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HomeMy WebLinkAbout0017 HAMDEN CIRCLE - Health 17 HAMDEN CIRCLE,HYANNIS r a I i I r i q p Commonwealth of Massachusetts 07 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 17 Hamden Circle t Property Address Tana Moyer `{ Owner Owner's Name information is :- required for every Hyannis _ MA 02601 10-24-19 page. City/Town State Zip Code Date of Inspection . ., Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. ��\tig11 t I I I tlq flryl// Important:When A. Inspector Information "' •:' �'�-. filling out forms a�t5 r` y on the computer, a' JAMES •': ' use only the tab James D.Sears key to move your Name of Inspector ;y cursor-do not Capewide Enterprises use the return Company Name e'-ZIfTI , •8k y I. 153 Commercial Street s I N SPtiap`�� r Company Address Mashpee MA 02649 City/Town State Zip Code •� 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector In full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: I. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-26-19 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. 15insp.doc•rev.712612018 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 t, 96ed XeJ dH 9£:80 660E t,0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hamden Circle Properly Address Tanya Moyer Owner Owner's Name information is required for every Hyannis MA 02601 10-24-19 page, Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary:Complete 1, 2, 3,or 5 and all of 4 and 6. 1) 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: The system is a 1000 Gal, Tank D. Box and two 500 Gal. dry wells. 2) 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. r 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): 15insp.doc-rev.-,128l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 g a5ed xed dH 9£:80 61,0Z b0 AoN Commonwealth of Massachusetts . Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °< 17 Hamden Circle Property Address Tanya Moyer Owner Owners Name information is required for every Hyannis MA 02601 10-24-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. ❑ 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): E 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): 3) 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. a. 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: Mrnsp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 9 a6ed xed dH 9£:80 6 LOZ b0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hamden Circle Properly Address Tanya Moyer Owner Owner's Name information is required for every -Hyannis MA 02601 10-24-19 - page. Cltyfrown. State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other:, 4) 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 tSnsp.doc rev.7/2812016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 L a5ed xed dH 9£:80 61,02 tV0 AoN I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hamden Circle Property Address Tanya Moyer _ Owner Owners Name information is Hyannis MA 02601 10-24-19 required for every page. City/Town State Zlp Code Date of Inspection C. Inspection Summary'(cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in is less than 6"below invert or available volume is less than '/z d ay flow -4 4 A f N*e ❑ ® 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. An portion of a cesspool or privy is within a Zone 1 of a public water supply ❑ ® Y P P P vY P 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 2000 gpd- 10,000 gpd, . ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7!2612018 Title 5 Met Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16 9 a5ed xed dH L£:90 6 X2 b0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.� 17 Hamden Circle Property Address _Tanya Moyer Owner Owner's Name information is required for every Hyannis MA 02601 10-24-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or "no"for each of the following for al!inspections: 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)j I t5insp.doc-rev.7r26l2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 6 a5ed xeJ dH LE:80 660Z t70 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Hamden Circle Property Address Tanya Moyer Owner Owner's Name information Is required for every Hyannis MA 02601 10-24A 9 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal. Tank D Box and two 500 Gal. dry well's. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No . If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system Inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gP ))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: Dateesent 15inap.doc•rev.7l26/2058 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 7 of 18 01• abed xed dH 8£:80 6l.OZ b0 AON Commonwealth of Massachusetts U UO Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hamden Circle Property Address Tanya Moyer Owner Owner's Name information is required for every Hyannis MA 02601 10-24-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 11insp.doc•rev.112WO11 Title S official Inspection Form:Suburfaoe Sewage Disposal System-Page 8 of 18 I,t abed xed dH 8£:80 61,OZ b0 AGN Commonwealth of Massachusetts Titles official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F� 17 Hamden Circle Property Address _Tanya Moyer Owner Owners Name information Is required for every Hyannis MA 02601 10-24-19 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2016 Permit f#2016-299 Leaching. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 32" 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.): Pipeing is 4" PVC SCH -40. t5insp.doc•rev.T(26(2018 Title 5 Oftlal Inspection form:Subsurfaoe Sewage Disposal System•Page 9 of 18 Z l, abed xeJ dH K80 61,02 b0 AON I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 17 Hamden Circle Property Address Tanya Moyer Owner Owner's Name information Is required for every Hyannis MA 02601 10-24-19 page. CitylTown state Zip Code Date of Inspection D. System Information (cont.) 6, Septic Tank(locate on site plan): Depth below grade: 22" teat Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness V1 Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt- Plan -Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tank and inlet cover at 22"Woutlet at 16". In and outlet tees. No sign of leakage or over loading, i5insp.doc-rev.7126I2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 10 of 18 £6 a5ed xeJ dH 8£:80 6 60Z 170 AON Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 17 Hamden Circle Property Address Tanya Moyer Owner Owner's Name information is required for every Hyannis MA 02601 10-24-19 page. CitylTown State Zip Code Date of Inspection D. System information (cunt) 7. 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.): 8. 