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Home My WebLink About0190 HAMDEN CIRCLE - Health �90 'H �, amderi Circle �y 1 Hyannis 'P -A�,= 309, 244 I e i r� e j 0 S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22 2014 required for every Y Y , 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. Important:When A. General Information filling out forms on the computer, (� use only the tab 1. Inspector: key to move your VVV J cursor-do not David D. Coughanowr, IRS use the return key. Name of Inspector Eco-Tech Environmental „b Company Name P.O. Box 1265 Company Address West Chatham MA §�02669 rs City/Town State .,,Z Code 508 364-0894 1328 Telephone Number License Number � td� B. Certification x 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. Tfie insp tion 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 ��ytNOF ❑ Conditionally Passes ❑ Fails DAVID ❑ Needs COUGH NOion a Local Approving Authority WIR No. 2 Mi ? ° July 22, 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form: rf.ce Sewage Disposal System-Page 1 of 17 i r Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22 2014 required for every y y 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the,failure criteria enumerated in Section D on pages 4-5, or specified by local regulations. The scope of this inspection is limited to health and environmental ` compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. t 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 Sep i6�tan;'ks(w.hether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration?.1 taii'I�failure isk imminent. System will pass rrj�PQ r. , inspection if the existing tank is replaced with a c arnplying septic to ik,,as approved by the Board of Health. -° AWOMAi OU1,J0 �} *A metal septic tank will pass inspection if it is stru..curallyry,soundrngt leaking and'if a Certificate of Compliance indicating that the tank is less than 20 yearold{soya{vailable. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 1 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22, 2014 required for every Y _ Y 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 ❑ 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 M 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22, 2014 required for every Y Y 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. I . ❑ 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 '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 • I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Y Hyannis MA 02601 Jul 22 required for every Y , 2014 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 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 ;M 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22, 2014 required for every y y page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper•maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 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 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22, 2014 required for every y Y page. City/Town State Zip Code Date of Inspection D. System Information Description: System was installed by Mid-Cape Septic in 1997 Number of current residents: 0 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 Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 131 gpd Detail 2012: 53,112 gallons 2013: 42,639 gallons Sump pump? ❑ Yes ® No Last date of occupancy: about 1 year agoDate 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 a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is required for every Hyannis MA 02601 July 22, 2014 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: family of owner 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): Septic Tank and Infiltrator leaching system 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 �M 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul required for every y Y 22, 2014 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 16+ years. Certificate of Compliance for Infiltrator system issued 9/22/1997 (Permit#97-522). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 x 5 x 6- 1000 gallon Sludge depth: 8 in 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 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 July 22, 2014 required for every y page. Cityrrown 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 26 in Scum thickness 3 in Distance from top of scum to top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Disposal Works Permit Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping was recommended at the time of inspection. