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HomeMy WebLinkAbout0100 GROVE STREET - Health 100 GROVE ST., HYANNIS 0 I� I �I i TOWN OF BARNSTABLE LOCATION 0ro✓e- SEE#`--I-nS(� VILLAGE�./_��� ASSESSOR'S MAP&PARCEL IN& bER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 00 LEACHING FACILITY:(type) `�'�����CaT (size) NO.OF BEDROOMS nn OWNER �'if'�G►�1� C PERMIT DATE: CQAU44ANGE DATE: .i ASP 5/ 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 leac lity) Feet FURNISHED BY M� . ♦ 4 t \ t h 4 t ♦ \ \ 4 4 ♦ 4 \ Y Y 4 Y Y 4 ♦ h h 4 4 4 \ t \ \ 4 \ 4 ♦ Y Y Y Y Y h .. 4f4/4fh�4J\'♦f4/4/4�♦/4/4J4/4/4/YJ4f4JY!\ 1 ♦ ♦ \ t ♦ ♦ 4 ♦ ♦ 4 t t t \ t Y Y Y Y 4 4 ♦ t 1 ♦ 4 ♦ 1 . t t t \ t t't t t t ♦ \ \ t 4 t t h 4 \ 4 4 4 h 4 4 4 4 4 4 ♦ \ 4 \ 4 k t t t t t t 4 t ♦ 4 ♦ \ t.,t t t t Y't Y ' f. J /, f f / J J f J J f J J f !•f'f ! f 4 t t h \ 4 \ ♦ 4 1'Y t t.t t t t 4 4 \ Y h 4 \ \ \ \ Y Y Y J f ! f ! f f J 18 t \ t 4 t \ t t t YJ\Jt/t/\/tfYJ\fY G \/t/Y/tJY/YfYJ♦ft 53 4 Y 4 4 t 4 \ ♦ 4 TOWN OF BARNSTABLE P � LOCATION i�1® �P C'[ SEWAGE# VILLAGE_,C�f 4W ASSESSOR'S MAP&PARCEL /w _ INSTALLERS NAME&PHONE NO. �� SEPTIC TANK CAPACITY _ �ap� LEACHING FACILITY:(type)A/ /.�",I - (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE 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 facility) Feet FURNISHED BY \ � J' Nw � � � K V ` ® � � �, '. �_ i ' i r ' f . TOWN OFBARNSTABLE LOCATION ll� J� SEWAGE # VILLAGE ASSESSOR'S L T INSTALLER'S NAME HONE NO. ((�� SEPTIC TANK CAPACITY �V LEACHING FACIUN: (type _ (size) pit NO. OF BEDROOMS BUILDER OR OWNER �' C 0p6 PERMITDATE: COMPLIANCE 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 facility) Feet Furnished by-- mL [TIM i TOWN OF BARNSTABLE LOCATION r0� -,A, ' SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 316- /(6 INSTALLER'S NAME 61 PHONE NO. A & B CANCO 775-6264 -SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i I Commonwealth of Massachusetts u Title 5 fficoal Inspection r F ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 DD ®mow' Property Address �✓ .� `o Owner l ah' ��-Q✓ __ ;wnr's Name ll information is •/ �o� �� t required for every Rspeion�-: page. own State Zip Code fDate:of Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not use the return ✓ key. Name of Inspector rrb Company Name 11 Q Company Address City/Town SCFS ��OState Zip Code Telephon er License Number Be Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 C R 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority /,Z& Inspector's ignature Date The system inspector shall submit a copy:.of.,this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. '"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �o VS { Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Selvage Disposal System Form - Not for Voluntary Assessments /00 M V @1®Iy Property Address as Owner Owner's Name !all A� information is required for every r 461& page. City/I own Bo Certification (cont.) State Zip Code Date of I pe on Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System P es: 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: i B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address J Owner Owner's Name information is required for every page. City/Town Bo Certification (cont.) State ZipCode Date of Insp tion ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.V6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address /®® Owner 1✓a Owner's Name information is required for every ear!l page. o 1 Bo Certification (cont.) Q City/Town State � s Zip Code Date of I spe ion 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ atic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool I ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less a than '/day flow t5ins-doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Foy Subsurface Sewage Disposal posal System Form Not for Voluntary Assessments e Property Address Owner ���✓ Owner's Name information is required for every �f — �f( l /®/ page. ;_� yTown State Zi Code p Date of Y sp ction o Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped.- Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ R? Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ system is a cesspool serving a facility with a design flow of 2000gpd- ,,The 0 000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth Of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Addr �roess vc— 5 Owner ��✓d� information is Owner's Name - required for every ✓y �60 J page. City/Town State Zip Code Date of ns ection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes ❑ P mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts .� Title 5 official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Nroperty Address l Owner ��✓� C information is Owner's Name required for every 0'� page. �Ciy/Town State Zip CodeDate of Io System nformat¢on P tion Description: / /000 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes 10 Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: C_-,(I!A V7.e �- Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 F �L, Commonwealth of Massachusetts Title 5 Official Inspection Foy Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every 4�11d 9 f AX as 6®/ -� e page. City/I own State Zi Code P Date of i spection Do System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy em: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner 1 N Lo/ Owner's Name information is - required for every q�4lf � ®/ page. City/Town State Zip Code Date of Insp ctio D. System Information (cont.) Approximate age of all components, date installed (if known)an source of information: C40 6 �o � �� `� ®6®�9s, Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): �sf Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: ® ® T feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ®/ Depth below grade: feet � Materia f construction: concrete ❑ metal ❑fiberglass g El polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: J Sludge depth: ® l/ t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /®® Owner Owner's Name f �� information is required for every page. City/Town State Zip Code Date of Inspe tion U. bystelrn Information (cont.) Septic Tank (cont.) 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 ai Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? It /ce Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 10 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc.•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 • P Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner4�6.Q/ ;Owne;r's Nameinformation is required for every � /page. n State Zip Code Date of ns ction Do System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date I Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments qc /®® Property Address GTroye- Owner Owner's Name information is required for every U ®� B page. City/Town State ZipCode Date of Ins ection D. System Information (cont.) Distribution Box (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.): IVO -Z:e-4 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / / Owner �^/ C �-� information is Owner's Name required for every """ �® page. CityZlon State Zip Code Date of I pect on ®oystems nformatoon (cont.) Type. 0 T/ � '/ ❑ leaching pits number: ❑ 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.): 49 7"' l� �lcr ed`a t r Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M ®® 6/'®V �7- Property Address Owner Owner's Name /� 6�� information is required for every page. City/Town State ZipCode Q' Date of I sp -tion D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /00 I Owner Owner's Name o information is required for every 141141 A-Yr page. City/Town State Zip Code Date of In pectton ®• System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two per anent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pu water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately J ® � 14 r t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M /®10 P Sri roperty Address ����� Owner Owner's Name information is required for every � f page. City/Town D. Systems Information (cont.) State Zip Code Date of In pecQ on Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Bo 1of Health -explain: / ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must des a how you es gablished the high ground water elevation: AIV �e- 14 Before filing this inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property � Addre Owner ss /�� Owner's Name information is required for every d !i t4P1`5f page. iyieport / n State Zip Code Date of I pe Ion ompleteness Checklist Inspection Summary:A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems) Completed Sys m Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 b 44 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Grove Street Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives Owner Owner's Name information is 1330 Phinney's Lane, Hyannis MA 02601 May 28, 2009 required for 01 State Zip Code Date of Inspection every'page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the (� ` 41,�./��j ((��lJ11� J computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 City(rown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority (-\2---,jVX May 28 2009 Insp is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 09-88 Freddie Mac.