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 t5insp.doc•rev.7126f208 Tide 5 0 fidel Inspecdon Form:Subsurface Sewage Disposal System-Page 11 of 18 b 6 a5ed xed dH 6£:90 61,02 b0 AoN Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments v s 17 Hamden Circle Property Address Tanya Moyer Owner Owner's Name information Is required for every Hyannis MA 02601 10-24-19 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. 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.): D Box is 16"x 16"-42" below grade w/cover at 1'. Box is clean and solid wltwo line's out. No sign of over loading or solid carry over. t5insp.dw•rev.7/2612018 Title 5 Omdal Inspection Form:Subsurface sewage Disposal system•Page 12 of 16 Si, abed xed dH 6£:80 660Z b0 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 17 Hamden Circle Property Address Tanya Moyer Owner Owners Name information is required for every Hyannis MA 02601 10-24-19 per. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: E 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. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: t5insp.doc•rev.7128/2018 Title 5 Official Inspecion Form:Subsurface Semgs Disposai System•Page 13 of 18 9 t abed xed dH 6£:80 Me b0 AON Commonwealth of Massachusetts Title 5 official Inspection Form 11 Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 0 17 Hamden Circle Property Address Tanya Moyer Owner Owners Name required foati fo is every r Hyannis MA 02601 10-24-19 requir Page, Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 500 dry well's w/4'stone. chamber's at T-6"below grade w/cover at 18". 2"water w/no sign of over loading or solid carry over. Wall's are clean like new. 12. 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.): t5lnsp.doc-rev.7128/2018 Tole S Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of I �I• abed xed dH 6£:80 61,02 b0 AON Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Tanya Moyer Owner Owner's Name information Is required for every Hyannis MA 02601 10-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 13. 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.): 15insp.dcc rev.V28l2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 18 gl, abed xeJ dH W90 6602 to AoN i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Tanya Moyer Owner Owner's Name information is required For every Hyannis MA 02601 10-24-19 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately D E�h A rPaarf I rp A—t ` jar -e -3 = 36-.Ir C -� `{s� i iWsp.doc•rev.7126/2016 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 16 of la 66 a5ed xeJ dH Ob:90 660Z tb0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Hamden Circle Property Address Tana Moyer Owner Owner's Name information is Hyannis MA 02601 10 24-19 required for every - page. City/Town State Zip Code Date of inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to highoground water: 11, 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: 7-22-16 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed IJSGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plan 7-22-16 11' no G.W.. Bottom of chambers at 6' below grade. Bottom of chambers at 5'above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page.. t5insp.doc rev,7i26f2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 o11a 02 a5ed xe:1 dH Ot7:80 6 60Z b0 AoN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Hamden Circle Property Address Tanya Moyer Owner Owner's Name information is Hyannis MA 02601 10-24-19 required for every page. City/Town Slate Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed &Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D.System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included r/ o � •� CABaINt N� Gw t5insp.doc-rev.7!2812018 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System-Page 18 of 18 62 a5ed xeJ dH Ot,:80 6TOZ tp0 AoN TOWN OF BARNSTABLE LOCATION IZZ.La SEWAGE# e}b lf— yILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY1 LEACHING FACILITY:(type) a (size) :L� K 1 3 -e NO.OF BEDROOMS OWNER PERMIT DATE: -t Pa COMPLIANCE DATE: (p Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility t 'S� 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(ppftA✓tQ-e L`eaj e•••rr4i f C S J u M No. Fee HE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1 Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS I 2pphcatton for Nsposal 6psteuY Coustrutttott VPrmit Application for a Permit to Construct( ) Repair( /upgrade( ) Abandon( ) ❑Complete System 21ndividual Components Location Address or Lot No. 1 7 Q/ 44e) e/' fe Owner's Name,Address,and Tel.No. 40^N3^ 905(p Nyatin iS Same Caa'� i l I azk q e0j A4ry Hauer,Oj Assessor's Map/Parcelc291 /PBq t A0 . • Installer's Name,Address,and Tel.No. 602 9-90/ 9377 Designer's Name,Address,and Tel.No. 6Z3-3C 2-j/W/ �vt�oi6( i,Co;+s{rvci`c,�,3ne. Po� Sax Toe/ ZuA MAr� i!lSMA Oa6 g y46 Type of Building: Dwelling No.of Bedrooms 15 Lot Size f U S� sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) c5 6) gpd Design flow provided 30 gpd Plan Date M1, 99 c 4, Number of sheets , Revision Date Title 7,' -2 Si". 26—n 4- --#-/'7 P.wden 0 d-4e- 1-1 L/ann 1 s _ 4M Size of Septic Tank eXtS+-i via Type of S.A.S. (it), Description of Soil�5u_Qzt�te3c-1 � Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. %ie Q Date � �S Application Approved by Date Application Disapproved Date for the following reasons Permit No. r Date Issued r r 7 I ... �• n • No. -Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:M 1(9 Yes PUBLIC HEALTH DIVISION - TOWN OFI BARNSTABLE, MASSACHUSETTS 2(pplitati0n for Disposal ,6pBtem Construction Permit Application for a Permit to Construct( ) Repair( Xupgrade( ) Abandon( ) ❑Complete System 2Individual Components r Location Address or Lot No. 7 a pn (21-<cle Owner's Name,Address,and Tel.No. 74o^.9<13• '20 Sfo Assessor's Map/Parcel.2f/ Aff`j &Lr4-art i i( .2a q CouAjry Ikue,,dZ! aoa Installer's Name,Address,and Tel.No. s6�i 93 77 Designer's Name,Address,and Tel.No. t�it•4c�IbtCi,C'�ns��'�tf-r'cr-,,1nc• P•o (3�k 705/ t�XiJh Ci+-1C2. �9 i n,e�d%�"5,1nc 4 35/�l�i.�5� MarsF Mils MA oa6.Vfr 6-767 Type of Building: If? . -� Dwelling No.of Bedrooms J Lot Size q.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 U gpd Design flow provided 3 Y 9 gpd Plan Date 3�„ ag , aai 4, Number of sheets / Revision Date Title T,'4e S i I•e. Plea n C -#/r7 1-ira wrd e-n ee r c-L 4 I/z_n n(*5 Size of Septic Tank e_Xi S}-1,-,G )C (�,�g_„Q Type of S.A.S. „04�p �1C� J c�< y .�c AS X 1 A,�3 ; led Description of Soil o„ y,^li,� Sn e 0 i i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: YY4a Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage-disposa system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation-u t 1 a Certificate of Compliance has been issued by this Board of Health. _ Si edj / � Date Application Approved by � / ,/ / Date Application Disapproved by Date for the following reasons Permit No. /J Y Date Issued ------------------------------------------ --- ; -------- /. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate Of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by {��a , �i,i, rrvc�i or�._Ln c- at 1'� 1-f/� ��0 \ C t(Z'e 14,10 rt n;g has been const}�"nacce4with the provisions of Title 5 and the for Disposal System Construction Permit N . ed Installer �� ln L Gi r%S���� 1'on 71fx. DesignerLJ e�0 n P el�, �l�1n<_ y #bedrooms Approved des n o 1 33 ct and The issuance of t s pe it shall not be construed as a guarantee that the system wifui'cti�J as desig�ed. Date l �• Inspector � i o A I - ----------- a---------- -------------------------- --------------------------------------- /No. _ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal �6pstrm Construction VPrmit Permission is hereby granted to Construct( ) Repair(K) Upgrade( ) Abandon( ) System located at / ? Q� a �I fi and as described r, sc bed in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction rri be'o� laced within three years of the date of this permit. f Date / � Approved by 4 No. Fee HE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS �Dispo8al �6pstrm (0,7,xms�.urttott Permit Permission is hereby granted to Construct( ) j Repair( ) Upgrade( ) Abandon( ) System located at I and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons�truc o m t be ompleted within three years of the date of this permit. Date V Approved by Town of Tarnstable Office: 508-862-4644 Regulatory Services Department Fax: 508-790-6304 an L& + Public Health Division �? Thomas A.McKean,CHO 200 Main Street, Hyannis, MA 02601 Payment Receipt ,Septic(Disp.Constr. Permit) Payment received: $75.00 (Check) on 5/2/2016 Permit number: 2016-143 j ,,Check number: 134 Check amount: $75.00 Name on check: Dibuon ,Owner: NICHOLAS W TR LAZARES ;Address: 31 WOODLAND ROAD, Hyannis I I .... i s. TKE Town of Barnstable Barnstable .� Regulatory Services Department BARNSPABM o 9 ,` : Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1520 0000 1968 9668' June 21, 2016 Donald S.Nichols 17 Hamden Circle Hyannis, MA 02601, ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,•TITLE 5 The septic system located at 17 Hamden Circle, Hyannis MA was inspected on 06/07/2016 by Michael DiBuono, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of 1995 TITLE V(310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level,<12" below inlet (per Town Code 360-9.1). You are ordered to repair or replace the septic system within Two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH - keaeR.S., CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\17 Hamden Circle,Hyannis.doc Town of Barnstable sA�vsrasr.E, + . ,.� Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA'02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) XLeaching pit or cesspool with high liquid level, <12"below inlet(per Town Code 360-9.1) o Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Parcel Detail Page 1 of 3 THE e BAAIlSYABLt:', 'r `i VI fht LWI;9. � +7a"'�' -- ' m t Logged In As: Parcel Detail Monday,June 20 2016 Parcel Lookup Parcel Info Parcel ID 291-189 I DeveloperLoot LOT 86 I Location 117 HAMDEN CIRCLE I Pri Frontage 124 Sec Road I Sec Frontage[.. Village jHyannis I Fire District HYANNIS Town sewer exists at this address NO =I Road Index 10654 Asbuilt Septic Scan: P Interactive y = # w 2911891 Map �- Owner Info Owner NICHOLS DONALD S Co-owner 1%CARTMILL'JANE D TR Streets DONALD S NICHOLS 2016 LIV TR I Street2 17 HAMDEN CIRCLE City HYANNIS I State FM—A1 zip 02601 Country Land Info Acres 10.23 use Single Fam MDL-01 I zoning fRB I Nghbd 10104 Topography Level I Road jPaved I Utilities 1PUblic Water,Gas,Septic Location Construction Info Building 1 of 1 Year 1978 Roof Ext Built I Struct,Gable/HipI Wall Wood Shingle Living 1368 I Roof AS h/F GIs/C AC Area Coverm p I Type�one �) 16 0 WDK .1 Style(Ranch I Wall Drywall r_..._.a.I RoBed 3 Bedrooms I 26- Ts Model(Residential I Floor Carpet I R Bath '2 Full-0 Half ( gAs. Grade Average Minus I Type Hot Water I Rooms 6 RoomsI Stories' 1 Story I Heat Gas I Found Fuel ation Poured Conc. Gross 2 I Area392 Permit History Issue Date Purpose Permit# Amount Insp Date comments 8/10/2015 New Roof 201505078 $5,800 6/30/2016 REROOF HURICANE NAILED(STRIPPING 12:00:00 AM OLD SHINGLES http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=22742 6/20/2016 Parcel Detail Page 2 of 3 Visit History F Who Purpose 01 12:00:00 AM Paul Talbot Meas/Listed-Interior Access 1987 12:00:00 AM ML Meas/Listed-InteriorAccess Sales History Line Sale Date . Owner Book/Page Sale Price 1 10/31/1996 NICHOLS,DONALD S C142529 $90.000 2 6/21/1978 OSTROWSKI,EDWARD S&JUDITH C74571 $0 3 6/7/2016 CARTMILL,JANE D TR D1296227 $0 4 2/19/2016 NICHOLS,DONALD S&CARTMILL,JANE D TRS C208802 $1 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2016 $102,200 $23,500 $2,300 $68,700 $196,700 2 2015 $96,300 $21,700 $2,700 $65,600 $186,300 3 2014 $96,300 $21,700 $2,800 $65,600 $186,400 4 2013 $96,300 $21,700 $2,900 $65,600 $186,500 5 2012 $96,300 $21,500 $2,200 $65,60Q $185,600 6 2011 $119,300 $3,300 $0 $65,600 $188,200 7 2010 $119,200 $3,300 $0 $70,600 $193,100 8 2009 $114,600 $2,600 $0 $164,900 $282,100 9 2008 $133,500 $2,600 $0 $180,400 $316,500 11 2007 $132,900 $2,600 $0 $180,400 $315,900 12 2006 $122,900 $2,600 $0 $142,600 $268,100 13 2005 $115,000 $2,600 $0 $128,100 $245,700 14 2004 $93,200 $2,600 $0 $96,000 $191,800 15 2003 $83,400 $2,600 $0 $38,000 $124,000 16 2002 $83,400 $2,600 $0 $38,000 $124,000 17 2001 $83,400 $2,600 $0 $38,000 $124,000 18 2000 $67,500 $2,400 $0 $24,200 $94,100 19 1999 $67,500 $2,400 $0 $24,200 $94,100 20 1998 $67,500 $2,400 $0 $24,200 $94,100 21 1997 $64,500 $0 $0 $20,200 $84,700 22 1996 $64,500 $0 $0 $20,200 $84,700 23 1995 $64,500, $0 $o $20,200 $84,700 24 1994 $60,900 $0 $0 $29,100 $90,000 25 1993 $60,900 $0 $0 $29,100 $90,000 26 1992 $69,300 $0 $0 $32,300 $101,600 27 1991 $79,400 $0 $0 $40,400 $119,800 28 1990 $79,400 $0 $0 $40,400 $119,800 29 1989 $79,400 $0 $0 $40,400 $119,800 30 1988 $55,800 $0 $0 $17,500 $73,300 31 1987 $55,800 $0 $0 $17,500 $73,300 32 1 1986 1 $55,800 $0 $0 $17,5001 $73,300 Photos http:Hissgl2/intranct/propdata/ParcelDetail.aspx?ID=22742 6/20/2016 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 17 Hamden Circle C Property Address Estate Of Donald Nichols Owner Owner's Nam information is Hy annis Ma 02601 6/7/16 required for every s page. City/Town State Zip Code Date of Inspection co A Inspection results must be submitted on this form. Inspection forms may not be altered in a y. way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: , key to.move your cursor-do not Michael DiBuono use the return key. Name of Inspector DiBuono Sewer and Drain Company Name 8 Johns path Company Address rBrn S Yarmouth Ma 02664 City/Town State Zip Code 508-364-958-7 S103522 Telephone Number License Number B. Certification 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 -' 6/9/16 Ins ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. VSt5ins'•3/13 - �bCl _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden it I Circle e Property Address a= Estate Of Donald Nichols Owne'.