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Home My WebLink About0011 GOAT FIELD LANE - Health _.1;1 Goatfield Lane �� _, Hyannis f 0 j TOWN OF BARNSTABLE LOCATION ZZ �'�v,4% f'/Z / ZX1 SEWAGE# 2oo iP VILLAGE ASSESSOR'S MAP&PARCEL G- V 7 INSTALLER'S NAME&PHONE NO. f17.9 f;�ic,� � 2WO SEPTIC TANK CAPACITY LEACHING FACILITY.(type) 0 64,!p6e/S (size) f?'2 NO.OF BEDROOMS 3 OWNER IN fA,7 -,70S, PERMIT DATE: / Z —d 9 COMPLIANCE DATE: O Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility /S'Z�' feet Private Water Supply Well and Leaching Facility(if any wells exist A,� on site or within 200 feet of leaching facility) �A feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility),. I'14 feet FURNISHED BY ' n � ,�� h e � �- :y� ..� �..-_ �- . ' , ,, w. • No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Enteredincomputer: Yes ..PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Mid onl �&p$tem Con0ru-ction VCrpt Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 116r047(-7 e ld C.gvt,.Q_ Owner's Name,Address,and Tel.No. Assessor's Map/parcel Z,`Y 7 .—lq 7 Installer's Name,Address,and Tel.No. �v�sr� (�( f t�,t�/ Designer's Name,Address and Tel.No. /jv%C 6 6Cj ZC � f JAY,a�c-41 ?7-4 o ZSb 3 s�9�-i/��✓t �r..q-PS . Type of Building: Dwelling No.of Bedrooms - Lot Size sq.ft. Garbage Grinder Other Type of Building Si ✓I ce ,�=A�r �y No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 gpd Design flow provided ��/o gpd Plan Date �- - ( — o Number of sheets t Revision Date oN� Title Size of Septic Tank Type of S.A.S. tzocl �G/gvYl62✓S Description of Soil S'�2, Pi A-VI Nature of Repairs or Alterations(Answer when applicable) 04 S y-4, _R_ LP Date last inspected: N IA- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si e Date r Z-,3 � O ..Application Approved by _ Date Application Disapproved by: _ Date for the following reasons a on Permit No. '� Date Issued No. � :" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION p:TOWN OF BARNSTABLE, MASSACHUSETTS Yes l �.ppfication for Mtzpo 6pgtetn Congtructiott errnit 1 - . Application for a Permit to Construct( ) Repair( ) Upgrade�X) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. G i/=i e �o� ��-Z. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 2- -7 _�0/ rh j i r Installer's Name,Address,and Tel.No. P�j p�5�'� g /�( f.'4,,,fit.Y Designer's Name,Address and Tel.No. az 5Z�3 f/-7.,i c-ti .v? 4,rS 04'33 Z/ 77 Type of Building: ` Dwelling No.of Bedrooms -� Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building ,f, /1 i-/Jisr- /c/ No.of Persons Showers( ) Cafeteria( ) �,•'' Other Fixtures Y Design Flow(min.required) 3 3 d gpd Design flow provided -7 SRO gpd Plan Date I L - 1 — b Number of sheets ( Revision Date °/l/-e_ Title - Size of Septic Tarik\ I Soy Type of S.A.S. 1,QOC4 (16-40,be✓s Description of Soil Nature of Repairs or Alterations(Answer when applicable) UPI Sn A(Y2. PxCc57r/1C Gl P Date last inspected: N /1* 1 Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions,of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r, f Signe q/�/ �r Date I 2- 43�� o Application Approved by r / Date ,. Application Disapproved by: \ Date y for the.following reasons Permit No. Date Issued 1 -------- -- — --------------T ------ '`-- ` THE COMMONWEALTH OF MASSACHUSETTS E "Ali � ��-lU� BARNSTABLE, MASSACHUSETTS s 5 Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (,r ) Abandoned( )by Uv S ;2 (cl S'A✓i �4 J P wr c..2 3 N c at I G DA-f' Gro (d L_A-,1.Q has been constructed in ac ordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer 3 044 s`,e Designer 4C. Ctv,v #bedrooms 1 Approved design flow / gpd The issuance of this permit shal not be onstrued as a guarantee that the system w' nction as designed.4AM L Date !