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Commonwealth ofMassachusetts
Title 5 Official Inspection Form -
.l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f
45 Hampshire Ave I ;
Property Address
Shayam Kumar
Owner
Owner's Name
information is
required for every Hyannis / MA 02601 5-10-19 -
page. City/Town State Zip Code Date of Inspection 1-
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.
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A. Inspector Information 88zo
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services '
Company Name i
P.O. Box 73
Company Address l
E. Falmouth 'MA 02536
City/Town I State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification i
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was'performled 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:
1. ® Passes I
2. ❑ .Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
i 5-10-19
I spector's Signature i "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 o j ly 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
I'll Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town 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't
® 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 good working order with no sign of failure.
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.
*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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
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Commonwealth of Massachusetts
Title 5 Official ial Inspection Form
Pi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� I
45 Hampshire Ave I
Property Address
Shayam Kumar
Owner Owner's Name
information is i
required for every Hyannis MA 02601 5-10-19
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
pumps/alarms are repaired. -
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❑ 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 El ❑ ND (Explain below):
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❑ obstruction is removed El ❑N ❑ ND (Explain below):
❑ distribution, box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
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❑ 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 pips (s) are replaced ❑Y ❑N ❑ ND (Explain below): i
❑ obstruction isremoved ❑Y El ❑ ND (Explain below):
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3) Further Evaluation is 1 equired by the Board of Health:
El 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 thle system is not functioning in a manner which will protect public health,
safety and the environment:
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6 Commonwealth of Massachusetts
r� 3 Title 5 Official Inspection Form
01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is Hyannis MA 02601 5-10-19
required for every
page. City/Town 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.
f ❑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
El ® 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
Commonwealth of Massachusetts
rill rw Title 5 Offi'cial Inspection Form
N Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
�t� I
45 Hampshire Ave I
Property Address
Shayam Kumar f ,
Owner Owner's Name I
information is required for every Hyannis MA 02601 5-10-19 .
page. City/Town j State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
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Yes No
❑ ' ® '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 Y2 day flow
El ® 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 water supply
well.
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❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50feet
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.]
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❑ ® 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 C.4.
Yes No
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❑ ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
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 aH 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?
® 0 Wasthe 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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
r Commonwealth of Massachusetts
Title 5 Official Inspection Form
r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: t
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 1
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 years usage (gpd)):
Detail:
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Sump pump? ❑ Yes ® No
Last date of occupancy: •- " 5-2019Date
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
��i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town 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: Town----pumped 2017
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: New system
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` �rf
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town State Zip Code Date of Inspection r
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:
2017
Were sewage•odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
_
Depth below grade: 1211feet
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.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 6" Both
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: 2-1000 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 151-
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both tanks in good condition with baffles installed and no sign of leakage.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
B. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar .
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town 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.):
Good condition with water at working level and no sign of back-up from trenches.
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
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Commonwealth of Massachusetts
a� w Title 5 Official Inspection Form
i-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
Property Address
I
Shayam Kumar i
Owner Owner's Name
information is required for every Hyannis 1 MA 02601 5-10-19.
page. City/Town State Zip Code Date of Inspection i
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: El Yes ' El No*
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Alarms in working order: ❑ Yes ❑ No*
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Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
I,I - ,
* If pumps or alarms al,Ire 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:
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Type:
❑ leaching pits " number:
❑ leaching chambers number:
❑ leaching)galleries number:
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® leaching trenches number, length: 2--2x2x50
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❑ leachinglfields number, dimensions:
❑ overflowlIcesspool number:
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❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ibl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
``' 45 Hampshire Ave
Property Address,
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City(Town 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.):
Trenches in good working order with no sign of failure.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert i
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Fora
o.i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
J Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
- I
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
?�
Iw�'
pi Subsurface Sewage Disposal System Form Not for Voluntary Assessments
f � rrr
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
!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
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Commonwealth of Massachusetts
pt Title 5 Official Inspection Fora
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Ham pshire Ave .�s.
