions Taken/Results: /a(/O3 Investigation Date: Investigation Time: y j PM re e�Cr�� t,e_kri IJM TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date o /f /�, Owner��Sfe4L 1 O 01 via, Tenant C9G�d•, I C /S Ott Address Address 6coyer, 14, Compliance Remarks or Regulation k Yes No Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities y 6. Heating Facilities CO 7. Lighting and Electrical Facilities sl"n ri 9 9 �� I k4� eH 8. Ventilation 9. Installation and Maintenance of Facilities tm ISte! S u 6 ��17�2 ©� 10. Curtailment of Service remove ,-e 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing o0l PART II ;�1 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here Barnstable Assessing Search Results Page 1 of 2 k s Home: Departments:Assessors Division: Property Assessment Search Results 12 N PAT TON DRIVE, .Owner: DEOLIVEIRA,JOSE C Property Sketch Legend Map/Parcel/Parcel Extension 292 /126/ Mailing Address �y DEOLIVEIRA, JOSE C 5 % MASSE, RICHARD W r f rr s 36 DEVON LANE MARSTONS MILLS, MA.02648 2004 Assessed Values: ``'' 'f f33 Appraised Value Assessed Value Building Value: $55,000 $55,000 Extra Features: $0 $0 Outbuildings: $0 $0 Land Value: $76,500 $76,500 Interactive Property Map: ap requires Pig in: � p�C� .�*tf1�1!". Totals:$ 131,500 $ 131,500 I have visited the maps before Show Me The Map April 2001 photos available Sales History: Owner: Sale Date Book/Page: Sale Price: BAKER, MICHAEL B&CAROL F 5/30/1997 10774/298 $40,000 PECKHAM, DANIEL J 2563/205 $0 HAGENBUCH,GLENN E 11/15/1984 4317/304 $34,900 DICIOCCIO,ANTHONY D&SUZANNE 110/15/1987 5983/066 $69,000 DEOLIVEIRA,JOSE C 1/28/2000 12803/103 $74,000 MASSE, RICHARD W 4/14/2003 16737/244 $ 150,000 2004 Tax Information: Tax Rates: (per$1,000 of valuation) Town Tax $869.22 Town Fire District Rates Other Rates 6.61 Barnstable 2.01 Land Bank 3%of Town Tax Hyannis FD Tax $266.95 C.O.M.M. 1.10 Cotuit 1.52 Land Bank Tax $26.08 Hyannis 2.03 http://www.town.barnstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessin... 10/20/2003 Barnstable Assessing Search Results Page 2 of 2 West Barnstable 1.36 Total: $ 1,162.25 Due to rounding differences these values may vary Land and Building Information Land Building Lot Size(Acres) 0.22 Year Built 1945 Appraised Value $76,500 Living Area 825 Assessed Value $76,500 Replacement Cost$72,369 Depreciation 24 Building Value 55,000 Construction Details Style Ranch Interior Floors Carpet Model Residential Interior Walls Drywall Grade Average Minus Heat Fuel Oil Stories 1 Story Heat Type Hot Air Exterior Walls Wood Shingle AC Type None Roof Structure Gable/Hip Bedrooms 2 Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms 1 Bathroom Total Rooms 4 Rooms Extra Building Features Code Description Units/SQ ft Appraised Value Assessed Value i Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/tob02/Depts/Administrative$ervices/Finance/Assessin... 10/20/2003 U0 q ay cM ¢ REM: VED f U f DATE:4/18 103,U-R 2-7 2003 PROPERTY ADDRESS: 12 General-Patton-Drive TOWN OFBARNSTABLE HEALTH DEPT, Hyannis,Mass. 02601 On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1 000 gallon septic tank. FAILED INSPECTION 2 . 1 -Distribution box. 3 . 1 -1000 gallon precast leaching pit. Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78Code) 5 . The septic system is in hydraulic failure. 6 . A New Leaching area needs to be installed. 7 . The system should be pumped. 8. Waste water is less than 6" below the invert pipe of the leaching pit. SIGNATURE:s` Name:_J_P J. P. Macomber Jr_______ Company: JosePh_P. Macomber_& Son , Inc . Address: Box 66 Centerville , Ma . 