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22 2014 required for every -Y Y , page. City(rown 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.): 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 M 190 Hamden Circle Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is required for every Hyannis annis MA 02601 July 22, 2014 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No distribution box was indicated on as built card (town website). 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 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22, 2014 required for every y Y page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into the surrounding stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 8 inches below the top of the peastone layer. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22, 2014 required for every y y 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.): 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 CD �_O 3d]SNl •_ CD C, _ 41 CL CDCD W Q 7• . - CD W, a R RTRTf CD 42 o o o I ❑® o m m m CD *G zP D3 r, '"f 3 Q � , vim cn Q3 �D o m m ( mm m �. WATER LINE to cc,: 0 3 rn oAND V7 CD n -0CD _ O n 0 n 3 N (D O ? r�ao_, n _� 3 CD a) cQ eD �11 tnp Z CD -0 0 lb CD v, m C nCD 0 a m C lei� CD :3o 0 Q_ S. v O1J p cn CL ' o m nyz 0 � o °' ;, D ra o p'f a 0' < ■• O m -», CD co O rn � 0 o PAVED DRIVEWAY P O � o o< 3 m Iupu Cl) p N O 7 (D v. fV : CD � � � C mon CL D CD � co N CD 0 cn _ w co . wN — non a 0C' W ^ � o � _ N � rn " n N cn N o O aN � aZp � CD mo. - • . oho � 3 5. j- —o n -O 0 0 0Ei. = o 0 52. Do rn p c z CD COrn rn-i n N v N Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 July 22, 2014 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+ 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: Disposal Works Construction Permit#97-522 was issued by the town on 9/18/1997 ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: Town of Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 15 feet above adjacent Crooked Pond. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 190 Hamden Circle- Assessor's Map 309 Parcel 244 Property Address Claire C. DeBarros Owner Owner's Name information is Hyannis MA 02601 Jul 22 2014 required for every _y 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 GEOHYDROLOGICAL PROFILE — NOT TO SCALE i +, t. w 86TTOM + OF LEACHING GALLERY 'LEACHING IS ABOVE HIGH OAOUNDWATEA GROUNDWATER ELEVATION PER GIS MAPS t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 MAR 21.20033:i 3:39PM 8768UBURBAN i WCV (781)356-0100' NO.460 P.2/2 Town of Barnstable Health Department 367 Main Street Barnstable, MA 02601 Attn: Tom McLean Mardi 21, 2003 Re: Septic system at property owned by Claire DeBarros at 190 Hamden Circle in Hyannis Dear Mr. McLean: This is to inform you that I have examined the septic system at 190 Hamden Circle in Hyannis and have found the following: 1. Per records on file at the Barnstable Health Department, a new system was installed at this address in September of 1997, permit#97-522. Records show the system is sized for 3 bedrooms. 2. I inspected the septic tank and found that it is not leaking and bas baffles in place and functioning properly. 3. 1 exposed the line leading into the leaching facility and stone surrounding the galleries and found it dry with no evidence of backup. 4. Per the Health Department there is sufficient distance between the bottom of the leach facility and adjusted groundwater for compliance with Title 5 regulations. If you need further information, or if a compete Title 5 inspection is required, I can be contacted at 508-962-3145_ Sincerely, David J. B ie Licensed Title 5 Inspector McKean, Thomas From: McKean, Thomas Sent: Friday, March 21, 2003 1:35 PM To: Mcauliffe, Paulette Subject: RE: 190 Hamden Circle Hyannis/Claire DeBarrows F.Y.I. On January 23rd, I received an application today to add a bathroom and a kitchen in the basement of her home. The owner originally believed that her home was connected to town sewer; however it according to the DPW, town sewer is not available there. She hired Wind River Environmental Company to inspect her septic system and to prepare an 11 page report, as required by Title V the State Environmental Code. The septic system passed inspection. The report should be ready on Monday. In the meantime, I have no objections to her proceeding with this application. 