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HomeMy WebLinkAbout0001 LOCUST STREET - Health 1,,Locust'.Street Hyannis ,;.P A 309 130 a e ° o ° a TOWN OF BARNSTABLE ^� ` LOCATION SEWAGE# VILLAGE n 1 `ASSESSOR'S MAP&PARCE & JAI INSTALLER'S NAME&PHONE NO. Q EX( .J4,0q J TOA -1M 1914 SEPTIC TANK CAPACITY k i SM (X�_L LEACHING FACILITY: (typeks)JW C Q, c Kit Az(size)3's 45 lx k a NO.OF BEDROOMS OWNER ,/�, PERMIT DATE: (0LIQ�02� COMPLIANCE DATE: O 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) N/A Feet Edge of Wetland and c ' acility(If any/flanxist within 300 feet of le a i ity) Feet FURNISHED B D 04 TOWN OF BARNSTABLE 4�:'l?;O.CATION SEWAGE# PILLAGE ASSESSOR'S MAP&PARCEL 3M —1 3 0 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY .LEACHING FACILITY:(type) t-fcQS (size) ' NO.OF BEDROOMS 3 -4- OWNER evci1d v CRM105 PERMIT DATE: 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 EQ " �JFC OVERFLOW OCESSPOOL , 2 PRIMARY OCESSPOOL C [GARAGE A EXISTING DWELLING LOCATIONS # 1 A e C 1 55 ft 20 ft Z 2 70 ft 30 ft 38 Ft J WI 3 LOCUST STREET NOT TO SCALE No. Fee IUD THE COMWNWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zippritation for Mi oBal 6pstem Construction 3pPrmit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lott No. ��-S �{Lp nft Owner's Name,Address,and Tel.No. (, Assessor's Map/Parcelpaico ZD ,�M—I3d #30f as l r Jp A Installer's Name Address,and Tel.No.50.(}- (, Designer's Name,Addres ,and Tel.No. Ca W, (� Cd N rs QXY '�=� l Type of Building:' ), Dwelling No.of Bedrooms 'l Lot Size 1� �-1 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 d jai f a� Number of sheets Revision Date /A Title 0)04 Size of Septic Tank Type A.A.S.L§ sw_ Description of Soil " L Nature of Repairs or Alterations(Answer when applicable Date last inspected: Agreement: The undersigned agrees to ensure t e onstruction and maintenan of the afore described on-site sewage disposal system in accordance.with the provisions of Title 5 t Environmental Code and of to place the system in operation until a Certificate of Compliance has been issued by this Bo Health. Signe Date t �� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued r ,.r^t ."_.,�t,,,."4+.�r'"•k_ y,�M�..,'.,R- ,.� '^.. No. (�"� -3 6 Fee ! THE COMMONWEALTHSOF MASSACHUSETTS Entered in computer: COMMONWEALTH PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS I>: r .,: 01pplication .for -Mispoeal 6pstetu Cons-tr rit- on Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) "`❑Complete System ❑Individual Components Location Address or Lot No.I �(�v��/��,} {{t fp(�(1 j�j Owner's Name,Address,and Tel.No. p Assessor's Map/Parce)' (1,. a-t X(� ' `���Q Q( '.�n hf-6 HeoLLq +353 (to Owuo Installer's Name-,Address,and Tel.No.S (lpl� W& Dr. Designer's Name,Address,and Tel.No. jj Type of Building: Dwelling No.,of Bedrooms Lot Size��;,V Lk sq.ft. Garbage Grinder( ) Other Type of Building� l�(\ No.of Persons, Showers( ) Cafeteria( ), - Other Fixtures Design Flow(min.required) �! gpd Design flow provided:u-- • y gpd Plan Date 9 1a71 1..)-I Number of sheets Revision Date N /A Title i Size of Septic Tank 'SM1 Type of .A.S.��� SW ()CJ rh a A A�V f� Description of Soil �F Nature of Repairs or Alterations(Answer when applicable)N—to,)a\( - � , \Q�c ll\.1 G, P,:2.\CA Date last inspected: s Agreement: f�� /f r The undersigned agrees to ensure the e'onstruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of,4 Environmental Code and of to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. - q Signed° ----__._ /" _- - - Date i Application Approved by / V 1/� / Date / s ��� _ Application Disapproved by Date for the following reasons Z Permit No. Date Issued F THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance / THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(J ) Upgraded Co/ ( ). Abandoned(:' )by ?.)QIZ-^a-'�1 C��l�4trck l at , L « Uq 1�� , N t=I`r\f has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�Z dated j Z - Installer E"/ kJdY\C1r, l.-G 1 Designer #bedrooms Approved design flow_ �f gpd The issuance of this pe7it shall not be construed as a guarantee that the systems,ill function aLe;�si ned. Date �(� «^' r ' Inspector No. (N j "3 ev Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pet m Construction Permit Permission is hereby granted to Construct( ) Repair(/) Upgrade( ) Abandon( ) System located at 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:Constcu))cttiiori'must be completed within three years,of the date of this permit. jl Date 1 I /2 Approved by �� Town of Barnstable ices I d RichardI'll.Scan,Interim Director BARNSTAEM .: �6 g aPublic Health Division Thomas_Mckean,I)frector IN 1Tain Street,I-1 a nls,MA O'7Ct't1 Offiuc 508-862-4644 Fax, 50S-79.0-630 InsEal[er a� esz�net: e�:tifcation Form ­2 �;�j Date: i( ����'� sewage�eirmi # Assessor's'MapTarcei_ c� �esbnet:. c +�, �r n t uc ��� tn�tafller::. Address: )2 b 1 C s ` :lc/ Adda-ess ytGv u� 11 1 _ .... __...>_.. ... v On. .. 