�, Owner's Name informlition is required for every Hyannis Ma 02601 6/7/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in failure. leach pit is full rite up to the cover. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ 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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. City(Town State Zip Code Date of Inspection B. 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. i ❑ ® 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. ® 0 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is H required for every annis Ma 02601 6/7/16 y 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 El 0 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)] D. System Information Residential Flow Conditions: 3 3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: System is in failure. leach pit is full rite up to the cover. i Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 187 GPD 9 ( Y 9 (gP ))� Detail Sump pump? ❑ Yes ❑ No Last date of occupancy: OccupiedDate 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None provided 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) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Installed in 1977 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Pipes not inspected. Failed system Septic Tank (locate on.site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e a 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is Hyannis Ma 02601 6/7/16 required for every y ' page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3„ Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i J Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. Cityrrown 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.): Tees are in place and levels are normal. 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 Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments } a 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Signs of push back and carry over Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan).- Pumps in working order: ❑ Yes ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit is full to the top and no longer leaching 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-•3113 - 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 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ponding no break out as of yet. 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 6/9/2016 Assessing As-Built Cards TOWN014 BARNSTABLE LOCATION 4�0 C',Y6~, SEWAGE N VILLAGE &A ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACPTY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist I within feet of leaching f Feet FurnishedbylL� I 1 Al --n b 13( �2b3 z ,kZ-a-z� 62-try� >i3-25 63,SI _31 &t 346 http://www.townofbarnstable.us/Assessi ng/H M display.asp?mappar=291189&seq=1 1/2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately '- t5ins'•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is required for every Hyannis Ma 02601 6/7/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with'local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Will be determined at time of perk test. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 17 Hamden Circle Property Address Estate Of Donald Nichols Owner Owner's Name information is Hyannis Ma 02601 6/7/16 required for every y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 SEP-15-2016 03:08 From: To:15087906304 Pa9e:1,'1 FROM FAX NO. Sep. 14 2019 12:55PM P1 `own of Bamstabxe Regulatory Services ,. Thomas.V.Geiler,Director A Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 . office: 508462-4644 Fax-- 508-740-M304 inista&r&Designer Ce«rtifica#on Form Date: J I Sewage Permit,f c20/1— t�Y9 Assessor's MapVFarcol ° f bo ,qDesigntr: LJJN �, fAt�v3 Installer: K& v� 6 M Address: —L - �, c. Addrerua: `U w !. On was issued a permit to bAall a (clue) installer) septic system at W �� based on a dw ibm.drawn by _. . �addTcss Ol.a�►I . . (� _..r-_..__. dated 019D I Co deiez) 1 certify that the septic system referenced alxwc was insta.U.ed substantially sccOrding to the deo;tlret, whioh may include minor approved changes such as lateral relocation of the distribution lx5x and/or optic tank. I certify that the septic syqe:m reyrorefnced >,ah0ve wa 4 installed with major 011m ages (Le. greater thm 10' lateral zelmation crf the SAS or any vertical relocation O��any cOmNncnt of the y septic system)but in accordfince with State&Local Regulations. Y lan revision,or certified by desipe;r to follow. • H OF Atgr_ r uAhgFLA. � 0jAtA lnstziller s Sigaxalure) GIVI- �^ Na.46507 o- ,STY��D��W r —��• l�rsS�ONA4 (llesigliez's Si. nature) (Affix llcsigner's taws Rem) PLEASE UTURN T4 BAaRY91'ABLE N'U8L1G IiGAL1'l ll V�I$[ON� C 7Ir If,.'rE ()F COMPLIANCE MILL NOT iiF_ ISSI RaD UNTIL BOTH TMSLEiM ANn A&5-ItCJIg.T C�UD ARE JSVECEaEED)j3 M I3ARN' rABL .Pumig IZALTI'X 910 T.9614KYOU. Q,Hcatth/SepddDesigner Cefificatiou FunA M6-04.dec _ t d0, Town of Barnstable P Departnierit of Health Safet an'd?Envtronmental Services do A Piublic!,Mki lth DiSiiskil Date; ` T 1 367 Main`Street,Hy�_anis MW0 601E 0, = BARNSTABLE, < AtA&4 // ,D =ass~ .� � �� l � Time�.. Fee Pal. </�Q k).' Uy It( rFo�uct� Date Scheduled . r `oil ,Su tabilio Assessment for og° Sew a Disposal `l Performed By: �\��� \��\fit\l s Witnessed By:. fiL.. :....&i.....RAI T:.: Location Address /7 14 [ am &J �� Owner's Name Assessor's Map/Parcel:/ / Eng�neer's`Name (�p i,{j� 2 t NEW CONSTRUCTION REPAIR Telephone# (,.s Land Use �lG.��'� Slopes(%). � Surface-Stones l� _ Distances from: Open Water Body �© ft Possible'Wet Area W{ ft Drinking Water Well ft - Drainage Way Y o 4 tt Property Line ft Other It SKETCH:(Street name,dimensions of tot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) s a Z, N �I< ;�• - Y�at ' • �Z�� .+.fit Parent material(geologic) rA)v1 ! Depth.to Bedrock Z!0 4_ Depth to Groundwater: Standing Water In Hole: Weeping.from Pit Face 4 Estimated Seasonal.High Groundwater_. Method Used:'::::::I'if f�r�J�:>>:::•;;;:.;;:•;;:.;;;:•;;:;•:;:•:;:.;:.;;:�::::::::::::::::::::::::::::::.::::. Depth Observed standing in obs.hole: in. Depth to soillmottles: t + in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment It• Index Well#___•_._ •Reading Date:_,___ Index Well level•-.;_�' Ad0factor 'AdJ.Groundwater Level_ .