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Grove Street Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives Owner Owner's Name information is 1330 Phinne 's Lane, Hyannis MA 02601 May 28, 2009 required for y y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank is not in need of pumping at this time leaching system shows no evidence of surcharge. 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: I ❑ 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 09-88 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °y 100 Grove Street Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp C/O Tim Waldron Realty Executives Owner Owner's Name information is 1330 Phinney's Lane, Hyannis MA 02601 May 28, 2009 required for State Zip Code Date of Inspection every page. Citylrown B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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. 09-88 Freddie Mac.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives Owner Owner's Name information is 1330 Phinney's Lane, Hyannis MA 02601 May 28, 2009 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to-each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 09-88 Freddie Mac.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives Owner Owner's Name information is required for 1330 Phinney's Lane, Hyannis MA 02601 May 28, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 09-88 Freddie Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Grove Street Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron, Realty Executives Owner Owner's Name information is required for 1330 Phinney' y s Lane, Hyannis MA 02601 May 28, 2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 0988 Freddie Mac.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Grove Street Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp C/O Tim Waldron Realty Executives Owner Owner's Name information is 1330 Phinne 's Lane, Hyannis MA 02601 May 28, 2009 required for y y every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Unknown Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 09-88 Freddie Mac.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 115 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives Owner Owner's Name information is 1330 Phinne 's Lane, Hyannis MA 02601 May required for Y Y Y 28, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner), ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 8/10/06 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-88 Freddie Mac.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives Owner Owner's Name information is 1330 Phinne 's Lane, Hyannis MA 02601 May 28, 2009 required for _ Y Y Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): ' Depth below grade: 1 feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10.5' long x 5.8'wide- 1500 gal. Sludge depth: 311 Distance from top.of sludge to bottom of outlet tee or baffle 30" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured 1 I d 09-88 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron, Realty Executives Owner Owner's Name information is 1330 Phinne 's Lane, Hyannis MA 02601 May 28, 2009 required for y Y Y every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert and tees are intact and clear. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 09-08 Freddie Mec.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron, Realty Executives Owner Owner's Name information is 1330 Phinne 's Lane, Hyannis MA 02601 May 28, 2009 required for Y Y Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or high stains present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09.88 Freddie Mac.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives Owner Owner's Name information is 1330 Phinne s Lane Hyannis MA 02601 May 28, 2009 required for Y� � y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 7 Infiltrators ❑ 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.): SAS was probed and no signs of saturation or hydraulic failure were found. 09-08 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron, Realty Executives Owner Owner's Name information is 1330 Phinne 's Lane, Hyannis MA 02601 May required for Y Y Y 28, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 09.88 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron, Realty Executives Owner Owner's Name information is 1330 Phinne s Lane, Hyannis _MA 02601 May 28, 2009 required for y y —___--_— ----- — y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Grove Street Water Service \ \ \ \ \ \ \ \ \ \ \ \ \ \ O p f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 100 Grove Street, Hyannis MA 02601 Property Address Federal Home Loan Mortgage Corp. C/O Tim Waldron, Realty Executives Owner Owner's Name information is 1330 Phinne 's Lane, Hyannis MA 02601 May 28 2009 required for y y y every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 20+' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record II If checked, date of design plan reviewed: Date I ❑ 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 20 and topo map shows property at el. 40. 