'u CCU, w�a ` was issued.a pe1, lit E.o:install a (date) (installer) septic system at 1 ����5 4 S� � t�c�ti t✓�^�A S d_ based on a design drawn.by - (addre,ss) . Z_ (designer) certify that the septic system referenced above was installed substantially according t0. the design, xvhich may include minor appsoved:changes sucli. as lateral relocation of the distribution_box andr'or septic tank. Strip out (af remdred).teas inspected and the soils w,61 r, founrl.,sztistactoll-: 1.cerfifr that the "septic systerxt .rztezenced'abote was installed with:irtajor changes (t.' . greater than 10' lateral relocation of the SAS or_any, el'ticaI relocation of any cotaaponent of the,septic systeni) but it accordArice with State S local Regulations. Ilan revision.or cei,,titied as=built by designer to foilahx.. Stz'ip orEt(if required)was inspected and the soils Were found,satistactoty S cettify that t e system referenced aboue was:constructed.in with the terms of floe lA a royal letters(if appli lc)lay F lnst ez S' nature civil. �, gyp,35�09 {,Designer's Sign;Mlre) (Affix Designe ere)' pI X,ASC+ RRET$1I2i 1 I 0,.I$AI2i STABLE PUBLIC HtALTH IN%ISION. CT RTIF'IICATE, OF COMPLIANCE WILL N0 BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BA NSTAi3LE PUBLIC III ALTH DIVISION. THANK YOU. dot>ir J 5i tct Certification Form +'.doc Engineers nate-Tn s certification isiimi#ed to'ar as builE inspection nr system components as installed prior to bacit;rll.The engineer dicl not:superyme:construction o:the system.The installer assumes responsibifity for all materials,wrorkmanship,backfilling to C(1q(:1{!R!'t nK7.ri a¢t+.n7fiY�rniv+r nntn narinn tinri<ottinn-r+eara.rnrarc�c rt<n.+n nr+thariocinr:p.S�n - - . t ' i Commonwealth of Massachusetts ,0 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 1 Locust Streets I Property Address Evaldo Campos Owner Owner's Name information is quired for Hyannis MA 02601 August 25, 2008_ very page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. Oenercil Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name 43 Triangle Circle r s� Company Address =`• `' =t Sandwich MA r-1 ` I v� 02553 3 City/Town State ca� Zip Code 508 364-0894 1328 ' Telephone Number License Numberi ; -• cs ca r— CD t'T 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 V August 25, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5-2967.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 f i t, ,* Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is Hyannis MA 02601 August 25, 2008 required for y g every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> Aseptic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. See note page 13. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass irspection 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 t5-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments �M 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is August 25, 2008 Hyannis MA 02601 Au required for H Y g every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Bj, System Conditionally Passes (cont,): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will ass inspection ect on if with approval of h y the Board of Health p p ( pp ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet,of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic 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. 15-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is Hyannis MA 02601 August 25, 2008 required for Y 9 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform 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 cesspool is less than 6" below invert or available volume is less than '/2 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is required for Hyannis MA 02601 August ust 25 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.,l 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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking 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 f Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is Hyannis MA 02601 August 25, 2008 required for Y 9 every page. CityiTown State Zip Code Date of Inspection C. Checklist „ „ Check if the followinghave been done. You must indicate es" or no" as to each of the following: Y 9 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? SAS also Were all system components, excluding inspected ® ❑ y p 9 the SAS, located on site? No Tank ❑ ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the:site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5-2967.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is August 25, 2008 Hyannis MA 02601 Au required for H Y g every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions:' Number of bedrooms (design): n1a Number of bedrooms (actual): 3-4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No 288 d Water meter readings, if available last 2 ears usage d gp 9 ( Y 9 (gP )) Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft.,.etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is g required for Y H annis MA 02601 August 25, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Occupant 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age unknown. Overflow pit added in 1988 per Board of Health files. Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2967.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 f , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Locust Street M Property Address Evaldo Campos Owner Owner's Name information is Hyannis MA r02601 required H August 25, 2008 for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2feet 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.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? t5-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is Hyannis MA 02601 August 25, 2008 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-2967.