Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0017 KELLEY ROAD - Health
1? KELLX,RD .HYANNIS A 292 071 LL�� ° ° ° C e ° ° TOWN OF BARNSTABLE tLOCATION"I!'7 Well PV 120 SEWAGE# ;Z()JQJ_ (�J VILLAGE \I AAWJ S —ASSESSOR'S MAP&PARCEL 07 INSTALLER'S NAME&PHONE NO. DO!.SNCK. � ,t,xUWr,w XA C., SEPTIC TANK CAPACITY kXIS� N LEACHING FACILITY:(type) Aic 3 G NC i-1 'go (size) 2.,6d3 X(,Q NO.OF BEDROOMS 3 OWNER PERMIT DATE: COMPLIANCE DATE: 7 Separation Distance Between the: 13oFr(1MiMI9WS $LO® Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility i✓t)&b)eA -Q,5_Feet Private Water Supply Well and Leaching Facility(If any wells exist on kite or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)L Feet FURNISHED BY �P�GS 9� r - i TOWN OF BARNSTABLE v/ LOCATION I k `le SEWAGE G VILLAGE - d1 IA:-ASSESSOR'S MAP&LOT 4, INS'2 A.LLER'S NAME 4 PHONE NO_ SEPTIC TANK-CAPACT'I'Y LEACHING-FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of le=hing facility) Feet Edge of Wetland and Leaching Facility(If any w Hands exist within 300 feet f leaching facili )) � feet_ Furnished by wh I r � t , e .. e i • r � 1 1 •' - t,J - 3 63 ���-. �� r � No. r�o � � Fee t THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0[ppricatiou for �Di.5pogal *paem Cougtructiou permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. �'��P�'�/ Rd /jy&"Jt,% Owner's Name,Address,and Tel.No. Assessor's Map/Parcel s^Leco Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. l'7b.�1a5 A ���� i,vc So$ j -qCV-71S_ --5�N c �r��N f 4tb110 TEO*17-5 1/7 Type of Building: Dwelling No.of Bedrooms 3 Lot Size 1YI25D sq. ft. Garbage Grinder ( ) Other Type of Building 'V►o yStip No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 30 gpd Design flow provided 316, 3 gpd Plan Date 1 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 4/C 76 //C Description of Soil i Nature of Repairs or Alterations(Answer when applicable) ,�;,a i 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. ^- Signed Date QV301)" Application Approved by Date �O 30—t o Application Disapproved by: Date for the following reasons Permit No. ov`'o' 3 b3 Date Issued 363 �. f 'No. )o � 1 _ >r• Fee TH�i COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes - : Application for Mtqo!5ar �&pgtem Conotruction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components 1 Location Address or Lot No. /7 X Q�I aT�, Rd dy ,vMl S Owner's Name,Address,and Tel.No. y. ' Assessor's Map/Parcel a Ci O71 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1�v51c.5 A _1�(aW,j c ',cyb-NW-7/S'rj v51 ti r ram, ,5 u>c✓/�S <CV 417'7.S?/ Type of Building: Dwelling No.of Bedrooms 3 Lot Size I-/Q5-0 sq. ft. Garbage Grinder ( ) t Other Type of Building V Vy-,-p No.of Persons Showers( ) Cafeteria( ) Other Fixtures Y Design Flow(min.required) 'j 3n gpd Design flow provided 3y6 3 gpd Plan Date _21 ho Number of sheets Z Revision Date Title ! Size of Septic Tank !k,�,i' /J k -6)lo-/I ,;t t T, 'e,o t S:•A.S. +} � �S � YP, �i� �/C ?G �C /7-2�7 A, Description of Soil V Nature of Repairs or Alterations(Answer when applicable) /q/S tli eyew �C Date last inspected: t 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. Signed TOV/U' Application Approved by -^~� ,Date $ 3U- O Application Disapproved by: +�/ Date; •1' for the following reas4-- Permit No. Date-Issued b '30— f•U i THE COMMONWEALTH OF MASSACHUSETTS i BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal-System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by u _T N at r I I N I has been constructed in accordance G with the provisions of Title 5 and the for Disposal System Construction Permit No. d 01 U 36 3 dated 0 - Installer }VG U -s A 13/v wn) N( Designer /�U/k f #bedrooms 3 Approved design floIn ` gpd The issuance of thi pe it shall not be construed as a guarantee that the system wil unc as desig d. Date f Inspector l i,- No. Fee THE COMMONWEALTH OF MASSACHUSETTS j PUBLIC HEALTH DIVISION— BARNSTABLE, MASSACHUSETTS tg ogaY *pgtern ion tructton Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at 1-2 Ilex and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and�the following local provisions or special conditions. ' � Provided: Construction must be completed within three years of the date of thisWFm'ir. Date _3 G �t'O Approved by " 09/07/2010 18:42 5084775313 ENGINEERING WORKS PAGE 01 Town of RaMstable Regulatory Services Thomas F.Gebr,DlmWr S Public Health Division Themw McKean,Director M Msb 9&aet, Ham,MA OM1 Mo.- 5084624644 Fax: 5W790-6304 Date: Q O Sewage Permit#Z6 l 0 -3(vi:�Assessor's Map/Pareel der. ;•nec rm c, v l+t t . Inetr�er: /� . cza.�.