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HomeMy WebLinkAbout0013 GENERAL PATTON DRIVE - Health 13 General;Patton Drive Hyannis`` A 292 103 q k r n TOWN OF BARNSTABLE LOCATION /"�' ��SEWAGE# ��6—� VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. �� SEPTIC TANK CAPACITY LEACHING FACILITY.(type)i�42''�� NO.OF BEDROOMS OWNER PERMIT DATE: OMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom�of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching fac 'ty) Feet FURNISHED BY ' 3 14 No. � �� �91 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitation for Misposal `pstem Construction permit Application for a Permit to Construct( ) Repair(�ade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No/ -m eR Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No 17 D gner's Name Addr s,apd Tel. o Type of Building: O� y� Dwelling No.of Bedroom ('Lot Size (J sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) > gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title ---� Size of Septic Tank i5 00 Type of S.A.S Description of Soil Nature of Repairs or Alterations(Answer when applicable) .71M Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of / Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. d"d o Date Issued ----------- ---------------_—---_------ -,,,-,,..•„,�-. ._-_ ...�.�.r+wn.•....,,d.}b..a.�r••r�'`n+r+'k.Y�v+�/w nrd'*'r"'w,�w•w3,....aowar..*•j��� .i _'.,•"`-:frw"""`^..""`"- -,�.'...-._..+'^"'r'+„yt'r`+� -�-.�-,ti,.i.,.,,".,f � ZA No. 0 9 1 � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION=TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpzitation for Disposal Ad tPrn"c�onstruttion pgrn it Application for a Permit to Construct( ) Repair Grade( ) Abandod( ) ❑Complete System ❑Individual Components c _ Location Address or Lot No j,� o6e/1?-/� � eri v� • Owner'ss Name,Address,and Tel.No. Assessor's Map/Parcel�s/,/ Installer's Name,Address,and Tel.No. rl /// r. Designer's Name,Addre s,and Tel.No r, //01, -a C �`�Ti/r G 57� .�/ /• o/ jih ��.�-yam/ �a�ivrclr`A& 0 � . Type of Building: Dwelling No.of Bedrooms �,l/ �6/ Lot Size �, 10 sq.ft. Garbage Grinder( ) Other Type of Building 7 No.of Persons Showers( ) Cafeteria( ) Other Fixtures H• �r�Design Flow(min.required) � � gpd Design flow provided gpd Plan Date _ Number of sheets Revision Date Title _ Size of Septic Tank j JJ y Type of S.A.S( `" 6 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heath. Signed ` Application Approved by Date �-- r : Application Disapproved by Date for the following reasons T Permit No. d U I �L' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (tertifirate of Compliance THIS IS TO CEE�R,TIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(1/' Upgraded Abandoned( )by at �1�� /�Cr f�P' //� Q�/!�� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0 G�� dated Installer ///�.�� ��� ii�%�' Designer <.r #bedrooms Approved design flow 3 3 3.'ttsC) gpd The issuance of this permit shall not be construed has a guarantee that the system will fimetio a`-"s des g`ned. Date f e-�L A5 // `� Inspector . _..•---� No. 00 o yj _r.---------------------------•---_•-___�-------------------_--•-----------------------"Fee ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION' BARNSTABLE,MASSACHUSETTS - �[s�lDsaY �pstem��onstCUrtl.on �ermit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and'the following local provisions or special conditions. Syr: d/ 4 Provided:Construction must be completed within three years of the date of this permit. Date �' 2- Approved by - v Town of Barnstable •°pE' I.� Regulatory Services Thomas F. Geiler,Director • BARNSPABLZ . Public Health Division ATE °' Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form a� Date: 2 Z l7� Sewage Permit Assessor's MaplParceI Zq Designer: / V" ► W Installer: //�41 ' /— Address: PO iw -L� Address: �� G ti ' z� / On vas vas issued a permit to install a (date) (installer) _ septic system.at �� f t 0-ZZt/J �T/Url'�I/, 2W`P based on a design drawn by (address) Lf dated 1% (designer) I certify that the septic system referenced above was .installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by,y designer to follow. OF- _MAss9c DARR y ME R (Installer's Signature) a No: 11 1' RFGIStE `� S01 TAROI'� ( esigner's Signature) (Affix Designer's Stamp Here) ,PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. .CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q: Health/Septic/Designer Certification Form 3-Z6-04!doc 0 YOU W 1SH TO OPEN A BUSINESS? ForYour hfDm aton: Business cerffmates (cost$4 0 00 for4 years).A business cerffmate ONLY REGISTERS YOUR NAME iz town (whhh you mustdobyM G L.--tdoesnotgaeyoupenn ssbn'tooperate.) You must first obtain the necessary signatures on this format 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis,MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE:&Ir > F213in pleas APPLJrANTS YOUR NAM E/S: .G Z C q jZ LQJ ' 0I//9 Lp 0 BUSINESS YOUR HOME DRESS: TELEPHONE # Hom e Tehph Num ber a ,t> NAM E OF CORPORATDN : "„�'.l.S / 2�7.G�C ----- --- ------------- NAM E OF NEW BUSINESS___ TYPE0FBUSNESS IS THIS A HOM E OCCUPATDN? YESS �7 ADDRESS OF BUSINESS AP/PARCELNUM BER 0,ssessng) W hen stardig a new business there am se�eraldings you m ustdo n order tD be is com plane w lh the ruhs and reguht has of the Town of B amstabh. This forn s intended to assst}ou h obtaining the inform at hn you m ayneed. You M UST GO TO 2 0 0 M aii St.- (comer of Yarm outh Rd.& M an S treet) to m ake sure you have the appropriate perm its and licenses required to hgaly operate yuurbusi-iess ii the-ttow n. 1 . BUILDNG COM M SSDNERS OFFrE Ths iidirdualhas been hfDr<n ed ofanyper<n,srequirem ents ihatpertan tD the type ofbusiaess. Autinori2ed S#iature* COM M EN TS: 2 . BOARD OF HEALTH Ths hdirdualhas b form ed of the n):1-,r m ents d-latpertah tD dib typeofbushess. MUSTQ OMPLY WITH ALL or d S-tnatr,re* 7 HAZARDOUS MATFRIALS RFGIII../- "^ COM M ENTS rn-1p - A, iTH A C-TS A-eA e6zt- &+ Ca P-A- l!TIC gee.0 o O ►T 'P 1kg-tSED I tJ "n+-C V#zf-1 V E7u A . Alo e Ala- A-AJ3 All 77 ye VZ-W/4 L Pl Of 1440eLe-7 rc- SrAckeo 6y 7wc b oa . "a , r-.4d3 Q)-,: P*LL-- "A-r .4i-7-l-o ace H A 6AjL-cA-1-4 vr y5 -A-C3 cr CAJ 3 . CONSUM ER AFFAIRS �=ENSNG AUTHORIPY) This iididdualhas been inform ed of the lbensiag requaem ents thatpertah tD di:i-.type ofbusness. Authored S#natzre* COM M ELT TS: c , Date: /0/ TOWN OF BARNSTABLE Akul TOXIC AND HAZARDOUS M/ /ATERIALS ON-SITE NAME OF BUSINESS: C,T /S' /y�,' '_�LF BUSINESS LOCATION: /�r2(r.eev( E227 70,,,- DIS INVENTORY MAILING ADDRESS: rb T�O,� J,o .2 Z h/ /�Or,,) 41 lylA.02 6;3 TOTAL AMOUNT: TELEPHONE NUMBER: ,rO8' X Zt f/y I ? CONTACT PERSON: 4011 Cw 2(o-j 011 n yvpo EMERGENCY CONTACT TELEPHONE NUMBER: '1t -Y151 ?2 MSDS O.N-SITE? TYPE OF BUSINESS: SrilIe r/ 2.aor- if k 6"-X2 �`� INFORM ION/RECOMM NDATI NS: ire Dist is Waste Transportation: Last shipment of Nazar ous was . Name of Hauler: Destination: `� ----_- Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosi e ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road sa (Halite) Hydraulic fluid (including brake fluid) Re 'gerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: gre e, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and me Printing ink Degreasers for driveways & arages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electro e)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash de rgents Leather dyes Car waxe and polishes Fertilizers Asph & roofing tar PCB's Pai s, varnishes, stains, dyes Other chlorinated hydrocarbons, L cquer thinners (including carbon tetrachloride) Any other products with "poison" labels NEW ❑ USED (including chloroform, formaldehyde, Paint&varnish removers,deglossers - hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash Gov WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials Town of Bnstable. A P#� Department of Regulatory Services Public Health Division BLE Date /o l i �ARIi4lA , ,"`6 S&y ems$ 200 Main Street;Hyannis MA 02601 s �ffD t,AA't� Date Scheduled I Time Fee Pd. i Soil Suitability Assessment for Se e Disposar Performed By: ! Witnessed By: i LOCATION & GENERAL INFORMATION Location Address Owner's Name A4 E nlP&J—4 {�J 6EN�✓1-Ai tb /"qua-ts vkt,vn.- 1�A•�LS i Address `►l `�AAnnaunt 1M¢- b2b7 Assessor's Map/P rcel: S12, I Engineer's Name��✓ -- M It Telephone# so Sl 360 —33 NEW CONSIR(�U�'1'!ON REPAIR I Land Use Slopes(%)9� VIA=— d Surface Stones Distances from: Open Water Body 7 U P ft Possible Wec Area��ft Drinking Water Well Z�� ft P . Drainage Way > O�� ft. Property Line � L ft Other ft SKETCH:($treat name,dimcnsious of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) i -TI Parent material(ge(jlOgic) t��^ ���,*"k S Depth to Bedrock r " I Weeping from PIt Face Depth to Groundwater. Standing Water in Hole: ! P g Estimated Seasonal oigh Groundwater DtTERMINtTION FOR SEASONAL HIGH WAT It TABLE Method Used: _In. Depth to Sall mottlt's: in. Depth C b� rved standing in obs.hole: — ; in, ©roundwnter Adjustment ft. Depth toiweeping from side of obs.hole Adj.