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is required for Y H annis MA 02601 August 25, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping`. Date Comments (condition-of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 15-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is Hyannis MA 02601 August 25, 2008 required for y g every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): Soils above overflow cesspools were unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into cesspool stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of the stone. t5-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is August 25, 2008 Hyannis MA 02601 Au required for H Y g every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration - 1 primary and 1 overflow Depth—top of liquid to inlet invert Liquid level at outlet invert Depth of solids layer 5 inches Depth of scum layer 0 Dimensions of cesspool 4 ft x 6 ft approximately Materials of construction Concrete block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool had concrete cover to grade. Surrounding vegetation appeared normal. Cesspool is made if concrete block. NOTE ON BLOCK CESSPOOLS-Block cesspools consist of concrete blocks arranged in a beehive formation and are held in place by gravity and soil pressure.Driving vehicles over or near block cesspools could potentially destabilize the structure and lead to collapse.DO NOT DRIVE VEHICLES OF ANY SORT NEAR CESSPOOLS.Eco-Tech recommends that the entire system be replaced with a sewer hookup or a conforming Title 5 system.Low interest loans for repairing substandard septic systems are available from Barnstable County Health Department. Contact Kendall Ayres Program Administrator,at 508 375 6610 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'.): t5-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is 9 required for Hyannis MA 02601 August 25, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. OVERFLOW OCESSPOOL 2 PRIMARY OCESSPOOL 1 C B GARAGE EXISTING DWELLING LOCATIONS # 1 A e c 1 55 FL 20 FL Z 2 70 FL 30 FL 38 FL J fill F 3 LOCUST STREET NOT TO SCALE NOTE ON BLOCK CESSPOOLS—Block cesspools consist of concrete blocks arranged in a beehive formation and are held in place by gravity and soil pressure.Driving vehicles over or near block cesspools could potentially destabilize the structure and lead to collapse.DO NOT DRIVE VEHICLES OF ANY SORT NEAR CESSPOOLS t5-2967.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syst=m-Page 14 of 15 L r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1 Locust Street Property Address Evaldo Campos Owner Owner's Name information is H annis MA 02601 August 25, 2008 required for y g every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on'record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Previous inspection report. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. Previous inspection report confirms this measurement. t5-2967.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: 4 , j BUSINESS LOCATION: 01 .&Q C-a -S 7_ s-7- INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: _5-0 ,f, Inle e- AO 9 6 CONTACT PERSON: A ro EMERGENCY CONTACT TELEPHONE NUMBER: -509- ` 00 BO 16 MSDS ON SITE? TYPE OF BUSINESS: �- " ! N G INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Haulere Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) g ( ate) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing-tar. - -- - - � _ PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc, Flammables hydrochloric acid, other acids) Floor &furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT!CANARY COPY-BUSINESS I Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: L 'N It BUSINESS LOCATION: 01 110 ca s 7 s 7 ""-0 INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: -SD l IV" AO 16. CONTACT PERSON: C- E 2 0 '�� EMERGENCY CONTACT TELEPHONE NUMBER: 50L 6 MSDS ON SITE? TYPE OF BUSINESS: P�9 "^`T'"/C INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous.waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed/Maximum Observed/Maximum Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides NEW USED �. (insecticides, herbicides, rodenticides) Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil NEW USED Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers =Asphalt-&-roofing tar _PCB-s Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) 0 NEW USED Any other products with "poison" labels Paint & varnish removers, deglossers (including chloroform, formaldehyde, .Misc. Flammables hydrochloric acid, other acids) Floor & furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) . Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS { COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED FEB 0 9 2005 Too,,ti� or,.- ASTABLE TITLE 5 HEAL-H DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: I Locust Street A � ol�T-,-,. . Hyannis.MA 02601 ,ARCEI Owner's Name: Christina Cary LOT Owner's Address: Date of Inspection: January 5.2005 Name of Inspector: (Please Print)James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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 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 Needs urther Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: January 12, 2005 The system inspector shall sub 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. 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 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I Locust Street Hyannis,AM Owner: Christina Cary Date of Inspection: January 5, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static.water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Locust Street Hyannis, MA Owner: Christina Cary Date of Inspection: January 5,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 Locust Street Hyannis, MA Owner: Christina Cary Date of Inspection: January 5, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 cesspool is less than 6"below invert or available volume is less than'/2 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. ✓ 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 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.] No (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 System: To be considered a large system the system must serve 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 has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 Locust Street Hyannis, MA Owner: Christina Cary Date of Inspection: January 5,2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 Locust Street Hyannis,MA Owner: Christina Cary Date of Inspection: January 5, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2004-82.500 2003-51.750,gals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/sgft,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: None on file-per treatment plant Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: A pit was added in 1988-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I Locust Street Hyannis,MA Owner: Christina Cary Date of Inspection: January 5. 