HomeMy WebLinkAbout0098 KENNEDY CIRCLE - Health 98 Kennedy Circle
Hyannis
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Commonwealth of Massachusetts YIP °?j,49—D5-ZP
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ca
�< 98 Kennedy Circle
Property Address
u�
John Weisman
Owner Owner's Name
information is Hyannis MA 02601 7-24-15 t
required for every �
page. Cityrrown State Zip Code Date of Inspection FU;,
t.=
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, �,ZN OF rAf4
use only the tab ��o '0 ........
•ssq'�.,
1. Inspector: :• ••.•
key to move your o.
cursor-do not James D.Sears
JAMES
use the return _ _
ke Name of Inspector SEARS e
y.
Capewide Enterprises,LLC *' 0-
Company Name '?mil
153 Commercial Street ���UF 5 I N S ��`���\
Company Address nj
Mashpee MA 02649
Cityrrown State Zip Code
508477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7-24-15
nspector'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.
II
o� I/S
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
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:
The system is a 1000 Gal.Tank D Box and five infiltrators.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years oJd*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is Tess than 100 fleet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in eesepeel is less than 6" below invert or available volume is less
than '/day flow 4£X('11/N,67
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary-to a surface water supply.
-❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less then 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 16.303, therefore the system farts. 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 fotfowing, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CM 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
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?
❑ 0 Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)1310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M .'e 98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal Tank D Box and five infiltrators
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gP ))�
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.�' 98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 8/24/12
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank NA/Leaching 2004 Permit #2004-541.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 28"
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
i
Septic Tank(locate on site plan):
Depth below grade: 17"
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. Precast H-10
Sludge depth:
2"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Tape-Plan
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank at working level. Tank and covers at 17" below grade. Inlet tee, outlet tee. No sign of
leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owners Name
information is
Hyannis MA 02601 7-24-15
required for every �
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�t 98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information is
Hyannis MA 02601 7-24-15
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is WxIT-32" below grade w/two lines out. Box is clean and solid. No sign of over
loading or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No`
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
"If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hyannis MA 02601 7-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5
❑ 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.):
Leaching is five infiltrators i Ux3T. Ck D Box and camera out to chambers.Clean and dry
w/no sign of over loading or solid carry over.
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information Hyannis MA 02601 7-24-15
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hy annfS MA 02601 7-24-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public beater supply enters the building. Check one of the boxes below.
® hand-sketch in the area below
❑ drawing attached separately
13
l a
t5ins•3113 Title 5 Offiaal inspection r=omr.Subsurface Sewage Disposal System.Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M yf 98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every H ya nnis MA 02601 7-24-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells Q
N 11'6"
Estimated depth to high ground water: 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: 9-24-04
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:
T.H. on design plan 9-24-04, no G.W. at 11'-6". Bottom of chambers at 5' below grade. Bottom of
chambers at 6'-6"above T.H. Depth.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y�. 98 Kennedy Circle
Property Address
John Weisman
Owner Owner's Name
information
required for every Hy-a nnis MA 02601 7-24-15
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
L
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Fee ;L5
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pprication for Misposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System X Individual Components
Location Address or Lot No. q F < IR Owner's Name,Address,and Tel.No.
Assessor's Ma /Parcel (4 y S0RN+ REAIEE W-51SMa44
p �r.g O 5 3 bl CT POUE�496_q_-StE N.y
Installer's Name,Address,and Tel.No. ���- '17-8�?'� Designer's Name,Address,and Tel.No.
CQ nE w('0 6 6&)-R 2Wusiss
Cc WC&t _ S v' l�•ts( EFP�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
PkGy t y o� d k)S7�T C)o
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 Heal
Signed Date
Application Approved by Date 'a r
Application Disapproved by Date
for the following reasons
Permit No. Date Issued / t
-------------- ------ - -------------
No. 61 Fee �. J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
{ 4plication for Disposal .6pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System [9 Individual Components
Location Address or Lot No. 4 1 P_ Owner's Name,Address,and Tel.No.