� ———— — Inspector— /! —� !i�VV v Iry l ----=— I — — �r------- - -- No. �Xq_17,91 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS 1=igpo5al §pgtem Construction Permit- Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (X Abandon ( ) System located at k�i1ft^ ^.f and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction , ust�11-2q e completed within three years of the date of this peDateApproved by i Town of Barnstable' .r _ Regulatory Services - Thomas F.Geder,Director . : `�' • Public Health Division t Q. . °i Thomas McKean,Director 200 Main Street,Hyannis,AM 02601 Office:.508-8624644. Tax: 508-7.90-630 Installer&Designer Certification Form Date: 3 '-� . �,n 0 Designer: '/ \� • ''I �I Installer:. � SG Address: . � 7 I �J�W�w�GH Address: on / -Z —0 9 �� was issued a permit to install a (date) (installer) septic system at � � based on a design drawn by (address) �i��/I �• �� dated 12 12(�U00 (d=the er) 3�:certify septic system referenced above was installed substantially►accoFdipg'to " bie design, which may include minor approved-changes such as latga. Iocafi of the d�ttibution box and/or septic tank I celWIhat the septic system"referenced above was ins+..ed'ith'xi oz•,changes.'(i,e, greater Ifig410' lateral relocation'of the SAS or any vetticab'aralo ion'of any componeuit of the.septib-ji em)but in"accoidance with State&I.ocaLlt,eg�ilaL ons. Plan rev»pp o; celtified as bfilftby desi�t6 follow. D (Inst er's Signature) r VIN �r .; -Oc0066 yy sAN1TAR�P� (D ' er s Signature) ( s p:Here) PLEASE RETURN TO $AM'S3'AR 4 LZ HEALT$ DIY SIO C OIF- COMPLIANCE �FORM UiL. C RECEDHE:B- T�$LE P = TON: TAfitI OIU. Q:Hea1tA/Septic/Designer Certification Form _ - _.._._ •e -.. .. _ 9,. pis n .n I' ,.�� .s('� i'H A �� f R� a I �w" �� ,. � � Apo. �� U�_=�� F .m y„� 9." � ,fir 1. - �'h ,.. ..O' _ -.,�0 C ` � J _ �i+L� 0 { - � a n .. d y �.�1+'�:4 1. � �� <�',� � � .�,� }3. a�C1l. � � . f `� ''Y .9 A 1, ;' 1{y�� y � •ty� � `� iehY � i f�•(yl �i •1� �.Th' / �1 11 t 1 ,� .:.� +r- t� x ;fir�x•-.=" :�,��,, -�«� , ' �,. -40 Ac- .•ter , 4]K..yLr� .t^ yl`j ..a '� ♦ _ �f 7� - r P� �G15 top (ZI el ' � dd f 3 0 f �Co �ll.yah ♦ !� M w i•••�•••2 w U Lk/. .a t� s Aa � �� s a�,�}•S A�aoi} fd �: 0 ig kl d r�o a� fio � 604Td L�J r g - ro �rr Town of P# Barnstable _1A t� 3 Department of Regulatory Services Public Health Division Date t6J9 �� r 200 Main Street,Hyannis MA 02601 1 i ,.�' Date Scheduled f' Lv`!� Time : Fee Pd. ` Soil Suatabalaty,Asses`sment for Sew ge' isposal �yl-V 1 0 �- -'t`ww�o`ti� ��' 1 , J Performed By: Witnessed By: v� 7L� LOCATION& GENERAL INFORMATION Location Address '—±I I /�v�('� � �/_' Owner's Name �t �/1 Address Assessor's Map/Parcel: 7- /q / Engineer's Name} � S. 4 NEW CONSTRUCTION vvvy��\ REPAIR` Telephone# 0�e> Land Use- I �.;.:; + 1 , + t }t S`pes(S'o) `: I .� Surface,Stones_. Distances from: Open Water Body ft Possible Wet Area *ft Drinking Water Well ft Drainage Way ft Property Line — 1 eft Other ft _ SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) rri C. N ; l cn m 2 W rr, Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: / Weeping from Pit RQCf: Estimated Seasonal Hig i Groundwater / �- DE ATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Obse ed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment fr. Index Well# Reading Date: Index Well level Adj.factor Adj. 3rttundwater hovel,, PERCOLATION TEST ]date Thne._�_._ -- Observation %ft Hole# Time at 9" tr Depth of Perc Time at 6" .+ I� Start Pre-soak Time @ 'lime(91'41) End Pre-soak Rate Min./Inch i Site Suitability Assessment: Site Passed Z Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division,; ;" Observation Hole Data To Be Completed`on Back;---:----- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\S EPTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sdil Color Soil �ot Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.% vel BA22 DEEP OBSERVATION HOLE LOG :; Hole# Depth from Soil Horizon Soil Texture SoiUColor Soil ` d Other Surface(in.) (USDA) (Munsell) , ; Mottling, ,(Structure,Stones,Boulders. Consistencv.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (1vlunsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# ' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) - (Munsell) Mottling (Structure,Stones,Boulders. onsi ten i Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes ,✓____/ j Within 500 year boundary No " Yes Within 100 year flood boundary No— Yes Depth of Naturally Occurring Pervious_Material . Does at least four feet of naturally occurring pervio s a rial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is-the depth of aturally occurring pervio s material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviro mental Protection and that the above analysis was pe rmr by me