► 4 l v�� Address: TZ- W, G*4 s4`-cl cal C<A Address: Q Qo,K 1� ico•�e r�l�� �1�4 oz:G y Cent Ate MA p2C3-�_ on 1�A 'v�ra ,-4 exi I i-,c was issued a permit to install a ( e (installer) # septic system at_ l^? Ke l kLLJ 24 , N�j A A S based on a design drawn by ( ) Ft*Ve t1 C-&rCA T, f dated ' I certify that the septic system referenced above was installed substantiallyy accordingg to the design, which may include minor approved changes such as lateral relocation ofthe distribution box and/or septic tank. Stripout (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 tban 10' lateral relocation of the SAS or any vertical relocation of airy Component of the Septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) was inspected and the soils w and satisfactory. PETER T. ?sSignature) Mc.ENTEE CIVIL .. � No.35108 's Signature) ,,8 a ]ILLNOAM a rorowe. w ro�.a� i Town of Barnstable P# Department-of Regulatory Services _ Public Health DivisionMASS Hate ` G 200 Main Street;Hyannis MA 02601 Date Scheduled .,T,im e_ l/ Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By ✓ u'CL & witnessed By Pb_rl-_111U\ �)eS /t'I CV,C A S LOCATION-& GENERAL INFORMATION Location Address Owner's Name • � q�W V, r M I4 Address SS C: Assessor's Map/Parcel: Z r`0 �2 7 �`(q v�ti r i M 9 z' 0 � -( Engineer's Name NEW CONSTRUCTION 1- REPAIR 2 : / Telephone# Land Use I�9 C 7�1�A �G� Sl Z� 4J r opes,i%) S^ Surface Stones Distances from: Open Water Body _ft Possible Wet Area f�(S ft Drinking Water Weller Drainage Way ft Property Line .R Other SKETCH:(Street name,dimensions of lot,exact locations of test holes&.pert tests,locate wetlands in proximity to'holes) low P�l � Parent material(geologic , '-2—d ) Q , Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR.SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to still mottles: Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft. index-Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level Observation PERCOLATION TEST bete Time,. °� ' Hole# o^ Time at 9" Depth of Pere ; Time at 6" Start Pre-soak Time® �d2 r CPA`'� 'lime(9".6") End Pre-soak O �l 7i"� Rate MinJlach Site Suitability Assessment: Site Passed_1' Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observe dtion Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:1SEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# l Depth from Soil Horizon Soil Texture SoilColor Soil Other Surface(in.). (USDA) (Mansell) Mottling (Structure;Stones;Boulders: s•. onsisteftcZ ��- to �s M-C- Sal ems. DEEP'OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surfacc(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. . Consistency, lQ l25 DEEP OBSERVATION HOLE LOG Hole# Depth from. Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. dravoll r DEEP OBSERVATION HOLE LOG Hole# Depth=from Soil Horizon Soil Texture Soil Color Soil OW Surace(in.) (USDA) (Munsell) Mottling (Structum,Stones;Boulders. -Flood Insurance Rate Map: "Above 5 year flood boundary No_ Yes f- "With n'500°yearhoundary No Yes Within 100 year flood boundary No_/1— Yes Death of Naturally Occurring Pervious Material Does at'le. f four-feet.of naturally occurring pervto s material exist in all areas observed throughout,the. area-proposed for the soil absorption system? If not,what the depth of naturally occurring per ous material? �......_..� Certification 1�q1 y '1 certifythat.ori 1 (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 tr ng,expertise and experience described'inl0 C1VIR 15.017. - Dated ,. Signature 0:\S,FV171 1PBRCFORM:DOC 1 a °Ft l Town of Barnstable Barnstable Regulatory Services Department n1C8C Ry ' RARNSTA i6 9 � Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70081830000205009649 4/05/2010 Today Real Estate c/o David Holt 1533 Falmouth Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 17 Kelley Road Hyannis, MA was last inspected on March 23, 2010, by Shawn McElroy, a certified septic inspector for the State.of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. • Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement.action. :- —' THE B RD OF HEALTH Thomas McKean, R.S., CHO O p r0 Agent of the Board of Health / CJ� H Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis MA 02601 3-26-10 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information I �I 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 C3 A €tea � B. Certification I certify that I have personally inspected the sewage disposal system at this addre s and that information reported below is true, accurate and complete as of the time of the inspection. Thcytnspe-ption was performed based on my training and experience in the proper function and maitenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to S ction 1&- Title 5 (310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails CO rn ❑ Needs Further Evaluation by the Local Approving Authority X� /4�"- 3-26-10 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. I� t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Us posal System•Page 1 of 15 Commonwealth of MatSachusetts f' Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Kelley Rd Property Address Bank Owned (Contact'David Holt @-Today Real Estate 1-800-966-2448). ' } -Owner Owner's Name information is Hyannis MA . 02661 .3-26-10 t required for y 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: ❑ I have not found any information which indicates that'any of the failure-criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are - indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by .the Board of Health,.will pass. t ' Answer yes, no or not determined (Y, N_, ND)in the ❑ for the following statements. If"not { determined,"please explain.. 4, ❑ 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 aycomplying septic tank as approved'by the Board of Health. * A metal septic tank will pass inspection if it is structurallysound,:Aot leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old,is°avail'able. ND Explain: - ❑ Observation-of sewage backup or break out or high'static wat&Ii vel 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): + u .3 ❑ broken pipe(s) are replaced ' l • ❑ obstruction is removed • t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 { l C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis MA 02601 3-26-10 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: ❑ 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: El The system has a septic tank and•soil absorption system (SAS) and.th_e 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. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ti 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) - Owner Owner's Name information is required for Hyannis = s• MA 02601 3-26-10 'every page. City/Town State Zip Code Date of Inspection B. Certification,(corit.) • 4 C) Further Evaluation is Required by the Board of Health (cont.): ❑ 'The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform f 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. f r- 3. Other: , r' D) System Failure Criteria Applicable to All Systems: ' You must indicate"Yes"'or"No"to each of the following for all inspections: Yes No A ® Backup of sewage into facility or system component due to overloaded or El clogged SAS or cesspool' Y ® _„ Discharge or ponding of,effluent to the,surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool { Static liquid level in the distribution box above'outlet invert due to an overloaded ! _ or clogged SAS oir cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less • ❑ ® than % day flow , ® Required pumping more than 44imes in the last year NOT due to clogged or { • +i , ' obstructed pipe(s). Number of times pumped: ❑ ® r Any portion of the SAS,cesspool or privy is below high ground water elevation. 0 ® Any portion of cesspool or privy is within 100 feet of a surface water supply orI tributary to a surface water supply. . ! t5lnsp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 t r Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis MA 02601 3-26-10 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 j questions in Section D. j Yes No ❑ ❑ the system is within 400 feet,of'a surface drinking water supply ❑ ❑ the.system is within 200 feet of a tributary to a surface drinking water supply . ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Kelley Rd t Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis, MA 02601 3-26-10 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?El ., ® 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? Z ❑ 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? El® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. z ❑, 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)] I t5insp official document•03/08 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 15 I Commonwealth of Massachusetts , Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis MA 02601 3-26-10 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 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)): . s Sump pump? ❑ Yes ® No Last date of occupancy: _ 2-10 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 ElNo Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged.to the Title 5 system? ❑ Yes ❑ No Watermeter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document•03108. ', Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 'official.-inspection Form a . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Kelley Rd + Property Address 1 Bank Owned (Contact David Holt @ Today Real Estate'1-800-966-2448) ' Owner Owner's Name information is Hyannis . ' MA 02601 3-26-10 required for H'. y - , every page. City/Town •,- State Zip Code Date of Inspection D. System Information (cont.) ' General Information. .Pumping Records: c r n/a ,.Source of information: Was system pumped as part of the inspection? ❑ Yes ® No • �� If yes, volume pumped: ' gallons �. How was quantity pumped determined? Reason for pumping: 4 Type of System: r ® Septic tank, distribution box, soil absorption system + ❑ Single cesspool f t• ❑ 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 s maintenance contract(to be obtained from system owner) and a copy of latest " inspection of the I/A system.by system operator under contract t ❑ Tight tank.Attach a copy of the DEP approval: ❑ Other (describe): << 'Approximate age of all components, date installed (if known) and source of information: 1995 i Were-sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03I08 _ Title 5 Official Inspecton 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 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis MA 02601 3-26-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 6" - 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): 1" Depth below grade: 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: 1500 gal Sludge depth: ' 12" Distance from top.of sludge to,bottom of outlet tee or baffle 20 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 15" Tape How were dimensions determined? t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official 'Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis MA 02601 3-26-10 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis MA 02601 3-26-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) , Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0, Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): i Good condition with water at working level with clear signs of back-up from leach pit. 