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HomeMy WebLinkAbout0460 LINCOLN ROAD EXTENSION - Health 460 Loncoln Road Extension;; , A,= 271 028 � I P f i l fi i� iI p Fty �` o s TO OF BARNSTABLE c LOCATION LMQQ +moo\N o SEWAGE # VIj�LAGE C "-�'' S A SESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �ize) LEACHING FACILITY: (type) � �� K NO.OF BEDROOMS 11 BUILDER OR OWNER or P:S 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 leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by C7 � � � -� t �� � Y �� � � I _ _ q� o � -_. w co � . __, .��. , ; No. 7 d-(O ` ' ► ��� Fee y THE COMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS 0(pprication for Mgotar *p!tem Congtruction 30ermit Application for a Permit to Construct( )Repair:. Upgrade( )Abandon( ) ❑Complete System >qndividual Components Location Address or Lot No. 44o p Uj%)C O jn Owner's Name,Address and Tel.No. Assessor'sMap/Parcel �N1E 2' Installer's Name,Address,and.Tel.No. timber kS 'e�C Sg Designer's Name,Address and Tel.No. S4 8� S "S'C�es��cx1 S 51AM 9 Y Get g-S b%c) Type of Building: Dwelling No.of Bedrooms a Lot Size 10 ,65 .ft. Garbage Grinder( 41,c� Other Type of Building No. of Persons Showers( ✓) Cafeteria( V� Other Fixtures 2 rL L00a�t st+ �S �naa ZXo k% �Q�M Design Flow J J gall ns per day. Calculated daily flow y '3\.S O gallons. Plan Date S a•t O Or Number of sheets \ Revision Date Title Size of Septic Tank y l�r%1. �,[�S ��Type of S.A.S. Cviit-,!Lr ,50/ Description of Soil ' `40 Nature of Repairs or Alterations(Answer when applicable) !;21 n C� 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 prov' ions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ' eWhis d e Si ed Date 6b_5)&/ Application Approved by Date d Application Disapproved for the following reasons Permit No. gLoo y Date Issued S 4, ----------g----n,__..———————————————————————————————— � No / ; Fee y THE COMMONWEALTH OF MASSACHUSETTS Entered in compute r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS APPrication for 3io'o!6ar 6pgtem Construction i3ermit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System .Individual Components Location Address or Lot No. 4(+0 L.l N C(_A 11 l� C T. Owner's Name,Address and Tel.IP. i�1 e,r,ntc, mi4 ti}t1F)�rJ + F1 4 + Assessor's Map/Parcel 2-1 1 c)D 5 P M E Installer's Name,Address,and Tel.No. '�,Q J)Ar�C S I(S Designer's Name Address and Tel N �14 b-Q +9ke �k-)u(ccw,(" G\ S v CS. LEI 8_5310 `�' ' `dux L')- Type of Building: �f Dwelling . No.of Bedrooms Lot Size I C) ,Q sos ft. Garbage Grinder Other Type of Building (6- '70aZ No.of Persons Showers( ✓) Cafeteria Other Fixtures Design Flow J C) gallons per day. Calculated daily flow d gallons. Plan Date 5 O�' Number of sheets Revision Date, =' Title Size of Septic Tank UQr~ C.\ - Ext pe of S.A.S. C) SCC� C C!`nCM X Description of Soil �C 1 Nature of Repairs or Alterations(Answer when applicable) Gtl 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 thfEnvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ids ed ,1 this oard oVA e tli �1 Signed Date Application Approved by Date la \Application Disapproved for the following reasons Permit No. 9©© Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER FY that the On,-site Sewage Disposal System Constructed ( ) Repaired (Y)Upgraded"( ) Abandoned( ) ' at C �d -II C� l� ��( }Gf ]�f ff��}Y1 l /hasbFeen constructed in accordance with the provision,'-Of,Title 5 an c4or Disposal System Construction Permit No.�7� �� ►!/�r dated Installer J_ V / Designer J) /�l i l n /I r, 1 The issuance,of this permit shall not bye/con tr ed as a guarantee that the y"�em wilh¢¢functiio�- a desigrierd`� Date �� /�,� ! Ins ector 1 C f; �t/�vA® II � 01 `r ! / P - ———————————————————————— — —————————— No. C� `-� " 5 't_ , -— - Fee THE.COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -.BARNSTABLEs MASSACHUSETTS x3i.5pont *pgte Con!5trurtton Vermtt Permission is hereby nt to Cons uct )IVir ,Upgrade )rib.Abandon ( ) System located at `' a� �f/ "t'd i �/t '�-s and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructt n//_must e(coompleted within three years of the d to of this e i Date:_ � p �T Approved by - — P I. TOWIA OF BARNSTABLE r I, LOCATION �Vt�O t^-C�\N ` SEWAGE # VILLAGE wvti.v A SESSOR'S MAP & LOT 7I- INSTALLER'S NAME&PHONE NO SEPTIC TANK CAPACITY. LEACHING FACILITY: (type) NO.OF BEDROOMS 14 BUILDER OR ONER PERMTTDATE:W COMPLIANCE DATE: . Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by . (� 4P-L a ' 67- a J�1 �� o �3 I y ' Town of Barnstable THE Tp� do Regulatory Services Thomas F. Geiler, Director + BARNSTABLE. MASS. 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: 6/17/04 Designer: Shay Environmental Services Installer: Roberts Septic Service Address: 34 Thatchers Lane - Address: 5 Trenton Street East Falmouth, MA 02536 Yarmouth, MA On 6/15/04 Roberts Septic Service was issued a permit to install a (date) (installer) septic system at 460 Lincoln Road Extension, Hyannis based on a design drawn by (address) Shay Environmental Services dated 5/24/04 (designer) XX 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. .-CARMEN tip. (Insta ler's Signature)_ SHAY N No. 1481 Qt.STIE tgner's Signature) (Affix Design re) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form Sep - 20- 01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 • � ins%ol NOTICE: This Form Is To Be Used For the Repair Of Failed I Septic Systems Only, i I PERCOLATION 'TEST AND SOIL EVALUATION EXEiYIPTION FORM fleME+J hereby certify that the engineered plan sio ed by me datec concerning the property located at 4Lop L.ir-3CD\t1 meets all of the ^I:o.vtn�g "-�tena� • Thll failed system is connected to a residential dwelling only. There are no :orv-ser la; ar business uses associated with the dwelling, The soil is ciasst;-ed as.CLASS l and the percolation rave is less than or equa to -n.'n s per inch. The applicant may use historical data to conclude th!s r3c; or may r:((uCt �re!Irr,nar% tests ar the site without a health agent present • The Ic :s no increase In flow and/or change in use proposed The r hellc are no vanances requested or needed. I • The bottom of the proposed leaching facility will not be located less than fourteen I,) teet aoove the maximum adjusted groundwater table elevation. fAdiust the nu'nc:-.vater table using the Fnmptor method when applicablct I Please complete the following: ,n v' .� , -p �t Grounc. Surlaei' E.e attun (using C,IS Intorma.ton) a; cp.W Elcvat:or, _ -d;uscment for in,gh G.W. 3'S _ 33 • �D F�F�FNCF. C. ET'WE EN and 8 I I S G.IWE _ DATE: 5 I ,NOTICE 33sec Jr•r.n the above r.formation, a reoair permit wil! be issued For oedroorns bedrooms are authorized to the future without engtneerec :epl+c s_ste�s plans. I ! I I i A� Permit Number: Date: • Completed by: HIGH GROUND-WATER BEVEL COMPUTATION Site Location: 4, too Lg4 Lot No. lk,25 Owner: Ti Address: Contractor: T0LA Address:_'R.n. ( aa : I(»O A Notes: STEP 1 Measure depth to water table t i nearest 1/10 ft. .............................................................................. .Date 5 )� 0 month/day/year STEP 2 UI ing Water-Level Range Zone ar d Index Well Map locate site and determine: �1 AI Appropriate index well.................................................... 013a OWater-level range zone STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well mo th/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) determine water-level adjustment ..............................................:............................. 3 S STEP 5 Es imate depth to high water by subtracting the water. level adjustment (STEP 4) from measured depth to,water levlI at site (STEP 1) ................................................. ' ..,..................,.,.,............................... 33 S l; IFigure 13.-Reproducible computation form. . i 15 � I 3�-7- -/ ' FAr .E® E ECTI®N i Z� I � COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION 350 MAIN STREET WEST YARMOUTH,MA Cc�'1C0 508-775-2800 LNOV 4 2003ARNSTABLE TITLE 5 H DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 271 PAR 028 MAP 27 I Property Address: 460 LINCOLN ROAD EXTENSION `— q�j 0 ` HYANNIS,MA 02601 PARCEL CJ v Owner's Name: PAPPAS,SHAWN LOT � 2 Owner's Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Date of Inspection OCTOBER 31,2003 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that.l have personally inspected the sewage disposal system at this address and that the information reported below is n.true,accurate and complete as of the time