2005 BUILDING SEWER(locate on site plan) 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 on site plan) (Cesspool acting as a septic tank) Depth below grade: Cover to grade Material of construction: concrete _metal _fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 5'W x 5'T x 7'bottom to grade Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Measurinrz stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): An outlet tee was present. The cesspool had 5'of liquid on the bottom The cover was to grade RecommendpumpinQ and cleaning. GREASE TRAP: None (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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 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: 1 Locust Street Hyannis, MA Owner: Christina Cary Date of Inspection: January 5. 2005 TIGHT or HOLDING TANK: None (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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: None (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.): 8 • Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO RM PART C . SYSTEM INFORMATION(continued) Property Address: 1 Locust Street Hyannis, MA Owner: Christina Cary Date of Inspection: January 5. 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1-6'x 6'w/2'stone 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.): The bit had 2'ofliguid on the bottom. The scum line was Y up from the bottom There did not appear to be any signs of failure. The cover was Y below grade. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None. (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.): 9 Page 10 of 11 OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: I Locust Street Hyannis, AU Owner: Christina Cau Date of Inspection: January 5.2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage:disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A l3 OL P,r 10 r Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 Locust Street Hyannis, AM Owner: Christina Cary Date of Inspection: January S. 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- feet 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: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied,relating to the system, the inspection and/or this report. 11 f•� E . �-� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE ' Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor , Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • o „ e. CERTIFICATION Property Address: 1 LOCUST ST. HYANNIS MAP 209-PAR 130- rw Name of Owner MARY A.NELSON Address of Owner: SAME Y Date of Inspection: 4/23/99 99Q Aftd Name of Inspector:(Please Print)JOHN GRACI 000r ! ` I T 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) HO� Company Name: n/a r A Mailing Address: n/a Telephone Number: n/a � 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 The inpection is based on criteria defined in Title V Conditionally Passes - code 310 CMR 15.303.My findings are of how the system is _ Needs Further.Evalu ion By,the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the w - septic system and any of its components useful life. Inspector's Signature: im Date:4/28/99 The System Inspector shall sa 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 THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINING EVERYONE TO.TWO YEARS. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 LOCUST ST.HYANNIS MAP 209-PAR i30 Owner: MARY A.NELSON Date of Inspection:4123/99 INSPECTION SUMMARY:. Check A, B, C,'or D: ' A. SYSTEM PASSES: ' I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below: COMMENTS: { System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: x nLa 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. nLa 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 failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as. approved by the Board of Health. nLa 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 pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced.' obstruction is removed distribution box is levelled or replaced E Wa 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 x. .. _ revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 LOCUST ST.HYANNIS MAP 209-PAR 130 Owner: MARY A.NELSON Date of Inspection:4/23/99 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 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)THAT 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,surface water Cesspool or privy is within 56 feet of a bordering vegetated wetland or a salt marsh. . V' t / 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(SA'SJ 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 I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is'within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS ii 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 is equal to or less than 5 ppm,Method used to determine distance nLa_(approximation not valid). 