consistent with . the required training,e e d xperience described in 310 CMR 15.017 q Signatttr Date `� Q:\.S.EPInCIPERCFORM.DOC 1 � r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVHRONMENTAL PROTEI 11 _ RECEIVED �a MAR 2 5 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION i Property Address: 11 Goatfield Lane West Hyannisport MA 02672 MAP y Owner's Name: David Jendrejcak PARCELS 1 Owner's Address: 25 New Hampshire Drive LOT Bristol CT 06010 ' Date of Inspection: March 25,2003 Name of Inspector: PATRICK M. O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: (508)428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: I'dDate: L o 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 System in good condition leaching pit was dry at time of inspection and has never had more than three feet of standing effluent. ****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'] Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: I 1 Goatfield Lane,West Hyannisport Owner: David Jendrejcak Date of Inspection: March 25,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Goatfield Lane,West Hyannisport Owner: David Jendrejcak Date of Inspection: March 25,2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(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 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. 3. Other: I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 11 Goatfield Lane,West Hyannisport Owner: David Jendrejcak Date of Inspection: March 25,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool — _X— Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —X— Any portion of a cesspool or privy is within a Zone 1 of a public well. — —X— Any portion of a cesspool or privy is within 50 feet of a private water supply well. — _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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.] _No_(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: 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. A Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 Goatfield Lane,West Hyannisport Owner: David Jendre,icak Date of Inspection: March 25,2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner, occupant,or Board of Health i — _X_ Were any of the system components pumped out in the previous two weeks? _X_ Has the system received normal flows in the previous two week period — _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? — N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ — Was the site inspected for signs of break out? _X_ — Were all system components;excluding the SAS,located on site? _X_ _ 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 ? _X_ _ 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 _X_ Existing information.For example,a plan at the Board of Health. _X_ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] I �� o RECEIVED Page 6 of 11 PPRR 1 0 2003 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO WIN O LTH NSTABLE PART C SYSTEM INFORMATION Property Address: 11 Goadie1ld Lane,West Hyannisport RECEi Owner: David Jendrejeak Date of Inspection: March 2%2003 i APR 10 Flow CONDITIONSRESIDENTIAL. � rcvvN OF BARN- Number of bedrooms(design)., r3 Number of bedrooms(actual): HEALTH DEP. _ DESIGN flow based on 310 C 15.203(for example: 110 gpd x i#o bedrooms):330' Number of current residents:0 Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no).Yes Water meter readings, if available(last 2 years usage(gpd)): 30,750 gal for past 18 mos.=57 gpd. Sump pump(yes or no): No Last date of occupancy: COMMERCLUJINDUSTRLAL 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: r Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records None Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: _Ssilons--How was quantity pumped determined?_ Reason for pumping: TYPE OF SYSTEM X_Septic tank,distribution box,,soil absorption system Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _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 installer](if known)and source of information: 30 years+/- Were sewage odors detected when arriving at the site(yes or no): No T.. Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 Goatfield Lane,West Hyannisport Owner: David Jendrejcak Date of Inspection: March 25,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):ta? Number of bedrooms(actual): �?J DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents:0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):No [if yes separate inspection required) Laundry system inspected(yes or no):— Seasonal use:(yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): 30,750 gal for past 18 mos.=57 gpd. Sump pump(yes or no): No Last date of occupancy: COMMERCIALANDUSTRIAL 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 None Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) 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: . 30 years Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Goatfield Lane,West Hyannisport Owner: David Jendrejcak Date of Inspection: March 25,2003 BUILDING SEWER X (locate on site plan) Depth below grade: Materials of construction:_X_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: 12' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 10" Material of construction:—X—concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8' long x 5.2'wide(1000 gal.) Sludge depth: 7" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness: 4" Distance fi•om top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle: 9" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Liquid level at bottom of outlet pipe. GREASE TRAP: No (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.): Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Goatfield Lane,West Hyannisport Owner: David Jendrejcak Date of Inspection: March 25,2003 I TIGHT or HOLDING TANK: No (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: No (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: No (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.): n Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1.1 Goatfeeld Lane,West Hyannisport Owner: David Jendrejcak Date of Inspection: March 25,2003 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number: 1—6x6(1000 gal)pit leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Leaching pit dry.Never had more than three feet of standing water. CESSPOOLS: No (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: No (locate on site plan) j Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): s Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Goatfield Lane,West Hyannisport Owner: David Jendrejcak Date of Inspection: March 25,2003 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. Wls Cesar. it ,Z u 2s yo i Page 1 I of 11 . L OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11 Goatfield Lane,West Hynnnisport Owner: David Jendrejcak Date of Inspection: March 25,2003 SITE EXAM Slope Yes Surface water None Check cellar Dry Shallow wells None Estimated depth to groundwater: More than 20 feet. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: _X_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) _X_Accessed USGS database-explain: USGS map and town GIS You must describe how you established the high ground water elevation: Low point of abutting lot 5-10 feet lower than bottom of SAS. Checked town groundwater contour map and USGS topo map property at or above el.40 groundwater below el.20. 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'wA^F�^'£:...]�.^'P^+•S� 'r..cm^P3', _. .. _ ._._- ..,r..»H �98:4 —�.ASSESSORS MAP : TEST HOLE L0 G S J ��) PARCEL :--- ,� L��` r ---- SOIL EVALUATOR : ��\��J �°t k�� FLOOD ZONE : /t 4' �%!l�.� t„-„� 't��_' i �� _ '!l TTIESS : ' 1) The installation shall comply with Title V and Town of Barnstable Board of - _ REFERENCE : t � '� /7 �'� f�".�:'' %' DATE:_1 )�' -, \�� it Health Regulations. _ _ _ ) The installer shall verify the location of utilities sewer inverts and septic A �! ` l O componentsp for to installation and setts base elevations. p � .-�,� � PERCOLATION RATE : G. 2 �$' 1`-` — ' �-- � �' r�`'�C�,� �:::.ti r• setting ` - T}�- � TH-2 3) All gravity septic piping to be 4 inch Sch 40.PVC at 1/8'' per foot. The first two feet out of the d-box to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. Lt1 �� ti s� 5) All septic components must meet Title V specifications. t+ to 6) Parking shall not be constructed over H 10 septic components. 