of the inspection. The inspection was perfoned 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 Needs Further Evaluation by the Local Approving Authority ✓ Fails 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/A 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: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health)" broken pipe(s)are replaced obstruction is removed ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 C. Further Evaluation is Required by the Board of Health: N/A 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 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 pits is less than 6"below invert or available volume is less than''/z 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 SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone I of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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 is 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. Title 5 Inspection Form 6/15/2000 4 • Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. Or Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR-1 5.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 4 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) YES Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM J Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1985 PERMIT#85-1031 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 BUILDING SEWER(locate on site plan): N/A Depth below grade: Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): If Depth below grade: 18" Material of construction: ✓ concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 17' How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK AT WORKING LEVEL.TANK AND COVERS 18"BELOW GRADE.OUTLET BAFFLE,INLET TEE. NO SIGN OF LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: Material of construction: concrete metal fiberglass _ polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ./ (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.,): DISTRIBUTION BOX IS 9"xl5",22"BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS CLEAN AND SOLID. PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT 24"BELOW WITH COVER AT 4".PIT IS FULL 6"FROM INLET.LEACHING IS NOT WORKING. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(]ocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) Title 5 Inspection Form 6/15/2000 9 Page 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS,MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. lw Ii i ZAR � 1" Q 1 � Title 5 Inspection Form 6/15/2000 10 Page 1 I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 460 LINCOLN ROAD EXTENSION HYANNIS.MA 02601 Owner: PAPPAS,SHAWN Date of Inspection: OCTOBER 31,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 14" Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: ./ Observation 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: TEST HOLE 14"NO WATER. TEST HOLE 6' BELOW BOTTOM OF PIT. I i i �r Title 5 Inspection Form 6/15/2000 11 i (COMMON WLA.L'L'J 1 O.I' MASSACI IIJSI.1"I S ' EXECUTIVE OFFICE`OF ENVIRONMENTAL AFFAIRS DEPAIZTMENT OF ENVIRONMEN'FAI. PROTECTIO'i —� ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 oC lomfo€ft, )RUDY COXE 350 MAIN STREET �`.V"t Q� Secretary ARGEO PAUL CELLUCCI WEST YARMOUTH, MA f Governor 508-775-2800 llAV1D B. STRUHS .• . Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP 271 PAR 028 PROPERTY ADDRESS: 460 LINCOLN ROAD EXT., HYANNIS ADDRESS OF OWNER: DATE OF INSPECTION: SEPTEMBER 10, 2000 ANN GRISWOLD NAME OF INSPECTOR RICHARD K. CANNON I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY T OCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: WWI DATE: SEPTEMBER 25,2000 The system Inspector shall submit a copy of this inspection report to the Approving.Authority(Board of Health.or DEP) within 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 shall submit the report to.the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. NOTES AND COMMENTS: SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM.AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. I revised 9/2/98 1 , . ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART A CERTIVICATION(continued) Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD,ANN Date of Inspection: SEPTEMBER 10,2000 INSPECTION SUMMARY: Check A,B, C. orD: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A 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. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four 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 revised 9/2/98 ,2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD,ANN Date of Inspection: SEPTEMBER 10,2000 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A 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 IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 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 system 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 the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 1 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD,ANN Date of Inspection: SEPTEMBER 10,2000 D]SYSTEM FAILS: N/A You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. 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 sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow 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 surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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. 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: N/A You must indicate either"Yes"or"No"as 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 a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD,ANN Date of Inspection: SEPTEMBER 10,2000 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and the system has not been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X 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: X Existing information.Ex. Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)[15.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. revised 9/2/98 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD,ANN Date of Inspection: SEPTEMBER 10,2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 220 g.p.d./bedroom for S.A.S. Number of bedrooms(design) 2 Number of bedrooms(actual): 2 Total DESIGN flow Number of current residents: 1 Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): YES Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year usage(gpd): Sump Pump(yes or no): YES Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: Gpd(Based on 16.203) 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 no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1996 System pumped as part of inspection:(yes or no) YES 1,000 gallons Reason for pumping RECOMMENDED MAINTENANCE TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) I/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 installed (if known)and source of information: 1985 PERMIT#85-1031 Sewage odors detected when arriving at the site:(yes or no) NO revised 9/2/98 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD,ANN Date of Inspection: SEPTEMBER 10,2000 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: X (Locate on site plan) Depth below grade: 18" Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How dimensions were determined TAPE AND ASBUILT 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.) TANK AT WORKING LEVEL.OUTLET BAFFLE AND COVER 18"BELOW GRADE.TANK PUMPED AT TIME OF DISTRIBUTION BOX REPLACEMENT. GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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 7 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD,ANN Date of Inspection: SEPTEMBER 10,2000 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) DISTRIBUTION BOX IS NEW 9"X15",22"BELOW GRADE.ONE LINE IN AND ONE LINE OUT. PUMP CHAMBER: N/A (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.) revised 9/2/98 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD, ANN Date of Inspection: SEPTEMBER 10, 2000 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type: Leaching pits,number: 1 Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number, Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) ONE(1)1,000 GALLON PRE CAST PIT.24"BELOW GRADE,COVER RISER 4"BELOW GRADE.8"WATER IN PIT NO STAIN LINES NOTED. CESSPOOLS: N/A (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(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) PRIVY: N/A (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.) revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 460 LINCOLN ROAD EXT. HYANNIS Owner: GRISWOLD, ANN Date of Inspection: SEPTEMBER 10, 2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'(locate where public water supply comes into house) L. ZZ i i i� revised 9/2/98 10 I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 460 LINCOLN ROAD EXT., HYANNIS Owner: GRISWOLD, ANN Date of Inspection: SEPTEMBER 10, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to groundwater 16 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record X Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions X Check with local Board of health Check FEMA Maps Check pumping records X Check local excavators,installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(Must be completed) HAND AUGER TEST HOLE. revised 9/2/98 11 TOWN OF BARNSTABLE � LOCATION YIPy bWC 01AJ 6)r l'eA)IlcsAJ SEWAGE# "VILLAGE /U���S ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY ZwCa I LEACHING FACILITY:(type) /�� (size) `. NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER A W 0-n its Ljd� DATE PERMIT ISSUED: �� DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No -.� w� ..�. �� W w.� ,;. � - No.�Z/�.. Z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Ztpplitation for W000l *pgtem Conotruction Permit Application for a Permit to Construct( )Repair( X�Upgrade( )Abandon( ) El Complete System [4 tr vidual Components Location Address or Lot No. L j to B L.�r<ol v� CtA G wner's Name,Address and Tel.No. 4 C'mk% wold Assessor's Map/Parcel 2-7 /� O p (_�� l Ra x l L'v�T �� Installer's Name,Address,and Tel.No. -1�61 rJ Cfk,co Designer's Name,Address and Tel.No. 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil I Nature of Repairs or Alterations(Answer when applicable) 0 t S R 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 issu y i o alth. Signed 0 Date Application Approved by Date Application Disapproved for the following reasonslof Permit No. Date Issued 1 TOWN OF BARNSTABLE t x leAd'�W)v SEWAGE # ` Z ' LOCATION�� y Lr;�'C°�' q I �tJl�1 S ASSESSOR'S ;MAP & LOT VILLAGE . _. 775-6264 i INSTALLER'S NAME & PHONE NO. A & B CANCO SEPTIC TANK CAPACITY l ( (size) LEACHING FACILITY:ttYpe) /�� PRIVATE WELL OR PUBLIC WATER__-- NO. OF BEDROOMS_ i BUILDER OR OWNER i DATE PERMIT ISSUED: I, ..DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No :s No. Z :..-. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS -" 01ppYication for ligpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System 941idtvidual Components Location Address or Lot No. Ll ko Q L r c- of c` wner's Name,Address and Tel.No. G'R l$ w O� Assessor's Map/Parcel Z Cj Z L((.0 (-\,C- v Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. co Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixturest Design Flow gallons per day. Calculated_daily flow gallons. 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) e ,(� c� c s c�� r 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 dissuey i Bo� f H Ith. Signed Date Q -")- CDC) Application Approved by e Date Application Disapproved for the following reason i i Permit No. 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 N I C at y 0 O - \r\C o E & has been constructe4 in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�w-S Z dated V7 ZV Installer I Designer The issuance of this permit sh 11-not be construed as a guarantee that the system w_ill)function as designed: r { / l Date �� !��� �����) Inspector l V, _rK;7 7l i �, 1.jr' � _j ------_----------- No. r<� Z� ——— — Fee ..5�, ....,.. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Aigpogar *pgtem�)Upgrade ongtruction Permit ion is hereby anted to Construct Repair v AbandonPertness y gr p ( ( ) ( ) System located at `-I o L 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:Constru tion ust be completed within three years of the date of this a t. '4 Date: Approved by iJ . to CATION SEWAGE PERMIT NO. ?I V VILLAGE INSTA LLIR'S NAME s ADDRESS e U 1 L D E R OR OWNER DATE PERMIT ISSUED �-- DATE COMPLIANCE ISSUED g ...� i �o i J No................----_... . I— 1 Fmc.115.00....�. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH -•---- Town.-..-..OF.-...Barnstable .................... ......