02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE•SA GUARANTY OR WARRANTY V A JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • . ' TOWN OF, �RNS TABLE A''ION eM ��` "` SEWAGE LOC LADE 0,Cp®'l.A . ASSESSOR'S"&LOT - MSSA.rI.EWS NAiM&PHONE NO. � SEPTIC TANK CAPACTr'Y �� 1 LEACIM4GJ-FACR.s=: ( )NO.Oft-BEDROOMS C;,"- 0 4. BUILDER OR OWNER i f� PER-MITDATE: COMPLIANCE DAM Separation Dist=ce Between the: Maximum-Ad usted Grcu ndwater sable to the Bottom of Leaching Facility Feet Private Water Supply Well and LzacbiM l acility '(1f any trek exist on site or within 2CJ feet of leaching facility) ; met Edge of We'dand and Leaching Facility(if any wetlands exist within Mo fee€ leaching C // Feet Furnished by er Ca �� __�___ b n { . b D i �J w LR-_C-k ION SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S NAME S ADDRESS Ca F e v?c 1-1f' 8 UILDE R OR OWNER D T PERMIT ISSUED A E iSSU DAT E COMPLIANCE ISSUED 5; �: 1 Fl No.........�ON........ Fps.... . ...... THE COMMONWLALTH Ok MASSACHUSETTS BOAR® OF HEALTH Appliration for M-4p o sal Morko Tomitrur i amit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ...........................� 1... . o..> ...... ...................................--- ...................................................... oca�n-Add, sst o� r Lot No. ... �_..... �.r..�..!_°�/.. ................................ ......�1t{�,�+.��=�'� -............... �- Owner Address, - a ........ ..__ •_•• ' _____•............. F ._._................................................................... Installer Address 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. -, W Septic 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........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-___--___.______--_____. L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------- Description of s 1 Q ` �p}p W -•-------------------- *�' .. . x ---------------------------------------------------------------------------------------•--•---•----------------------...........------------ ------. Nature of Repairs or Alterations—Answer when a hcable_ �✓' .. ��.__ '_._.�. ..._ .���"._..�.... U P PP ..-•-----•------------------•--••--•••-••-----------------••--•-----------------------------------------••--•-----...------------ -----•--•--••--------•---------•-•----------------_._................. Agreement: The undersigned agrees to install the-aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?., 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 boardof'healt . 7;1 Sign -'--- ---------------- -�_ ` � -.-._- Rate Application Approved BY ------. ...................... /S 7 ' Date Application Disapproved for the following reasons-------------------------V------------------••-------------------------•--------.................................. --•-----------•--•-----------------•-•--.....-------------------------------------------••---•-•---......-------_...._..-•----------...----------------------------------------------•--•------....-••-- Date PermitNo.....................................•-.................. Issued_---=5- z y^. --f----•---------•-.._...... Date THE COMMONWEALTH Oik MASSACHUSETTS BOARD OF ' HEALTH Applica�'6d is hereby made for a Permit to Construct )'or Repair (��Individual Sewage Disposal System at Address Owner Installer Address | Other—Type of Building ............................. No. ofpecuoom---.,------- Showers ( ) -- Cafeteria'( ) � Other fixtures Disposalank '^� Tzcocb ^I�u-.--.--.-' gallons-_----'-- Iot� I.cug8z.-=_----- Totu area....................sg. ft. ~~ Seepage Pit No..................... Diaozeter.-.---.--.. Depth below inlet.................... Total leaching area..................sq. 6' U8zr� D�v��x��obo� / ) Doa��� �uo� ( \ �� ` ' ~ ` ' ~~ � Percolation Test Results Performed bv........................................................................... Date........................................ � Test Pit No. ]........