Tc7E}N+ RErJE'5 I�OSM/f�
Assessor's Map/Parcel o�(p8 0 5& H Y 3 8l l Cl— 'POJEiI96EP&E N y
Installer's Name,Address,and el.No. 50S-477 -S F'7 7 Designer's Name,Address,and Tel.No.
C Cat P6 wry E j7W_ 15sS Lrc.c_ W/A
153 C0M",t9AQl 4(., SZ 9490P0.E'
Type of Building: /
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) /+ gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
/3,0Jb,0 P �JZ7144 OYeJ G&�%,PCjaL, j=ROM
P&G-0 r0cx l QS71�7760
Date last inspected:
Agreement:
i
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
Application Approved by LA_41 Date
Application Disapproved by Date
for the following reasons
Permit No. o Date Issued
----------------------------------------------- ---------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by. (��^,A0 t✓wm g Q T ry P Q ka�
at �CE�NEDy �? IQCCS'C has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.901 s;'7'6 dated }' j
i
Installer CaAEwcoG Designer KkAl—
#bedrooms Approved design flow. / YV A gpd
( 1
The issuance of th" permit shall not be construed as a guarantee that the system will function asAesigned
u ✓ �./ .�
Date �-- 1, 11, Inspector
No. �( Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal ,6pstem (Construction Permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at 1S Keot�&—Dy uo,-;�,L� '(YAPP(5
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit_��� �U
Date — I Approved by r 1
=�&-
�^ TOWN OF
NAP-AT cv(.e. 05-b
LOCATION: 1f evvy e c 1-e
VILLAGE: d 0yrr—
LOT#. PERMIT#. o '7`
INSTALLER'S NAME! d /}
INSTALLER'S PHONE Fd Y
— �ff--)) `T c
LEACHING FACILITY: (type) [/V � - size O
NO.OF BEDROOMS: J
BUILDER OR OWNER: V tf tj:= V-4—wii
PERMIT DATE: to-
COMPLIANCE DATE:
'"` DRAW DIAGRAM ON BACK
lzd -FIZ
N
. 1a
TOWN OF
A--*A
LOCATION: ¢ �N,► ✓c
WLA
PERMIT4'
LOT k
INSTALLER'S NAME. {�
' INSTALLER'S PHONE#.
size
LEACHING FACILITY: t e
® �
'BEDROOMS:
NO.OF
BUILDER OR OWNER:
FPEDATE: 1
MPLIANCE DATE: O
DRAW DIAGRAM ON BACK
rir—
Da
_ j I►
01�
c s7
No. Fee v
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: le
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01ppfication for ]0igpogar *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System J!(J Individual Components
Location Address or Lot No. Q�'b�e�i� r�l✓ Owner's N e, ddress and Tel.No.
Assessor's Map/Parcel lI�� I ' ("`n n is �a
Inst is NWe,,Add re s, d Tel.j� Designer's Name,Address and Tel.No.
-7
Type of Building:
Dwelling No.'of Bedrooms Lot Size` sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 2
Design.Flow gallons per day. Calculated daily flow P> �r gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1$ 00 Type of S.A.S. -ft�72S
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provisions o Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued this Poard of He
Signed Date d /3 ID
Application Approved by Date
Application Disapproved for the following reasons
Permit No. C �"'r Date Issued ��
�4No5 Ll a'°'• ,' o g - Fee a
J'
Britered in computer:
-THE COMMONWEALTH OF MASSACHUSETTS <
PUBLIC HEALTH VISION -TOWN OF BARNSTABLE, MASSACHUSETTS s
2pplication for Mizpogal *p! tem Co.ngtruction Permit
Application for a Permit to Construct( )Repair(' )Upgrade( ' )Abandon( ) O Complete System l Individual Components
Location Address or Lot No.(,11p�,(enn a,l &rCl pL Owner's N e,Address and Tel.No.