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 Massachusetts Commonwealth of ' Title 5 Official, Inspection Form - Subsurface:Sewage Disposal System Form -.Not•for Voluntary Assessments, 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required,for y H annis MA 02601 3-26-10 ' every page. ''City/Town - State Zip Code Date of Inspection D. System Information (cost.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): . Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ° ® leaching pits number. 1-1000gal ❑ leaching chambers number: ❑ leaching galleries' number: ❑ leaching trenches> number, length: "y ❑ _ leaching fields number, dimensions: ❑ r overflow cesspool' �x number: ❑, innovative/alternative system Type/name of technology: I Comments (note condition of soil; signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had clear signs of hydrolic failure with stain lines above inlet invert. t5insp official document•03/08 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for Hyannis MA 02601 3-26-10 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 Ia' 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.): i• Privy'(locate on site plan): Materials of construction: ' I Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 .I Commonwealth of Massachusetts =' - Title 5 Official' InspectioWForm Subsurface Sevirage'Disposal System'Form -'Not for Voluntary Assessments GM 17 Kelley Rd - Property Address ' Bank Owried (Contact David'Holt @ Today-Real Estate 1-800-966-2448) Owner. Owner's Name information is Hyannis " MA 02601' 3-26-10 required for y every page. 'City/Town w State Zip Code Date of Inspection D. System Information fcont.) - '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. f ' 0 4 . -C /° 6 --- -C-- 314 f • F j t5insp official document-03108 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 • sd Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 Kelley Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name , information is required for Hyannis MA . 02601 3-26-10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: y You must describe how you established the high ground water elevation: USGS maps show groundwater at 20'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of`15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARThwx T OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617)292-6500 TRUDY CO: Secrets ARGEO PAUL CELLUCCI DAVID B. STFiL') Goverttcr ` II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Cozanurs.or ART 1 �P�/ �d l� ct,1Ar S �/J�CERTIFICATION /y LvyG Property Addreu: i7 O:Z&O/ Name of O `5`^s a✓► L O,��y Date '/,SILL ovo Adar.aa of 0 nar: 'a 7gax—3�T'3 /,fie��,, j��,..-� �Q Name of Inspector:(Please Print) 44,- I3 sm•OEP a�protad system inspector to Section 16.340 of TFtls 6 f310 Cfs1R 16.0001 _� l�� Company Name: �Vt — %C Mating Address: O 90 X IA L— Telephone Number: CERTIFICATION STATEHIE NT I certify that I have personally inspected the sewage disposal system at this address and that the informeticn reported below is true,accurate and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sew a disposal systems. The system: _v Pastes Conditionally Passes _ Needs Further E slustion 6y the Local Approving Authority _ Fails hispeetor's Signsnrre: -19 Date: 2 �rv77 The System Inspector shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEPtwithin thirty.(30)days of completing this inspection. If the system Is.a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner Shell submit the report to the appropriate regional office of the Department of�Environmental Protectfun. The original should bs sent tolfnt system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS • U4 2 S !oK�0 000 • F N �� revised 9/2/9S Ps�e l of li `�1 Prmled on Recycled Pape, SUBSURFACE SEWAGE DIBPOIAL8 YBTIsifY(iNBPECTION KMM PART' MTIRCATION 18NOWW1 Ire�� /�� / ��s �1✓9 0�?6 v ctoperty Address: p� Owner: L oy r, v7 Dates of.k+speatfon: s a '00 INSPECTION SUMMARY: Chw* A. B, a. 6 PASSES: C/ ve not found any Information which Indicates that any of the fallurs condition described in 210 CMR 141.303 exist. Any faUwe c.lterle not evaluated are Indicated below. , COMMIENTS: s. SYST>:M CONOMO11ALLY PASUS- N One or more system components as described In the'Conditional Pass'seatl=need to be replaced or repaired. The avatem.upon completion of the replacement or repair,of epprovad by the Board of Health,will pees, -ate yes, no, or not determined M N,or NDI. Describe basis of detsrmination M all lnttenoea. If "not daterminW explain why not. _ The septic tank Is metal, unless the owner or operator has provided the system Inspector with a copy of a CertMoste of Compliance(etteohod)Indicating that the tank was Installed wittin twenty(201 years prior to the data of tiro heePesdOn;or optic tank,whether or not motel,Is cracked,structurally unsound,shows substantial"tretlon or oxfilt"roon, or tank t"!bis Imminent. The system will poll Inspection If the existing$eptie tank Is replaced with a complying septic tank to approved by the Board of Health. t Sewage backup or breakout or high static water level observed In the dloMbution box Is due to broken or obstnrotad ptWa) or due to a broken, settled or uneven distribution box. The system will pass inspection If(with approval of the Board of Health) broken plpols)w*replaced obstruction Is removed distribution box is levelled or replaced The system required