-------'minutes per inch Depth of Test Pit . Depth to ground water........................ � Test 0 D of Soil' / ------------------------ -'---------------------------------''----'-'--------`'------------`-------`------`-`---- + [� .---__-_-^-_-...------' � - � o��r �b�o u � c �j Nature of or Alterations � _. .................. � '------' --_--_--_-..--_-__.--- Agreoozcor: � The undersigned agrees to install the ufore6escribed Individual Sewage Disposal System in accordance with the provisions of T I T iE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until u Certificate vf Compliance has issued�y the board of liealt�, ;eo" � ----_---'- -'��.-- ---'_-- J - ��r--����� Ann�at�� By-..���,� ate B��*��--- --. ---------- --��.�� -- . ' � /7 Date uDfor the following reasons:.............................................................................................................. ---------------_--_-------------..-'----'--'_--'----_-----'___----._--''---'-'-'---_---_-_'_--'---- � u�" Permit ` Date' ^�� ?r THE oomMoNvvsALrnqr\MAsSAC*usErrs BOARDP HEALTV � � -` 7.&Wn--- ... �, �-'~''--_- Tatv°w°a°r m�°~� ~mau~p°"~~~"~° ��uu S Syuuzn constructed ( ) Repaired (~~ -- ---- - - SECTION A -A 2g/ I = z000 + - tt)• min. from . VENT PIPE (O Least 24 inches tall)--� AL, OUTLE; PPES FROM THE NOTE: ALL PIPES ARE TO BE 4' SCHEDULE 40 P V.C. Schedule 40 Pvc w/ChOrtool oea Fate* � PROFILE VIEW OF ADDITION TO LEACHING SYSTEM DtS RIBUTION 90x SHALL eE house to septic Conk ,y Existing Foundotion SET LEVEL FOR A7 LEAST 2 FT COPOMTE COVER R� StpGc took oovtrs must De 3' of t/B" - t%2- Wasneo -eostone .�� wdhin 6 m of finsh*d prole �.. I v ' —Grodt O.W Soic Tank - 9P.O"_. 3/4" to 1 1/2 - Washe•d Crushed Stone � _ % �.•'-�. ,�Grooe oval D-Bo. - 9750 �--t:ro0e over SAS -vor,es from 9A00 to 9600 7 �' OT ET •'s• - \`` � KNOCKW7S F P / ` � - — 155' ouT Er tY INLET o s - oo2 _ Q HOLE y-tp __7t-1 .1 1 -t1.1 DIS' Box ? �ko*mum Cover r r- 1Y — NEW --____ 5-0.01 or Greater —..top of SAS - Eiev 9. 50 , , i.. 2 �A . 1 EXIST. PIPE � O 1.500 t_AL - - .-- F REM Ex1;T FOUNDATION x o 20• S- 0.01' Per root I - _ tp.5"Ilk � 4- - SCH 40 T t 7s Y w �F OIIC TANK �� �-1 Effect.a Depth } •j.. i �. H-to I !a o - - unrts e = 30 PLAN SECTION CROSS-SECTION Mp55o pt A cONCKTE FUL, FpeJNDATI v' ° o..t.ra. u I rn ' i �' S Or f Q, a>, rn PE n t- —--30' - - or d SITE �r �1'STEM PROFiL� 6 in of 3'4--t 1/2- I It — I --3b'— 3 HOLE H- 10 DISTRIBUTION BOX Y kk.o ompoctea stone o QO Not to Sc�Ie - I c' � e Effective Length NOT TO SCALE • ; LOCUS MAP re�ge �e 4 4 2.5. ,I 10 SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES 6 not 3/4'-t 1/2 compocted stone C Lfftctivt ►+ O m CULTEC MODEL 125 (H-20 LOADING)/ SHOREY PRECASTE 1. Contractor is responsible for Digsafe notification ?ttaro_n!_Initf4s_]_Elrr-;�459_______ (OR EOUIVALENT) Not to Scale and protection of all underground utilities and pipes. NOTE OVERALL HEIGHT OF INFILTRATOR IS IS- /EFFECTIVE HEIGHT IS 12- 2. The septic tank on j distribution box shall be set level on 6' of 3/4 -1 1/2" stone. 3. Bockfill should be clean sand or grovel with no -- --- — - ------ -- ---- — ----- ----- - — stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance P E R C 0 LAT I 0 N TEST with Title V of the Massachusetts state code, the approved plan and Local Regulations. Dote of Percolation Test: APRIL 7, 2003 6. If, during installation the contractor encounters any Test Performed By CARMEN E. SHAY, R.S., C.S.E. soil conditions or site conditions that are different Results Witnessed By WAIVER ( per Barnstable B.O.H.) r00 LOT #!41 from those shown on the soil log or in our design Excavator: ROBERTS SEPTIC SERVICE ' QDwlq G installation must halt & immediate notification be Percolation Rote: Less Than 2 MPI made to Carmen E Shay - Environmental