1 o� �4Y '6 N O x n Shm i t EiHffl Uq Ct i t _ r• c s . z ti , TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A " CERTIFICATION PAK�E-L Property Address: 190 Hamden Circle LOT 4. Owner's Name: Claire DeBarros Owner's Address: Same Date of Inspection:3/21/03 -iD Name of Inspector: David J. Burnie At R Q 1 2003 Company Name: Wind River Environmental Mailing Address: 120 Great Western Road TOWN OF BARNSTABLE South Dennis,MA 02660 HEALTH DEPT. Telephone Number: 508-760-4827 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 ` (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 22 Inspector's Signature: Date: J The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection.and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection:3/21/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection:3/21/03 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection:3/21/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/Z day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection: 3/21/03 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _X_ Has large volume of water been introduced to the system recently or as part of this inspection ? _X_ _ Were as built plans of the system obtained and examined?(If not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components, excluding the SAS,located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No _X_ _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection:3/21/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_NA_ Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents:_1 Does residence have a garbage grinder(yes or no): No_ Is laundry on a separate sewage system (yes or no):_No_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No_ Water meter readings,if available(last 2 years usage(gpd)):_2001 ,7,000 Cu Ft. 2002, 5,400 cu ft. Sump pump(yes or no):_No_ Last date of occupancy:- Current-COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records 9/22/97 Source of information:_Barnstable Water Pollution Control Was system pumped as part of the inspection(yes or no):No_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information:_New leaching in 1997_Permit 97-522 Were sewage odors detected when arriving at the site(yes or no):_No OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection:3/21/03 BUILDING SEWER(locate on site plan) Depth below grade:_24"from top of foundation_ Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_20+ Comments(on condition of joints,venting, evidence of leakage, etc.):_Lines appear to be sound with no evidence of leaking SEPTIC TANK:_C+D_(locate on site plan) Depth below grade:_9"_ Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_1000 gallons Sludge depth minimal Distance from top of sludge to bottom of outlet tee or baffle:_2+'— Scum thickness:_0-2"_ Distance from top of scum to top of outlet tee or baffle:_9" Distance from bottom of scum to bottom of outlet tee or baffle: 9" How were dimensions determined:_Probe 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 appears to be sound,levels normal, no recommendations for pumping or repairs at this time GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): f OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection: 3/21/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_NA_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection: 3/21/03 SOIL ABSORPTION SYSTEM(SAS):_E_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ _X_leaching chambers,number: (4)4' plastic flow diffusors. 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.):_Conditions appear to be normal,exposed stone surrounding diffusors and found it dry with no evidence of backup_ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): i PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection: 3/21/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. L Q A CZz OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 190 Hamden Circle Owner: Claire DeBarros Date of Inspection: 3/21/03 SITE EXAM Slope Surface water none Check cellar dry Shallow wells none Estimated depth to adjusted ground water_9.71 feet from bottom of SAS Please indicate(check)all methods used to determine the high ground water elevation: —X_Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) X_Checked with local Board of Health-explain: Checked water table maps and adjustment figures on file Barnstable BOH Checked with local excavators,installers-(attach