I�� 1 IG-c-�n n 1'5 /hare -
Assessor's Map/Parcel 020—05
Instkj e�r''s�N))am, e,Address and Tel.No. Designer's Name,Address and Tel. o.
DB- `97 tJ 15q 8
Type of Building:
Dwelling No.of Bedrooms Lot Siz sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �2 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank I 1 5 f Ulf Type of S.A.S. iiZ
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
A
Date..last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued y this Board of Heal
Signe Date Q /.3/10
Application Approved by Date //o.
Application Disapproved for the following reasons
Permit No. 300<-1 "'-57 Y I Date Issued O 3 G,-
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE T FY, that the On-site Sewage Disposal System Constructed( ) Repaired ( )Upgraded(�{ )
Abandoned( )by S
at_ has en constructed in accordance
with the.p ovisions of Title n the,for Disposal System Construction Permit No.u i dated
Installer Designer -
The issuance of this permit shal not be construed as a guarantee that the sys em w;1 ftunct asp esignc &'
~'
Date �► P � All Inspector ✓ fit � All 1 i
No. 5 LI I Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION.- BARNSTABLE., MASSACHUSETTS
Migo!gal *p5tem Construction permit
Permission is hereby granted t)o/wConstru t( )Repair( )Upgrade(X/ )Abandon( )
System located at /111 I1/ S
I
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 da of oY this pe
Date:_�//)// 3 o �/ Approved by
Town of Barnstable
1HE Tp�
Regulatory Services
Thomas F. Geiler, Director
• BARNSTABM r
6`& Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 101124164
Designer: Installer:
Address: o. 1 nx t Address:
, N A Oa f YGc m P P�
On C was issued a permit to install a
(date) (installer)
septic system at based on a design drawn by
(add ss)
nun dated >i�I 1 D
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
�ZN,:OF MASS.
( ler s Si a �o CAA RR..PAEf�'
SHAY
Wo: 1181
esigner's Signature) (Affix De ,^ t ere)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVIS N. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
7-7SECION�A -A*NOTE- ALL HEDULE,40 P.V.C. OU ET PIPES FRW THE PIPES ARE,TO BE 4",S64 4 I 7L __j 10' min., from /ENT PIPE (O Le,d;1/,24.Inches'tall DDITION TO "LEACIIING SYSTEM DISTRIBUTION BOX SHALL BE.) * PROFILE VIEW OPA Schedule 40 PVC rcool CONCRETE COVER Existthg —Foundation �h,,Seto septic tank h 12'Odor,ril ter SET LEVM FOR AT.LEAST-2 F-L . "' ':�d) Wtic ton covers must be Is�'ELEV. 100.00 (AS�i e f6P"'Orf-OUNDATION' ste 3* 6f,1/8' - 1/2* Washed Peastone shed 3*thIn 6 in."of Chi grode 51 OUTLET Gm&over Septic Tank 99�00 Grade over D-Box 99 17 over SAS 99.00 /4* to 11, /2 Washed Crushed Stone 