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HomeMy WebLinkAbout0018 HEMEON ROAD - Health 18 Hemeon Way Hyannis A= 268 —089 I TQ1 i+t:OF B? IS'x'ABLfi. �Y .I,A�sEr�� AS SES�OR'S:DriAP��.QT �'S PtAi1►��3'I-I�TIdE Y�'4 om SEF,NC-`T K C A E'Y NO �OFBFD1�C3flNi� '� .�' r I. 3'8� C N L APIC 13A. �p�attan i]�stancc Bet�re�n-�►c Maxuttulm, st d u� wata�fiable o tW� otioin of i Fa�tity feat F�ata'�!'�c SupFlx`li�eli andg 1� t (£any�r ' vn sits or antbua�i�at af.Fc'�it��) �: ` �t dSe oi~Wed and,I.eachl�gl Paa'ltty! f AYmetlands exist wthia 3Q4>feet �:teach,mg facxlrtj�} ) ,.. �: feet r � Pwy11 ORP O -F by �r � Tom- a a cz t c,� 91 �. � vv /q TOWN OF BARNSTABLE LOCATION 1/g fieneov, Ne y SEWAGE # VILLAGE 4 04 i< ASSESSOR'S MAP&LOT INSTALLER'S NAmiF-&PHONE NO_ SEPTIC TANK CAPACM /000 4� LEACHING FACPL rrY:(type) P (size) 6-6 r NO.OFBEDROOMS B` UMER OR OWNER z eo A 4 e✓", --- --- PERMITDATE: COMPLIANCE DATE; Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leading Facility Feet Private Water Supply Well and Leaching Facility (if any wells exist on site or whin 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet 0 leaching fa ' ity) Feet Furnished by �✓� ��/� �'� 1 '''' � {,.._..� n 0 � � � - _ n`I r1 O v � � 1 � �\�\ 1 a � 0 Commonwealth of Massachusetts Title 5 Official Inspection Form i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hy p annis ort MA 02672 9-23-20 " -- page. City/Town State Zip Code Date of Inspection S.. 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. A. Inspector Information c51# I'-f 09-(-o Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address East Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes ' 2. ❑ .Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority Ih 4. ❑ Fails 9-23-20 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form �bi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hyannisport MA 02672 9-23-20 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: ® 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 Commonwealth of Massachusetts Title 5 Official Inspection Form 16) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Hemeon Rd =' Property Address Beth Dunbar Owner Owner's Name information is p required for every West H annis ort MA 02672 9-23-20 -- y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): f ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): El- 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 El ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require_further evaluation by the Board of Health in order to determine if 'the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rlr;: 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hy p annis ort MA 02672 9-23-20 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. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes ' No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form wa Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hyannisport MA 02672 9-23-20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) .System Failure Criteria Applicable to All Systems: (cont.) r : ,Yes No w ❑ -Z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Y ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 dayflow ❑ ® 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. r ❑ ® 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. ® 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 b and chain of custody must be attached to this form.] - K •❑ ® 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. . �a .. . i. a,4 • - . 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10;000 gpd to 15000 gpd. ' For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions,in:Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form 3 r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (. . . 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hyannisport MA _ 02672 9-23-20 page. City/Town f 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 all 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? ® ❑ 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 Commonwealth of Massachusetts ;. Title 5 Official Inspection Form �l. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is West H anniS ort required for every Y p MA 02672 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2, Number of bedrooms (actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 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: a ' Sump pump? ❑ Yes ® No 9-2020 Last date of occupancy: Date Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f' Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form 01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tt.,rai > 18 Hemeon Rd - Property Address Beth Dunbar Owner Owner's Name information is West H annis ort MA 02672 9-23-20 required for every y p page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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: Owner----pumped 2018 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts r� '�l Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form Not for Voluntary Assessments g p Y rY , 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hyannisport MA 02672 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ .Tight tank.Attach a copy of the DEP.approval. ❑ . Other(describe): Approximate age of all components, date installed (if known) and source of information: -1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ® cast iron ' Z 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 r� Title 5 Official Inspection Form ! hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a ;<;" 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hyannisport MA 02672 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 611 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: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" 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.