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
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 high ground water: 12
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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i°► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
45 Hampshire Ave
Property Address
Shayam Kumar
Owner Owner's Name
information is required for every Hyannis MA 02601 5-10-19
page. City/Town State 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 4 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
t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of,18
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Town of BEWnstable P# 1 S3o2 q
' Department of Regulatory Services
naat4 F Public Health Division Date i 'H
rwMARS
eAM
j, �a39 200 Main Street,Hyannis MA 02601 j
tEft
Date Scheduled Tuna /
Fee Pd._
a
Soil Suitability AssesSment for Sewage isposal
�f - Z�92
Performed-By.-_ Witnessed By:
LOCATION&.GENERAL INFO
Locedan Address Owner'_Nam_ N
Address D
Assessor's Map/Parcel: <30 9 — z, Engineer's Name C�
/
NEW CONSTRUCTION REPAIR T_le hone# _S 7 3GaC1
v
Land Us_ �� �� Slope(96) �� Surfhce Stones ;Cx� • _ -
!3 w
Distances flum: Open Water Body R Possible Wot,Area {t Drinking Water I clw x�$
4 U
Dralhage WayAE 20fS •--'l{f Property Line Other I $
i
L910TCHC(Street name,dimensions of lot,exact locations of feet halos&pore testa,locate wetlands 1'n proximity to holes)
N
yjavv �� b
X)
V
4
_ I
�Z _ y
ZI _
I::j .
Parent material(geologic) G av&z �/t /!� /44w( Depth to Bedrock
Depth to Groundwater. Standing Water in Hole:- > Z Weeping iYarl Pit Fnoa �{'X
Estimated Seasonal High Groundwater > I
DETERMINATION FOR SEASONAL'IIIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hoc: �4 _In, �✓lQ _
Depth to call mattlarl
Do th t weeping from side of b .bolo: I- In, Groundwater usttdent
Index Wall-# Reading Date: _ B� Index Well ImVol /1� Ar��•thetbr ArQ.grtlun'dwatm Level I Z
PERCOLATION TEST Dais 19 d
Observation
Hole# Time at D"
Depth of Pow ��/ Time at 61'
SartPro-soak Time @ �� ' lJ 7t, Time(9"•6")
End Pro-soak
Rate MCn./lnoh �• l
Site Suitability Assessment. Site Passed Sitp Failed: Additional Testing Noeded(YIN) /w
I
Original: Public Health Division Observation Hole Data To Be Comploted on! ack
If percolation testis to be conducted within 100 of wetland,you must flrst notify the
Barnstable Conse.Tvation Division at least one(1)week prior to beginning. i
Q:1SEPTICIPERCFORM.DOC
i
DEEP-OBSERVATIONHole#HOLE LOG .
Depth from Soli Horizon Soil Texture Sdil Color Soil. Other
Surface(in.) (USDA) (Munsell) Mottling (Stnueturo,Stonei;Boulders.
_ y isistenr<y.g'Oravall
• A ��� � ?s�� v��ah� t D,Y/z 4/3
O ;
uz�
Z� Y
DEEP OBSERVATION HOLE LOG Hole# �3,4
Depth from Soil Horizon Soil Texture Sall Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
7S 2
A/'11CY
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Sall Other
Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.,
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Sall Texture Soil Color 81311 . Other
Surface(Ia.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
Flood Insurance Rate Man:
Above 500 year flood boundary No— Yes z ;
Within 500 year boundary No Yes
Within 100 year flood boundary No.,,-- Yes
Denth of Naturally Occurrine Perylow Material
Does at least'four feet of naturally occurring pervious mtiterlal exist in all areas observed thrpughout the
area proposed for the soil absorption system?If not,what is the depth of haturally occurring pervious material?,.___._....._....
Certiflcation
I cordfy that on ° '9 (date)I have,passed the soil evaluator examination.approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required tra xpertise a nce described in�10 CMR M017.
Signature Datb ,
Q,\!kRf TI0PHRCPORM.DOC
TOWN OF BARNSTABLE -7
LOCATION LDS��Yw j r�i (�V`e SEWAGE#
1'1✓l I.s ASSESSOR'S MAP&PARCEL O
VILLAGE h,yI Le
(�1 �
INST�LER'S NAME&PHONE NO. r 11%S Or'n'`e 6 Cal Sd' Sot-3 -6a3'
SEPTIC TANK CAPACITY lm aA 6-,ST-, 9xisT A-0— ;
LEA 1 HING FACILITY:(type) �Z-/2-C PG Pe (size) a Sa F/4d)
690
NO.OO F BEDROOMS ;5-MNE 44A;
OWNER cicE,(
PERM' IT DATE: S COMPLIANCE DATE: .