pumphlpinvre titan tourtlmea s yeerdu9 to bta*m w ubstroated p)pelst. ;ha 7Tswrn vddr-pvms•^ inspection If Iwlth approval of lift Board of Health): broken pipeU)are replaced obstructlon Is removed • i €a t a :�::5ed 91219 E page i or is SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 W-ell f�iYl/� o�TIFICATION r>,red) Property Address: ��p`� ""� 6 0 Owner: Loy Date of Inspection: C. FURTHER EVALUATION IS j�I&R BY THE BOARD OF HEALTH: N Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYS1 IS NOT FUNCTIONING IN A MANNER WHICH..WILLPRGIECT THE PUBLIC HEALTH-AND SAFETY AND THE ENWRONMEPLT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. . .i I 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM' FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system1has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply t; tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. ! The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption systei-and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER t revised 9/2/98 Page.3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:7 tie% &J od c p l Owner: L f'g 03 Date of Inspection: ,✓/ / /0 D. SYSTEM FAILS: You Jn t indicate either"Yes" or "No" to each of the following-1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure., Yes No Backup of eewage into iecili"r-system component•dnslo an overloaded orcbgged SAS or•ceeapool. =�•--'-- ' _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due town overloaded or clogged SAS or cesspool.. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy;is below the high groundwater elevation. Any portion of a 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 I o1 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system-is-within 200 feet of�ibtatery-4o® Durfaoa>•daink—water•supply - • -- •• -— - 1 _ the system is located in a nitrogen sensitive aran(Interim Wellhead Protection Area.IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the syste Ya in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2%98 Pape 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: p� Owner: Loy Ci Date of hspectkm: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye No Pumping information was provided by the owner,occupant, or Board of Health. _ None of the system compooarus.k&L*J en poatpad+/oratJeast two%ve"s an&lhe ystem hasbesoaaceiaagwasaBlow. rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. V _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ Existing information. For example,.Plan at B.O.H. V _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) The facility owner Land.occupaots,if differaut from-cwner).wera.prayidad.withiointmatioacn.tba4ucpwjnaintoaaa aaf Subsurface Disposal Systems. i P E' revised 9/2/98 Page soril SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j? j // n ' � /� SYSTE�III/IfINFORMATION Property Address: Owner: L O� Date of Inspection: /� J FLOW CONDITIONS RESIDENTIAL: Design flow: _g.p.d./bedro Number'of bedrooms(desiglq): Number of bedrooms(actual):, Total DESIGN flow?- / Number of current residents: Garbage grinder(yes or no): � Laundry(separate system) (yes or no):/V 4? If yes,sepame inspection.required _ Laundry system inspected or no Seasonal use(yes or no):� Water meter readings,if available(last two year's usage(gpd): Sump Pump(yes or no): /V0 Last date of occupancy:/Q OHO COMMERCIAL/INDUSTRIAL: a Type of establishment: Design flow: aad ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non•sanitary waste discharged to the Title 5 system:(yes or not_ Water meter readings,if available: - Last date of occupancy: OTHER:(Describe) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source ol inf manor J� ,V) 40 System pumped as part of inspection: (yes or no)_ If}yes,volume pumped: gallons Reason for pumping: TYPE PP'ISYSTEM Septic tank/distribution boxlsoil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) 1/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,'date i alled4i nown►•end source e4ewfemnation: Sews"odors detected when-arriving at the site: (yes or no)�' revised 9/2/98 P2ge6orLt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �e/f SYSTEM INFORMATION(continued) Property Address: / l� � �i�l�fS /j ©a- O/ Owner: L (/ Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: / - Material of construction:L/C.st iron 80 PVC_other(explain) Distance from Private water supply well or suction line Diameter Comments: condition of joints, venting, evidence of leakage,-etc.) i SEPTIC TANK:_ (locate on site plan) Depth below grade: 2 Material of construction:_'concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is Inetal,list age_ Js.