3 KNOCICOUTS Ir T------------r OU 7 3 HOLE 14-11D T LoW -Elev. 1"6.25 S 0.02 IEXIST. S-0.01 or Greater DIST. BOX NEV In 1,000 GAL' 0 0.01 L S per foot 75.x 2o' 0",Effec"b S FROM EXIST.FIOUNIDATMIN UJI Best I5 Units 6.25' W C H-10 ui ;i9".W-CROSS-SECTION PLAN SECTION 0 3' 3'CONCRETE PLILL'F0LWM'J1111 to(6 0.8 3' 00 inches) 5 6 In.of 3/4'-1 1/2' j3 HOLE H-10 OISTRIBUTION BOX' SYSTEM PROFILE compacted stone INOT TO CALE 0) -Effective Len th S A-Not to Scale c % 41, ,I - ABSORPTION SYSTEM �(SAS)4 SOIL-C 5'CL T , I :j INFILTATROR_'HIGH,CAPACITY �'(H-20 LnADING)/ GEORGE O'BRIEN" NOTES O
6 In.of 3/4*-1 1/2' 'a I 0 GENERAL Effective %ndth compacted stone ; 1: I .1 -, �,(OR'EQUIVALENT) Not to Scale 0 1. Contractor is responsible for� Digsof e notification NOTE. ALL COMPONENTS mus HAVE RISERS TO WITHIN 6" BELOW GRADE Bottom of Test Hole 1 Elev.=87.5 NOTE: OVERALL L HEIGHT OF INnLTRATOR IS 18' /EFFECIVE HEIGHT It 10* and protection of all Underground -utilities No Groundwater Obseryed 0 132" and pipes.2. The- septic tank anj box -shall'be set level on 6" of 3/4 -1 /2' stone. no Backfill should be clean �sand or,gravel wi stones over 3" in size.4. Thi system is subjec 'petion during installation S t t6 ins
by Carmen E.,Shay!-, Environmental Services, -Inc.5. The contractor shall install this system,in ,accordance with Title V of the 'Massachusetts state code, the approved,plan
LATION ' TEST. -Loc and of 4 Regulations.stalla "the' co' ' tractor'6. If duiin in on In g n encounters any Date �of Percolation.Test: SEPT. 21,, 2004 S soil:-conditions or 'site condition different TPerformed By: DARREN MEYER,' R.S.� C.S.E. NIF NORMA ACARES R egUlts -Witnessed By. .WAIVER per Barnstable B.O.H.) from those�shown n the' Soil or in our' design hM u NOWN installation immediate notification 'be EXCAVATOR:,:UNK '1nviro6menta'l Servic 'S.e made.to 'C,6rmen E. Shay e
P rcolation�Rate: Le Than '2`MPI 36* 7. No vehicle or heavy.machinery 'Shall drive over the septic syste unless'noted,as�H-20 septic components.
PL 193.00 8. Install Tuf it gas ,baffles or equals on all outlet tee ends.di ameter Schedule 40 NSF PVC pipes.
9 All Distribution Lines isholl'b'e 4
LOT #9 Hole 10. 'Alt solid piping., tees fl tings shall be 4",diameter t
15,850 Squ�tre�'Peet No. 1 Failed Schedule 40L NSF PVC pipes' with water tight joints.DEPTH :Leach Pit 11. Municipal Wat er.is ,Connected Ao ALL OF The Residence'and Abutting 0 0 99_00 Proo6itiOS'Within'L 15 Feet.DECK Loamy THE ROPERTY LINES ARE APPROXIMATE AND Sand GARAGE �COMPILED FROM THE'SURVEY 10 Y 4/2 PLAN GENERATED BY O., 96.56 EUSTING RICHARD LAN. R.L.S. 'ENTITILED ENTITLED " PLAN OF LAND IN HYANNIS, MA Of SEARS WOLFF,Loamy Sand -1958; & CASE #1190 ternber 24,