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Welland Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet)
Edge p f Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURI.IISHED BY
�r- RacPsc/ A
�6
r
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r
No. 4/ Fee ® 6
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
9pplication for Misposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. '3�-`� G ywner's Name,Address,and Tel.No. SO w
a �'�7 lYl *4b, ��� I.l aua& J j"'IT-1 �� O SN,$
Assessor's Map/P el --.-V-If
Installer's Name,Address,and Tel.No., Designer's Name,Address,and Tel.No. —36
1Kl"s A aid CryhS'� 19A S'4rvv
Type of Building: S lv��y
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
qyq
Design Flow(min.required) ® gpd Design flow provided 7 7 gpd
Plan Date Number of sheets ot- Revision Date
Title J—
Size of Septic Tank "' 10 00 U 15�` Type of S.A.S. a wfpA V,S'Q O L-�4G1t 1 f'�"
Av,Description of Soil �,�p Spy9 (tom
Nature of Repairs or Alterations(Answer wher_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.
igne Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. � Date Issued
Fee
—7 Y
NO. / r
/
`11 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplicatlon for Bisposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( )> Abandon-( ) ❑Complete System ❑Individual Components
c..
Location Address or Lot No. '3c 7 0 ?wner's Name,Address,and Tel.No. 5016
Assessor's Map/Paf'csel 1 /�S�►r%`f �;., ,. ti t-o! C/I l-l-f �_/ ) �J C)f,ri 5 to c wl,
Installer's Name,Address,and Tel.No.S Designer's Name,Address,and Tel.No. - ' -' 36/1
11 �� (jcor,4_6 Cc.1S) I 2
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures /J
Design Flow(min.required) `q`7/o gpd Design flow provided �7� gpd•
Plan Date n o , t I 1_ G Number of sheets •- Revision Date
U �
Title
Size of Septic Tank _ 10 00 ! Type of S.A.S. ? �• d.jG 4 C ,` L
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
t
r4 Compliance has been issued by this Board of Health.
} Signed lA Date 5 /l
Application Approved by Date 5/ �A
j Application Disapproved by Date
4
1 for the following reasons
Permit No. p/2 Z-3 Date Issued leb I
----------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
f BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
at I cr,"I i'51 � �� � �l L�'� has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No,9C�- /3 dated
Installer !- 4 0 O'o ! cc s i, Designer 1n (15 SA( ti
#bedrooms 4 Approved design flow n and
The issuance of this permit sha)1 not be iAstrued as a guarantee that the system ill I nc'o52 de ' ed.
Date Inspector
t ----------------
No. O "� 13 iD Fee /0 c
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Nsposal *pstem Construction 3pPrmit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at
Y f
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:Construction must be c mpleted within three years of the date of this permit.
Date h�, �'7 Approved by L w-•�...._ .._.,
Town of Barnstable
Regulatory Services
Richard V. Scali,Interim Director
•nxxsrnHt.E,
M�163 Public Health Division
9•A��
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
i
Date: '20'l7 Sewage Permit#:::A � Assessor's Map\Parcel C��-ozs 7,4
Designer: �cSv�Z 1��`� � Installer: 1 j 00!�
Address: 2 Address: z
1 A�f 75
On �' 8' 6" S' was issued a permit to install a
(date) (installer)
septic system at �i ��/�{��� /yb� based.on a design drawn by
(address)
,407W /G�¢��?-+� dated
-__ - -t- - -- ! -
esgner)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and .the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater.than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed i, . liance with the terms
of the IAA approval letters (if applicable) 3, �►i OF kgss9
DAVID �yG�
e' O D.
U FLAHERTY JR: � -
I taper's Signature) No. 1211
�FG/STEREO
'9NITAR\PN
(Designers Signatur ( ff Designer''s Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU. ,
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
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AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION !�/5 t,14 M'aSA1,,� )dUf SEWAGE # �
VILLAGE j't�{K�, (�i S ASSESSOR'S MAP Cr LOT50 -
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY Q aj+a��VV SrZ
LEACHING FACILITY:(type) .S-M �:I L�TV6a VOQS (size)
NO. OF BEDROOMS C5 PRIVATE WELL ��e'�E.ORt--
BUILDER OR OWNER rN
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: a-
VARIANCE GRANTED: Yes No
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=309025&seq=1 3/13/2017
l'0: ON: SEWAGE PERMIT NO.
VR_LLAG
1. S LLER'S NAME i ADDRESS
I U I L D E R OR NER
i
DATE PER ISSUED
DATE COMPLIANCE ISSUED /o
1
I
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TOWN OF BARNSTABLE
LOCATION aSAt., SEWAGE #
VILI:AGE � r`f��rM1Cd S ASSESS MAP & LOT
INSTALLER'S NAME & PHONE NO..
SEPTIC TANK CAPACITY
I� .LEACHING FACILITY:(type) -T"1Y Ff LTraToVS (size)
1Ri_i[`
aArfR
` NO. OF BEDROOMS c9 PRIVATE WELL O- - --
• I
N BUILDER OR OWNER .