(Jroundwater Level.,,"e, Index Well# _ Reading Date Index Well levdl-_.,-e,,..---.,- Act.factor,•,...r,� I _ . PERCOLATION TEST . Date [Observation Time at 9" e# Time at 6"pth of Pere 3 Time(9"-6") Start Pre-soak Time.@ 11 End Pre-soak Rate MinJInch all �( Additional Testing Needed(YIN) Site Suitability Assessment: Site Passed Site Failed: original:,Public k141th Division 1 v_ Observation Hole Data To Be Completed on Back ***If percolajion test is to be conducted within 100' of wetland,:you must first notify the Barnstable C4nservatien Division at least one (1) we6k prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil-Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel ci 0� 1 l� ,I -3f D 3 3�, 7 sy b/ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel) 0 l 14oh DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel DEEP OBSER TION HOLE LOG Hole# 14 Depth from Soil Horizon S ' Texture Soil Color Soil ther Surface(in.) (U (Munsell) Mottling (Structure,Stones,Boulders. Consisten ra 1 Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No Yes �. Within 100 year flood boundary No 7 Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring Aevious material? Certif cation I certify that on � (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with the requiredAr' in expertise and experience described in 3.10 CMR 15.017. Signature J Date 1A Q:\.SEPTICTERCFORM.DOC FEB-25 03 09:02 FROM:DAN A SPEAKMAN -508-432-5099 T0:508 398 0684 PAGE:02 ! COMMONWEALTH OF MASSACHZISETTS 1 �� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . a . DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP PARCEL ' LOT �,.�...�... . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE 'SMkI1�S SUBSURFACE SEWAGERT DISPOSAL SYSTEM FO PA CERTIFICATION FEB 9 Property Address: oC1 Ei2 G �� Z); N 0F6 i / F�Cr �FpTg Owner's Name e(F Owner's Address: ,o, AD3�rZ Date of Inspection: o Name of Inspector:(please print) Company Name: DANA.SPWMAN Mailing Address: con&tructfDr Telephone Number; hand 301V ing Me 5 EAT 01V p 15 SpeakWay PH.%508 432*Me CERTIFICATION STATEMENT North Harwich MA 02fWA I certify that 1 have personally inspected the sewage disposal system at this address'and that the information reported• below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.1 am a DEP approved system inspector pursuant to Section 15.340 of.Title 5(310 CMR 15.000). The system: �s Conditionally Passes. _ Needs Further Evaluation by the Local Appro�in;Authority Fails Inspector's Signature: Date: Z//Z 0? The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority, Notes and 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 rill perform in the future under the same or different conditions of use. Title S inspection Form 6/15/3000 page I FEB-26 03 09:02 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:03 Page 2 of l l OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACES SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION(continued) Property Address: Owner: Date of Inspection: _ lnspection Sammsry::Check A;B,C,p or E/ WAyS complete ail of Section D A. System Passes: t 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. Cotntnents: B, System Conditionally Passes: ,v114 One or more sy'tZ i``i �t?bent as,d scribed in the"Conditional Pass"section need to be replaced or repaired The ste u ����``''`" `p �Y. ? .�ql�R{et�o�r,'Of thg✓replacement or repair,as approved by the Board of Health'will pass. Answer yes,no or' aetemtined. Y- ;Q;Nb--�:tithe 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 infIM664`or extlltration or tank failure is imminent, System wit!pass inspection if the existing tank is replaced with a complying ieptic tank approved by the 136ard 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 brrak out or high static water level in the distribution box due to broken or obstructed Pipe(s)of 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): brokgn pipes)are replaced obstruction is removed ND explain: 2 FEB-26 03 09:02 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:04 Page 3 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: / /,? Owner: Ad;,,of Date of Inspection: 02-go C. Further Evaluation is Required by the Board of Health: /J /1 Conditions exist which require flu-they evaluation by the Board of Health in order to detemiine if the system is failin;to protect public health,safety or the environment, 1. System will pass unless Board of Health determines In accordance with 310 CMR 15.303(l)(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: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet of 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 FEB-26 03 09:03 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:05 Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM:II�SPECTION FOkW PART A. CERTIFICATION(continued) Property Address; Owner: 62 Date of Inspection: - D. System Failure Criteria applicable to all systems:. You=indicate`yes"or"no"to each of the following for jLinspections: Yes No _ Backup'of sewage into facility or system component due to overloaded or clogged SAS or cesspool L,,-Dischargc or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Vogged SAS or cesspool Static liquid level in the distribution box above outlet invert'due to*-an overloaded*or'clogged SAS or fesspool _ Ao'Li uid depth in cesspool is less than 6"below invert or available volume is less thin'h•day flow quired pumping more than 4 times in the last year NDTdue to clogged or obstructed pipe(s).Number times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. _o0lny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —Ae-'Any portion of a cesspool or privy is within a Zone 1 of a public well. _ ,�y portion of a cesspool or privy is within 50 feet of a private water supply well. _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 coliform bacteria,and volatile or 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.] At JO (Yes/No)The system fls.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: AJ To be considered a large system the system must serve a facility with a design flow of 10,000 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 _ 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—I WPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 FEB-26 03 09:03 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:06 Page S of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done.-You must indicate'Sres"or"no"as to each of the following: . w■� ,w�.ww ae w�wr�. Yes No Pumping information was provided by the owner,occupant,or Board of Health _Sz—�ere any of the system components pumped out in the previous two weeks? f Has the system received normal flows in the previous two week period? eve 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) ✓CVas the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? -&f-'f Were all system components,excluding the SAS,located on site? _1,� 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 _A,.-vExisting information.For example,a plats 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)] j 5 � t � FEB-26 03 09:04 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:07 y Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSA L SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address; .(3pi3O-.L`G`01�r� Owner; Date of Inspection: RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number or bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or no): A.�O !s laundry on a separate sewage system(yes or no):ti1pif yes separate inspection required) I aundry system inspected(yes or no):_ Seasonal use:(yes or no): A-t3 Water meter readings,if available(last 2 years usage(gpd)): p 57V t" Sump pump(yes or no):/JO aov a,8, Last date of occupancy:a- ysff ,i C0MMERCIALMMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15,203): d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):,r Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: ` Last date of occupancy/use:- OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as pan of the inspection(yes or no): A-I= If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM -!=-Vptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system tyes 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) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UAJ ac, Were sewage odors detected when arTiving at the site(yes or no): eLX3 6 FEB-26 03 09:04 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:08 Page 7 of 11 OFFICIAL,INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: s?r3t►J-a BUILDING SEWER(locate on site plan) Depth below grade:�1Z Materials of construction: v.Mt iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:—(locate on site plan) Depth below grade: j.,f) -e. Z"' co v1t 7� p c Material of construction:_concrete metal_fiberglass „polyethylene _hee6r(explain) r`_ES e,o c, If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: �_�.t'G ES Sl�d�A�I—.t�1 G gs � �G i`�✓r� Sludge depth: �' f Distance from top of sludge to bottom of outlet tee or bathe: 2h'' -- Scum thickness: Distance from top of scum to top of outlet tee or baffle: ge" Distance from bottom of scum to bottom of outlet tee or baffle: /I," r Now were dimensions determined: y&ZA S• V Comments(on pumping recommendations, Net and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of.leakage,etc.): �Gavl; �4 iiU c-� ��?�COry,y�'..� it/j•�/ � .�iJ�'�' ,ar,•7.e�.vCi GREASE TRAP-41ocate on size plan) Depth below grade:_ Material of construction:—concrete_metal—fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 FEB-26 03.09:05 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:09 Page a of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner:/ zi& Date of Inspection: J- -D TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:!concrete meta!_fiberglass polyethylene_,r other(explain): Dimensions: Capacity; gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level; Alarm in working order(yes or no):_ Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: +,. tf present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D' 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.): LD o,t' L�_•J yo4 d co.c,o�T7a-J �— �y S'��i-J S PUMP CHAMBER:4400cate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): r i FEB-26 03 09:06 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:10 i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION'(continued) Property Address: /3 ! , y?A91 Owner• ��� Date of Inspection: ,3 SOIL ABSORPTION SYSTEM(SAS): ,(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number. .-leaching chambers,number: 'L.. _leaching galleries,number: _leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number:_ ittnovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): / CESSPOOLS:„-- cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: / ~ Sd Depth-top of liquid to inlet invert: T Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of nroundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc,): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,ctr.): 9 FEB-26 03 09:06 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:11 Page 10 of l t OFFICIAL,INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: / _6 0}7" Owner: Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. t 67/2i4C /4'-'7M-AJ 40 IF. ZO 32' ,a 03 t :10 FEB-26 03 09:07 FROM:DAN A SPEAKMAN -508-432-5099 TO:508 398 0684 PAGE:12 " Pagt I I of 1 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS.IIrNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propert) A'Oeress. X9 41 Owner: Date of Ltspection:*� — SITE EXAM Slops Surface water Check cellar Shallow wells , Estimated depth.to ground water'eLd feet Plea,e indicate(check)all methods used to determine the high ground water elevation; . _.__. Obtained from system design plans on record-If checked, dace of design plan reviewed: Observed'site(abutting property/observation hole within 150 feet of'SAS) Checked with local Board of Health-explain: _ Checked'with local excavators, installers-(artach documentation) Acccssed USGS database explain: You must describe how you established the high ground water elevation; Teo vN o c.EZ/ = Ile 3 '1 W c .t .. 5 revised 9/2/98 FAX COVER SHEET Company: , Today' Fax Number: v No. of Pages, Including Cover Pa e: REAL ESTATE g , g g 487 Station Avenue South Yarmouth, MA 02664 Date: C�- %` 7 From• ic'e Telephone Number: 508-398-0600 Reply by: ❑ Phone Fax Number: 508-398-0684 ❑ Fax Comments: „ _." - 3 i 1 � S 1-15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . , DEPARTMENT OF ENVIRONMENTAL PROTECTI-ON—4 . FEB 2 6 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /� �EaJEi2�}G �i9j 7aoU ,c7?. Owner's Name: '7� /�! -j Owner's Address: SO*' 35Z �1 iS GOB Date of Inspection: Name of Inspector: (please print) Company Name: DANA.SP Mailing'Address: pn$trjclLfon L, nd Sulveft&TPJ6 8 Eng.Dv Telephone Number: 15SpeekWaypH,,a432»fit CERTIFICATION STATEMENT . Nodh Harwich AA A OM r, I certify that I have personally inspected the sewage disposal system at this address'and that the information reported below is true,accurate and complete as.of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on,site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: asses Conditionally Passes . Needs Further Evaluation by the Local Approving Authority Fails / g Inspector's Signature Date: Z/Z'r The system inspector shall.submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system.is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and 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: Owner: Date of Inspection: co-f;&-62 Inspection:Summary,: Check A,B C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more`system rrinponents as described in the"Conditional Pass"section need to be replaced or repaired.The systerrm,,�upopc�oitpJetton of the.replacement or repair,as approved by the Board of Health,will pass. 111 l 11 Answer yes,no or not''deteI'mined(Y+;N;NDr)'Jhithe 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 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: Page 3 of 1 1 OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION.. FORM PART A CERTIFICATION (continued) Property Address: 104_ Owner: &,,4f Date of Inspection: V-n?o-U3 C. Further Evaluation is Required by the Board of Health: X) 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 environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system.(SAS)and the SAS.is within 1.00 feet of a surface water supply or tributary to a surface water supply. _ The system has aseptic tank and SAS and the SAS is within a.Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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. j I 3. Other: 3 Page 4 of 11 .' 4 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL•SYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) Property Address* / 3 Gem, Owner: Date of Inspection: 4 -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 _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _4?-15ischarge 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 fespool , vLi uid depth in cesspool is less than 6"below invert or available volume is less than'/z.day flow quired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number times pumped 4/Any portion of the SAS,cesspool or privy is below high ground water elevation. _L,Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _k-Any portion of a cesspool or privy is within a Zone l of a public well. _Z,,- Cny 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 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.] A JO (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. E. Large Systems: ou ��-- To be considered a large system the system must serve a facility with a design flow of 10,000 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 the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or.failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 . g Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: "/ olie'��'$ tL Owner: Date of Inspection: 02 -�1—Q? Check if the following have been done. You must indicate"yes"or"no"as to each of the followine: Yes No �Pumping information was provided by the owner, occupant,or Board of Health ire any of the system components pumped out in the previous two weeks? f Has the system received normal flows in the previous two week period? eve large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site ? Were the septic tank manholes uncovered,=opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: . Yes no _Y�'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)J i . i 5 Page 6 of i I •f .t OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: '(j Owner: Date of Inspection: = j-D FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): .. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): OU0 Is laundry on a separate sewage system (yes or no): ti if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): AXI Water meter readings, if available (last 2 years usage (gpd)):m�OO/ SUU ccc Sump pump(yes or no):,t)C C?Uv a- $-, Last date of occupancy: �ac-'-U COMMERCIALIINDUSTRIAL / Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (yes or no):— Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection (yes or no): itA If yes, volume pumped: gallons --How was quantity pumped.determined? Reason for pumping: TYPE OF SYSTEM I eptic 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) -Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed (if known)and source of information: U/J-'Ar �JC7 Gy of Were sewage odors detected when arriving at the site(yes or no): /�r3 6 Page 7 of I I OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner• /I/-.../ Date of Inspection: 61-r9f)-o � BUILDING SEWER(locate on site plan) Depth below grade: G/2 Materials of construction: %.east iron 40 PVC -other(explain): Distance from.private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage, etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: b� Cr-'%-1CiVT 70 ez-14 Q� Material of construction: concrete metal fiberglass_polyethylene �r(explain) T'fS C,o C-.k If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: G c ES SPOc7C..A C/�tR1 G ,g S SE �rC �9=✓tt' 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: E: Distance from bottom of scum to bottom of outlet tee or baffle: /y`2- How were dimensions determined: S. f Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels. as related to outlet invert, evidence of.leakage, etc.): cili / Z sty�vJ e G P.�.-� GREASE TRAP:14(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: /�j n Q�czn moo, �PiJ�! Owner:/✓u,O�yYn�lva�c..F� Date of Inspection: �p-1116-O15 TIGHT or HOLDING TANK: tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.):. DISTRIBUTION BOX: if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: E7 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): s I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION:(coni:inued) Property Address: Owner: Date of Inspection: „?-fit SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ ,/leaching chambers,number: 2 leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CZ� C v 7 n—C rY�°� v� T S CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: • Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: .Alocate 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.): 9 Page 10 of I 1 s: OFFICIAL INSPECTION°FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: la Gey�®� O Owner: Date of Inspection: 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. 1y n� Z3 ' 2 i ,10 Pa2F 1 1 of 1 i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property A` ress: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth.to ground water feet t Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole 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: //J Fo , s v�' L �(J Z O C �f ���— =-----=-- ------ /J '0 E;fX V. -- Pagc 11 of 11 revised 9/2/98 t 10 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS- DEPARTMENT OF ENVIRONMENTAL PROTECTION- ��E® ONE HINTER STREET,130STON MA 02108 (817)292.5500 xg or - �� r ARGEO PAUL CELLUCCI �' ' DA-- TRLJfi$ GovernorC01riII1Ii810ner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA PART A r3 ���cI AC $'1 T/ZVrJ O�cE1�Tia lcArloN Adldress: Name of Owner !/i^) �C-- hr �� ^^'9. Addirm of Owner: T e�j S . Y?Lh. ,S O. =�J�v/S IA Deft of hvpec tion: w kello0 OZ 4 G J Name of Inspector:(Please Prl 14� I am s DEP approved system lrsapactor purwarR to Section 16.340 of Ttee 5(310 CItAR 15.000) Company Name: Tele Address: Q)WW_i Telephone Number: FK CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the information reported below Is true,accurate and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sews disposal systems. The system: _ Passes Conditionally passes N or Evaluation B Local Approving Authority _ ail$ inspector's Slpsettn: Deft: _2, The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)withln 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 eo,v 77/0,0 �J� �h' 3 eP 7"�G S YES �`'I ,4�UQ /.S A) revised 9/2/98 Page Ior11 Printed on Recycled Papa tl ULWAf h 11WA69 WMtAL"VW MH1011WI k FORM Cdt1'SfCM1tIH11.(eestriwll , Property Address: Oerew� , ties d eesrECTtoM usat ItT: t3lraeb A. M, C, eN A. STSTItl1 E!: I have not found any Ihfo►msson whtoh Ind eat#$that'any of the fallu►e amadagf detettbsd Ih lid CMA 16.263 Stiff. Any htkrte eritert o net o"Wed of 1111111011114111 eftuw, •_ srstoe COMSTI INALLV PASSIE: r--lk One or more tyftaM tompoMnte a datedbed to the"Condidonot Pass' fecdon Head to be teplteed a► sited. The W10m,upon v u M Ittl '"'Op antont or tspolt,of epptoved by the lasrd of HaWh,vrll pea. Indl1:n4*4bi,4f1st'Nete► d fY,N. w NDI. Dofbdbo beet$of dotorndnat)en In IN lnft$HeN. If`het ditftminad',atplom why net. 4-411 A Alwatwis,matill,unlset the ewnot or epeWo►het pwWdad IN eyttern Inapootet with a copy of o Cordflesto et Schad)Indicadrq that the tank was Inttatled wltftlrt twenty 1261 years prior to Ow that of the InspNteni or. 11 r er not Mae1 M maoked,struceuren unfound,shows substantial InflkrtNat of atfit►adon, or Conk t;k,whoths Y "t{ A t fi :p 1 mnditfht, th$11Y119 M w10 pass wtpectlon If#0 eslfahy updc to*Is npiaefd whh a cernplrtn3 oSptle rant as sword by the Iead of Heoh)t. eeweeo baekup w bn•teut et NO ftetle Wear level Observed to the dlettbutleh bait Is des to broken of chrofineted OWO or due to a broken.eettlod at uneven dlet►lbutlen ben, The"am*6 pace lnopeeUen If(wlth Gpp►eval of tM used of ' HNkhl. broken olpolo)its lfpleefd obsituatlam la t$h►$wad d1$Nbudeh bes le lewead er teplaeed The eystom roqulrad ptimop nwo than feu dmaa a Vast due to bteksh at HaMfetfd 011111. tits W"M will Rase Intpeeden 11 lolth approval of the SeeM of Health): broken plpefd a$toplaead 6woettett Is twavad revised 9/2/99 hit 3eflt 11JUMAd MAN DISMAL S1►ATMM Pl' U PANT A eE1H`p�ATlklN fsoe�trwd) :n�Ae�t /3 ��,�vE2,�c ,����J ��., HY•9..c.��/9.t east c. aIRT M IVALUAT1oM1 M R6oLMM#V TlM 60ARD Of WALI* Condhions exist wMoh require bulbar sveluatlen by the beard of Hasltb In order to detarm6w If the system Is tafte top M I M the Puble been.000h and the sovlmw4nt. 11 SYSTEM WILL PASS U LNS BOARD OF HEALTH DETERM M N ACCORDANCE WITH!to em f S.i!Nltbl THAT TH!SYSTEM M NOT IUNCTKWNS M A MAMM WMlCH:WILL M OITICT THE PIIBLID HEALTH AND SAMY AND TO M MOWAM; Cesspool or privy Is wltWo 60 het of suttees,Witter Cosepeel at privy Is wltNn 60 hat 01 t b&derira ira6st$Nd wetland of a mA marsh. 21 SYSTM WILL PAR UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPUM,IF All"01110 THAT THE @TO MM to TilNCT101S1UA IN A MAIM THAT PROMUTS THE PUBLIC HEALT"AND SAFM AND THE bNYlRWMKP - The ty$larn MA a aeptle tart and se8 a►rerpldn systlnl(1A61.oul the SAS It.withln 1 Do.bet-sf a.mu. O.Wetw supply w &bmry to a surtaea wetM supply. _ The tWtam has a$#oft link end sell a►sarplon syatsin sod tht SAO Is within a lone I of a P611a wMp wppLy,Wd. _ The system,has a$optic lerfk and sop ob$arpeon$yotorn and the SAS Is within 60 het of a pdvm water supply wait. Thu system has a s*ptlo tonk and sob obow"an systmr and the SAS Is hat then 100 Nat but 60 fall at Mn fine■ PdvNa Mstet$up*w",unless 1 win mm analysts tar aeltorm bums ww Volatile 6nwm attnpetmee bidleabe that the wain Is free,hem pellulbr from that helgty and the presntet Of sty MIM1r 1660e1 and M VM fft*W Is God to or hat 1Mo S ppm. Method tiled to daterWal dtttnoa _ -. • (0001 drtlalletl rat adldl,- 31 OTHER revised 9/2/98 IhM$�afll OUMI111/ACE sI�MYAOE pM1/0rlll f1NtY1 MNl0Q1'IDM 90N11 P�AAYyA aelpwltr Adiw: . Oe1e M IAQNMrk I ' D. Sys"FAM You bdteate dew"YN'0"No' N NON of tM btlewtnet / l he"deto I that one a rneN of the fak*"f0wo eondMtnte**too daorlbed M 310 CMR 11,M, 1M h*b►tlde delerndttetlen a tdbndf»e IMew. tfa teeM,01 ffelfM lheue N ttefltel:bld 1e dI►tt>nllle�M+et t M freeeafy ro t:elfeet them". Ya No sedup et eewe0e I ft M611001 eyew eetiom"t bete bit ovede""ert"i"eftlaepeel. �•+rv+• — Dleeharbo«panMb e1 ofMwnt to tM eu►heo of the Oreund a eulleee weteH due to en b+atebded er ebMed•AS« e�eped• #to*Mquld bah In tM dotM tMo bet ebow oudot Invert due to in aver 04M«db$W W«eleepse. U*W NO In eMpeal t1 Wt than 8'bNow kwM d evM M vehm It lea OM 112 day Aew. „ RoquWd pknpN mm Om 4&m M the Mat yo« to d"d w ebmwted OWs). WUWAW of tweee pumped_:.,, ._ Any pewrdW of 00 leg Abee OM Oyatern,Nuped«pdvy Ie b"Ow IdOh om mmdweHr oNvwin. _ — Any portkn of o eNopeW a/pMvy b tNthtA 100 feat of b eWMee tNblef MgDply a MNNRe1r 1S a twNee tMeM►supply. Any petNen of a tote"a O#Wv u MW a gene 161 a"Me wet.. — _ Any perden of e,Mlpeel a ahry Is whMn 60 foM of O ph to wept Sip*tneM. Any poft of a Nlopeel at prlvq Is bee•then W feet but 46etof then 88 bel here t pkete woH►a**wo r t M eeeopteble wets fOdIV IWMI. If the w44 he been M*W b be eaeptM,tMbeb o"of Wd W@W p"We ter +e801"beetede,Vol"brOWNo•ebKft $,Wfi*M 1r IP!end Mt IN Oil! F. LAWN$VIM FAIU: You nrst Y&eeto ethor•Yp'«'Ne' to Nth of the blewMf: fhe khalris whom epphy to bw tyolbAne M b&MM to dN atartb obe"I "Is syoterb selves a Witt wM b dNldll flea►et 16.000 Odd at woow tLUN evewn!NM me.."em"w b we drat*am to pubN heshk end eehty end the avlHnewnt beeeuee errs«Inolo of the WO MOO eeneaeW#Wtr Yet No — — Rw eyateM+u t>rllAte 40D feel of a wtfeee drlyddnp wet1/luppk — _. t#e eyetenr IawlWe=�feMaf a•bblrlery le b blirleeb�tflket�Net1r�d � •�•. ++•. .