-------------•-•-•--•------------- Appliration for Uispvii al Warkii Tonarur#inn prntit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: Lincoln RoaSt..Ext_._._Y_annis.•............................... Location-Address or Lot No. •Lillian Gri ARgid...................................................... �b�O...Linealxa..Rct.-_F ...�iycaraYai�-..........--•---•---. Owner Address _.fl..Ganco..:...-••------------------•-•--......-----•---------...--•-••----•- st....w.....'XAM10aath................................. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms._-__._.___3 ..............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Othe 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........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2........._......minutes per inch Depth of Test Pit.................... Depth to ground water........................ --••-•••-••----•-----•••-•---•-••-•-•••--•••-••••••-••••..................... ....................................•-...------.....--•-----------•--•----- 0 Description of Soil..............................:......................................................................................................................................... W _._.-•----••-------------•---------•-----•-•----••------------•-•---•--•••••---••--•••••-•-------•-----•••---••-----------••------••-•------------•••---••••-••-•••••--•••••••••-•••-••----------•-____. UNature of Repairs or Alterations—Answer when applicable-------IDOO---gall.on-••septio.-_tank..With___D-gox -•--------•---•••-.and..1000•galleon.._stone•-packesl..leac..h•-pit----••-••••------•---••••••••-•----••-•-•---•-•-••••-••-•-•••-•----.....-•---•-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i s� ued by the4bDoa of health. Signedl��•�/j� _.__1�' Date Application Approved C' Date Application Disapproved for the following reasons:----•-------•---•-•----------•--.....--•-•--•-•--------••--------•-----•--------------------------------------_ --•..........--•••-••---••---•--••.....................•---------•---------------•--...._...._..-------....•.........._......_.__....---•-------•-•-.................................................... Date Permit No................�.cc...�......_ .r..._..._.. Issued. = - Date e ~r No... .M.a..�...�.�. 1 S Fas...$15.00. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _TOWn.......OF......Barnstable ..............•--.....-------------••-............--•••- Appliratiun for Disposal Works Tonutrttrtion "rrutit Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal System at: ..Lincoln.Road Ext. Hy_Annis...................••---....... ..._... �aQ........... ----...........: ...---... ... ...... ........................................... Location•Address or Lot No. -Lillian Griswold ..A.W..UnchU...R&...lxt...d 3v=is............_......-- Owner Address aA & B Ca�Cp_:---•-----•-•---•---...-- 35fl Main St4--W,�.Yarmouth __---------------- -----------•---............ ................... ..---...... Installer Address Type of Building 3 Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g -------------•----•-•--••-•- P ( ) — Cafeteria ( ) Otherfixtures -------------••-•------•--•---...-•-•------...-•--••--.•-••....••-•--••••••......--•---•----•••-•-•-•••••---•-••-•-•..............----......--•--•-•-- 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ 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........................ a ..............•-•----•---•------•-...._...........•••-•---••••--•••-•-•-•--•-••----.......__................................................................. 0 Description of Soil...................................................................................................................................................-•--•-----•-......... W ...... UNature of Repairs or Alterations—Answer when applicable.......10QO...allon-_sep.tln...xank..1�'ith..D-Biwc .................... nd._1000..9allon... t9x3lr }? Cked..Mach..hit.................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ..........................-.... ^` Date Application Approved ................ .......i'�'"/' - "�'`8_........•---.....-•----.............................. ........................ ...