DATE PERMIT ISSUED: - �-
DATE COMPLIANCE ISSUED: __ -16
QVARIANCE GRANTED:•;Yes,... J No ��
o�
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M1
q
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1
Nog y':�....2....3. Fmc.......I.. .............
�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ZF HEALTH
r!" E ............OF.....
..
Appliration for I)Wpoiial Vorkg Tomitrurtiun rautit
Application is hereby made for a Permit to Construct ( ) or Repair (Z-1"'an Individual Sewage Disposal
System at:
9
---------------------------------------------------------------------------•------------•-------
eLocation-Address �.....- --•---• -•-•-------------or.Lot No.
�--.................................................. ....................................................
Owner Address
5 �-•-•-----------•-•------•-----------
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.__.................................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
W . 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 Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.........--......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
_.. .�.. Percolation Test Results Performed by----•--------------------•----•-•-•••-••---------•-----•-•-•-••--••-----• Date........................................
�u
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
............................................7................................................... --- -... !...............................�y
Description of Soil•-•••� an" .........c,.,P- .......l-Y• �*r'^..... - '......0......
W
V Nature of Repairs or Alterations—Answer when applicable.__-_ w..••-___�ig. ---------- ......%
Uac�_..---------•------------•-----------------•--•-------------....----------------------------------------•-----------------------------------••-•-•-......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI'= 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i ed by the board of health.
Signed...... .. ..... -•--- ....... �/1....
Application Approved By............. . ..... . ... -•-•-• .......................... J�......e
Date
Application Disapproved for the following reasons:..............................................................................................................
.......-••--•-••-•----•....•-•-•--•---•••---•-•••---•-•------------•-•-•------------------•----...........--•••••-••••-••--•--•••------•-•••-------•-------•-••-•-•-••••• ........... ............
Date
PermitNo......................................................... Issued......................................................
Date
.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
...... .........OF.... .. ........................
Appliration for DiAposal Works Totutrurtion thrmit
Application is hereby made for a Permit to Construct or Repair (4-j"'an Individual Sewage Disposal
System at:
......... .P�.'e. ..................................................... --------------I.....................
Location-Address or Lot No..
ZOwner... .........
Address. . ........................................... ................................................ ..... ------------------ ---------------
Installer Ad'diress*'.
Type of Building Size Lot.—.........................Sq. feet
U Dwelling—No. of Bedrooms.._2
...........................................Expansion Attic. Garbage Grinder
P4 Other—Type of Building .............I......... ..... No:' of persons.....__.._...........:_._... Showers Cafeteria
Other fixtures
Design Flow............................................gallons per person per day.,Total daily flow............................................gallons.
04 Septic Tank—Liquid capacity............gallons Length__::.:.......... Width.-.............. Diameter---------------- Depth.....__..._.....
Disposal Trench—No..................... Width_............_...... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No..................... Diameter___......___.__..... Depth below inlet._...._............. Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.................................. Date........................................
---------------------------------------
Test Pit No. I................minutes per inch Depth of Test Pit__.........__....... Depth to ground water........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit___.............._.. Depth to ground water.-.__._.._......._.___..
............................................. �'f..................................... 7..Y....... ............. .... . .......
0 Description of Soil---- ....... ........Z� .......... ..... . ---
U ..........................................................................................................................................I........................ ........
.......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...Zr..Ov-------;P,.4/........ ......
...........4.�......... jP.........................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Coridpliance has-been i ued by the board of health.
, 'Jer.
Signed_----- . . ...... ..... ... ...... ...... ......
r
Application Approved By......... "Ir...................
Date
Application Disapproved for the following reasons: .............................................................................................................
..............................................................................................................................7--------------------------------------------------------------------------
Date
PermitNo......................................................... IssuedL.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.. 0 F.le.5�............................ ........................................................
.Trrtffirzttr of Toutphatta
THIS,IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by........./ .......... .. ...........................................................................................................................
at....... ................9,.-, Installer
...........19��..............................................................=.yr...........................
has been installed in accordance with the provisions of TIT _ Yhe State Sanitary Code as described in the
application for Disposal Works Construction Permit No._9 �M............. dated-...............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE?CONSTRUED A GUARANTEE THAT THE
SYSTEM WILI,4LJNCTION SATISFACTORY.
DATE......A At_X................................................... Inspector...... .::...................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........OF....... .. . .....
No4e!l
................ FEE... ...........
intro orko TDOnstrudialt pantit
Permission is hereby granted........ ....... .............................................................
to Construct or�Repair an Individual Sewage Disposal System
atNo....�7fl ....... _�A.!r. .O.W........... . ..............Street................ .....................................................
as shown on the application for Disposal Works Construction Pe t No..................... Dated.._.....___-......_.__....._..............