__...... .. .,., — �, tfM oy.tern le leeotod M•tVMeOen eentitlw etee Ihkatrr IAloelwed�roteatlert Ara�IYV►AI«e nrbppN gene d M b pttblN watts sup*wolq The owner or op moo of My sash eyetOrM eM0 updrOe the eyeM IM MOMMMee wide 810 CMR 1/.10mal, "we eebwll tM ma too" of l"of tm Depelb"m for fu ft Mtbfdatlob, revised 9/2/98 hp4e111 !tf!lltWAC!KWAAE(M OMM 9""M MMPEC!flttN PM PAftt s pRMm" Pfee«ty Addreu: /,j G���c',9 C �•4�....1 dpTc':, N%iq-✓.-./i� t� tads et Ineoseren: CMA if the feaew6+0 he"Mop deA81 Vau Must load b am*`Veto a"No,,is to ueh of the fd6*WVs iret Ne - PWriphig lofat M MA was praNded by the ewne,eeeupsnt,at$sod sf Meow None of the#Y#I#m teh+pGWtt Anredeeeh ptwMped+hceK/Nit two•wesks autM!►s slrtteRl hses>tattsaeelrMtrtltaslttiillevr ritet du►AO that pa►lod, this Molls of webr haw not bun Inaedueed Itttb the"don tt>a *at M pur df!tale Nttpettloh. At built plant!We bier ebtalntd and atrNned. Note it they ere not evOobh Kith NIA. lo-�ths W11111y er d*&MMd Wet Inepoattd fqr Memo of uwees beoh-up. _ the eyete►n dens net teaaive noh-seAN&V Of lAduddal*14%tow. the as wM InSP red to Mypts of breakout. At eyrtste eeh;pee W1. IsdudlAo the Bet AboerOtlmn RyHorh,hove been leaded on tho Mo. the$alme tank Manholes were U teoVlred,opened,and the IM061 of the espda tent wet lmpeoted for eama m of beMn a tote,lWadil of eonatruetlen,flmentlons,depth of hould,death of eluddt,depth of teum. The ettt SAA htalteA at the fell Abterptla IyetaN er•tla oho his been(loom Md Wad ens f lt11dA0 mfom"a*R,fat sail*#.f o It M.G.M. 1341 ilrlsd lit the oeld of my it the fellute ttRalt rolsod to Patt C It et flogs,epprotdrnathn M doli es is artaeesPtsbtet 116.�02f911b>i . The feellty,owner lied deeupa N,N ditbd frent.awaed wua.phssddad.11 M WarAlka bPft~AWammMje# l ibfutfeee dlepeaal AyltetNe. . a revised 9/2/99 Pe�sleflt +Ki aist tlr kr t ' OMMIfIMAAE flrllAtM< 1,1�` ��t'll A .. .. ewe =: Properly Addrowel i 1".O colluiimmv. Des LM, o•p.1.Aedroorrt. I i i Munreiw e/bdrsnr(d nit•,,` Nunibal of bsdm A UaluMl+?- I } Taw t�E81e1lf4;;; Numl w of eurrerA/soldsMH III I i�. Mra7 yl Wrmp VOW&fyn er ne1: � 7 Laundry frown syatst 4 lyao at ne►1;d&t N yN, faro Meopoetlen tdt>allnd I 51 . Loa dry.I1►t"hwNOMIe1 emend use free a set � �Q'd S?� WOW nret&Me",n"Aft IM t""If ea O"l two.=. ?"Z�.�. 9�-9 g /vS.oo� ��C sump fhteep lya of f+eh _., _ . Last dots of may e-J j , 7t,y1 Two of e oat: 114 ! ; Dodo"now: aid (Isla an 16.2031 lade of design flow Orlas trip piosetel IM a MO!_ krduetrld MOO NO"Tet1fU p/1ISUM("I er fb1� i Mon-Sealtwy w"I*dlsehwood to the?Ms t avows(yoa M 8e1_•, Water now roodlnia,If awNsefo: Leo dots of eastomy: OTNM:f0etedba! Last dote of eerApMey:. I�u►t rI1rI�11MA� - � :��t �� a , r }III Jt•'Nyl>),Il rt a �i F.� tyeeeet pumped as poet of Mutpoetlen:(yos at Ile) Rom for Putno"I Typiy�flM1 ' • , lople tank/dletrlbrrtlaa bes/od doupdo t#"tw Moo d"llsaf ; Ow flow wnpad Ihorsd eye M ly»w eto) Of yu,ntuaM opwaus boosts"tosetda.If ony! IIA Tel>ehtofW oft.Attoeh ft"of up to OMO Apoisti lad IMWWM W oor~ i T"Tort t:epy of Oil APP" I i Other AFMXIMA72 AIDE of al is ip011 M #Me IMMMMtN(itlMly -wA oeeMtef 14.1*MIMflft1 "I Swisp eden dal" Who fntl"of Nto sw l"e w fle)to I , i I ! 511t�kM�`4'Y . revised 9/2/99 t�artdeftt I 1 s , Y. 'C PARt 1: - �tn�l ttlnotUU►Ylolf leefltirpfedl 1�riiperly�►dd:au: /3 �y E��?,�� /Q11-77M.v owrtir: f?eflb of IpsplO�dlk (10ebte ttN On►WU bNrth be"lade: G � fWtbdal of ee:+etruetis:t: . ben t0 Mit:_olhu Ib:pfdnl Dlttmce frail pifvbN*It"supply*60 or!!!left"Irle:.,:....,._,...,....._ aannttt►_� Ceismerw:(eenelden el fehtte,YbltditQ,etAdenes of feeMaM�te.l .-.. . .. .. .. .M'.......,.. .�i-�^ice SEP I Te ll (!sane an oft$PING Depth below grade: ~ mumat of conmuauon:_concrete_meth_f9berpinl Pol�etfryler:o,_otRorleaplstnt '-� � r1��T aL n N tam b ptehL Bet ape_ ; fe.w.boitfltiilbd-by Cardflabfb of Ca"Ifi ab !Visual Dtrrunetone: L �X t i CE S,Sfa00S r f}t Tis�1 AS S EPTt C 7,-4J k Skidpe depth: ^ Distinct from top of sludge to better!!of audit to or 60 1 �9 - 8tumthlcknat: W 1 Dletenct herd top of icunt to top of outlet to at beffIc-lelLt Dtttenet from bettem of eeW to bertbertl of eutht 18e of bbfRe:.Z ` How dlmendmte were dMl Ated: ....f�!!�/a�S. Cormnante: (wommendadon for puMplttl},6esdklen at WN slid eulet tell er•bbmes,qh of nqm N"In 1610en to eudet lmtt,tbubbrfstlftNOdM. Wdence f lattelb,Oft.) C,D., . . S �®OL .:. �/ — .c►.. GREASI T1nJth pdteh on*6 0"1 Depth below pride:` Me""of ea"Mcleh:_eorterete_theta_,�rbsrpue _poNelfprlens,`ethsHNtptnnl Dnr,.netoM: - - SetArt tNeknge: _ Dlelsnee from top of eetah to top of bulol tee M bbfAes____ Dletanee f►arrt banal"of taut!to M06M of eudet Ns at mmo! .. . Date of►set pvrrrpktl: Com►nentt: lrnommondslen far pumplrtd,6011011311 of Inlet Ind sine!test et baffles,de0dt of Bgtld IavN In Mole*to sudet Invot ebuettm-ju rity, bMdend of lebksle,ON ................_.. revised 9/2/96 y !. - 1 y ''1!I rril til„�Si i �tn*nl`LI,Ets 1 t 9{.': 5 moo r - `' In1� jj It 1+'li'i�tft�il t�`,.sf•�ft �!. TACO laMAmN DII/OrAL tawf�MI1r0710M AIM� � �,,f 777i1cY+'.!��tir c;:r� Psepuh At km! +l;l DM of boon oft I M�wNyO /W •�Qe yy�N-",y y ' ,.W:. 1 pr ti r ht 4s+ Room an as pled 'S J 1 . b.-e ��� L F �Cw'�� •I�r3�j' � Depth below graft. INeteflel of 0eavisu l:—e0 "m—NW11—m MmMu:,,_►elYedrilenl Olm�nebM! Cepeft. M fl.s 111i'a { wrs"r"a1 y DWgm flew: gMauNN AMmn pmmet Mt Ab wm. AN h WO MM IF&I TO Deb of p►wbYe puwq*w. I ` d a a rra rt:entlleen of Mdet too,eend" of MMn M/Ibef WMeANO'$".I;, �,{!+' �" F ,t dn, DOTWMVTMN Reeete an ON plenl Depth of OeftAd INael ebow eedet 1010 mete•if level"d Is N IM�eplr . t2 'yi D , NAdenM�Mtrefq"6rf�rsw►►�eJINR 1 _ - •III .. �y 33jtf �t�l ilZ+ G�1.1 4Af�'r1 ', it nk.rt r I+CyY}I� A"�it t 1 A i y� rr r 1 � Poems on SIN 1 4 s �.k�.g.11iCbttn.;, ►tNnpe M woA:lno ettie►t rrN of Ilfel.,,..., - , F AMrene in weft*eNe11rN een Ineb Of Pit"Pit"$1dRftI ON et mm!pe M11.mmum MeN'Ne 1 �� r I t + �F VQ 'I r rp�• V i a u +s r[ �uEis� 3r'!dk cf�r • a �11+4.�d'il��l'�i'>:�;� .� ".. rl f r�q�+ a�, ....'s. 7 t v... 81io.. 5 e.'' limit �1!jf lrii rTn iFy, �T^.§, '��yv' 1�7,�n,:• ` ntc,�` �04,��.-«.t , f .�.S� yt a+�r�,, revised 9/2/98 /Melefll ` ' " ,t+gt�t • t 3=r1 dTt ii E'' ,�.yy ��.a>�,�� i {I 1.' 7 I h 1 �EI Ib IYMNMfM"WAfIlI OmFft l STOW MMPWtbll MIA'.• PAAf f4 Pig 7 1--) OT�) /yA ✓r /JS''" 00 M httlNem RM 11MOIM110N IYlef!#A lRAgt_� Ikeete on ttte NMI.N ;lttetttreMen hel Mf�dfld,IAeitlen tMY M Ippft tidily lIeM*0 m"Mofhedll. M net IoalNd.NalIU1: +. .. . Typo: ! I fdw .T Mad**ehombo►e,rwtnber:....Zr IaeettkV$illalee,aurtbM:_ NNdwq loldo,ftttmbo,AKIP41"t- overflew eutpeef,lMl M!,- . Anerrtt#A oYetlnn Napo of ttohnele0l+: - , Cannnnt�: ttteq of lei.Mrs of hyd"t f*Xi et"Not dov Idi 48"Nlh wpintlem W.1 !� .ti.✓, S sV _.� .__.. _ Iteoate en Nte►IMtI - trumber Depth-to of Rt}M to Net IMvMb... -- - ~• Depth of owde M"h_ Depth of MM loy&-. DlMtntfeM of eeeelMel• - ' ., MettrloM of eenitruetlen: tndlelNen of prltlndwlfor: _:...._ ..„ , Inflote feMapall Atult N pun1lld I/pIM u._MtNM!!eh)• - - Inca tonddat of od,lips Of h>rdnuhe Aral,INN)if pwtft"md"0me"WOMb 0.1 Ikem in Pon) BAeteriala of t�uebttetlOn:-. �..,___...:_,_t_:.M:_,;,._�_�w,x,��_.:....._�._... ....:..-__�..•e:_bIIMn/11M:�_�..._..,_.,..__ Depth of aaede: _ CM11rMfttl: ItteM tendden M MII,t�111 et hy1►ltpe AIMaI,kvN N f •ett'f►dtfeft of wrlMtleAt Na.l . e + revised 9/2/98 it,1lef it • _ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /3 EoV E?AL /�j9 �L7iJ Q2. � r�j/�9�•Jn/�S Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �3 32 3 7,1 AaA�,E 3 revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /3 GC�ER�)C. Pr AJ OTZ. r/yf7a�l/Vi�$ Owner: Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater.3Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting property, observation hole, basement sump etc.) _Determined from local conditions Checked with local Board of health / Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) � Y�'c> v•vo Lv.q-i E�1 - 2 S � //� Fo , .S v�/�C.���'J /.� % ish'�7�5. /-!, ,D LU6:LC s- t revised 9/2/98 - Page Ilor1> HJ - i 2�, 0 TOWN OF BARNSTABLE - LeE-RGROUND FUEL AND CHEMICAL STORAGE REGISTRATION MAP NO. PARCEL NO. ADDRESS OF TANK: /� C -AZ. PaIIOAJ �1&105- VILLAGE: MAILING ADDRESS �{ I F DIFFERENT.