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018' Title 5 Official Inspecdon Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form Ioi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /rl 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hyannisport MA 02672 9-23-20 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.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hyannisport MA 02672 9-23-20 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hy p annis ort MA 02672 9-23-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 s Commonwealth of Massachusetts 3� Title 5 Official Inspection Form i t Subsurface Sewage Disposal System Form -Not-for Voluntary Assessments 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hyannisport MA 02672 9-23-20 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.): Leach pit in good condition and holding 12" of water with stain line at 24" off,bottom of pit. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is required for every West Hy p annis ort MA 02672 9-23-20 -- 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 4el., Commonwealth of Massachusetts �i Title 5 Official Inspection Form i I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' g p Y rY 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is West Hyannis port MA 02672 9-23-20 required for every p 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 k r. 39 . [7 3 ' _7 , p t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form L Ii,i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Rd Property Address Beth Dunbar Owner Owner's Name information is West Hyannisport MA 02672 9-23-20 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' 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: USGS and town maps show groundwater at greater than 20'. i 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 inl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Rd ' Property Address Beth Dunbar Owner Owner's Name information is West Hyannisport MA 02672 9-23-20 required for every 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 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 1 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Vt Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection formes/may not be altered in any way. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification >F Q I certify that I have personally inspected the sewage disposal system at this address and ththe Cl information reported below is true, accurate and complete as of the time of the tnspection.The inspection was performed based on my training and experience in"the proper function and intenance of or_�i-ite sewage disposal systems. I am a DEP approved system inspector pursuant to,�Section 4.5.340xof Title 5 (310 CMR 15.000).The system: it - ® Passes ❑ Conditionally Passes ❑ Fai r i R ❑ Needs Further Ev ation by the Local Approving Authority 8-10-09 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every 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: ® 1 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. 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 t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 , Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) _ B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order.to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that-the system is not functioning in a manner which will protect public health, safety and the environment: , El 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: a , , ❑ The system has a septic tank and soil.absorption system (SAS) and the,SAS is within 100 feet of a surface water supply orrtributary to a surface water supply. J ❑ 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. t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 f F j Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. 'City/Town State Zip Code Date of Inspection B. Certification (cont.) C Further Evaluation is Required b the Board of Health (cont.): q Y ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate'nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. { 3. Other: N 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 El ® 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 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. t5insp official document•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No , ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 watersupply.. ❑ ❑ the,system is within 200 feet.of a tributary to a surface drinking water supply. El the'system is located in a nitrogen sensitive area (Interim Wellhead Protection El Area-1WPA) 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 i system in accordance with 310 CMR 15.304. The system owner should contact the appropriate -.regional office of the Department. t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every 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 Ian 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)] t5 nsp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 8-09 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow,(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No ,Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name Information is required for y H annis MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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): Approximate age of all components, date installed (if known) and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Trtle 5 Official inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 16"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 8 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: 1000gal Sludge depth:. 10" Distance,from top of sludge to bottom of outlet tee or baffle 22 Scum thickness 0 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 16" How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. City/Town 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.