---.---"C -------- ...........
..........C_ . .. . ............................................ -----
oard of Health
DATE--_-----------_----------Y:::..2
FORM 1255 A. M. SULKIN, INC., BOSTON
0_}'-
THE COMMONWEALTH OF MASSACHUSETTS /Fimz..'3.Q...............
BOAR® OF HEALTH ApPROVED
TOWN OF BARNSTi4BLE Garr► eb16C0W0W>t��n"e0t
Appliration for Elhipvii ai Works Taymift e z Fate
Application is hereby made for a Permit to Construct ( ) or Repair (1,,<�n Individual Sewage Disposal
System at:
• - ...---•-----------------•--.............
Locp1ion Address or Lot No.
�- k G 7� .......... ..................:.. ..v'� s.�......................................................
Ownet Addre s
........... ( .. .I ..s C�L:............. .�4_._.� � ...... ��................................_.._
Installer Address
PQ
d Type of Building n Size Lot...:...................... S. q. feet
U Dwelling—No. of Bedrooms...._}......_.... .....Expansion Attic ( ) Garbage Grinder ( )
A4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures .----••-•---•----•--•--••------. -
------
W Design Flow_._.._.'C.,.�........................gallons per person Zsr day. Total daily flow___��... _......................gallons.
WSeptic Tank-� Liquid ca acity.�_ "gallons Length____ __________ Width._��. ....... Diameter................ Depth................
x Disposal Trench—No�s - 3Width....:�i.......... Total Length___- ....... Total leaching area....................sq. ft.
Seepage Pit No..,.................. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1-___--___-___-minutes per inch Depth of Test Pit.................... Depth to ground water........................
fi, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water.........................
a •--••--•--•-•-••••--•----•---•---••-•-----•--••----•-•-----•---••-•---•....................••-------.........................................................
0 Description of Soil.......................................................................................................................................................................
x
w
x --•-------------------------------------------------•-••• --•-••---•-• . lit
•--•--•-•---•-•------------••-------.._._..............-----•......--- ••-•--•••-----••--•-•-•-..... •----•..........---
70
U Nature of Repairs or Alterations—Answer when applicable._____ .......L �.___S`'e __---_ �"'__.
-L ..........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Com Hance�has �issu��bo �of health.
Signed ............ .................... ..............................
Dare
Application Approved BY ` -- ----------------------------------------------------------
e
Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------- - --
-------------------------------------------------- -- -----.........................................-------------------------------------------- -----------------------
---- ------ ..........------'...................--
.
Dare
PermitNo. ......... .d .:.^... r t-- -------------- Issued ........................D--ace------ ............................
• a
30d -- v-D S
0 ,
THE COMMONWEALTH OF MASSACHUSETTS
.BOARD OF HEALTH
TOWN OF BARNSTABLE `
Applirativit for Disposal Works (nott ��� A rruti
Application is hereby made fora Permit to Construct ( ) or Repair -6�an Individual Sewage Disposal
System at:
Luca-on-Address or Lot No.
W owner Address
Installer ` Address
Type of nn Size Lot_ Sq. feet
Dw�No of�e&o --�`------------------------------Expansion Attic ( ) Garbage Grinder ( )
`4
a Other-Type of Building ------------_-------------- No. of persons--------------------___--- Showers ( ) - Cafeteria
Gl ( )
dOther fixtures ------------------------------------------------------------------------------------------------------------
W Design Flow_---- _ _------------____--gallons per person per day. Total daily flow---- __
Septic Tank 4L Liquid-city-�- -gallons Length---- ----------width_ -____-- Diameter-------_____--Depth------
Disposal Trench-No,;?_4i .9 Width-----_F----------Total Length----�D -----Total leaching area--------sq.ft-
3 Seepage Pit No--------------------- Diameter------------------_; Depth below inlet------- _Total leaching area_----___sq. ft_
z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by---------------------- - --- -------------- ----___-_ Date_-_—_ -----
a
a Test Pat No. I----------------minutesperinch Depth of Test Pit--------------- Depth to ground water----------------_._--
(i, Test Pit No. 2_----------minutes per inch Depth of Test Pit------- Depth to ground water____-__----__
a ---------------------------------------------------------------___ --- -
ODescription of Soil----------------------------____�--_-------------------------------_-_____ -
W _
r`F C (l1
U Nature of Repairs or Alterations-Answer when_applicable___--
-----------------=L&?U----==t'`.-`fit LZ a (Z--_1-f-d-- -
Agreement_
The undersigned agrees to install the aforedescrlbed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental,Code-The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been lss b the board of health_
g -----------------------
r Application Approved By ------------------ € ---�:�>_ - -- ----- - - ---------- - - � ��-��--
Application Disapproved for'the follotting reasons.