09-88 Freddie Mac.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 t I No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y Zipplication for MigogaY *pftem Construction Permit Application for a Permit to Construct O RepaiX Upgrade O Abandon O ❑ Complete System Individual Components Location Address or Lot No. C-.g-QQC -ur �4A%?ArgW%5 Owner's Name,Address,and Tel.No. A�-�fl�o Cobb Assessor's Map/Parcel 3 l o /l(v 6 �jAME Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. tZodnE� �s��� S�qY �roW SQvcsa ��g-24�s 2 csa S3R--+9(Cta Type of Building: Dwelling No.of Bedrooms Lot Size 14.3U0 sq.ft. Garbage Grinder (N/A- Other Type of Building enmPla r< No.of Persons 14 r Showers(✓) Cafeteria Other Fixtures L Ad A"Tb-7- ni Design Flow(min.required) 330 gpd Design flow provided M4, y gpd Plan Date (0- 5 - ®to Number of sheets Revision Date u� Title l Size of Septic Tank �i[its T t,�cso Q a� A,Gnk Type of .A.S. 'X e1 g X2 0 r+ 4Te47*S Description of Soil Nature of Repairs or Alterations(Answer when applicable)'. �m i>� Date last inspected: /1� (�V 1 one J ri/l-Qe•- Agreement: l 7 V 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 Boa5jJ7f Health. Sig a ,Z / °� Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued No s .�,. '. ::._,. . Fee ,THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y .,PUBLIC HEALTH-DIVISION -' TOWN OF BARNSTABLE, MASSACHUSETTS Zipplicatton for �Digogal 6pgtem Cottgtruction Permtf Application for a Permit to Construct O RepaiX), Upgrade O Abandon-( 0 Complete System,��Individual=Components 'i' ► .Location Address or Lot No. too G t 4A eA,,3w i5 Owner's Name,Address,and Tel.No.,,' Assessor's Map/parcel 3 t d //!a 6 (---AMC Installer's Name,Address,and Tel.No. - t-� gesigner's Name,Address and Tel.No. RcdrhpY t �H SligY ENS SkVCS 50@- 2-4ko-Z 9oD S3q--49(oto Type of Building: Dwelling,K No.of Bedrooms 2 Lot Size �J 3(90 sq.ft. Garbage Grinder (NI Other Type of Building 'p t2Aa E No.of Persons 4 Showers(✓ ) Cafeteria Other Fixtures L AV 917p2Y c ve Si r l / _i Design Flow(min.required) 330 gpd Design flow provided .344 gpd ' Plan Date - - C;to Number of sheets Revision Date D Title r. r\ A, C Size of Septic Tank (114%- T t .oc"o Q c,,\ t(nk Type of A.S. S 'x 14 F, X Z /"f-1 tT Q ATUPS Description of Soil Zl o '�-{ An Nature of Repairs or Alterations(Answer when applicable) —V"Q�.E A-n (J\r'r-, Date last inspected: ( ", (� 1'�^� r� � 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 Boa f Health. Sig Wedl -_;�' //G)i/� / / G` 'Date Application Approved byV�I �! Date Application Disapproved Date ` for the following reasons -Permit-No. r Date lssued w �: THE COMMONWEALTH OF MASSACHUSETTS I' BARNSTABLE, MASSACHUSETTS - Certificate of Compliance THIS IS TO CERTIFY Aha the On-site.Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by at ZdQ l,'ZOkfe' S/ has been con tructe I* acc rdance with the provisio s of Title 5 and for Disposal System Construction Permit No. �L.! dated 1 t7 Installer Designer #bedrooms" �� Approved de*gnnflow:,-,\ .�c�✓ gpd The issuance of this pejrmit shall not be construed as a guarantee that the system wi 1 fund,on as design d. Date 7/ 006. Inspector ' ------------------- ---- AOOKI�_ Fee �� THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS y tgpogal 6p5tem o/ugtruction Permit Permission is hereby granted to Construct ( ) Repair (v f Upgrade (/ ) Abandon ( ) System located at / (9,e�v-e-- a 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: Constru tion 'ust be completed within three years of the date of thise�rrnILI it. Date 4 /, � Approved by f 4 • f Town of Barnstable' F THE Tp� do Regulatory Services Thomas F. Geiler,Director * BAMSTnat.E, Has Public Health Division A'f1 1A. 6. Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Desicner Certification Form Date: a Designer: Shay Environmental Services, Inc. Installer: II Address: P.O. Box 627 Address: East Falmouth, MA 02536 )r!A ,t-Ah On was issued a permit to install a (dat ) staller) septic system at 2�v: , 1,,1 S based on a design drawn by (address) ShU Environmental Services, Inc. dated (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) ��u�t in accordance with State & Local Regulations. Plan revision or c ied as-built,by designer to follow. E CARMEN crGN Installe nature) E. c0i', SFIAY No. 1181 ' 0 �S P (Designer's Signature) (Affix De ' p 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 1 ems- � 2� � / COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 100 GROVE ST. HYANNIS 3 -' �lQ I✓�� Name of Owner SAWER&COPOLA \ Address of Owner: 64 GEORGE ST.HYANNIS MA.02601 Date of Inspection: 9l2/99 Name of Inspector:(Please Print)JOHN GRACI Act ct 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) S�Cp �✓£O Company Name: n/a tp 1 0 Mailing Address: n/a 40P �999 Telephone Number: n/a .0 hST CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Eval all By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:9/3/99 The System Inspector shal isubmit copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS ` THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 GROVE ST.HYANNIS Owner: SAWER&COPOLA Date of Inspection:9/2/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. Wa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Wa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced _ obstruction is removed _ distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed i revised 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 GROVE ST.HYANNIS Owner: SAWER&COPOLA Date of Inspection:9/2/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n[a-(approximation not valid). 3) OTHER Wa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 100 GROVE ST.HYANNIS Owner: SAWERB COPOLA Date of Inspection:9/2/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 912/96 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 100 GROVE ST.HYANNIS Owner: SAWER&COPOLA Date of Inspection:9l2/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 100 GROVE ST.HYANNIS Owner: SAWER&COPOLA Date of Inspection:9l2/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):.1 Total DESIGN flow: = Number of current residents:Q Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):DLO Water meter readings,if available(last two year's usage(gpd): D& Sump Pump(yes or no): NQ Last date of occupancy: 8/1199 COMMERCIAL/INDUSTRIAL Type of establishment: nta Design flow: nta gpd(Based on 15.203) Basis of design flow: WA Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:nLa Last date of occupancy: nLa OTHER: (Describe) nLa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: D& System pumped as part of inspection:(yes or no):MO If yes,volume pumped nLa_ gallons Reason for pumping: nta TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nLa APPROXIMATE AGE of all components,date installed(if known)and source of information: 1977 Sewage odors detected when arriving at the site:(yes or no): MO revised 9/2/98 1 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GROVE ST.HYANNIS Owner: SAWER&COPOLA Date of Inspection:9/2/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 1 6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: Wa Comments: (condition of joints,venting,evidence of leakage,etc.) n& SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO n& Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 3E Scum thickness:4 Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14_ How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle:.n/A Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n/a revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GROVE ST.HYANNIS Owner: SAWERB COPOLA Date of Inspection:912/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n1A Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nta Capacity: WA gallons Design flow: Wa gallonstday Alarm present: NO Alarm level:_nLa_ Alarm in working order:Yes—No—: NQ Date of previous pumping: nla Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DLa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:Wit Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) . nLa PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GROVE ST.HYANNIS Owner: SAWERB COPOLA Date of Inspection:9/2/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLd Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: jaLa leaching galleries,number: _nLa leaching trenches,number,length: nta leaching fields,number,dimensions: nLa overflow cesspool,number: nLa Alternative system: nLa Name of Technology: .3La Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT HAS NOT HAD MORE THAN 3'OF WATER IN IT CESSPOOLS: _ (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: nLa Depth of scum layer. n& Dimensions of cesspool: nta Materials of construction: nLa Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection)nta Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions:n& Depth of solids: nta Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GROVE ST.HYANNIS Owner: SAWER&COPOLA Date of Inspection:912/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a A � b Cti C O AAay AA 30 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 100 GROVE ST.HYANNIS Owner: SAWERB COPOLA Date of Inspection:912199 NRCS Report name: n1a Soil Type: n1a Typical depth to groundwater: Wa USGS Date website visited: nla Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 , TOWN OF BARNSTABLE LCATION SEWAGE # VLLAGE� ,,5 ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO.�,, SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 1 I-WIV4 DATE PERMIT ISSUED: s� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No - ``� !� _� �-. ,'°� �` �. \ � �� i � _ �}-, ��,� � � _ � �� �'/� s r� �` r _ , �� } K r 0 . 3/D -/� No.- . ... _ Fss.... ...3��.:......r�.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ]�X�[ an Individual•Sewage Disposal ' System at: 100 grove Street Hyannis ................__....... ..... •_ !�njjL§.............................. --....•-----•----•••--------•---------•---• -...••---•------•-----------------•------ Location-Address or Lot No. Tom McGrath ......................-- ...--- ........................ .......•_-. -------•--•----•-----_.. Owner Address W J.P.Macomber Jr. Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling x No. of Bedrooms................. ..........................Expansion Attic ( ) Garbage Grinder ( ) � a'4 Other—T e of Building No. of ersons____________________________ Showers Other—Type g ---------------------------- P ( ) — Cafeteria ( ) QOther fixtures -----------------•--•--•-••-••------------------•••••.•-•-----------------•••---------------•----------••-- W Design Flow......_........................._____-------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.__...............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ GX4 Test Pit No. 2......_.........minutes per inch Depth of Test Pit.................... Depth to ground water........................ 94 ----•------------------------------------------------------------------•••----------•••••--•---•--•-......................................................... 0 Description of Soil............................................................................................................................... ....................................... W Sand & Gravel v ...........................................................--------...-•-------------•-•••---------•--•-----•-------•-•-----•••------------...-•--------•---••--•------•-----------••...--•------------- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------------1--100()__.ma_llan---t_axihml _.1_1?_Q0...ala Illan...Le.a_c i iaa... 1t_..-------•-----.......__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n is ued by the boar of he th. d - ,�-'! 10/23/90 Signe • 6 Dace Application Approved By ----- -- ----- --------------- ----- .......... - -- .. ................. ..................................................... ..........--..-Dace----------"---- Application Disapproved for the following rearons: - ........................................------- .... . ........ ---------------------------------------------------------- ---------.................... / � --- Dace Permit No. .. ............. Issued --- -/i ce .... Fimic .$....30-.00 t THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH TOWN OF BARNSTABLE f Appliratiou for M.6posal Workii Cfoustrurtinn Vamit Application is hereby made for a Permit to Construct ( ) or Repair kr XX an Individual Sewage Disposal System at: t�� '`i°• j-�f r 100 P,rove Street Hyannis Location-'Address ' or Lot No. TomMcGrath - - .............................................. Owner Address Jxp--•-----•---------------•----•---•-•--••-----........ Installer Address � feet Type of Building Size Lot___________________________S q. Dwelling-X No. of Bedrooms.................2---.....................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Otherfixtures ............-......................................................................................................................................... W Design Flow............................................gallons per person per day. Total daily flow.........................._.......7:'_.......gallons. 1:4 Septic Tank—Liquid'capacity.....__.....gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No..................... Width.............._._._.. Total;Length....__. _ ....... Total leaching area....................sq. ft. x - _ Seepage Pit No------_-----------_-Diameter.................... Depth below inlet......f..._-...,._._.._.. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ` aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_--______-__-_--,__- Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ •-•-----•-------------------------------------------------••---.....