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: _ Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bore o of flat tee o baffle: How dimensions were determined: ,9 a o, evi(,e Comments: (recommendation for pumping, co dition of inlet and outlet t s or•baHles, depth o liquid lev�al in rel i n to outle invert, etructureFtintagrity,evidcnc�of le age.a c.) yr ✓9 i.r p � �y- L O Or n ✓) O •r GREASE TRAP: (locate.on site plan) Depth below grade:_ . Material.of,construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions- Scum thickness: Distance from top of scum to top of,outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: I Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page7efll - � .i' •1 °� SST li,. � 1 � i �� S,L, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t� / PART C ) IG` SYSTEMSINFORMATION_A// (continued)- On DO�-1v O Property Address: �� f �/ Owner: `/J 1� Date of ku on pecti : �/ ��J ° °/ TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) I (locate on site plan) Depth below grade:_ Material of construction: concrete metal Fiberglass—Polyethylene—other(explain) j Dimensions: 1 Capacity: gallons i i Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) I DISTRIBUTION BOX:_ (locate on site plan) ,/1 Depth of liquid level above outlet invert:✓ r arr-7A Comments: (note if Ie I and distribute n is equal evidence of olids carryover/eve i Jence of leakage into or ou of box etc.) — -— 43 ro PUMP CHAMBER:z (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) t revised 9/2/98 Page sorll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icotttinued) �r;4H�s Property Address: Owner: Z_ O G/C ion Dote of Inspect : ✓n�jd'O 0v SOIL ABSORPTION SYSTEM(SASI_ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type T/`leeching pits, number: leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note ondij*on of soil, igns of h draulic failure,level of p ding, a p Soil, o dition of vegetatio , etc.p or l ui►� d►e G�roKr7 -C rl a✓� d11 o 19.7.- 1 r C9,4 r o O to O C+c r � CESSPOOLS:_ (locate on site plan) Number and configuration: I Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materiels of construction: Indication of groundwater: inflow(cesspool must be pumped as pert of inspection) Comments: i (note condition of soil, signs of hydraulic failure,level of pending,condition of-vegetation, etc.) PRIVY:,/✓ (locate on site plan) Materjals of construction: Dimensions: 1 Depth of.solids: Comments: (note condition of Soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) /.f revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM PART C / e SYSTEM INFORMATION(continued) Property Address: g OaGo Owner: L ✓/ Data of Mupectioo: SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100- (Locate where public water supply comes into house) • i i 07 Yo cu 143 6'1 - 3), - - 92 ,36 � revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / L I ' o Owner: OgDeM o,kapectien: "/ . 0� NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 131-Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 5 JeAV J rp n�i-tio�7�� Vic' Or L) J bv.d-30 revised 9/2/98 Page 11of11 TOWN OF BARNSTABLE ` L`OCATION SEWAGE # VjLLAGE �� a- t r 1 � ASSESSORS MAP & LOT `��&7/ INSTALLER'S NAME & PHONE NO. i SEPTIC TANK CAPACITY 16 g O LEACHING FACILITY:(type) e-/4-L (size) L NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER_ BUILDER OR OWNER T 6!' DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i �,�s" i --. i � a l � (� C,� ��� � �� i i i . - i ` �� .. 0 No.._.. . FEB...3.9.!t.o 0.......... COMMONWEALTH OF MASSACHUSETTS COMMONWEALTH OF HEALTH TOWN OF BARNSTABLE Appl iration for Dili-pu l lVnrk.6 Cnd ustrurtion ItPrmit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: 17 Kelley .Rd Hyannis ................_..................�. ..... .-........•-•----•-•--.......................... .......•-••-••••••••-••--•--•-------•---•-•-•...--•---._...•--.................................... .. \ddr•ss or Lot No. Jane..Logan....._.. a , ly Ogan •-•--- --------------------------------------•-------•-------.....---•----.........._......•---•...••••-- Owner Address a .........E�...Robinson Sint7-Q... er.V.!c_e............. ... ...O......Bost....1.OB9....Centeru.i11e........................ Installer Address UType of Building Size Lot............................Sq. feet .. Dwelling—No. of Bedrooms........ ----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ).— Cafeteria ( ) Q' 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........................................ W Test Pit No. I................minutes per inch Depth of Test Pit.--........------... Depth to ground water......................... 44 Test Pit No. 2................minutes per inch, Depth of Test Pit.................... Depth to ground water...----.....---....--... 040 •-•••-•-•--•------------------••---•----•--••--•-••-••••-•-•-----•-••••-......•---•-........-•-•--••......................................................... 0 Description of Soil...............s.and............................................................................................... .............................................. W U N u e of Re a' s or Alterations—Answer when applicable---install a .. 000 gal tanks _____________ — ox a�c� a precast stonepacked pit . .................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been • sue by the board of health. Signed ...... ... ..�.../.... . .................. ..Q...................... ..`.l ..�L... ApplicationApproved By ...... .. .. ... ..... ... . . .. .. .... ...©........ .... .... . ... . e Application Disapproved for the following reaso : ............................................................................................. ........................**''* :.................................. ........ .. .. Permit No. ........ ... ........... ... .. ........................... Issued ...............0. ..d.ie ..W/. ........6 a1e...... NO..-..►...J O� D 3 0 0 0 r Fss.............................. VCO MMONWEALTH OF MASSACHUSETTS MASSACHUSETTS OF HEALTH TOWN OF BARNSTABLE Appliration for Diopoottl Worlm Tonotrnr#inn rmnit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 17 Kelley Rd Hyannis ..................................