--- - ----------------------------------------- --------------------------- --------------------------------------------- - -
Permit No_ ------- -� 1"� ---------------- Issued - - ------�- - ------�--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
der iftrate of Coutplimme
THIS IS 7O CER77FY, That the Individual Sewage Disposal System constructed ( )or Repaired
by-- --- -----------------------------C�_------ AM - (--. --- -----------------
at --- ---- - - -----Ac,vV1)S lek ihas been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. __��-���-__ dated --_THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.r
Ins -----V r -
--- I
or
----- — - --------- —
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE r--
`... Cosa Works (Imtoftuman Vermit
Permission is hereby granted---------------____--c� 1-P-e L 64c U)_'5-�-
to Construct ( ) or Repairs( Indivldual✓Sewage Disposal Syste ,
at No_____—_-- -� _-_�_- //``ft
Street
as shown on the application for Disposal Works Construction Permit No.,2- -V'• y Dated ---___-_
DATE Board Of Health
FORM 365M 140885 a WARREN.ffWC-PUBLISHERS -
c ,
SYSTEM DESIGN
RAISE COVERS TO WITHIN 6" OF FINISH GRADE ON DESIGN FLOW
SILL ELEV. .35.60 FINISH GRADE PROPOSED VENT PORT RTOn GRADE 4 BEDROOMS AT110 GPB/D 4AS GPD
GRADE ELEV. EXIST, ELEV. 33.4 FINISH. GRADE ' {
44' � //� //� � ELEV. 34.5 ELEV. 35.1 REQUIRED SEPTIC TANK
,� //,G� \� GROUND ELEVATIO 35.2
LINE#1-40'®S=0.02 4' OF COVER T4.1 OF COVER / / �\ •" `z _440x2 ___ _ 880 GAL.
LINE#2-68'@S=0,026- TOP ELEV 31.10 BOTH EXISTING 1000 GALLON 'SEPTIC
# �-,r- 4 PVC SCH 40 3 ®S= 0.01 = 0,005 „ TANKS TO REMIAN (2000 GAL. PROVIDED)
SCH 40 TANK#1
2 MIN-3 MAX " '
INV.= EXIST. INV.= 10"TEE 14'TEE TANK #1 ^ INV.=30.35 SIZE OF LEACHING FACILITY REQUIRED
S 31.80 INV.= g° cy cv DESIGN PERC RATE _ MIN./INCH
GAS BAFFLE 31.60 H-20 DB4 . ,LONG TERM APPL. RATE 2•_74_GPD/S.F.
TANK#2 2 WIDE,X 50 LONG.LEACHING TRENCH:•, 77
INV.= 4'-1" LIQUID LEVEL TANK #2 D-BOX >
INV.= INV.=30.80 INV.=30.60 v SIZE OF LEACHING SYSTEM PROVIDED:
�. 32:80 32.60 INV.=30.63 a
: ..f:
I'N50.0' I to o 28.35 440 _ 0.74 SF/GPD = 595 S.F. MIN. REQ.
° °° - USE.(2) 50' LONG LEACHING TRENCHES ^ '� USING (2) 50' LONG L ING TRENCHES
DATUM BOTH EXISTING 1,000 GAL TANK TO REMAIN WITH 2' MIN. OF STONE UNDER PIPES V. 21.2 _
WITH I40MIL POLY LINER ON FND. SIDE NO GROUNDWATER TPIT#2 2'x2'x2 X 50_ - 300 -G RENCH
VERTICAL DATUM: BARN. GIS - MSLt 2 TRENCHES ® 300 = 0 S.F
CONSTRUCTION'NOTES:
BENCH MARK USED: CORNER OF CONCRETE 2 OBSERVATION PORT 600 x 0.74 G/SF 5� = 444 GPD
STEP ELEVATION 36.05 1. CONTRACTORS / INSTALLERS SHALL VERIFY GRADES AND. CREW CAP TO GRADE
ELEVATIONS AND SITE CONDITIONS PRIOR TO COMMENCING »• 444 GPD. PROV >. 4.40 GPD REQ. = 4 .GPD RES.
WORK ON THE SITE. SAND FILL
S 1 TE SEWAGE 2 WID DETERMINATION HAS TH DEEDED OR ZONING BEEN MADE AS TO REGU REGULATIONS. OWNER /LIANCE APPI CANT NO (GARBAGE DISPOSAL / GRINDER ALLOWED)
REPAIR - PLAN 3. VEH VEHICULAR TO ITRAFF C, PARKING OFN SUCH OVEHICLES AND N FROM APPROPRIATE
AUTHORITY. N
MATERIALS OVER THE SEPTIC TANK IS PROHIBITED.