-.FROM ABOVE)-: OWNER NAME: /� C///i �/ / t y/� rL✓CAL PHONE: (�' $41 INSTALLATION DATE: f�/fir BY: AR V(-e INSTALLER ADDRESS: .62 12o% l bf . A414 �I-CERT.iJ0. . - *TANK LOCATtION ;: _�. � • � . . .dam .� .;! '� - (DGOQFQ I LiG TANK LOQAT I ON w-x TH RQCPQQT. TO 1U S L ENO) - CAPACITY cP �-� TYPE OF TANK 0#-C: -fie AGE YRS FUEL/CHEMICAL f L/l el TESTING CERTIFICATION C I PASS [ ] 'FA,IL,, DATE__ -- -- -�h.-; c LEAK DETECTION C ] CHECK IF 'N/A TYPE/BRAND /G % j,<- . lee-1tJ ZONE OF CONTRIBUTION. [ ] . YES`"' '[" ] NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED [ YJ YES [ ] NO DATE 1c;L11161217 CONSERVATION [' ]~CHECK• IF N/A DATE / BOARD- OF HEALTH .TAG NO.� [ / !0 ] -DATE qI _ t r * PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD ,, .,,�__:m�-.-�.-r. ^-r++�+.=a.try<.#,r_.,..:f?yy.-�i'•,:,...�.Y'''.r�;.�}r'*i`'r't""",".�"'..°'-."�'"`".'�..�...,,',..-..._`i`31'ra.'Q".T.-...--.--r..,.s.-r—._.._:wr..v -... m,.�. .._ ---n TOWN OF BARNSTABLE - WNDDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION MAP NO. PARCEL NO. r ADDRESS OF TANK: A3 VILLAGE:, 14,i;'AI,4// t `: Number atr��t !✓ MAI-LING AD-DRESS - -IF- DIFFERENT ._EROM'( ABOVE) : f��� OWNER NAME: �r-/t.: �/l jr C k.I: PHONE: �. .•� _ 3r'���� �m '. HY.i ...�0,.i ' r. INSTALLATION DATE: INSTALLER ADDRESS: / gal j A 'CERT.�JO. �.... .4TANK. L-OCAT•ION: , . ,r.. " ,� � ... DG�Qii S DG TANK LOQAT Z ON WS T..H i•RQOPQCT TO mU 2 LD S NO) - CAPACITY TYPE OF. TANK 014-L - l-e ',AGE YRS. FUEL/CHEMICAL TESTING CERTIFICATION [ ] PASS C .,] FAIL DATE . L'EAK DETECTION -C . ]"-CHECK. IF :N/A TYPE/BRAND �%"� - j .-� 04 re'f` o. V. ZONE OF CONTRIBUTION C,,] YES `[ ] NO DATETOf BE' REMOVED\ FIRE DEPT. PERMIT ISSUED C A YES C ] NO DATE 7 t �x CONSERVATION [ ] CHECK IF N/A DATE HOARD OF HEALTH TAG NO. ' [ /3-7 ] DATE a PLEASE PROVIDE, A SKETCH SHOWING THE TANK, LOCATION ON THE BACK OF THIS CARD z r� i -1HE 'Town of Barnstable 0 Department of Health, Safety, and Environmental Services * BA NSTABL& 1639n. ,0� Public Health Division �fDMA'�A P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health September 14, 1999 Mr.Kevin Rodericks 13 General Paton Drive, Hyannis,MA 02601 RE: Above,: ground Fuel Storage System located at 13 General Paton Drive,Hyannis and listed as Assessor's Map 292 ,Parcel 103 Dear Sir/Madam, Our records indicate that you have a 92 fuel oil above ground storage tank that is presently unregistered with the Health Department. Please complete the enclosed Registration card(s). Include any evidence of the date of purchase and installation,a copy of the permit from the Fire Chief within ten(10)days of your receipt of this letter. Upon entire completion of the Registration card(s),you will be issued a brass valve tag(s)by the Board of Health. These valve tags shall be picked up by you or your representative at the Health Department located in the Barnstable Town Hall. The tag(s)shall then be attached to the filler pipe/cap of the above ground tank(s). Please return completed Registration card(s)to: Town of Barnstable Health Department,P.O. Box 534, Hyannis,MA 02601, as soon as possible. If you have any questions,please telephone(508)862-4644. Office hours are Monday through Friday from 8:15 -9:30 a.m. and 1:00-2:00 p.m. PER ORDER OF THE BOARD OF HEALTH as A. McKean Director of Public Health OF-'Mda 29 nnnnnnn 63AD De 1 of 9 ICKS,KEVIN A St lul Mr , 13 GENERAL PATTON DR 00 HYANNIS M 0-0000-000 KEVIN A 0000005300 GENERAL PATTON DRIVE Unassigned Road Name "Al HYANNIS FIRE DEPARTMENT" 95 HIGH SCHOOL ROAD EXTENSION HYANNIS, MASS. 02601 Paul D. Chisholm S,�tral�e irleteCtUr.� Sane .`iUed BUSINESS: 775-1300 CHIEF EMERGENCY- 775-2323 To / Town of Barnstable , Board of Health - T. McKean Town of Barnstable , Conservation Commission - From ; Fire Prevention Bureau , Hyannis Fire Department Subject The installation of above ground storage tanks . Date ; /b< Persuant to the applicable sections of 527 CMR - Fire Prevention Regulations , this Department has inspected the following location for above ground storage . ADDRESS : 13 General Patton Drive OWNER/OCCUPANT gpgers / Tenant Rodericks / Owner PHONE 771-9271 430-5302 SIZE OF TANK (S) :_275 gal. Outside / Oval/ Steel COMMODITY STORED # 2 fuel oil PURPOSE FOR STORAGE . Heating THIS INSTALLATION IS . PRE-EXISTING A REPLACEMENT X NEW This installation complies does not comply _ with the required installation regulation listed below. FIRE _PREVENTION OFFICE For: PAUL D. CHISHOLM, CHIEF HYANTNIS FIRE DEPARTMENT 1-860-923-3025 CT 1-888-YOUR LS P 1-508-798-2570 MA (1-888-968-7577) 1-508-792-1466 FAX-MA VaoorgoSAssociates Environmental Consulting & Services P.O. Box 397 - Auburn, MA 01501-0397 13 February 1998 Mr. Thomas McKean Director-Board of Health Town of Barnstable 367 Main Street Hyannis, MA 02601 RE: Notice of Response Action Outcome (RAO) Statement Rodricks Property 13 General Patton Drive Hyannis, MA Dear Mr. McKean, This is notification pursuant to 310 CMR 40.1403(3)(f)that a RAO Statement has been issued for the above referenced site. This RAO document is available for review at Vargo & Associates Environmental Consulting, Inc. and the Massachusetts Department of Environmental Protection (MADEP), Southeast Regional Office, 20 Riverside Drive, Lakeville, Massachusetts. If you have any questions or concerns regarding this matter, please contact,me at 508/798- 2570. Sinc .ago & sociates v , (�-Wr&O. Vargo, LSP President UVCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI S 8 DEPARTMENT OF ENVIRONMENTAL PROTECTION e9 SOUTHEAST REGIONAL OFFICE WILLIAM F.WELD 19 Y COXE Governor lj,. 91 Secretary ARGEO PAUL CELLUCCI D STRUHS Lt. Governor ommissioner ti URGENT LEGAL MATTER: PROMPT ACTION NECE T CERTIFIED MAIL: RETURN RECEIPT REQUESTED C (OPY April 10, 1997 Jim Rodenex RE: BARNSTABLE-BWSC 13 General Pollen Drive 13 General Patton Dr. Hyannis, Massachusetts 02601 RTN: 4-12941 NOTICE OF RESPONSIBILITY M.G.L. c . 21E, 310 CMR 40 . 0000 Dear Jim Rodenex: On April 4 , 1997 at 11 : 20 a.m. , the Department of Environmental Protection (the "Department" ) received oral notification of a release and/or threat of release of oil and/or hazardous material at the above referenced property which requires one or more response actions . A tree limb fell onto the fuel oil filter of a 275 gallon fuel oil tank rupturing the filter and discharging approximately sixty (60) gallons of fuel oil onto the ground. The Massachusetts Oil and Hazardous Material Release Prevention and Response Act, M.G.L. c . 21E, and the Massachusetts Contingency Plan (the "MCP" ) , 310 CMR 40 . 0000 , require the performance of response actions to prevent harm to health, safety, public welfare and the environment which may result from this release and/or threat of release and govern the conduct of such actions . The purpose of this notice is to inform you of your legal responsibilities under State law for assessing and/or remediating the release at this property. For purposes of this Notice of Responsibility, the terms and phrases used herein shall have the meaning ascribed to such terms and phrases by the MCP unless the context clearly indicates otherwise . The Department has reason to believe that the release and/or threat of release which has been reported is or may be a disposal site as defined by the M.C. P. The Department also has reason to believe that you (as used in this letter, -"you" and "your" refers . to Jim Rodenex) are a Potentially Responsible Party (a "PRP" ) with 20 Riverside Drive • Lakeville,Massachusetts 02347 • FAX(508)947-6557 • Telephone (508) 946-2700 i -2- liability under M.G.L. c . 21E §5, for response action costs . This liability is "strict" , meaning that it is not based on fault, but solely on your status as owner, operator, generator, transporter, disposer or other person specified in M.G.L. c . 21E §5 . This liability is also "joint and several" , meaning that you may be liable for all response action costs incurred at a disposal site regardless of the existence of any other liable parties . The Department encourages parties with liabilities under M.G.L. c . 21E to take prompt and appropriate actions in response to releases and threats of release of oil and/or hazardous materials . By taking prompt action, you may significantly lower your assessment and cleanup costs and/or avoid liability for costs incurred by the Department in taking such actions . You may also avoid the imposition of, the amount of or reduce certain permit and/or annual compliance assurance fees payable under 310 CMR 4 . 00 . Please refer to M.G.L. c . 21E for a complete description of potential liability. For your convenience, a summary of liability under M.G.L. c . 