documentation) _X_Accessed USGS database-explain:_USGS groundwater monitoring well information_ You must describe how you established the high ground water elevation: Ground elevation at SAS site is 38' ASL Groundwater level per groundwater maps Barnstable BODH is 21.49 Bottom of SAS is Approx 3.5' below grade Adjustment figure for Maximum potential high groundwater is for Well MIW 29 Zone C=3.3' 38—(21.49+ 3.5 +3.3 ) Town of Barnstable ° a Health Inspector Office Hours Regulatory Services 8:00—9:30 Thomas F.Geiler,Director 1:00—2:00 IAMSTABLB, Only MASS. Public Health Division ArEo�� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT QUESTIONNAIRE 1. General Information: Address: d gGe�d/ ( /�AW;,Map3pq _Parcel a z1'1 — Name: � ¢_ „ � �O� Phone: 2a. How many bedrooms exist at your property now? o 2b. How many bedrooms total are proposed at this property(including the amnesty unit)? 2c. Please include a copy of the floor plans for the entire property. 3. Is the dwelling connected to public sewer? ES2 or NO If the dwelling is connected to public sewer, skip 4-9 below. 4. Location of dwelling is INSIDE or UTSIDE Zone of Contri ution Upubli supply wells? 5. Is the dwelling connected to an ONSITE WELL or PUB WAT o 6. Is a disposal works construction permit on<acing S or NO X 6a.If yes, how many bedrooms were approved to this permit? - cu Bedrooms. - r-- 7. Were any building permits obtained for construction of additional bedrooms? YES o NO 8. Is there an engineered septic system plan on file at the Health Division? YES or 9 the septic system been inspected by a DEP certified inspector within the last two years? YE or NO FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INSPECTOR/AGENT ONLY The Public Health Division has no objection to 3 bedrooms at.this property. Signe Date: Inspector(Print): Q;1health/wpfiles/amnestyapp LOT 60 LOT 61 UI?AI,V EASEM T 8 5 { S81 5 I POND L 07` 64 cz� LOT G,& c v� NOTE` SHED APPEARS r •h'\ ` J3 M HE O IIER .LOT LINE .{ W 0 ` � 'd 4� r q LOT 63 ��0y 'o 5 � ��•.L 80• 0" .HAMD_ IV RES. ZONL'. 'R-I3" This MORTGAGE I3�SI'ECTION Plan 36 For FLOOD ZOXF-- "0" 7REGISTRY OWNER: MARS�- AMEN — — —_ -- TOWN: A.4 — - SAL EF: -. L' T L2ffl5 —BUYER: _CLA E D Ah 1S� CA[.�E:S 30 -----1'1 I �1' tilt+ ut ' CER'I'lF'Y TO 5 :�1� f ' 1_CQ( 1, ,: __• -- EA '� Y �Ni�I�}: Sl_ [2\ 'TI?C: I?h?1.1}ING .'1; THIt PLAN IS I.UCAT)rD ON THE GROUVI] Ati �" I ' ��N'�'ND THA'r ?TS POSITION DOES _ CUI�I'ORbf O�R17>HE� ? 40B INDUSTRY ROAD ZONING LAW SETBACK REQUIRE 1BTS OF THE � (tI MARSTONS MILL-9. �tA. 02D4!! I�f'�,'�r�TRBI��-_ ------------AND THATt'UT rEL: 428-0055 �_—_.. LIE �VITHIN THE SPECIAL FL 011� ��ZARD ' .I20-555:3 SHOW\ Obi THE li-li.I}. MAPLAN �c%T 1t,1!)1C.�`.t0.1 AN 1NSTit. .. ENT �19,3 (V 1'OR rrNCES, ETC 7 McKean, Thomas From: McKean, Thomas Sent: Thursday, January 23, 2003 2:55 PM To: Mcauliffe, Paulette Subject: 190 Hamden Circle Hyannis/Claire DeBarrows F.Y.I. I I received an application today to increase the number of bedrooms from 3 to 4 at the above referenced address. The owner originally believed that her home was connected to town sewer; however it according to the DPW, town sewer is not available there. I then telephoned the applicant and requested her to hire a DEP certified septic s stem inspector to inspect her septic system and prepare an 11 page report, as required by Title V the State Environmental Code. t 4 1 TOWN OF BARNSTABLE LOCATION r 9 o L •�6 r�'�' i SEWAGE# " 51 � VIfLAGEa'sa ASSESrS�OR�'S:MAP& LOT`' INSTALLER'S NAME&PHONE NO. f - SEPTIC TANK CAPACITY v . LEACHING FACILrrY: (type) (size) � � NO.,OF BEDROOMS BUILDER OR OWNER C 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet Within 300 feet of leaching facility) Furnished by CT TOWN OF BARNSTABLE LOCA' ION SEWAGE # / ' or%L VILLAGE ASSESSOR'S MAP & LOT Dr INSTALLER'S NAME&PHONE NO. l SEPTIC TANK CAPACITY Q,L► /D O O LEACHING FACII.TTY: (type) _�Qp lei (size) L 6 ti►�:e NO.OF BEDROOMS BUILDER OR OWNER A { PERMTI'DATE: - 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 leaching facility) Feet Furnished by .. r - • r a'r� t , No. ' b Fee C s T E COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Tipprication for Dig;pozal *pgtem Cougtruction Permit Application for a Permit to Construct( )Repair( [Jpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. k-1 o +tj 64-t .