/c GENERAL NOTES:
HA MPSH1RE_ A V C. 1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. f D.T.H. #1 � D.T.H. #2
TITLE V AND THE .TOWN OF BARNSTABLE RULES AND REGULATIONS 8.0' DATE: 4-21-17 DATE: 4-21-17 -
I N FOR SUBSURFACE DISPOSAL OF SEWERAGE. END VIEW GROUND ELEV. 34.2 GROUND ELEV. 33.4
H YA N N I S, MASS 2. AT LEAST ONE ACCESS POINT OVER TANK TEES SH'ACL BE NO GROUNDWATER NO GROUNDWATER
ACCESSIBLE WITHIN 6" OF FINISH GRADE, WITH ANY REMAINING I CERTIFY THAT I AM CURRENTLY APPROVED BY THE
ACCESS PORTS BROUGHT TO WITHIN 12' OF FINISH GRADE: DEPARTMENT. OF ENVIRONMENTAL PROTECTION TO CONDUCT �_-
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE SOIL EVALUATIONS AND THAT THE RESULTS OF MY SOIL A FILL
DATE: APRIL 29, .2017 12°
CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY. ARE .EVALUATION ARE ACCURATE AND IN ACCORDANCE WITH 310 LOAMY SAND A/E
UNDER OR WITHIN 10' OF DRIVES OR PARKING AREAS THEY CMR 15.100 U 10YR 4/3 4" LOAMY SAND
MUST WITHSTAND H-20 LOADING. e--w B _ -10YR 4/3
OWNER/APPLICANT: 4. THE EXCAVATION CONTRACTOR SHALL VERIFY THE LOCATION -- - - - - ---- LOAMY SAND 10YR 5/1
OF ALL UTILITIES PRIOR TO ANY EXCAVATION. EDWAR . A. ST NE, CERTIFIED SOIL EVALUATOR 7,5YR 5/6 16"
LACKEY FAMILY 5, ANY MASONRY UNITS USED TO BRING COVERS TO GRADE 4 - � B.
OR WITHIN 6" OF GRADE SHALL BE MORTARED IN PLACE. P • ``` 18' LOAMY SAND•
IRREVOCABLE TRUST 6. FINISH GRADE SHALL HAVE A MINIMUM OF 0.02 FEET PER ELEV =32.7
GROUNDWATER ADJUSTMENT 7.5YR 5 s -
FOOT OVER THE S.A.S. AND DISTRIBUTION BOX.
45 HAM P S H I R E AVE. 7. SEPTIC TANK SANITARY TEE'S SHALL BE CONSTRUCTED OF �y ` NO OBSERVED'GROUNDWATER '' - ELEV =31:0 ` 28"
" DEPTH TO BOTTOM OF HOLE' 12' 38 ,
H YAN N I S, MA 02601 , ,THE EFLOW LINE AND SHALL ULE 40 PVC AND ABE ON THE CENTERLINE LL EXTEND A MINIMUM OAND ABOVE e C C
LOCATED DIRECTLY UNDER THE CLEAN OUT MANHOLES. f COARSE SAND COARSE SAND
SHEET 2-OF 2 8. THE INLET PIPE INVERT-ELEVATION SHALL BE NO LESS THAN 2.5Y 7/6 2.5Y 7/6
2 INCHES NOR MORE THAN 3 INCHES ABOVE THE INVERT 10%-GRAVEL 10% GRAVEL' '
ELEVATION OF THE OUTLET PIPE. ZNOF
PREPARED BY: 9. THE SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9 INCHES - ' r �� � NO G. WATER f 144" 144°