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: . feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) w Dimensions: a 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.): a. *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level. Pump Chamber(locate on site plan): ` Pumps in working order: ❑ Yes_. ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis' MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection , D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ^ � r Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ® leaching pits number: 1-1000gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow'cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was empty at inspection with stain line at 12"from bottom of pit. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis • MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Gt Cr qa- .D ` �Y i t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Hemeon Way Property Address Leo Ahern Owner Owner's Name information is required for Hyannis MA 02601 8-7-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ,r.�•./ ❑ 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 showno groundwater at 12' with bottom of pit at 8'. t5insp official document-03/08 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 16 TOWN OF BARNSTABLE LOCATIONZL o Pbs SEWAGE # F'" 5_12'A VILLAGE 0!$"wNIS ASSESSOR'S MAP & LOT Qq Vr INSTALLER'S NAME & PHONE NO. 6_ct S f3n-dS Can�S� "77I-r36� SEPTIC TANK CAPACITY c> LEACHING FACILITY:(type) h 1`T- (size) o o o NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER Py3l.ie, BUILDE P R WNER � �a�C�-off DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 4 e e f i q-4 k kk ��,... SSESSORS MAP NO. 'ARCEL NO. - No........................ Fmc.......,� . 1,01�ar. THE COMMONWEALTH OF MASSACHUSETTS �A I BOAR® OF HEALTH ..-----.O F..... AvOrFa#ion for Di-qvnsal Works Ta nstrurtivat Errant Application is hereby made for a Permit.to Construct X or Repair ( } an Individual Sewage Disposal System at: _ -: ... Location-Ad .. _ or Lo No. ,LJ �/ �oD Owner Address w Installer Address Type of Building Size Lot-- .-Sq. feet Dwelling—No. of Bedrooms..._�-.................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of. Building No. of persons............................ Showers — Cafeteria P4 Other fixtures .----------_--•-•--•---•--•---- w Design Flow.......... `:.'-__....................gallons per person per day. Total daily flow:......... �?._.__...._...........gallons. 41 PG Septic Tank—Liquid capacityt���gallons Lengthdf:� .' Width.r�_.. . Diameter................ Depth__...._�_..� Disposal Trench—No..................... Width .................. Total Length.....................Total leaching area..___-------.___.---sq. ft. Seepage Pit No--------------------- Diameter..... Depth below inlet. _.......__..__ Total leaching area o_1.......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...12t.......... Depth to ground water........................ (i Test Pit No. 2----5.Z _minutes per inch Depth of Test Pit.../ -....._._.. Depth to ground water--------- 94 ---•---•--------------------------•-. -----------------•-•-•---•--•----------------------------- O Description of Soil---_fJ '�d ..... 2.--------------------------------------------------------------------------------------------- w U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------_................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with the provisions of'T';1 E ;of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Cert•ficate of Compliance has been leissued by the board of health. a/ C% �G��S � ► 3 ' � Signed '"`%C ---�c =�-"'_-- !-----------•-------------- � �__......_,..�..+ Date Application Approved BY.......---- �.....'�-,�,.s�•�-----'_'�--•-•------•-•-•--------•------•-- ........................................ Date Application Disapproved for the following reasons:............................................................------------------•------------------••------------ --•---•-•----•---------------•-------••--•---•-••---•------...-•--•-•------------------------•----------.._...........-------------•------------------------------------------------------------•-------- p�a Date PermitNo........U. l ------------------- Issued-....................................................... Date No................/-t---- {. Fps..�', ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. ApplirFatinn for Disposal saal larks Tonstrnrtiun ramit Application is hereby made for a Permitxto Construct X) or Repair ( ) an Individual Sewage Disposal System at: .....)...AA; ..1�.�'.��...D __.... �..:�.-•-•............................... ............... .....-.. •---............................................. Location Add s or t No _ �r. .._...•-----------------------•-•-- cr.�-r,z 4. .! x-7 �" /-......!!v_�. 'y %✓.1_� f� �' Owner V-,Address W "t � ........... Installer Addiess s �+ d Type of Building Size�..ot_� .1>_' 7...Sq. feet Dwelling—No. of Bedrooms__...rr....•..................................Expansion Attic ( ) Garb ge\Grinder ( ) Other—T e of BuildingNo. of persons............................ Showers — Cafeteria Q' Other fixtures ----- _ W Design Flow.........4-�•''-_-7.....................gallons per person per day. Total daily flow......... _ P....................... G4 Septic Tank—Liquid ca acityL....._.__ allons Len thy'...R__- Diameter________________ De th.4......___.. ', Disposal Trench—No. .................... Width......._............ Total Length................._L Total leaching area_-_--__-____-.-----sq. ft. 3 Seepage Pit No..................... Diameter___+-�........ ... Depth below inlet._"'_' ....... Total leaching areal RI.......sq. ft. z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by----------------------- . ••-------------- t Test Pit No. 1...'�'._~'2__mmutes per inch Depth of Test P.it__l i_�._...._ Depth to ground water--_.