HOUSE To"LB r-A SURVEY PLOT PLAN '10 IVR 5A #9, (ak.a. #98) SkOULD DED AND IS�NOT"INTEN
Bw EXIST. 1000 go IT USED FOR NO P 6 2e 97.001 �eptic Tank Full Foundation Med.. # THE-SEPTIC SYSTEM.INSTAUATION.LOT 8>and 0 Crawl Space SHED EXISTING LEAC PIT:TO'BE: PUMPED OUT,AND 24*-1 38 87.50 REMOVED TO FACIUTATE NEW SEPTICL SYSTEM INSTALLATION 0 LOT #10 NOTE: ANY STRIPPE6'60T�SOI L� C NTAIN Nb LEACHATE
ID- 'FROM THE EXISTING 1EACH ,PIT TO BE DISPOSED BOX OF ASPER BOARD OF HEALTH SPECIFICATIONS.-MARK NO WETLANDS ARE PRESENT.WITHIN 200' OF THE PROPERTY TOP OF FOUNDATION ELEV. 100.00 (Assumed :U ASSESSORS MAP 268, PARCEL 056
f 7.2 LEGEND
TEST #1 7 L Pere #1 ELEV.tm� 99.00'to 46" PROPOSED �Depth to Perc:` I11 04X I Perc Rate Less Thb 2 MPI R-SPOT G ADE Groundwater. Not ObserVed DENOTES EXISTING No Observed ESHWT eVL X 104.46 El None ADJUSTED H20 SPOT �GRADE I_IY P11 PROPER L�'LINE L- -65r.00 'PRbPOSED 'CONTOUR I �50.9t 97 GCONTIOUR DEEP 'TEST HOLE &-is' DIAM. ACCESS MANHOLES�2 PEPCOLATION`�TEST 'LOCATION T 6 , FOOT 'S OCKADE ENCE I0 A
_j02V2V_E7_D T P LOT N r THE A CcESS COVERS FOR THE SEP C ANK. -(40 FOOT, RIGHT�:'OF WA`0 71 T SET DEEPER THAN 6 INCHES BELOW FINISHED SEPTIC :.'SYSTEM UP G DISTRIBUTION BOX AND LEACHING COMPONENT 0 F PRO PLOSED ,�," RAID E GRADE SHALL 13E RAISED To WITHIN 6,OF IFINISHED GRADE. , FOR REINFOrt6 kECAST,CONCRETE"'L 'L, � �,' "�, — L- �L I I �,I ) , -
PREPARED
TE OAS BAFFLES OR EQUALS INSTALL TLF-T!P LA N VI EW f!�.,--,,LARF0v �',&, ,PATR1C1A` MARTI N
7-�O"'ERS 3-24,REMOVABLE'C I# 4- L E a k#9 --CIRC #�8)KENEDY'.3'min. deolonco,, Io, tle a fn�. 1 2 IYAN i� IINLET -E= N IS,5, I_7 5 n 15 OF S R PREPA ED 8 T Uquid cepth Number.of Oed�7ro6ms- 3 Equivalent"to 330 bol,/Day (336'Got 'Min. pW t1tio \o Ooy ly IGarbage Grinder. No nged, 330 Col.'Leaching,Capacity,,P Ill. Per -dtl Ar I C HA�Y-rop�!�epti Tank 4'.�11 W 2 ENVIRONMENTAL�_SERVICES,L"JNC�660 1.0 c X EXIST. 0 GAL.,-Septic n 0 N P EA IA-Sidewall i6a: gal./iq. ft. x 8 sq.- ft" OUT'68 a 11 on " -' ' I:,i I - 0 �,,80'X' �627 ,�370' tq. ft. 273.8 gallons'OSSL 0 .74 '�gal/sq. ft. x CR "SECTI END:LSECTIOIN SOIL ABSORPTION'.AREA: ,�'Utfno�pei�6olotion :rate ofk2 min./inch BottorYf"Are ST- FAN MA 2 53 6 7 I-I"
N L K� H
VI TARN ITEL/FAX 5 8'�-GALLON -.SEPT C 7ANK : .. L - , " `,. ___ I v:� -1 " . . - L Provfdincy.'TYPICAL 000,: I b 648' 0796 IN -20 UNI H 1;001UU,Ut iK�F Le 4el%W4
D t DRA 'O TOBE 1 20 N CAPACITY H ATE.s 6 _PTH,'A 1 `20 Tt AVING
TO�SCALE NOT LVATOR HI
NCHES) EFFECTIVE"OF
W R' 12 2 004�ON HE WAsHEDL-S ONE- �SIDES,,! E��'TO,BE TH`;4.0' P T#PROJEC PpiDWGL SD64 1 ]LENA SHEET 1 OF 1:SD641 M I-ON THE ENDS NO DER.ITONE.UN 4 I