21E is attached to this notice . You should be aware that you may have claims against third parties for damages, including claims for contribution or reimbursement for the costs of cleanup. Such claims do not exist indefinitely but are governed by laws which establish the time allowed for bringing litigation. The Department encourages you to take any action necessary to protect any such claims you may have against third parties . At the time of verbal notification to the Department, the following response actions were approved as an Immediate Response Action (IRA) : • Excavation and disposal of up to 25 cubic yards of contaminated soil . ACTIONS REQUIRED Additional submittals are necessary with regard to this notification including, but not limited to, the filing of a written IRA Plan, IRA Completion Statement and/or an RAO statement . The MCP requires that a fee of $750 . 00 be submitted to the Department when an RAO statement is filed greater than 120 days from the date of initial notification. Specific approval is required from the Department for the implementation of all IRAs and Release Abatement Measures (RAMs) . Assessment activities, the construction of a fence and/or the posting of signs are actions that are exempt from this approval requirement . In addition to oral notification, 310 CMR 40 . 0333 requires that a completed Release Notification Form (BWSC-103 , attached) be submitted to the Department within sixty (60) calendar days of April 4 , 1997 . c 3 -3- You must employ or engage a Licensed Site Professional (LSP) to manage, supervise or actually "perform the 'necessary response actions at this site . You may obtain a list of the names and addresses of these licensed professionals from the Board of Registration of Hazardous Waste Site Cleanup Professionals at (617) 556-1145 . Unless otherwise provided by the Department, . potentially responsible parties ( "PRP' s" ) have one year from the initial date of notification to the Department of a release or threat of a release, pursuant to 310 CMR 40 . 0300, or from the date the Department issues a Notice of Responsibility, whichever occurs earlier, to file with the Department one of the following submittals : (1) a completed Tier Classification Submittal; (2) a Response Action Outcome Statement or, if applicable, (3) a Downgradient Property Status . The deadline for either of the first two submittals for this disposal site is April 4, 1998 . If required by the MCP, a completed Tier I Permit Application must also accompany a Tier Classification Submittal . This site shall not be deemed to have had all the necessary and required response actions taken unless and until all substantial hazards presented by the release and/or threat of release have been eliminated and a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c . 21E and .the MCP. If you have any questions relative to this notice, please contact Robert Kearns the letterhead address or at (508) 946-2865 . All future communications regarding this release must reference the following Release Tracking Number: 4-12941 . Very truly yours, Richard F. Pa kard, Chief Emergency Response / Release Notification Section P/RK/re CERTIFIED MAIL #P 058 740 587 RETURN RECEIPT REQUESTED Attachments : Release Notification Form; BWSC-103 and Instructions Summary of Liability under M.G.L. c . 21E CC : Board of Selectmen Town Hall, 367 Main St . Hyannis, MA 02601 Board of Health Town Hall, 367 Main St . Hyannis, MA 02601 f -4- cc : Fire Department 94 High School Road Hyannis, MA 02601 DEP - SERO ATTN: Andrea Papadopoulos, Deputy Regional Director r` t COMMONWEALTH OF MASSACHUSETTS O� ew EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION= 4.1 S SOUTHEAST REGIONAL OFFICE WILLIAM F.WELD DY COXE GovernorG Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Lt. Governor Commissioner URGENT LEGAL MATTER: PROMPT ACTION NECESSARY CERTIFIED MAIL: RETURN RECEIPT REQUESTED December 3 , 1996 John Butler RE : BARNSTABLE--BWSC 6 Waster Street /3 25 General Patton Drive Worcester, Massachusetts 01609 RTN: 4-12683 NOTICE OF RESPONSIBILITY M.G.L. c . 21E, 310 CMR 40 . 0000 On December 1, 1996 , at 4 :40 p.m. , the Department of Environmental Protection (the "Department" ) received oral notification of a release and/or threat of release of oil and/or hazardous material at the above referenced property which requires _.one or more response actions . A 275 gallon aboveground storage tank located outside the home at the above referenced location released approximately 100 gallons of fuel oil to the surrounding soils . The Massachusetts Oil and Hazardous Material Release Prevention and Response Act, M.G.L. c . 21E, and the Massachusetts Contingency Plan (the "MCP" ) , 310 CMR 40•. 0000, require the performance of response actions to prevent harm to health, safety, public welfare and the environment which may result from this release and/or threat of release and govern the conduct of such actions . The purpose of this notice is to inform you of your legal responsibilities under State law for assessing and/or remediating the release at this property. For purposes of this Notice of Responsibility, the terms and phrases used herein shall have the meaning ascribed to such terms and phrases by the MCP unless the context clearly indicates otherwise . The Department has reason to believe that the release and/or threat of release which has been reported is or may be a disposal site as defined by the M. C. P . The Department also has reason to believe that you (as used in this letter, "you" and "your" refers to John Butler) are a Potentially Responsible Party (a "PRP" ) with liability under M.G.L. c . 21E §5 , for response action costs . This liability is "strict" , meaning that it is not based on fault, but solely on your status as owner, operator, generator, transporter, 20 Riverside Drive • Lakeville,Massachusetts 02347 • FAX(508)947-6.557 * Telephone (508) 946-2700 -2- disposer or other person specified in M.G.L. c . 21E §5 . This liability is also "joint and several" , meaning that you may be liable for all response action costs incurred at a disposal site regardless of the existence of any other liable parties . The Department encourages parties with liabilities under M.G.L. c . 21E to take prompt and appropriate actions in response to releases and threats of release of oil and/or hazardous materials . By taking prompt action,, you may significantly lower your assessment and cleanup costs and/or avoid liability for costs incurred by the Department in taking such actions . You may also avoid the imposition of, the amount of or reduce certain permit and/or annual compliance assurance fees payable under 310 CMR 4 . 00 . Please refer to M.G.L. c . 21E for a complete description of potential liability. For your convenience, a summary of liability under M.G.L. c . 21E is attached to this notice . You should be aware that you may have claims against third parties for damages, including claims for contribution or reimbursement for the costs of cleanup. Such claims do not exist indefinitely but are governed by laws which establish the time allowed for bringing litigation. The Department encourages you to take any action necessary to protect any such claims you may have against third parties . At the time of verbal notification to the Department , the following response actions were approved as an Immediate Response Action (IRA) : ® Temporary Covers or Caps . ACTIONS REQUIRED Additional submittals are necessary with regard to this notification including, but not limited to, the filing of a written IRA Plan, IRA Completion Statement and/or a Response Action Outcome (RAO) statement . The MCP requires that a fee of $750 . 00 be submitted to the Department when an RAO statement is filed greater than 120 days from the date of initial notification. Specific approval is required from the Department for the implementation of all IRAs and Release Abatement Measures (RAMs) . Assessment activities, the construction of a fence and/or the posting of signs are actions that are exempt from this approval requirement . In addition to oral notification, 310 CMR 40 . 0333 requires that a completed Release Notification Form (BWSC-103 , attached) be submitted to the Department within sixty (60) calendar days of December 1, 1996 . You must employ or engage a Licensed Site Professional (LSP) to manage, supervise or actually perform the necessary response actions at this site . You may obtain a list of the names and addresses of these licensed professionals from the Board of Registration of Hazardous Waste Site Cleanup Professionals at (617) 556-1145 . -3- Unless otherwise provided by the Department, potentially responsible parties ( "PRP' s" ) have one year from the initial date of notification to the Department of a release or threat of a release, pursuant to 310 CMR 40 . 