•---•--•-- Date Application Disapproved for the following reasons:..........................................................................................................--- --•.....-••-•••...•-•-••-•----••----•---•-•---••-•--••-•--•-•-•....-•-•••-••--•-••-•--•------...---•-----....----•...................•...•----••............----••-•-••••-••---•-•..........----......._ Date Permit No.............�?. r - '-r------- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... oF.....AA Al ........................ ...... ........................... Tntif iratr of Toutplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X) by----- A--&...B Cana 350 Main St. W. Yarmouth 460 Lincoln Rd. Oct. H annis Installer at.. •-•---. -•-------•..........................•- y .............. -• - has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..... __:: _:..._L� .I... dated------/L..`,.`Y'.�'_' ."` THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................•-------.............---..............--........... Inspector...... .. - .................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable NoC..... G?�v l ..........................................oF..................................................................................... Fay................................. Disposal Works Tonstrttrtion rrrutit Permission is hereby granted.......: : iP •--C#1+..,...:........•..---•...........................•-----..................................................._.. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No....... _.---•.� t A tea,I In '•kd. .....................................................•---- ............. Street as shown on the application for Disposal Works ConstructionPrer,Eit No.5-�-... a f. Dated... . -- `� ` --- b J I Q , Board of Health Dkf E................................................................................ FORM 1255 A. M. IN. INC.. BOSTON �� - , 'd►w�0uy, tt� i „ c ON A -A SECTI THE.;. : �u Dunn PiPEs FxaM � olslRiBUTKIq aoc$11AL1 .� 1 1z• SCHEDULE 40P.V.C. OTE. ALL'PIPES ARE TO 8E 4 SCH P S TB GOHtatEtE CovEYt N PROFILB`�{ill's 1I OF LEACHING YS �l' SET LEVEL.FtrR AT a FT. 10 mu1.,from LEAst :. .# o [house to septic onk .. .-, �... H� . . sue'" Existxl Foundatwn - 3 s GuttEr 9 . took cavere rtwst bs � .. ► c .. -. : KNOfXW75 1 tviMdn 6 n. of r,�,ish.d grade _ r r/a ►..�s ar.a.a ar.�. V rp' t/1t'Rdst Ir..Nwn over SAS ETEV.•' 00 m • - Grant avw D-Box 9Q00 � Grotto over fit.Tonle 98.00 t._ • . �P _. SS.�._._. � a•, Iarr a t46fEat S•+0.10 _ To of SAS Etevs95.50 j , . , - dST. 80X 3 NoxNrwm Cover P 15 6` OR GRTooc. EATER - r - 10 EXIST. s aolo• er toot . 4 SCH. 40 1. Ili7tS' .t $ x t- 1000 GAL + o E i - • Mcfins , W sEPT►c TANK $ it PLAN SECTION GROSS SECTION i!s x ap o 20 , ErfeeBve OepM 2 Units Q 8 5' 1T , ® w H 10 m o o > wa p ro N an . > o»r.w. o -----19 : to to _4 4 0 0 �r FULL �rx� - ... of ,... O� O • - � 3 HOLEH 10 DISTRIBUTION BOX 3. 5 .3_5 M 25� $ e Y ,J O1 1lOa - h_ > > Effective Length NOT TO SCALE : r. w STEM PROFILE o o Y ct.d aas_ _ - 12 I r �P4 0 0 aao+ioettr�wezir a , Not to Scale a >e Effective Width i SOIL ABSORPTION SYSTEM (SAS) - W N PRECAST 500 C H 10 LEACHING UNITS / IGGI SGENERAL NOTES S GE E E 6 1n.of 3/4'-1 1/2' Yo Not to Scale octed stone O] , , �w 1. Contractor Is responsible for Dlgsafe' notification T HAVE RISERS TO WITHIN 6" BELOW GRADE of Ted Hole I Elev.-8�.15 NOTE. ALL COMPONENTS MUST VE SE 0 Bottom and protection of all underground utilities and pipes. w Obs. Groundwater`- Test Hole 1 Elev.= NONE OBSERVED 2.'-The se tic tank on distri ution box shalt be set level on 6" of.3/4 -1 1�2" stone. 3. Backfill should be clean sand or ravel with no 9 ..r- stones` over 3" in size. 4. This system ,s subject to inspection during installation 1 Y 1 Pe 9 PERCOLATION TEST 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 Ian 'Date of Percolation :Test: MAY:12, 2004 PP P and Local Regulations. Test Performed B . CARMEN E. SHAY, R.S., C.S.E. - ` + Y + i Witnessed WAIVER (per BARNSTABLE B.O.H. 6_ If, during;installation the contractor encounters any Results Hesse By. (P ) <soil .conditions.or site conditions that are different Excavated By SHAY ENVIRONMENTAL SERVICES, INC. Y from those shown on the soil to or in our design Percolation Rate. Less Than <2 MPI 9 S 13d 41 00 iP notification must 'halt & Immediate notification be mode to Carmen E. Sh -`Environmental Services, Inc. 75.00 °y 7. No vehicle or heavymachine shall drive:over the machinery Faded _ � septic _system unless. noted as H 20 septic components. Leach Pit = Test" Hole _, I s. 8. Install Tuf Tite 'gas baffles or, equals on all outlet tee end No. 1 25' 0.5 „ 9. A11 Distribution Lines shall be 4 .diameter .Schedule 40 NSF. PVC pipes. DEPTH SOILS ELEV. ` _ t .. c.:- _._ . _ 10. All solid piping, tees & fittings shoo be 4 diameter 0 fi8.15 y 1 t ; t Schedule.:40 NSF PVC pipes with water tight rots. !