----------------••......-•---.......-•-•-•------...----•-----................•-••-•.----- ODescription of Soil.................................................................................................................................................. xSaxld---�C._Gravel.•--....-••-•-------•---•-•-----•-•---••------•---------•---••----•---•-----------------------•--------•---------------------•-----------•------.....---•---- U W --------------------------------------------------------------------------------------------------------------------------------------------------•-------•-------•-------•-----•-----------------.--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... 1 sl nrn -g�;i ....................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System id accordance with the,provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of hea th. Signed..... . ��.,../ ........ ........l0/23/90 Q Dare Application Approved By ...... ............................................ Dare ,Application Disapproved for the following reasons: ---- "--------' .......................................'-------'----------'--------------' . ---- ---- -- .................................................. ..0...+�.......... .....-.^...--......-...----....................................---...---....-.................../ ......... 1 ---' Dare..........--'--..- Permit No. .. � �.' Issued .....-...l.l. !/.(7-- .................... f re/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C.ertifirak ti# C antylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired XXX3- by.............J,,P.Macomber.-Jr.--.......... -------'-- 100 rove Street Hyannis Installer at ---------------- ----- ................------........."-....--'.....y........ ....-.................................................... ...........................................................---------------.................. has been installed in accordance with the provisions of TITLE he Stat rfonmental Coc�efas described in the application for Disposal Works Construction Permit No. .... ..... ........ dated .... /.._/...................---.----._------. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRU D`AS A GU RANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / / DATE.--.. .�..i.. ."....`� .................''-'--"'........ ."'---"--'-----'--... Inspector ..-- ../%mil �-............................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN-OF BARNSTABLE No...70 FEE......-#.-i�ae.00 ............... Disposal Vorks Tono rudwn Vprrmit Permission is hereby granted......J.P.Mac omb e r Jr. to Construct ( ) or Repair (XX) an Individual-Sewage Disposal System at No------100...grove.Street_Hyannis.............................................. /.......r............. Street as shown on the application for Disposal Works Construction it No.... ........... ated...... o ., / ....... .. G� ) . v .. v� DATE_ I . �_i.. soa d of xealth FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS SECTION A -A ALL OUTLET PPES FROM,HE *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. t iSMEUTtON Box SHALL BE 12. COVIR ►� �`""`� �nJ 10' min. from PROFILE VIE1P OF ADDITION TO LEACHING SYSTEM SET taxi FOR AT(EAST 2 FT. CONCRE house to septic tank D-BOX cover must be . r Existing Foundation tanker met 6 M. of finished grads �� u Mw� ' � e T.O.F. elm - 100.00 ` M 3" of 1 B" - 1 2" Washed Peaston 3-r OUTLET ' °``' a ��ot w I' wkhM B M. of tktlehed grade I / toLMOU's 4t • Grade over D-Sax-99.50 over SAS-9s.50 Grade over Septic Tank- Y9.00 /- le to 1 1/2 " Washed Gushed Stone ' I tau � �aRl tin a r� t• a ar / - s - ' TO BE S: 0.02 3 HOLE /r T OF 5 INSTALLED AND T01 6Oou F GRADE : 6' s �tm�t W ystem- Elw.-9&75 + 4 1N dnm v (H-10)DIS T. BOX 3' Moxkmxn Cover rp .palest St ^{ 1 S aylnd EXIST. PIPE a 10' EW 1,500 G S-0.01 or greater S. MOW foot 0" 155• 1.7S• ;� 90 d CM ptwst � cony Cad tON Fti�NDATIDN SEPTIC T 20' PLAN SECTION CROSS-SECTION �`" k,• 1 ,n - 2 EFF oEPI►t TOTAL, „t s, taN-�J N H- 0an some N o t - 4chrial+n'" B 1 1� CONCRETE FULL FOI111DA 'c N M 0 2' D TOTAL y•Aoadrny sS% '.� V On 3 HOLE H-10 DISTRIBUTION BOX SYSTEM PROFILE �, o ° 2.Y2 i25 NOT TO SCALE IlQh �' O`r Y Not to Scale o e • R r 3.75' ta7010R�ni c.nereya r,',. M 'r rpD - f`�f�,n tom® �tw' 5-3. 1 0 l� - 8, GENERAL NOTES 0 5 /Pt��f e( Effective Length s M of a/4-1 1/2' -t Effective Vldth .: for safe notification, Verification of Utilities NOTE: ALL COMPONENTS MU HAVE RISERS TO IN e B w GRADE compacted starm C o �� �<Y3 R r S13IL ABSORPTION1. Contractor is responsible Di SYSTEM (SAS) p Dig safe Bottom of Test Hale 1 Ekw.