6 Y-) 7) The property is bounded by property corners and property lines. LOCAT �� MAP ___ '' ' jK {� I � �, �, " 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed a ! approval of the design flow by the owner. F ' 9) The existing leaching or cesspools shall be pumped p p p and filled with material °! It per Title V abandonment procedures. Those within the proposed SAS shall r `t be removed along with contaminated soil and replaced with clean sand per — - .. _ _ t _ Title V specs. -mill / �Z'2, 10)System components to be 10 feet from water line. Sewer lines crossing the ;;I, water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if I-- 3 1 �S E P SYSTEIM DES app.icabl . The pro posed SAS is 1_)einb installed below tile .ater service line. The line is to be sleeved as aforementioned and maintained in place. ---_.___ 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOya, EST 1 MATEowner to ensure such. GAL/DAY 12)The installer is to take caution in excavation around the gas line. -� BEDROOMS AT GAL/DAY/BEDROOM - w � ► �i� 13)The installer shall verify the location, quantity and elevation of the sewer �J lines exiting the dwelling prior to the installation. SEPTIC TANK GAL/DAY x 2 DAYS - GAL USE )90 GALLON SEPTIC TANK AAA •,�� / � �� - i � AV �SO]VL�ABSORPTION SYSTEM - 1f„•.... G...3 '\G✓ " 1 1 € 's`''r 1 ems, . SIDE AREA: BOTTOM AREA: .. ,��1 ' �� ..�1 � �r� �� ;t ✓''�. � s i � —y SEP.- I C SYSTEM SECT 10 e ki '� 3� GAL �' ; �r► � � � � � � �.. t 0 1 SEPTIC TANK # it ' } t Cam - A :9 S I TE AND SEWAGE PLAN LOCATION : ,. , r �:;�.� PREPARED FOR s — e— y DAB! 1 D �AAS�Ji� DATE: 1 / �'' D ' ,, Z C ENVIRONMENTAL RONMENTAL DESIGNS � � EAST SANDWICH . MA J DATE HEALTH AGENT ( Sfl8 ) 33— 2177 Z Jffj I ASSESSORS MAP : , ` TEST HOLE LOGS NOTES: _..__ PARCEL : V�- /`7 7 FLOOD ZONE SOIL EVALUATOR: 1�1I11� � f! : , �bT � �""" WITNESS . iAYI I' 'f 1) The installation shall comply with Title V and Town of Barnstable Board of _. .. ....._. _.___.. . .._...__ _._____.____ REFERENCE: / �Y . ,t "+ f DATE: \ Q Health Regulations. 77 ' .._... -��' '- --� 2) The installer shall verify the location of utilities, sewer inverts and septic PERCOLATION RATE: G- Z to i 1 components prior to installation and setting base elevations. f . 3�� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first TH-2 two feet out of the d-box to the leaching shall be level. 4) This plan is not to be utilized for property line determination nor any other ► purpose other than the proposed system installation. 'LvAtli P 4v 5) All septic components must meet Title V specifications. ,, �a y,�.�th a t Co 6) Parking shall not be constructed over H10 septic components. 54� LO1 13 7) The property is bounded by property corners and property lines. LOCATION MAP b � ( 8) The property owner shall review design considerations to approve of total ,�_. � 1 . �.�,,�� , -515 design flow and number of bedrooms to be considered for design. Receipt CO'W 5 j /' +r 4Y� of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material C1 per Title V abandonment procedures. Those within the proposed SAS shall I + 1� 2� be removed along with contaminated soil and replaced with clean sand per —Vb_hQW9 L01AGam Title V specs. 'fir �2'ZA C) 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if ry� SEPTI . : SYSTEM ^D E S i G N applicable. The proposed SAS is being installed below the water service \ 3® line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the -- _�� FLOW ESTIMATE owner to ensure such. BEDROOMS AT I GAL/DAY/BEDROOM -� zZJ, �/�,GAL/DAY 12)The installer is to take caution in excavation around the gas line. . 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. - 41 SEPTIC TANK 4 / ?�I CAL/DAY x 2 DAYS - 1 GAL USE )0O'GALLON SEPTIC TANK �-(Z SOIL A.BSORPT I ON SYSTEM I�JD UNIT LO/ 10 .r �.- u... � •,tom SIDE AREA. 2.�„ 2�7� � -f- �ZrlZX.� r i r //V ,` /{j�T/ — — 1 c� ' BOTTOM AREA: . ► � 1Z Z C � =°�ZZ f,,°�•+--"t�l A,� &;� — �� 4,:.i � is i�-' ,y,i ;--w SEPTIC SYSTEM SECTION '' `' "` �j{ 1 � _ l�r/ 4� �w A -80 .e SEPTIC TANK Q3 ' - � z5,2" �t 12,2 . _ 711 �'' tj .off' T L+\1 .... . -c.r 1• 2-�, - SITE AND SEWAGE PLAN LOCAT I ON : PREPARED FOR : 2;005F1F/--D c5 C SCALE: " DAV I U B . MASON DATE: /Z DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA w DATE HEALTH AGENT ( SOS ) 833- 2 1 77 3 W 2