-'""""-""'-___--. 44 Test Pit No. 2....!;LZ,._minutes per inch Depth of Test Pit.. Z..._...._.. Depth to ground water-------- ....... a ...................................... ----•---••................... O Description of Soil.._O _ LdiJ, t? . .........................................------------•--------------------------------------------------- x c '" r ' -.c , " !�... ----------._•--------------------------------•-------------•---- W UNature of Repairs or Alterations—Answer when applicable_...............................................................................•............. ..............................-.......................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli ,.%c,* the provisions of TTTt.- 5 of the State Sanitary Code— The undersigned further agrees not to place tlig',syste�i�in� operation until a Cert•ficate of Compliance has been issued by the board of health. ✓ Signed- --....._..-:- Date Application Approved By.......... e �.-. ,a.�,.,.--...-.. .................................... Date Application Disapproved for the following reasons:..............................................................•.____.__..__-•---------..._..............._...__ ...--•-•----------•------------------•-------------------•--•------------....--------------•---------•----------•---•----------------------•-•....----••••--•------------•----------•-----•-•••--------- Q Date PermitNo.----..L1_ .�- ................... Issued---------------------------------•-•-----------•------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........../- ...........OF............. N•.................................. Tntifiratr of Tuntpli tta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( } by..........................................................••-----...........-----••--•----- --•-----•-....----------.......--•------•-----------..................•----........---•------------ y� Installer at. �..G -A :• �-�f ------ - ------------•----.-----------------------------.-------------- has been installed in accordance with the provisions"of T_'a j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-----F-0_.7.r_•__S7/. ....... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT-YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE...............�aZ.-.. ...� -------------------------------- Inspector...............4� -4.1).--------••----.......---•--------............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �/C±`� I ✓.. G.:: '.G..........OF..... 1\i0.•C�_-!. _ 1� FEE-- ........ Disposal Works TPLantrndion arAit Permissionis hereby granted............................................................................................................................................. to Construct or Repair ( ) an Individual tS'ewage Disposal System �q 8t 1�T0... tJ / ly. ............�T/...... Street .a.ta............................................................. r as shown on the application for Disposal Works Construction Permit No ?= �„_ Dated.......................................... ............................. ........ . ---------------------...--------------------............. Board of Health DATE.---••---•-•----•--...-a••-------------••••-•-----------•----•-••--•--•-••--- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - ofTMEro TOWN OF BARNSTABLE ' .OFFICE OF i BABa9T1BLL i. YAs. BOARD OF HEALTH 367 MAIN STREET HYANNIS, MASS. 02601 December 17, 1986 Mr. Arthur Dolgoff 20 Sunset Terrace West Hyannisport, MA. 02672 Dear Mr. Dolgoff: You are granted a variance from the Board of Health Interim Regulation limiting sewage flows to 330 gallons, per acre, in designated zones of _ contribution, to construct an on-site sewage disposal system on Lot 89, Hemeon Road, West Hyannisport with the following conditions: (1) The designing engineer must be on-site and supervise the construction of the on-site sewage disposal system and certify in writing to the Board of Health that his design has been strictly adhered to prior to the issuance of a Certificate of Compliiance. (2) The dwelling is restricted to two bedrooms. (3) A garbage grinder can not be installed. (4) The septic system must be pumped every two years with written certification submitted to the Board by a licensed septage handler. This variance is granted because the dwelling cannot have more than bedrooms with a daily sewage flow of only 220 gallons. This lot is approximately 14,452 Sq. Ft. In a highly developed area it is the boards opinion that an additional on-site sewage disposal system in the area will not significantly alter the existing poor groundwater quality. This variance will expire January 1, 1988, Ve truly yours d be t . Chi s, a an BOARD OF HEALTH TOWN OF BARNSTABLE RLC/ka 6'4 finished area a 3 i N Unf inished Area � 24' Mechanichai 15'-3 ' 6'-4 C--7 r---� r--3 C==7 0. � I — �g 0 FOUNDATION PLAN • Gonra,Gue mce rcur .` L='`JRA1�fIV1.S NAlrLRS AT JG-O.G. iA �ATTIC � . O �:BATH w b_ n t..r.,�, •rel. MTCHEN :DMMG ROOD g ��.1L. BEDROOM BEDROOM • yvsra w�.r�,yr w nn''a•`Aaw.c $ tx = �� LrMGRpCM MASTER A BEDROOM x'os�z. o b W BEDROOM v s E— u• f ; _T W O� z GROSS SECTION s_ W gag FIRST FLOOR PLAN Public Health Division Town ofBamstab1e P0.Box534 . HYannis,Massaoh C el 5 Oit/ 1D.e, n c0 49III .y Q a / IVO i CON/-�v/ZA-f coo E- T/TLF Tr, f}ti=D i 7`i'� /2:1��� y�jZc"'��1� -A :%U ,f T �!_r J .5 "'g�ei✓ yr�;Yf;. GFL`�/�fi��>> `r�},�'. Gr' /'JftC� ©L^fic=ri3L if7_ 7 .J�.��, r� W/^ ��.. L L '_n v/c. I-` tiz��A T� v ti A, .�.,.j '� ,�a'% 15' y ' -A , !,� i `7 �/f�i.> � � -`� ��r1 s,��.� �: /'fa fz/-�.:fi FG.�' 1,� �" »'�^=� >�'�"��7�1 .444444 2 TAX / `�—' //C7 c' /'�%�" /°� �'•v�i //r T /fir/ > ;�!r'b..•,�fi T - r ..i /, � .�r� ref./ /1r:•/frf - _ _ f 3k / .rds ),"IA. % f 10 • � l c ,Q s _ e r ' — ,, 4 p ��—s�Ge�'�✓ 34 G`/? Af _J�_` x G r Ixx Ar S L � r x •z ca , a �� «, u.f 1 S•.4 E �j 4 1 r LLC : CA ^_- _ -.1 j , T Lv / I � L� i / P ry'C � � G3 yLllcdN I C