-87.50 ro and protection of all underground utilities and pipes. Groundwater observed- NONE OBSERVED - rWILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN 2. The septic tank on j distr ution box shall be set (OR EQUIVALENT) Not to Scale level on 6 of 3/4 -1 1p2 stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. P E R C 0 LATI 0 N TEST 4. This system is Subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance Date of Percolation Test: JUNE 3, 2006 with Title V of the Massachusetts state code, the approved plan Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations. Results Witnessed By. WAIVER (Per Barnstable B.O.H.) 6. If, during installation the contractor encounters any EXCAVATOR: Shay Env. Svcs. soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPI 0 36" from those shown on the soil log or in our design Test Hole installation must haft & immediate notification be Test Hole made to Carmen E. Shay - Environmental Services, Inc. No. 1 No. 2 7. No vehicle or heavy machinery shall drive over the DEPTH SOILS ELEV. DEPTH SOILS ELEV. septic system unless noted as H-20 septic components. 0 98.50 0 98.50 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. Sandy Loom sandy Loam 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. 10 YR 3/2 10 YR 3/2 10. All solid piping, tees dr fittings shall be 4" diameter 0"-8' Ae 98.00 0•-e" A, 98.00 Schedule 40 NSF PVC pipes with water tight joints. �rtdy Sandy 11. Municipal Water is Connected to ALL OF The Residence and Abutting Loam Loom Properties Within 150 Feet. 10 YR 3/6 10 YR 5/6 THE PROPERTY LINES ARE APPROXIMATE AND e"- 3s• Bw 95.50 e- 36 Be 9&50 COMPILED FROM THE SURVEY PLAN GENERATED BY Medium/Coarse Medium/coarse Sand said DAVID GREENE, SURVEYOR ENTITLED "PLAN OF LAND IN HYANNIS, MA 2.5 Y 7/4 Z.5 Y 7/4 TEST HOLE #1 TEST HOLE #2 DATED SEPT. 27, 1963, LCC PLAN #10504-E 38'- 132 C, 132 ELEV.= 98.50 ELEV.= 9821 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN 92.00' IT SHOULD BE USED FOR NO PURPOSE OTHER THAN THE SEPTIC SYSTEM INSTALLATION. 0•k' - GARAGE 0• EXISTING LEACH PR TO BE PUMPED OUT AND REMOVED D-Box I NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE Faile -- FROM THE EXISTING LEACH PIT TO BE DISPOSED Leach Pit --�. �. OF AS PFR BOARD OF HEALTH SPECIFICATIONS. O-- �L�IST. 1.000 GAL EXIST. Perc #1 2 ' SEPTIC TANK THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY Depth to Perc: 36" to 54" 99--- ----------- ---------- ----------- ----- ----99 Perc Rate= 2 MPI ASSESSORS MAP 310 PARCEL 160 Groundwater Not Observed PROJECT BENCH MARK No Observed ESHWT TOP OF FOUNDATION LEGEND ADJUSTED H2O Elev. = None ELEV. = 100.00 (Assumed) EXISTING 2 BEDROOM HOUSE a F1-54-x-11 DENOTES PROPOSED 2-Ir DIAM. ACCUS MAINSICLEs © f00 o SPOT GRADE r I D IIVEWAY X 104.46 DENOTES EXISTING •r :.- a- .e. .. 1.0 SPOT GRADE LOT #40 pL PROPERTY LINE 9tl E•r ^) = _ 7,sso S�'e Feet +/- _. ' s 96 - PROPOSED CONTOUR 98 --- --------=--------�------------1 ----t----- ---- ---98 y a THE ACCM C0VM FOR THE SM11c TANK, I I fi ------97 EXISTING CONTOUR ND DtsnwunON Box A LEACHM COMPONENT 92.00 SET DEEM THAN a PICKS BELOW nNISHED ' GRADE SHALL BE RAISED To 1r11HIN e• OF I STEEL REINFORCED PRECAST CONCRETE GRAM , l DEEP TEST HOLE & PLAN- VIEW INSTALL'W TrIE GAS BAFFLES OR ECUAIs _ _ _ _ _ PERCOLATION TEST LOCATION 3-2e Roio AXE COVERS-� «--. 6 FOOT STOCKADE FENCE :�..� - 4• ... .ti; GR U VE ,S' TREE' T a mM ekavro. 13, titter MET r n*-L F r min.trdet to outlet s. .t OUTLETL.1au�- (40 FOOT RIGHT OF WAY) ` td n•n. � � IT L 5!-7• P OT P LAN ` ' = ' ' °°�� = OF PROPOSED SEPTIC SYSTEM UPGRADE ~' PREPARED FOR .7:.E. %i "'?•'-• is�_.,.. r• ... + ... •j MR. ANTONIO COBB CROSS SECTION END-SECTION AT TYPICAL 1000 GALLON SEPTIC TANK # 100 GROVE STREET NOT TO SCALE HYAN N I S, MA Design Calculations Kitchen �,. ��of M Number of Bedrooms: 2 Bedroom EXISTING Bedroom /Dining '?/ E„ , Bat PREPARED BY: Lee Ginder No aching Crapacity Required: 330 Gal./Day (MIN. PER TITLE V) CAR1►,L M I E. SH.A Y Septic Tank : - 2 x 330 Gal./Day - 660 USE EXIST. 1,000 GAL Septic Tank. Living ENVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rote of CL min./inch ii�� Bottom Area: 0.74 gal/sq. ft. x 240 sq. ft. = 177.60 gallons Bedroom Room 'P �cc P.O. BOX 627 Sidewall Area: 0.74 gal./sq: ft. x 212 sq. ft. = 156.88 gallons 0 20 40 50 �GIs Providing: = 334.48 gallons SAN�TAR�P� EAST FALMOUTH, MA 02536 Use: (7) SEVEN INFILTRATOR HIGH CAPACITY H-20 .UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE TEL�FAX 508-539-7966 2 BE HOUSE FLOOR SCHEMATIC SCALE: 1"=20' DRAWN BY: CES DATE: JUNE 5, 2006 DEPTH, To BE USED WITH 1.0' OF WASHED STONE ON THE SIDES, AND 2.125' OF WASHED STONE ON THE ENDS. (1) ONE FOOT OF STONE UNDER. SCALE: 1"=20' PROJECT#SD930 FILENAME: SD930PP.DWG SHEET 1 OF 1