>:.;::::::::::::::::.:ECUZ�1T (Jai.<Tf ' '.::::::::.:::;.;: :.::.::. ............:.....:::. ......................:............ Observation t.9,me,Tia " Hole#' �. ,., >,:: Depth of Pere -/'—Gam,-- Time at 6 Start Pre-soak Time Q 1 " Time,(9"-6") ff End Pre-soak lVr�lO Rate Min./Inch � �/t✓� Site Suitability Assessment: Site Passed.• �% r -,Site F.ailed:*owu Additionnal�esting•Needed(YM). -• 'Y'9ryir.... � «�,.' 1�'t•�'.s �` Original: Public Health Division Observation Hole Data To Be tr®trtpleted on Back Copy: Applicant B�IiiITI0I1: .:::::::: .:::::' ::::::::::.;;:.;::.::.:::::::::::::::::::::.::.::..;:.. rt: :::::on Soil Other Depth from Soil Horizon Siiil'rT`exturell 3 7iSdilrColor it>"{s" S face(in.) (.USDA), }. (Munsell) Mottling (Structure,Stones,Boulderes. 0 Ct �" tG sip 5q-l3Z Gz C� � ?/ } S Depth from Soil Horizon Soil,Texture Soil Color Soil Othee "Surface(in.) W 'AY (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,°°Gravel) Z .::. :.::::......: .: X. »:<:::>::;:«:>:::.;----;»:>.:;:;.;:.;;::.::::::::.::::::::::::::::::........................u'..... Depth from Soil Horizon Soil Texture I Soil Color Soil Other Surface(in.) (USDr+) (Munsell) Mottling (Structure,Stones,Boulderes. — - - o si--nc• °'o r 'cl DEEPUBSER' 5 ;;>:>:;;::.;::::.;::.;• .�.. Depth from Soil Horizon Soil Texture Soil Color Soil Ot ier Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Co nsi en °o Gravel) ' W 216d4nsu'�an'ce 01W Man• •' E"4 `' �' #': id Above 500 year tlood,boundary,!,Nop_ Yes P` t -Within 500.year.boundary No Yes wltFiin t00'year flood"LLb'oundary Noy 7:Yes *epth of Naturally OccurrlB Pervloas Material Does at least four feet of naturally,occurring perv'ou material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? C-ertification I certify that.on E) (date)I fiave passed the soil evaluator examination approved by the -Department''ofEnvlronmentarilpedtection_and,that"•the above analysis was,performed by,me consistent,w,.ith tle required�training,expertise and experience described in 310 CMR 15.017. r Date Signature / l ��p I� TOWN OF BARNSTABLE Dater/g7 TOXIC AND HAZARDOUS MATER LS ON-SITE INVENTORY NAME OF BUSINESS: BUSINESS LOCATION: '�� �l � �,4/i �/.�/,�,i ,A;�4 INVENTORY MAILING ADDRESS: 2 TOTAL AMOUNT- TELEPHONE NUMBER: . . CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBE MSDS ON SITE? TYPE OF BUSINESS: "5&ve G INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants 6:X/d Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Si-a at Staff's Initials YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: /' / Fill in please: APPLICANT'S YOUR NAME/S: a r'a4t#rf t liu ib rt far -al l ',-Aj W; BUSINESS YOUR HOME ADDRESS: lr1' R y I , C�' s LL—C:�C� /SILL/r1.yLLlCI� } TELEPHONE # Home Telephone Number '7 ' NAME OF CORPORATION: TY1S✓L 4 ",% C�, NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO Of< ! .�r�� ` » G ( �� ADDRESS OF BUSINESS Sez/rnL. /7 / �-t v�+' i �� MAP/PARCEL NUMBER Zq U� (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this tovvn. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual has been r�eFJgf�the permit requirements that pertain to this type of business. MUST�.OMPLY WITH ALL 1 Y V(� 1 HAZARDOUS MATERIALS REGI-J!_A Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS (LICENS G AUTHORITY) This individual has fn inUP me of the licensing requirements that pertain to this type of business. Auth rize ignature COMMENTS: A Q TOWN OF BARNSTABLE Dat@5. - TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS:Vy�� ` cz( BUSINESS LOCATION: ! 7 11—e117 - �� `} .:� INVENTORY Qf MAILING ADDRESS: a,, 'k- TOTAL AMOUNT- TELEPHONE NUMBER: d 7 l = 7C 3 CONTACT PERSON: LZ4w,.,, r -A EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: /(/ Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers -- Windshield wash �� WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signat a Staff's Initial Commonwealth of Massachusetts Executive of Environmental Affairs D-E P Department of I' L Environmental Protection EC SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO'IRM PART A - - - CERTIFICATION r1 i . Property Address: i I Kew. Address of Owner: s.-bL r, ,aLi (if different) Date of Inspection: i S liy\icy„ Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - Mashpee Ma 02649. Tel : (508)4771420 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 I Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector 's Signature: �i 2 Date: The system Inspector shall submit a copy of this inspection report to the Approving Authority 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: %-t tt p,%AA«, C;j Owners : Date of Inspection: - - INSPECTION SUMMARY: — - - - - - Check A,B, C, or D A) SYSTEM PASSES: .X, I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES: .... One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes, no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If"not determinated", explain why not. ---- The septic tank is metal, 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 conforming septic tank as approved by the Board of H ealth. --- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). ..... broken pipe(s) are replaced ---- obstruction is removed --- distribution box is levelled or replaced •-- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): •---- broken pipe(s)are replaced ..... obstruction is removed � 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address U . Owner : bszQ,S,�', Date of Inspection: C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: --- Conditions exist which require further evaluation by the Board of Health in order to-de- termine if the system is failing to protect the public health , safety and the environ- ment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 a surface of water --- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. --- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notoogen is equal to or less than 5 ppm. D)SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: %,A Owner: c '2bLiL', Date of Inspection : D)SYSTEM FAILS (continued) -- 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 over- loaded or clogged SAS or cesspool. -- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. --- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). number of times pumped --- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. -- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I of a public well. -- Any portion of a cesspool or privy is within 50 feet of a private water supply well --- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality ana- lysis. If the Well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �-1 