••----••--•---....----.....--•-----•-••-•••--.._..•-----.-.....• -----•••••-------------•••-•--....----•-•-----•--•----.-..._...._........---•-•-----•••---•-•-•--. L ati r \dd ss or Lot No. .Jane Locran �`a�'lY Cogan ......................_._....................................................................... -------._...._._.-••---•-•---------••--...••-•----•--•-•-•--•-•------.........------•--••-•-•-•--- Owner Address a .._.W_._E.__.Robinson---Septic_ ---Service-.--•--•----- o�_..BS?x.._1-OS�..._ Qxlir �ti.lie........................ Installer Address Type of Building Size Lot............................Sq. feet ►. Dwelling— No.-,of Bedrooms........ ----------------------------------Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building a yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 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........................................ ,-a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f-T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ _.....--•........................................_..-----•---._...._._..._--------••--•....---------......................................................... O Description of Soil..............sand •••-------•-•-•---------------•----••-•-••---•------•-----_... x w UN u e of Rea s or Alterations=Answer when a plicable_ ns_tall a 1 ,000 gal tank, d—rbox AM a precast stonepaekec� pit ��� � � i �y ............................ Agreement: The undersigned agrees to install the aforedescribed'Individual Sewage Disposal System in accordance with i 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 sue by the board of health. Signed ...... .�...1.... .. o . ............................................... .... Dare Application Approved By ..... V...l: ./.. . .. .. ........... � /. !1 ..................... ........................................ /f I Dare Application Disapproved for the following reaToryr:/.........................`........................................................................................................... -............................. - .........................................................................................................1?...... .............. a n Dare n PermitNo. �`� ............................ Issued ............... . .. ...�...�'//... .................... ........:.... ................ .. Dare / I _.----.----.--.— --.—_. _----_ —.---.-----—.--- --...--_— ---.—.—➢—.--------_—,—,—..—.---_—.—.--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ce>rtifi ate of Contylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed x g p y ( ) or Repaired ( ) W Ee Robinson Septic Service ................. .......wil.e........................................................................................................ y ..1..7....Ke1.�..y....Rc�. ... Hyannis +' ins rrl lcr ... has been installed in accordance with the provisions of TITLE 5 of he State Ems' onmental Code as described in the application for Disposal Works Construction Permit No. ........... ji. dated ............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY._-• DATE................�.` ..: " ^../ �....... .... ......... Inspecto v... .. .............G1 --------------------------------�- ------------------------ ------r-------7 THE COMMONWEALTH OF MASSACHUSETTS I VVV BOARD OF HEALTH TOWN OF BARNSTABLE 30•-..00.No._.._..--•............... FEE.---- .._............ t �io�os�tl orl;o �onotr�rtion �rrmit Permission is hereby granted__.T.E. Robinson Septic Service ........................................... .------••------- _,-„ •............................................ to ConstI>;ctl�,,),o Repair x ) an, Individual Sewage Disposal System atNo............................................ annis Street � as shown on the application for Disposal Works Construction Per it Nc-_..__-__•___..�_� Dat ff/I ..................n__;�.__ y Board'oE Health l � / J DATE3 -r•------t t-------------------------------------------•--•---- (v/ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS r� t S 12.49'46" w I LEGEND J 6�0^ N -- gg -- EXISTING CONTOUR sum x 100.98 EXISTING SPOT GRADE -�/-/,� OVERHEAD WIRES � ROUTE 28 yV EXISTING WATER SERVICE o G EXISTING GAS SERVICE Rd LOCUS DTEST PIT -4g- BENCHMARK Lot 13 & 1/2 Lot 14 p o -C 14,050f S.F. ,�� ' a Ma 292rn P � G 1�1 �drid98 Patton Parcel 071 pa,65 P A Z LOCUS MAP m GENERAL NOTES: NOT TO SCALE J W 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL i cn BOARD OF HEALTH AND THE DESIGN ENGINEER. 1 co94 rn Ln 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS N \ �'�edge of clearing OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE m \�� 39�83�/ 41,9� 2x 42,89 LOCAL RULES AND REGULATIONS EXCEPT AS REQUESTED BELOW: x 60 5• -310 CMR 15.405(1)(b): TP-1 5 5• \ 1) A 2' variance to the 3' maximum cover requirement, for 5' of 1' 0 5 1 max. cover: S.A.S. shall be H-20 and vented. E x 41,22 /'� I 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR � I TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE TP-2 +1,14 �� _ EXISTING,LEACH PIT DESIGN ENGINEER. It SPIKE �� �\ - x 42.71, TO BE PUMPED, FILLED 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING W/ SAND,AND ABANDONED FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN + 41,08 _ r-417-.9'ff� x 42.97 ENGINEER BEFORE CONSTRUCTION CONTINUES. BENCHMARK SET _ 42.95 --44 `'s 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. Orange paint/Conc. Block 42.51 �- , 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF EL.