►. 1 P Pe 9 10 Loom AREA r y I W --.,- . -_. - 11. Municipal Water. is Connected. to The Residence and Abutting , w--�- 'o rR 3/2 0.5 Properties Within 150 Feet. I O TEST HOLE 1 • A 7.25 � 11E O O ELEV _ 98.15 � Loamy v Sand Ct� � w V 'r THE PROPERTY LINES ARE APPROXIMATE AND yo rx s/e ti E _ 23 rn COMPILED FROM ,THE SURVEY PLAN GENERATED BY + tt 3s . s5.t5 : EXIST. 1000 gal RICK HAHN SURVEYOR'OF` NEW HAVEN :CT ENTITLED 3 Septic .:Tank FRED Medium P T SHORE -SECTIONS A-B-G-D FALMOUTH MA Sand "SEACOAST S, 98 - DATED APRt 15 1947. IT SHOULD'BE USED FOR NO PURPOSE � � b TE L 10 YR 7/4 f�� ' 3 42' 132 C, ------��1 W OTHER .THAN THE -SEPTIC SYSTEM INSTALLATION. 1 + EXISTING CESSPOOL TO BE ;PUMPED DRY & # O IF FOUND TO BE NECESSARY TO INSTALL NEW SAS. REMOVEDU t , o LOT,.::#24 26 i LOT .;- PP OUT CONTAINING CHAT . # / r NOTE: ANY STRIPPED 0 501E 0 G LEA E r r I O ,< r r .. M' EXISTING P T DISPOSED FRO THE SING CESSPOOL TO' BE r .I + PER F HSPECIFICATIONS. OF, AS E BOARD. 0 HEALT EXISTING >r 't3 2 BEDRflO.Y r_ . PROPERTY. , < NOTE: 'P PRESENT;WITHIN IN F OF ROPE 0 E. NO ARE RESEN TH 200 FEET I r HOUSE r r , P R ; ASSESSORS MA 271 PARCEL r # 46 _ . � . � 0 Perc #1 t t r " „ t LEGEND Depth to:Perc: 36 to 54 + , O + Perc Rate= 2 MPI assumed i + DENOTES PROPOSED Groundwater Not Observed E i 104X1 N Observed ESHWT 'l t ASPHALT I O SPOT GRADE { o 4 H2O Elev. None RN AY ADJUSTED � DRIVEWAY t o DENOTES EXISTING 1 ' - t X 104.46 1 t I SPOT GRADE UJ \ + 1 . I P PROJECT BENCH MARK IT, I PL PROPERTY LINE TOP OF FOUNDATION __-t--------- - - ---- 98 96 ' ,. PROPOSED CONTOUR ELEV. - 100.00 (Assumed) , +LOT 25 3 . ��.-- 0 ED f0050 S Fet:t_t t 4+�'►•e, ._'- EXISTING CONTOUR t I DEEP .TEST HOLE # t I PERCOLATION 'TEST LOCATION t I 75.00 TYPICAL 1000 GALLON SEPTIC TANK s 'EDDY STOCKADE FENCE NOT TO SCALE N '13d 4 P 00" E 2-11r DIAkL ACCESS MANHOLES i - , LINCOLN ROAD EXTEN.S'ION b PLOT P LA , ' 4 F RI T F, WAY• � 0 00T GH . 0 1. ._ c ) OF PROPOSED SEPTIC SYSTEM UPGRADE OUT MRET , T _ PREPARED FOR •_ .. THE ACCESS COVERS FOR THE SEPTIC TANK, =7WUT10N Box AHD LEACHING COMPONENT S H A W N P A P P A S r = s -+y -.f-.r-r-;�*? r-'-►� SET DEEPER THAW B INCHES BELOW FItN5i1ED ,r'- i 'R •• } a •+ : GRACE SHALL BE RAISED TO TRTHIN B' OF STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE AT INSTALL nW-THE GAS BAFFLES OR EQUALS #460 LINCOLN ROAD EXTENSION 'PLAN VI•�W �I 3-24 RNOVAS.E CONM H ANNIS MA . - -, . •r -_ ..-. .•. 4 -_ - -.- Design Calculation , _ m►i. el.orenoe : . z Hat PREPARED BY. s MaET r Number of Bedrooms: 2 Equivalent to ` 20 Gall./Day min. 2' into. iidet to otdNt -: um o q 2 � e• OUTLET o a -TdT.w+ Grinder: No 330 ;, minimum per Title V Garbage ,r • , ` Mln. Per Title V AR11 'N '. ASHA Y � s -7' � _, s 7" Leaching .Capacity Proposed. 330 Got./Day Minimum ( ) �5 Tank. i Tank x 330, al. 660 =US� EXIST. 1 000`GAL.- tic a k. 4-o mM. Septic a 2 G /Day Sep z NVIRONYENTAL SERVICES, INC. ON toUsing :• un�depth percolation rate of <2 min. inch , t, _ SOIL`ABSORPTION 'AREA _per on s0 40 - 4 2 50.. one P. `6 7 Bottom Area. 0.74 'gal/sq. ft. x ;'300s . ft. 222 00 Olt d .BOX � q 9 O ". Sldewall Area. 0.74gal./so. ft. x ; 148 .'ft. 109.50 gallons sq. 9 `EAST:. FALMIJUTH MA 02536 s� . .,,�•-e• • • -•fi- :_ _ •, ••• .. - __... - r Provld►ng:' � '331.50 gallons. NtTJ(t't� -u- 4• -10- TEL FAX •: 508 -548-=0796 t y .. I T:5 -C NITS HAVING A 2 EFFIECTtvE DEPTH •` Use.. 2 PRECAST 00 U , . . ND SE TION E C _ MAY- 1 0 4 i CROSS SECTIUN ;SCALE. 1 20 DRAWN BY, :CES DATE M 2 2 0 i TO BE USED MATH 3.5 OF WASHED STONE ON THE SIDES AND SCALE. 1 -ZO H O ON:THE ENDS. . 4 OF WAS ED STONE A . _ x 4 PR J T 576" FILE E. SD576PP.DW SHEET 1 F 1 . �;_ 0 EC LSD NAM G 0