Owner: ck:,rrRz�sy Date of Inspection : E) LARGE SYSTEM FAILS: ._ -- The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- the system is within 400 feet of a surface drinking water supply -- the system is within 200 feet of a tributary to a surface drinking water supply --- the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CM 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: cysT ,,^�ti Date of Inspection: Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receivin g ng normal flow rates during the period. Large volumes of water have not been introduced into tr a 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 sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions,depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Sal Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 11 rt%wa,,4Q at_ Owner: o:;;-rZvwc-v Date of Inspection: \ ► ��` RESIDENTIAL: Design flow: y LL O gallons Number of bedrooms : o L Number of current residents: d Garbage grinder (yes or no): %.,u Laundry connected to system (yes or no): yr,S Seasonal use (yes or no) : *�ao Water meter readings, if available: tit*, Last date of occupancy : COMM ERCIALANDUSTRIAL : Type of establishment: Design flow: gallons/day Grease trap present: (yes or no) Industrial waste holding tank present (yes or no) : Non-sanitary waste discharged to the Title 5 system (yes or no) : Water meter readings, if available: Last date of occupancy : Other: (Describe) .......................................................................................... Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information- System pumped as part of inspection (yes or no:....... if yes,volume pomped: .................... gallons Reasonfor pumping :............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: \-1 N�•J�dcry c.�,L Owner: Date of inspection: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system - ---- - -- ---- - -� Single cesspool --- Overflown cesspool --- Privy --- Shared system (yes or no)(if yes, attach previous inspection records,if any) --- Other (explain). ......................................................................................... APPROXIMATE AGE of all components, date installed (if known)and source of information Rc1A-,x....Qc�t...::...�.%.y. .Q&........................................................................................... ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site : (yes or no)....NQ... SEPTIC TANK : ...��j.... (locate on site plan) Depth below grade: .1T.`��� t Material of construction: ...k concrete ......... metal ........ FRP........ other (explain) ................................................................................................................................................ Dimensions: �.XS... Sludge depth:... Distance from top of sludge to bottom of outlet tee or baffle:......3`................ Scum thickness :....n`!........... Distance from top of scum to top of outlet tee or baffle: ...... �............ Distance from bottom of scum to bottom of outlet tee or baffle:......1 e.`.'............. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid Level in rel tion to outlet invert,structural integrity,evidence of leakage,etc.)... �. .,......................................................... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: %-I Owner: Date of inspection: - GREASE TRAP : ......V—.t..... -- - - (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... 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.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:... Z?.... (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: N j Owner: psWsv_� Date of inspection: DISTRIBUTION BOX:... (locate on site plan) Depth of liquid level above outlet invert%.A v4.WA WET M1Q\KV-K Comment: (note if level and distribution equal evidence Df solids carr ,over, evidence,of leakage int or out of box,etc.). '. x.,- ...� ... Z ............................................................................. .��.. ................................... PUMP CHAMBER:...... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.).................... .............................................................................................................................................. . ............................................................................................................................................ SOIL ABSORPTION SYSTEM (SAS):...tS,...� (locate on site plan, if possible; excavatibbfh not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ T .... ... ........:........... .......... .. ............................. ................................................................... ype:.. .... leacHng pits, number: ....k............ leaching chambers, number:........ leaching galleries, number:........... leaching trenches,number , length:..................... leaching fields, number,dimensions:................... overflow cesspool,number:.......... Comments: (note condition of soil, s' ns of hydraulic failure level ofponding, con ition o(vege tian, tc.). �.. . ....-. ........ .. . .�:�(...... .. .. . c�,11 .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: k'-k Owner: Date of inspection: t ; `.` b _CESSPOOLS:....I .. _ (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) ................................................................................................. ................................................................................................. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: .. .... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 1-1 \Avrw,ckv,, Gam. Owner: Date of inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100' IS DEPTH TO GROUNDWATER: Depth to groundwater: feet Method of determination or approximative: V.:S.. Q� s� ..����r ............................... ............ ................................................................................................... a;7 ? LOCATION, -�_, _ SEWAGE PER IT NO. k P - t VIII A GE IN.STA LLER'S NAME & ADDRESS B U I'L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED Z ., � - ........... ^ , u k -C-9 NO...................... FRic THE COMMONWEALTH OF MASSACHUSETTS 4<rl .......... ......OF.... BOARD 1 OF HEALTH I .......... ......OF.... . ............................. q Appliration -for Bhipoiial Works TomitrUrtion Prinift Applicatior is laereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: % j2o ..... ........ ........L RvJqi..�).............................................. L c n-Address or Lot No. Tp L.......................5.0.A...... ...4-.O.QT..................... —4 ddress 0 A 1 IC-0............................................................ . .... --------------------- --------W_�"�A.....Ti ix). Installer Address Type of Building Size Lot_--------------------------Sq. feet U Dwelling—No. of Bedrooms______________________________ __ -Expansio Attic Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons._-___7--I---------------- Showers Cafeteria ( ) PL4Other fiat es -------------------------------------------------------------------------- -------------------------------------------- ------------------------- I ly I Design Flow.................14 4------------------gallons per person per day. Total daily flow....._._......_ _____..__.._._gallons. W Septic "Tank—Liquid �p acity------------gallons Length................ Width._..__.......... Diameter_---_----___-_ Depth.__._----__----- ' Z Disposal Trench—No..................... Width___--------__--_---- Total Length___..__..__......_.. .Total leaching area--------------------sq. ft. It Seepage Pit No----------I--------- Diameter-J&C-0..... Depthcftv t otal leaching area------------------sq. f t. . Z Other Distribution box Dosing tank ( ) r Percolation Test Results Performed by - ------- .P.. .................... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit_..________..._..... Depth to -round water.._._.--__.-_-.__._. - fX, Test Pit No. 2................minutes per inch Depth of st Pit-------------------- Depth to ground water__.._._.--_---_.___-.... . ;P1, -------- --- ----------­--- . .. (�!V---- --- - -----------------------------*---------------------------*------------------------------------- 0 Description of Soil--------4��>Aij�,.......... .......... ---------------------------------------------------------------------------------- -----------------­-- �4 _�-9--7 U --------------------- -------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable........................................ ------------------------ ----_-----_-- --------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is -d by the board of heal" Si ' d....... . . - . _= ---------------_------- ...rl, I.,,,t e ---------------------- pliance s been i ed by the board of j Si Application Approved By------------------ ... .......... -- --------- --- -------2 Date Application Disapproved for the following reasons:.................................... ............................................ --------------------------- ........................................................................................................................... ----------------­----------- ---------------------------------------------- Date Permit No. ................................. Issued.....3----—­- ;>dc' .. ................................. Date --------------------------------------------------------------------- i _ DIo TOWN OF BARNSTABLE 0 � ) VLOCATION 072 kiQ M d cn C' rc)c. SEWAGE# X - 199 d LLAGE L/Ucx n n;S ASSESSOR'S MAP&PARCEL 091 -- ,INSTALLER'S NAME&PHONE'NO. B -,R EX=Izal o SEPTIC TANK CAPACITY 1000 gcLJ LEACHING FACILITY.(type) C 2,) 7'rcnchc S (size) x 3 A 32 NO.OF BEDROOMS 3 OWNER PERMIT DATE:G J?Slj p 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 �? w Pion-) -Dwc 1 l;nct WA �� L2jO 1 TOWN OF BARNSTABLE jLOCATION v� P��w� .(�. �+,1�, SE WAGE# 11 —31� rf V'+.LAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. �� SEPTIC TANK CAPACITY . f5 LEACHING FACILITY:(type)L iv-,,%c-L,-v (size) �, ty NO.OF BEDROOMS OWNER tG�'. T' .� l� �x"��v� �y�►��v� PERMIT DATE: COMPLIANCE DATE: 51—.; 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 c . O O � � D .o Q � � a A O � F (5,7 j No......................... l Flms.. ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...;;�� ..........OF ..1:JP1.9--*a s-T�.1,.� ...................... AVVIirtttion -fur Biipuuttl World Tomarurtion Vrroiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ` ocatton- ------- Add or Lot No. a .._.413sP !M ..UT.9d------------------•--- Owner Address Sl .......... V ..................•.._.._..... . � Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........... .............................Expansion�ttic ( ) Garbage Grinder ( ) a Other—Type of Building ___ _ No of persons_____ __________ _________ . ........ .. ._..._.._........ Showers ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------------------------•-------------------------.-.-.,--,-,-,-�--l------------------------------------- W Design Flow................5_®--------------------gallons per person per day. Total daily flow..........�!0-__-___-____-_-_.--..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..h Gam______ Depth Q. aid _ _ ___________ Total leaching area------- it. z Other Distribution box ( ) Dosing tank ( ) `- / — 7 ~" Percolation Test Results Performed by------------- ---------- Date-_----•____________________._----..--.. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.------................. (I, Test Pit No. 2................minutes per inch Depth of ' est Pit.................... Depth to ground water:.....------__-.____-_ - - -------------- ........................................................................................................Description of Soil--.___°caml�l 1 :._.. _ _.x -- ---------------------------------------------------------------------------------------------------- V ------------------------------------ ---••------------•----•-•-••-•••-•--•••••••---•--••••'••--••-•-••-••'----------••••••--••--•--------•-............-------•----... ---------------- W V Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------. -----------------------•---•---•-•-----------------•-----.--------.----------------------••--------------------•---------------------..----.-----..--------------------------....---------------------.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ed by the board of hea C Signed--- .......• -.....•... --- •-- .. -------••-_------------- / Date Application Approved By--------------- - � �f _........ 2 �'�` . ...7 Z-- Date Application Disapproved for the following reasons--------------------•----•---------- --.................................................................... --•---•----•--- '-'---------------------------•-----------------...-------•-••---------•--------•-------••--••------------•--•--------------_----•-----------•----------------- .- Date Permit No---- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD , HEALTH ...OF.... .. ... .... ......................................... Trrfifirtttle of f-Hipp aurr T T C " IFY, That th In iviclual Sewage Disposal System constructed ) or Re aired P ( ) y -- -------• -- _ •`_.•------ -------- er ---------------- --- A-- - --- •-----•------------ --- -----.......................................................... has been installed in accordance with the provisions of Art I of e State Sanitary Code as esc�bed in the 11 application for Disposal Works Construction Permit No.