10. THE OUTLET SANITARY TEE SHALL BE EQUIPPED WITH A GAS DAVID , ELEV =22.2 ELEV =21.2
1.E A S SURVEY, INC. BAFFLE, 4 INCHES IN DIAMETER AND CONSTRUCTED OF 4" PVC . y F H TY,
11. ALL PIPES SHALL BE SCHEDULE 40 PVC SEWER PIPE AND t o 211 INDICATES DEEP B.O.H.,
P. O. BOX 2 9 SHALL BE SLOPED 1/4 INCH PER FOOT MIN. EXCEPT FOR THE DTH #1 TEST HOLE DON DESMARAIS
FIRST TWO FEET OUT OF THE DISTRIBUTION BOX WHICH SHALL 1 SOIL EVALUATOR
,SANDWICH ,* M A 02563 BE LEVEL , SaNirAR�PNINDICATES ED. STONE
12. CHANGES OR REVISIONS TO SEPTIC DESIGN REQUIRE NOTIFICATION _ P-1 �38" PERC TEST BACKHOE OPERATOR.
P H. (5O8) 888-3619 TO EAS SURVEY INC. FOR B.O.H.,AND.DESIGN ENGINEERS REVIEW Zy �/ ELLIS BROTHERS (KEVIN)
AND APPROVAL. NO MOTTLING SOIL TYPE _1 `
CELL (508) 527-3600 13. MAGNETIC TAPE OVER ALL_COMPONENTS. NO WEEPING PERC RATE: :5 MIN. PER INCH
EAS.SURVEY@YAHOO.COM 75" INDICATES ADJ. GROUNDWATER LOADING RATE: 0_74 GAL/SF/MIN
712
LOCUS DATA
OF 0 �`' CATCH
EDWARD = �O BASIN'
CURRENT OWNER LACKEY FAMILY �� A _ N
IRR. TRUST. NSTONE P
o.289
PLAN REFERENCE 14034—A
DEED REFERENCE CTF 183242
ZONING DISTRICT RB
�, LOCUS MAP
FLOOD ZONE X E / C �` A �W NOT TO SCALE:
. p�P\NI� 1 � �p0 / —
ASSESSORS MAP 309 / I / o. 17 0107
PARCEL' 025 / 5N• / 1p EXISTING LEACHING AREA.
/� TO BE PUMPED,'CRUSHED a
OVERLAY DISTRICT NOT A ZONE 11 i A AND ABANDONED IN
/�l� �.• E ACCORDANCE WITH TITLE 5.
LOT AREA 9,0.00f S.F.
SITE & SEWAGE EXISTING SEPTIC TANK #1
p I -33 TO REMAIN. INSTALL NEW
R E P A I �\ PLAN OUTLET PIPE & TEE.
p�/� PROPOSED SEPTIC LINE #1 `
#4" - L O��G / % GA GEo �• DA BOXNK N NV =30.80 V. OUT .60
HA
UP
u c I /� 34- LENGTH - 40
/�7A/V//-SHIRC A VL. _ /,S�000f S.F. /� /A SLAB=32.4
, o SLOPE = 0.02
// / _ PROPOSED 40 MIL
H YA N N I S, MASS EXISTING POLY LINER
' 4 BEDROOM BENCHMARK: CORNER
DATE: APRIL 29, 2017 SHADED AREA INDICATES /� DWELLING 15 0 OF CONCRETE STEP.
AREA OF CONCRETE �, '
ELEV=36.05
PATIO TO BE REMOVED, XISTING 100
PROPOSED T
CONCRETE i
OWNER/APPLICANT: ate: PATI ,p. Oo VENT.
LACKEY -FAMILY s. 10.0 �� a: • .
o, D.T.H. #2 �' i �12-8j
IRREVOCABLE TRUST I o
4 � PROPOSED D ..BOX
45 H A M P S H I R E AVE. / �'I i 3 INLETS / 4 -OUTLETS a
EXISTING SEPTIC TANK #2' . WIGGINS, PRECAST
H YA N N I S, MA 0 2 6 01" TO REMAIN.
PE T MAI INSTALL NEW D.T.H. #1
SHEET 1 OF 2. too 1�' , PROPOSED (2) 50' LONG
LEACHING TRENCHES WITH 4' OF
t .✓ i 66�� SEPARATION BETWEEN TRENCHES.
PREPARED BY: ' EXISTING LEACHING AREA /� , 5
TO BE PUMPED, CRUSHED
E A S SURVEY I N C. AND ABANDONED IN - i PROPOSED SEPTIC LINE #2
ACCORDANCE WITH TITLE, 5. i TANK INV. OUT = 32.60
'BOX INV =30.80 -
P. 0. B O X 17 2.9 D
SANDWICH MA 02563 : _ LENGTH = 0
SLOPE _ '0:026 0 20 30 40
PH. (508) 888-3619 TITLE V. VARIANCES REQUESTED.
CELL (508) 527-3600 T. TO`�ALLOW THE`LEACHING TO BE 15' (WITH' 40MIL-POLY LINER) FROM A FULL FOUNDATION WALL IN. LIEU OF 20'. GRAPHIC SCALE:
EAS.SURVEY�YAHOO:COM .2. TO ALLOW A LEACHING TRENCH TO HAVE,.4' OF COVER (VENT PROVIDED) IN LIEU OF 3' MAX.-ALLOWED. 1 INCH; = 20 FEET