0300, or from the date the Department issues a Notice of Responsibility, whichever occurs earlier, to file with the Department one of the following submittals : (1) a completed Tier Classification Submittal ; (2) a Response Action Outcome Statement or, if applicable, (3) a Downgradient Property Status . The deadline for either of the first two submittals for this disposal site is December 1, 1997 . If ,required by the MCP, a completed Tier I Permit Application must also accompany a Tier Classification Submittal . This site shall not be deemed to have had all the necessary and required response actions taken unless and until all substantial hazards presented by the release and/or threat of release have been eliminated and ' a level of No Significant Risk exists or has been achieved in compliance with M.G.L. c . 21E and the MCP . If you have any questions relative to this notice, please contact Dan Crafton at the letterhead address or at (508) 946-2721 . All future communications regarding this release must reference the following Release Tracking Number: 4-12683 . Very truly yours, C- G Richard F. Packard, Chief Emergency Response / Release Notification Section P/DC/jt CERTIFIED MAIL #Z001 192 856 RETURN RECEIPT REQUESTED Attachments : Release Notification Form; BWSC-103 and Instructions Summary of Liability under M.G.L. c . 21E CC : Town of Barnstable Office of the Town Manager 367 Main Street Hyannis, MA 02601 Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 Hyannis Fire Department 94 High School Road Hyannis, MA 02601 -4- cc : DEP - SERO ATTN: Andrea Papadopoulos, Deputy Regional Director DEP - SERO - BWSC ATTN: Data Entry 3. .• r LEGEND HYANNIS Rom 28 BENCH MARK PROP. 1 ,50OG EXIST. LEACHING PROPOSED CONTOUR s SEPTIC TANK NOTE 1 O 4 CORNER OF ® PROPOSED SPOT,.GRA_DE�,_ y� CONCRETE PAD (� ) — —98 -- EXISTING CONTOUR �ZE 'Zs ELEVATION = 42.75 - rn Ro BARNSTABLE GIS DATUM 43 120.35 ft 1�� + 96.52 EXISTING SPOT GRADE 3� AUCIA RD. `n1 ° 45 44 LOT 9` cas o W` EXISTING WATER SERVICE AREA = 8039 sf +=` -O m 19 TEST PIT GATE O T ly dT 9 �J c, SITE 0-0 TP-2 TP 1 \ v j \ ZO ft E KC J 1 �N `' — WA ER m �p wFLUNG METER 42 GENERAL N DRIVE TOP OF FNDN t f \ t EI- = 43-14 LOCUS MAP 01 \ � LOCUS INFORMATION p \ O / n �z et Jr 1 5p ports \ \ O TITLE REF: BK: 16526 PG: 200 N 1 f PARCEL ID: MAP 292 PAR. 103 f E`NAY PROPERTY IS NOT WITHIN A NITROGEN SENSITIVE AREA DRIV / vent o b GARAGE f 42 SEPTIC SYSTEM ,-o-ft REPAIR PLAN 43 w LOCATED AT: i 44 45 13 GENERAL PATTON DRIVE HYANNIS, MA PREPARED FOR ELEONORA MENDONCA f FEBRUARY 21, 2012 SCALE: 1 = 20' GENERAL NOTES: 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED OF 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. BOARD OF HEALTH AND THE DESIGN ENGINEER. 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING DA OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE CONSTRUCTION. No. 1140 LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: - — 310 CMR 15.405 (1) (B): 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE V. �tsisT ° 1) A 2.34 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION QNITA?0 w R 3 FT. 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY (MAX) ELOW GRADE VS E D TO BE 5.34 FT Q (H20/VENT PROVIDED) AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 13. NO PRIVATE WELLS WITHIN 100 FT. OF PROPOSED LEACHING TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 14. ALL PIPING TO BE 4" SCH 40 @ 1/8"/FT (UNLESS SPEC. OTHERWISE) MEYER 8C SONS, INC. DESIGN ENGINEER. 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW P.O. BOX 981 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FOR THE USE OF A GARBAGE GRINDER EAST SANDWICH, MA. 02537 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING j. ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. (508)362-2922 ' 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF j THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF } HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. SHEET 1 OF 2 J 1367 ' V w .. i NOTE: TO, PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:39.66 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. T.O.F. EL.=43.14 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER Y INSTALL A 4" DIAMETER INSPECTION PORT OVER 1 �� � INSTALLED OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6 OF GRADE ONE CHAMBER (MIN.) AND SET TO 3' OF F.G. LENGTH -Iy EL.=42.5t F.G. EL.=43.50t F.G. EL:44.Ot F.G.j'EL: 45.00(MAX.)' ' �� OF M9ss9 1/,--F,G, f it s.45' -y ' D A E G VENT77 L 35't 9" MIN COVER/ I L = 30' L = 15'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) 1140 0 S=1% (MIN.) 36" MAX COVER 0 S=1% (MIN.) ® S=1% (MIN.) r 1237" 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVCiC/ E � 6 10.38" TO FF SNITA0 •, 14 INV.= 40.07 4e'LIQUID INVERT INV.=39.82 COUPLER DETAIL"LL1 LEVEL INV.= 39.20 , GAS BAFFLE PROPOSED D-BOX 4 ROWS OF 4 UNITS 0 5'/UNIT � 3 COUPLERS 0 1.16'/UNIT = 23.48'/ROW ". DB 5 Jj-20) INV.=39.35 INV.=39.52 - SOIL ABSORPTION SYSTEM (PROFILE) PROPOSED 1.500 GALLON SEPTIC TANK EXISTING OUTLET ,RESTORE VEGETATIVE COVER INV.= 40.80 BACKFILL WITH CLEAN PERC SAND 60" TO TOP OF CHAMBERS NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING 7. PIPE INVERTS PRIOR TO CONSTRUCTION 2) TANK AND D-BOX SHALL BE SET LEVEL AND BREAKOUT=TOP ELEV.=39.66 TRUE TO GRADE ON A MECHANICALLY COMPACTED INV. ELEV.= 39.20 SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 38.33 310 CMR 15.221(2) 2 88' EXISTING SUITABLE 3) INSTALL INLET & OUTLET TEES W/ 5' MIN. ABOVE BOTTOM OF MATERIAL GAS BAFFLE AS REQUIRED T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 4 x 2.88' = 11.52 (5.83' PROVIDED) USE 4 ROWS OF 4=A0S ARC 36HC BOTTOM OF TESTHOLE EL.=32.50 (H20) UNITS - N0j'STONE W/ 3 COUPLERS ` IN EACH ROW SEPTIC SYSTEM -PROFILE TYPICAL SECTION N.T.S. xrs r 16" SOIL LOG P#: 13558 , DESIGN CRITERIA DATE: FEBRUARY 21, 2012 SECTION fo3s" NUMBER OF BEDROOMS: 2 BR DWELLING 3 BR. DESIGN SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE. #1614 INVERT / HEIGHT END CAP WITNESS: DONALD DESMARAIS, BARNSTABLE BOH SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN Elev. TP-1 Depth Elev. TP-2 Depth ADS - ARC 36HC CHAMBER (H20 LOAD) DAILY FLOW: 110 G.P.D/BR. DESIGN FLOW: 330 G.P.D. 43.50 0" 43.80 A 0" MODEL ARC 36HC LOAMY SAND I LOAMY SAND GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER) 10YR 3/2 10YR 3/2 LENGTH 63" NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SEPTIC TANK: 330 pd x 200% = 660 d USE PROP. 1,500 GALLON SEPTIC TANK 42.67 •10' 42.30 18" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 9 9P g B EFFECTIVE LENGTH 60 LOAMY SAND �D f LOAMY 0YR SAND6/ LEACHING AREA REQUIRED: (330)/0.74 = 445.94 S.F. I SIDE-WALL HEIGHT DIFFER10.38' 40.67 34" 40.88 C 35" OVERALL HEIGHT 16" DISTRIBUTION BOX: 5 OUTLETS (MINIMUM)(H20 LOADING) C �i „ 4640 TRUEMAN BLVD MEDIUM SAND OVERALL WIDTH 34.5 PRIMARY S.A.S. HILLIARD, OHIO 43026 ^ .5Y 6 4 10.7 CF Iff4s. 2 / I MEDIUM SAND CAPACITY USE 4 ROWS OF 4 - ADS ARC C 616 UNITS-NO (80.0 GAL) ADVANCED DRaNACE SYSTEMS, INC. f d AND EXTENDED 1.16, W COUPLERS IN BETWEEN EACH UNIT PERC ® 39.17 2.5Y 8/4 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF CHAMBER) i, PROPOSED SEPTIC SYSTEM SITE PLAN (CHAMBERS: 4/ROW)16 UNITS x 5.0 LF x 4.80 SF/LF = 384.00 SF 32.50 32" 1 32.80 '3z" 13 GENERAL PATTO N DRIVE, HYAN N I S, MA (COUPLER: 3/ROW) 12 UNITS x 1.16 LF x 4.80 SF/LF = 66.82 SF 1 t TOTAL AREA = 450.82 SF PERC RATE <Z MIN/IN. ("C2" HORIZON) Prepared for: Mendonco DESIGN FLOW PROVIDED: 0.74GPD/SF(450.82SF) = 333.60 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering b SCALE DRAWN r g 9 y: Surveying by: MEYER&SONS,INC. Boo Tech Env. NTS D.M.M. .,� • I, Darren M. Meyer, R.S.; CSE; hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 po9OX98f (508) 364-0894 PATE; to conduct soil evaluations and that the above analysis has been performed by me consistent with the CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Eval. Exam in October, 1999. SST SANDWICH,MA 02537 211 2 02 { 508-362 2922 / / D.M.M. 2 0 F 2 ' f� General Notes W.C. W.C. W.C. RACMD VIEW DRNEWAY VIEW SCALE:Y"=t'—D' SCALE:Y'=t'-O' REAR D LOCATION OF NEW ADDRION SCALE Jf=l'—V DRNEWAY BACKYARD W.C. REAR U&M SCALE:Y'=t'—O* No. Revision/ueue Date P pd NeM.aW A"— Henning 13 General Patton Drive Hyannis MA,02601 NEW DDMON oats 5t5 g- 1e1 emr, SPECIFIED t o�Ra FRONr JMG s PAPER SIZE: 11x17 91_6a Geneal Notes 2�_�1 2'-5° 2'-5° `2 �'-- I AW1251 2'-6° -SE C-TJON A 2'-6" d - $' BEDROOM NEW FLOOR PLAN 14'-6° co 6 CAD- �D 2-6 co F I 2666 � No. Revision/ha" Date - w0d imr me A"— Henning CLOSET UT�L� c 1� 13 General Patton Drive '1 Hyannis MA,02601 ROOM W/D NEW DRION oa. 12 5 ,5 g- 1 .2 JMG PAPER SIZE: 1 1 x17 �4