�-.........1 --`�r_ .._.___.__. dated. .______-......_�..... .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................................---------- ................................. Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No. --oG FEES--........ il� >a ttl u k,l �t�tion prrotit Permission is hereby granted----------- - / . ................................................................... to Construct ( or Repair ( ) an ndivid 1 ewage D• poss3 SysT t at No. _ �f»-----0-1-,V +� / treet as shown on the application for Disposal Works Construction PermitAo_--- _ _____________ Dated--------;!f¢--en77___........ ..................... oa4... l DATE -•-------- --- F FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS TOWN OF BARNSTABLE !t' LOCATION ����— SEWAGE # Vr,.LAGE �Niv�� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of�luility) , Q Feet Furnished by —moo } i i l r / t � a ,I 6` Cz rp, (� 4 a 1 l'y vw .... a •, a /},. " I \\ /j I �\ /rj ,`_ ,s.. +' .mod+• a y♦"' - - F t2. ll4u,G LEVEL t ; 2� of TYVtCAL SEPTIC T*d,l{L ST-9-IbU_T'IONJ B01C_ y0T 7 0 ••,,CALF NOr TO SC..LE , i j Fir..,s�, G�IZvoa NAP 6s.a_odc ' Or - Ov KvL TAh," �_ {4K5_ O,/E� F I-r TOP oc �}�_ - r:•� - Lac~� � r 11rL. F. �?X5o I L, 1= � f'srs Aet C7C7C� rijl►L + ELe� - 9K4 I QE�.,sec�so �c ! I D 1 5T gOX V , O' I c o c • Ih . `'caUSN» 31�► -� To BE L_EV6L ►� ` `- - TAP., r_ r • I j'T r SY TIHE M PPOF near ro _scA.ug� _ _- _ M ,( •�. __._ __ i ,cam r i .c.o7- 27' LaT 26 coo2SE .$A N'D t /can`� L�.o a�cl�• • `? 72. i /4 3 6-• 1 - ►+. /4yq f ie,sT F/• E4 /.SW ° SA Al7> L 4„ �,� /QDd G"4G •r—�fit'' Q J�'f "'��`��; . t- A,;. Vol - (O io Ev e . 2/ 1WIlAl d H ��►� ;b"90,E � lwsPEG PA0G / IaRR�vy-.B.4e l• /3D• of N,, L7Al � _ _ 4•d0 141r9 M D E G Ile C L1,5 yy{ Woo IA C� S,Ew�� � SCALE OATS !MEET • r' - -" - ' C AAWN •V CHKO BY APM a �AM 1,1Q. � f i;. ACC' Nr-- - „�� ,,•.;4�� s,Y,�. ALL SHALL TEM SYSTEM PROFILE MARK DS WTHC MAGNETIC TTAPE OR BE NOTES PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS NAVD 88 Route 28 ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE �o m 2" PEASTONE OR GEOTEXTILE TOP FOUND. EL. 39.5' FILTER FABRIC OVER STONE 2. MUNICIPAL WATER IS EXISTING s Q c o n o 37.5' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 31-33' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. `ocCb PREcnsT H-�o NOTE: 2" MIN. WALL BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST ' RISERS TTH-1 THICKNESS REQUIRED PRECAST RISERS UNITS TO BE AASHO H-LQ 2'0 35.84 4"0SCH40 PVC MORTAR ALL H-10 .,.;,. 6" MIN. SUMP PIPES LEVEL 1ST 2' COMPONENTS 5. PIPE JOINTS TO BE MADE WATERTIGHT. o 12" MIN. INT. DIM. 4 (TYP.) 4' a� Hyo. E et ENDS SIDES 30.03 tr 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE Locu E/em. Sch. h St. t P N ." 10" "EXISTING 14" EE °° °°°FE 0 0 0;0 O .. o Q o 0000000o WITH 310 CMR 15.000 (TITLE 5.) rtegens or n 5 TEE SEPTIC TANK TEE *34.44' ®®� 00®® ao�a �o° ° ° ° ° ° WATERTEST D'BOX°°°°°°°°°°°° ' ° ° ° ° o o o o 0 0 0 o o o 0 0 0 0 ;°°° ° ° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND Mitchells GAS BAFFLE::` ° ° ° ° ° ° FOR LEVELNESS ci ���������'�- ���0��0�0®� °' °o°o°�°o°- >°o°o°o°o °o°e5°odo°o°o°°°° ��Q��OQ®®QQ ° NOT TO BE USED FOR LOT LINE STAKING OR ANY L t. 29.47' 29.3' °°°°°°°° °°°°°°°° 27.2 OTHER PURPOSE. , 1�5 th 5t ' LH--10 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ai Main 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL �o 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR West Moln St. St. Vo ALL AROUND PRECAST STRUCTURES e o 6" CRUSHED STONE OR MECHANICAL CONCEALED WITHOUT INSPECTION BY BOARD OF c� �� OVERALL DIMENSIONS TO OUTSIDE of STONE: 25.00' X 12.83' iv HEALTH AND PERMISSION OBTAINED FROM BOARD Pie o COMPACTION. (15.221 [2]) ,i OF HEALTH. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND VERIFYING THE OF ALL UNDERGROUND & 22.0' BOTTOM TH-1 OVERHEAD UTILITIO SA PRIOR TO COMMENCEMENT OF LOCUS MAP ( 12 % SLOPE) ( 1 % SLOPE) NO GROUNDWATER FOUND WORK. FOUNDATION EXIST. SEPTIC TANK 40' LEACHING D' BOX 12' FACILITY 11. ANY UNSUITABLE MATERIAL ENCOUNTERED NOT TO SCALE SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED LEACHING FACILITY. ASSESSORS MAP 291 PARCEL 189 *THE INSTALLER SHALL VERIFY THE **INSTALLER SHALL CONFIRM MINIMUM SEPTIC 12. EXISTING LEACHING FACILITY SHALL BE PUMPED LOCUS IS NOT WITHIN A ZONE II LOCATIONS OF ALL UTILITIES AND ALL TANK SIZE AT 1000 GALLONS AND ITS SUITABILITY AND REMOVED OR PUMPED AND FILLED WITH CLEAN BUILDING SEWER OUTLETS AND FOR RE-USE. REPLACE WITH 1500 GALLON LEGEND SAND. ELEVATIONS PRIOR TO INSTALLING ANY SEPTIC TANK APPROPRIATE TO SITE CONDITIONS I 99_ EXISTING CONTOUR PORTION OF SEPTIC SYSTEM NOT SUITABLE X 99.1 EXIST. SPOT ELEV. -[99]- PROPOSED CONTOUR 198.41 PROPOSED SPOT EL. TH1 36 } TEST HOLE 3y SYSTEM DESIGN: SLOPE of GROUND 32 GARBAGE, DISPOSER 1S NOT ALLOWED m UTILITY POLE CLE r� DESIGN FLOW: 3 BEDROOMS @ 110 GPD = 330 GPD FIRE HYt}RAnT p�14 C1 USE A 330 GPD DESIGN FLOWV NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING 3� �s rn SEPTIC TANK: 330 GPD (2) = 660 _ **RE-USE EXISTING 1000 GAL. SEPTIC TANK TEST HOLE LOGS 12q• ��� o LEACHING: CRAIG J. FERRARI, SE 13871 30-� SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD ENGINEER. # PROVIDE 40' OF 40 MIL LINER AT 5' / " BOTTOM 25 x 12.83 (.74) = 237 GPD DAVID W. STANTON RS OFF SAS IN AREA SHOWN. TOP AT WITNESS: ELEV. 30'. BOTTOM AT EL. 26'f 1 LOT 86 TOTAL: 472 S.F. 349 GPD DATE: 7/22/2016 `O 0 10 8 S.F. �29� h�2 O PERC. RATE _ < 2 MIN/INCH 5' REMOVAL OF UNSUITABLE SOIL REQUIRED 3g 00 USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) AROUND PERIMETER OF LEACHING FACILITY, 39 0 WITH 4' STONE ALL AROUND I 15108 DOWN TO SUITABLE SOIL LAYER. REPLACE o 0 CLASS SOILS P# WITH CLEAN MED. SAND, TO MEET 39 SPECIFICATIONS OF 310 CMR 15.255(3) ° n ELEV. � ELEV. �1 3, ° M ECK MA 0,9 33' p 34' ►�� EX;STING / APPROVED DATE BOARD OF HEALTH ' DWELLING TOF 39.5 FILL FILL B N M K - T P 0 B T M STEP. 2619 24" EL 8.3 � C1 C1 2j DECK TITLE 5 SITE PLAN FSL FSL 9 �� w OF CP 10YR 5/6 ' 10YR 5/6 54" 28.5 S\ 50 29.8 6 �� �o #17 HAMDEN CIRCLE 4.00 HYANNIS, MA C2 C2 `S� PREPARED FOR \ PERC �� 1 JANE CARTMILL CS CS DATE: JULY 29, 2016 10YR 7/4 10YR 7/4 \tA OF Mgss9c Va�O�A CF MIq off 508-362-4541 ti� /o� DANIEL �� ( fax 508-362-9880 DANIELA. s S s o OJALA ( A downcope.com CIVIL ' i OJALA � • • • 46502 No.40980� down cope ellg�neehft f, h7C. 132 22 132 23 °��`�crs �R °Fes 0 civil engineers NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' - -Z� FSS/'ONA ENG� � osuftv� � land surveyors 939 Main Street ( Rte 6A) iiiiiiiii ME ICE # > 6-22 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 16-227