Services, Inc 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. Test Hate ; i t► 8. Install Tut-Tito gas baffles or equals on all outlet tee ends NO. 1 I tL \ 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes 10. All solid piping, tees & fittings shall be 4" diameter DEPTH SOILS ELEV 0 J 9650 t 93 Schedule 40 NSF PVC pipes with water tight joints. Loorny f `� 11. Municipal Water is Connected to The Residence and Abutting Sand LOT ##42 LOT #32 �� -J Properties Within 150 Feet. 9,693 Square Feet +/- gy o -6" to Ae/2 96 00' f , / THE PROPERTY LINES ARE APPROXIMATE AND 3 COMPILED FROM THE SURVEY PLAN GENERATED BY LO 1t TEST HOLE Sand 1 AMERICAN SURVEYING COMPANY, OF WALTHAM, MA ' - i � 10 ,.R 5/6 �\ 1t ELEV = 96.50 ENTITLED " CERTIFIED PLOT PLAN OF #12 GENERAL PATTON DRIVE, ` HYANNIS, MA", DATED JULY 2, 1992, 6 40 Be 9320 f4_� 6r __1 VENT PIPE AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Sand 11 t IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 25 r 7/4 ' ;=a; �'" THE SEPTIC SYSTEM INSTALLATION. 40"- 132 C - }; . �•t 1> `i a,":'. , i; - - EXISTING LEACH PIT TO BE PUMPED & FILLED IN PLACE. - 96 FAILED ,LEACH PIT NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE D-Box `` FROM THE EXISTING LEACH PIT TO BE DISPOSED ` I - OF' AS PER BOARD OF HEALTH SPECIFICATIONS. ` -- 97 Perc #33 #1 Depth to Perc: 42" to 60" �\ 45`, LEGEND Perc Rate= Less Tho 2 MPI EXIST. 1000 gal Groundwater Not Observed Septic Tank �� PROJECT BENCH MARK No Observed ESHWT p TOP OF FOUNDATION DENOTES PROPOSED ADJUSTED H2O Elev. = None �� ELEV. = 100.00 (Assumed) 104X 1 SPOT GRADE LOT #31 \`M DENOTES EXISTING \ X 104.46--98 SPOT GRADE M PL PROPERTY LINE EXLSTING ,- 99 Ln _ 96P PROPOSED CONTOUR 2 BEDROOM - `-- I I HOUSE ; ; - - - - - --97 EXISTING CONTOUR — --- -- — - #12 ' a DEEP TEST HOLE & 2-18- DIAN, ACCESS MANHOLES I a i PERCOLATION TEST LOCATION i�_. fS• I In � I � - 99 6 FOOT STOCKADE FENCE 7 0 0 1 I -- 1 -� e THE ACCESS COVERS FOR THE SEPTIC TANK, INLET TON DISTR18uT BOX AND LEACHING COMPONENT 67.00� OUT ET SET DEEPER THAN 6 INCHES BELOW FINISHED -- GRADE SHALL BE RAISED TO THIN 6 OF _ _ I PLOT PLAN ,4 '.` FINISHED GRADE -. '.r .�.— INSTALL TUF-TITS GAS BAFFLES OR EOU ALS ----------- -----..- ------ -------------Z -- - --------------------'- ----- T 'EDGE OF PAVEMENT 7 EDGE pF PAVEMENT '. OF PROPOSED SEPTIC SYSTEM UPGRADE STEEL REINFORCED PRECAST CONCRETE PLAN VIEW �'V PREPARED FOR �- 3-24- REMOVABLE COVERS MR . J O S E D E O L I V E I R A AT m;r'�I:o:a;;�� 99 # 12 GENERAL PATTON DRIVE INLET -Ti_min r t2" inn. Diet to outlet i3 RaET. ---�' - -- OVTLET — HYANNIS , M A -r��d (level JLJ .: � -- ---- -- Y 5- -7- ---- -- s' -7' Design Colculotions - -> E 4-e min r%N- 4,o PREPARED BY: e.edb Lgv,d depth Number of Bedrooms: 2 Equivalent to 220 Gol. Do 330 Got. Do Min.04 q / y ( / y per Title V) Garbage Grinder: No Ltd r> ,. Leaching Capacity Proposed: 330 Gol./pay Minimum (Min. Per Title V) 1 1`Y�L Il Li Li . SHAY ' Septic Tank - 3 x 330 Gol./Doy = 660 USE Exist. 1,000 GAL. Septic Tank. 0 )(, 40 S ' 8•-0' 4' -to' SOIL ABSORPTION AREA: Using percolation rote of <2 min./inch 50 P�� 1 ENVIRONMENTAL SERVICES, INC. Bottom Area: 0.74 gol/sq. ft. x 360 sq. ft. = 266.4 gallons F { ;` P.O. BOX 627 CROSS SECTION END—SECTION Sidewall Area: 0.74 gal./sq. ft. x 92 sq. ft. a 68.08 gallons scl -�<a ,; EAST FALMOUTH, MA 02536 Providing: 334.48 gallons ,`�A'17�,tZ�l' 'ems USE E X I ST I N�� 1000 GALLON H — 1 0 SEPTIC TANK Use. (5) CULTEC MODEL 135 UNITS, HAVING A 1' EFFECTIVE DEPTH, SCALE 1 "-20 fr � TEL/FAX 508-548-0796 TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3' OF WASHED STONE SCALE. 1 "=20' DRAWN BY: CES DATE. APRIL 8, 2003 NOT TO SCALE ON THE ENDS. NO STONE UNDER. PROJECT#SD409 FILENAME: SD409PP.DWG SHEET 1 OF 1