=43.74 (Assumed) ���' -��\ 0 EXISTING SEPTIC TANK THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF + 45.22 �J �� TOP OF-TANK, EL.=42.99f HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. DECK x 43,39 i INV. OUT>; EL.=41.66f 43.05 43,44 ( 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 43,94 x 1 + 45.86 � '� k6 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 45.31 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS �I iEX/ST/NG AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE DIRECTED BY THE APPROVING AUTHORITIES. HOUSE (#17) 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY T.O.F.=47.41f THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. 45.58 45.89 P\�� OF Mgsf9� 1.1. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 46.78 46x5U6 6 z�`` PETER T. yo IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND i o �/ 4`�40 �" REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). McENTEE DRIVEWAY 7T- o CIVIL 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE 45.78 3 0. 35109 INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. x 45.42 A REGISZER 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 44.88 O,r 6� IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. 1 45.12 90 00' A& PROPOSED SEPTIC SYSTEM UPGRADE PLAN 7B44,91 45.80 \S 15'4 '446',s `, �I 2y ( j u 17 KELLEY ROAD, HYANNIS, MA 0- OWNER OF RECORD Prepared for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 45.01 START edge of 46.25 Povement 46,60 UP SHEA, JOHN & 45.48 46.82 PACHECO, WAYNE Engineering by: SCALE DRAWN M 175-10 i %FEDERAL NATI MTG ASSOC Engineering Works, Inc. 1 =20° KELLEY ROAD ! P.O. BOX 427 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. g HYANNIS, MA 02601 (508) 477-5313 7/24/10 P.T.M. 1 Of 2 NOTE: ITO PREVENT BREAKOUT, THE PROPOSED BACK OF HOUSE FINISH GRADE SHALL NOT BE < EL.37.3 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D—BOX PROPOSED S.A.S. D CK INSTALL RISERS & COVERS OVER INLET & CHARCOAL OR _J INSTALL RISER & WATERTIGHT INSTALL INSPECTION PORT OVER END UNIT CONVENTIONAL VENT L — T.O.F. OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE 1• F.G. EL: 42.3(MAX.) EXISTING F.G. EL.=43.5t F.G. EL: 42.0t MAINTAIN 2% GRADE (MIN.) OVER S.A.S. L INSPECTION 34' L = 2'(MAX) PORT �C ® S=1% (MIN.) ® S=1% (MIN.) 6 - 4"SCH40 PVC 4"SCH40 PVC 5 1o'I 1a" 6" 10 3 !RTITof PRO?0 6� EXISTING 48" LIQUID LEVEL ADD INV.=36.87 i-- GAS BAFFLE) INV.=39.17 PROPOSED INV.=39.00 (1 ROW OF 12 UNITS AT 5.0'/UNIT) = 60.0 INV.=41.66f D—BOX EXISTING SOIL ABSORPTION SYSTEM (PROFILE) EXISTING SEPTIC TANK S.A.S.LAYOUT ESTABLISH VEGETATIVE COVER BACKFILL WITH CLEAN NATIVE OR NOTES: PERC SAND TO TOP OF CHAMBERS 15 5' (3) 5" DIA.OUTLETS 16- 2" 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE ~—� INVERTS, PRIOR TO INSTALLATION. '•' ` •:.'=��; "` �•� 2) D—BOX SHALL BE SET LEVEL AND TRUE TO TOP ELEV.=37.33 1 GRADE ON A MECHANICALLY COMPACTED SIX INV. ELEV INVERTS, 1155. ` t t2" INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.=36.00 310 CMR 15.221(2), 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 2.83' Top View 4 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 5' MIN. ABOVE BOTTOM W. Section 2" ) T.P. EXCAVATION OR G.W. H-10 LOADING AS MANUFACTURED BY TUF—TITE, ZABEL OR EQUAL. EXISTING SUITABLE D-BOX NO G.W., EL=30.5 = MATERIAL SEPTIC SYSTEM PROFILE USE 1 ROW OF, 12—ADS Arc 36HC UNITS 63.25" IN TRENCH CONFIGURATION WITH NO STONE N.T.S. TYPICAL SECTION 1s" DESIGN CRITERIA SOIL LOG 34.5" NUMBER OF BEDROOMS: 3 BEDROOMS DATE: JULY 22, 2010 (REF#12,995) SOIL TEXTURAL CLASS: CLASS I SOIL EVALUATOR: PETER McENTEE PE(SE#1542) WITNESS: DONALD DESMARAIS R.S. DESIGN PERCOLATION RATE: <2 MIN/IN HEALTH AGENT TOP VIEW DAILY FLOW: 330 G.P.D. ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH 60" " END CAP END CAP DESIGN FLOW: 330 G.P.D. 40.5 A ++0 41'0 A 0 FRONT VIEW SIDE VIEW GARBAGE GRINDER: NO S 0YR 4/2M f S ANDY M 0YR 4/2 END CAP 40.0 6" 40.5 g" REAR/TOP VIEW LEACHING AREA REQUIRED: (330) = 445.9 S.F. B B SANDY LOAM NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW SANDY LOAM TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY 10YR 5/8 DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. EXISTING TANK: 1000 GALLON CAPACITY 38.3 32" 4640 TRUEMAN BLVD PROPOSED D—BOX:: 1 INLET, 3 OUTLET (MINIMUM), H-10 RATED 37.5 C 36" C 34" HILLIARD, OHIO 43026 PERC ILLLLWI Are 36HC DETAIL 46" ADVANCED DRAINAGE M7EM i c. H-20 LOADING USE 1 ROW OF 12-ADS Arc 36HC UNITS M—C SAND PROPOSED SEPTIC SYSTEM UPGRADE PLAN IN TRENCH CONFIGURATION WITH NO STONE 2.5Y 6/4 M—C SAND 17 KELLEY ROAD, HYANNIS, MA (GENERAL USE APPROVAL FOR 7.80 SF/LF IN TRENCH CONFIGURATION) 2.5Y 6/4 12 UNITS = 60.0 FT Engineering by: SCALE for: D. A. Brown, Inc., P.O. Box 145, Centerville, MA 02632 60.0' x 7.80 SF LF = 468.0 SF 30.5 J120" 31.0 120" LE DRAWN JOB. 10. / PERC RATE <2 MIN/IN. ("C" HORIZON) Engineering Works, Inc. NTS P.T.M. 175- 0 DESIGN FLOW PROVIDED: 0.74(468.0 S.F.) = 346.3 G.P.D. NO GROUNDWATER ENCOUNTERED 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. I (508) 477-5313 7/24/10 P.T.M. 2 Of 2 1