• py h? err's Name,Address and Tel No�, Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �, 7�-Obi`{ Designer's Name,Address and Tel.No. &-�?e S k, iv r3ad-e,� Rem., N��.ti;s Type of Building: Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building a No. of Persons Showers( ) Cafeteria( ) Other Fixtures r,� Design Flow 112 0 gallons per day. Calculated daily flow 3`Ac I gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ( ,,-V\q I av-v Type of S.A.S. Description of Soil 5 Nature of Repairs or Alterations(Answer when applicable) "l iv 40 l i —:r. W csJ 1 t 5 T� 4 c I t� �...�a.� 21 C✓L � a�c+n 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 no to place the system in operation until a Certifi- cate of Compliance has been issue d of Signed Date Application Approved by Date Application Disapproved for the following reasons o. Date Issued c" —�`• — l � •.• ��,j. 4,i` �f _ . r _ ,+�FN:.�" v r ._._.' .. ... -".^.WW�..v-.. � sf - -1'.r..". #iY.^-{,. + =� f No.- j 'R Fee . T E COMMONWEALTH OF MASSACHUSETTS Entered in computer: _ Yes PUBLIC HEALTH DIVISION.-TOWN OF BARNSTABLE,MASSACHUSETTS - Zipplication.for Migoar 6p$tem Construction Permit\ Application for a Permit to Construct( )Repair( Upgrade( )Abandon,,( ) ❑Complete System ❑Individual Components ` Location Address or Lot No. 4'10 {'jNM N 4�.8��. j jy ,,Q yer's Name,Address and Tel.No�, Assessor's Map/Parcel ^� (4 \t`C 4 Lgf 1(-1 CT! �► Q'�t Installer's Name,Address,and Tel.No. �. C—�7?-06?q Designer's Name,Address and Tel.No. 4-Y\�� -CC,-e 0- S*. i 2.J (3a tx- �0�� yLv\h i S Type of Building: Dwelling Na., of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building e5" kt No.;of,Persons Showers( Cafeteria( ) Other Fixtures € Design Flow ��Q gallons per'day: Calculated daily flow 73(Aq gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank X t S t`hA S t, c��'Z7 Type of S.A.S. 4,- Ce` C r Description of Soil �4 h.}' j tot "O y,� r 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 Certifi- cafe of Compliance has been issued lei - d of Signed - Date - l Application Approved by Date Application Disapproved for the following reasons C Permit No. Date'Issued r ------------------ — ---------- ------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( V Abandoned( )by so_OA- C__ at has been constructed 'in laccorda ce with the provisions of Title 5 and the for Disposal Syste m onstruction Permit No, r 9-0- 7-dated Installer Designer The issuance of this t h 11 not a construed as a guarantee that the syste will function as designed. D pe.ate T . w Inspector 1 f Y� No. �,1�'",�s � -------------------------Fee ,. . THE COMMONWEALTH OF MASSACHUSETTS t PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wisposaf *poteT Construction Permit Permission is hereby granted to Construct )Repair Upgrade( )Abandon( ) System located at O a CA O Ah C.��de, L& "-V\11; S and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this Oe it. Date: `� �� Approved NOTICE: This Forin-is-to--I)e-tised-for-the Repair of hailed • • `�'� Septic Systems Only CI:K�'IfICA'I'ION UC SKETCH AND APPLICATION FOR A DISPOSAL IVOIU6 C UNS'I'IWC7-IUN I'1�IZ�911'(1V1'I'IiUU'I' DESIGNED PLANS) NS) �e, hereby certify that the application for disposal works construction permit signed by me dated —� C1�� .eottterning the property located at RO � AL D� C( tmeets of the following criteria: t/ . Thcre arc no wetlands within 300 feet of the proposed septic system V • Thcre are no private wells within I50 rector the proposed septic system r) . The observed groundwater table is 14 feet or greater below the bottom of the leaching facility V . There is no increase in now and/or change in use proposed " • There are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I .\ f k' 1 1 V V `sF�VI ;1 .. � {. _ ��41,_ h r. r L0C-A'T' -0N SEWAGE PEPIT NO. zhl- .mV111_hcA E INSTA LLER NAME S ADDRESS BUILDER OR OWN R r _� �/' r'��_ _►mil��?�l�G•G�J DATE PERMIT ISSUED Z�4 DAT E COMPLIANCE. ISSUED y ZT AP) G O � 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD 0/,f HEALTH Application is hereby made for a Permit to Construct or Repair an Individual Sewage Wiosal ... . ........... ------L_r It.1.../V.. ........ ........................................... 71-1..................../ Ow At i r Type of Building Size Lot../e_q_3,__0------Sq. feet Other Distribution box Dosing tank 3 d-?(I -------------- 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 ugrees-ummy6cethe system in operation until Certificate of Compliance hhas been suedd boy the board of Ith. 7 Ig Date Application Approved D __^��_��___- o"� � Application Disapproved for the following reasons:............................................................................................................... ........................................ ------------------------------------------------------------------------------------------------------------------------------------------------------.......... Date - ' PermitNo.........................................-------------- Iouued--_----_—_'_-__-_-_ Date No..---•-••--•-------4 FEa........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ? _.._..._... U /. OF.......... . ... .t.L�h .......................... .................... I Appliration -for Diupuuttl Works Toms# urtiuri Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal Syst . ..................r. ........ ---cl�................................................... -,N:. .........# jjLocation Addr Lot No. W � Ow r Addres Insta er Address Type of Building Size Lot._ -f_3. ...... feet I--. Dwelling—No. of Bedrooms-----------,,----------------•__-__.-___'Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building _________________ p ( ) ( ).......__,. No. of ersol>s.______ Showers — Cafeteria --------------- G4 -Other fixtures --------------- -------------- W Design Flow........ ......... ..............gallons per person per day. Total daily flow--------- -------------------gallons. WSeptic Tank—Liquid capacity_ gallons Length---------------- Width................ Diameter_-_.__.._...____ Depth.__.._.___.__... x Disposal Trench—No- ____________________ Width...... ------------ Total en th----------------------- Total leaching a ___._sq. ft. Seepage Pit No_______ ___________ Diameter f_. ._.._ Dept1 ' _,--------- C chit ---------sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by----------- -----•--- ---------------------------------------------------- Date------------------------------------.... Test Pit -No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water....___.___..__.._.-_-- fs Test Pit No. 2----------------minutes per inch Depth of Test Pit..................... Depth to ground water--___._____-________.... 04 ------------- _ .............../------------------------------------------------------- ------------- 0 Description of Soil------------------------ 4..` ..._..._ :..------------------------------------------------------------- I 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 issued by the board of alth. t { /1 7/ -- Si Tied----- •. - ---------- - `/ i Date Application Approved By-- � `'� " - ..-% 1�� '11 ------------------------------- --r�.%�y'.7. -�--------- Date Application Disapproved for the following reasons_______________________ -•---•--•-------•--------------------------•-• --••----------------- -----•-------- ---•--__.-•-----------------•---•-•-•-----•-------------------•-------------•-•-•----•-----------------"------------------•----•----------------------------•--------------------•...---•--------------- Date PermitNo_...................................................... Issued....................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ` 1�(........OF................. ........................................................ Trrtifirate of 10.11uutpliatta THIS IS rO (AERTIFY, Tharlhe'Individual Sewage Disposal System constructed ) or Repaired ( ) by n,1. :• ' ..- --- ---------------•--•. --•- ----------••......---••--•-- -- = 'j. -------------- . � �" at......... t! !� //!G(iY.%vt b jfid- ( I�Vke .r. ---••-------- - % ha�heen installed in accordance with the provisions of rticle 1I o/�h e State Sanitary Code as described in the application for Disposal Works Construction Permit No�..1- ...d1 dated..l_-_1.y-_-%_7.,_..........._.._. THE 'ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE® AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... .......Z.7........... ._OR.......... Inspector----0---___c. THE COMMONWEALTH OF MASSACHU TTS BOARD O" HEALTH OF ................................................... No......................... FEE---' .............. �i��u�ttl f ,urk� �uu o�tiutt �rrmit Permissions-hereby granted____Zl�r _ -..._._ to Construct (( ) or R pair ( ) an Individual Sewage Di osal,System� ' at No._ st / v r. " �' S 7< _ 7 v Street ' /,! 7/7as shown on the application for Disposal Works Construction Permit-No------- _ ______ Dated_��_-.._.__._:_�______....____....___. �;- It == �.,_.;_ .c�1i.�. L-- . Board"of Health DATE. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS __._ I 1 O