3) OTHER Wa . . .f i revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . . PART A CERTIFICATION(continued) Property Address: 1 LOCUST ST.HYANNIS MAP 209-PAR 130 Owner: MARY A.NELSON r Date of Inspection:4/23/99 D. SYSTEM FAILS: 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 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. m - _ X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water,supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1,of a-public well. - X Any portion of a cesspool or privy is within 50 feet.of a private water.supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.. <5 E. LARGE SYSTEM FAILS:, You must indicate either"Yes"or"No"to each of the following:" The following criteria apply to large systems in addition to the criteria above _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: - Yes No X the system is within 400 feet of a surface drinking water supply X. the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive'area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) -The owner or,operator of any such system shall upgrade the system in accordance with 310 CMR_15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . Property Address: 1 LOCUST ST.HYANNIS MAP 209!PAR 130 Owner: MARY A.NELSON - Date of Inspection:4/23/99 r' 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 been receiving normal flow rates during that period.Large volumes of,waterhave 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,excluding 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: i Existing information,For example,Plan at B4O,H, ' X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) e tbl.[1 5.302(3)(b)1 X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of : SubSurface Disposal Systems. w .„s y ,,y Y• r ` s revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .�.SYSTEM INFORMATION Property Address: 1 LOCUST ST.HYANNIS MAP 209-PAR 130 ` Owner: MARY A.NELSON Date of Inspection:4/23/99 4 FLOW CONDITIONS- RESIDENTIAL: Design flow:34.Q g.p.d./bedroom Number of bedrooms(design): 4 Number,of bedrooms(actual):-4 Total DESIGN flow: 4411 ` Number of current residents:1 ' Garbage grinder(yes or no):N_Q Laundry(separate system)(yes or no): No If yes,separate inspection required; Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage'(gpd): nLd , Sump Pump(yes or no): MS2 Last date of occupancy: nLa r COMMERCIALINDUSTRIAL + ti Type of establishment: nLa Design flow: nta gpd(Based on 15.203) Basis of design flow: nta , Grease trap present:(yes or no):M Industrial Waste Holding Tank present:(yes or no): rl_Q '' F Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available:n1a Last date of occupancy: nLa j OTHER: (Describe) nLa. Last date of occupancy: nh , GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NQ . If yes,volume pumped nLa- gallons Reason for pumping: n(a TYPE OF SYSTEM 4 X Septic tank/distribution box/soil absorption system Single cesspool d.. Overflow cesspool U. 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: Wit t APPROXIMATE AGE of all components,date installed(if known)and source of information: MAIN-ORIGINAL WITH A NEW PIT INSTALLED IN 1989 PERMIT 88-488 Sewage odors detected when arriving at the site:(yes or no). NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 LOCUST ST.HYANNIS MAP 209-PAR 130 Owner: MARY A.NELSON Date of Inspection:4/23199 BUILDING SEWER: (Locate on site plan) Depth below grade: Ft Material of construction:_ cast iron X 40 PVC _.other(explain)- . .. . . . Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,'etc.) n(a , SEPTIC TANK: X (locate on site plan) ' Depth below grade: I EVEI . Material of construction:X concrete_ metal_ Fiberglass _.P o Iyethylene _ other(explain) n(a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nLa Dimensions: 676'BLOCK ' Sludge depth: a Distance from top of sludge to bottom of outlet tee or baffle: is Scum thickness: 3"' - Distance from top of scum to top of outlet tee-or baffle. ' = ' Distance from bottom of scum to bottom of outlet tee or baffle: 15- How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY ONE TO TWO YEARS. r. _ GREASE TRAP: ti (locate on site plan) Depth below grade: , Material of construction:_concrete"_:metal_ Fiberglass'_:Polyethylene_other(explain) Dimensions: n/A Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:_DLd F Distance from bottom of scum to bottom of outlet tee or baffle n& Date of last pumping: n&" - 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.) ; nLa revised 9/2/98 Page 7 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C :. SYSTEM INFORMATION(continued) Property Address: 1 LOCUST ST.HYANNIS MAP 209.PAR 130 ` Owner: MARY A.NELSON r j' Date of Inspection:4/23199_ TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) A Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa 1 Dimensions: Wa Capacity: nLa gallons ; Design flow: nLa gallons/day Alarm present: NO Alarm level:jita- Alarm in working order:Yes_No_: N4 Date of previous pumping: nLa F Comments: (condition of inlet tee,condition,of alarm and float switches,etc.) nta � r DISTRIBUTION BOX: 9 (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER:' NS2 (locate on site plan) Pumps in working order:(Yes or No): N4- Alarms in working order(Yes or No): NO ; a 5' Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Wa revised 9/2/98 Page 8 of I I a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ° SYSTEM INFORMATION(continued) Property Address: 1 LOCUST ST.HYANNIS MAP 209-PAR 130 Owner: MARY A.NELSON Date of Inspection:4/23/99 y SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,'location may be approximated by non-intrusive methods) A ,_ If^not located,explain: 1La Y •: Type 1 leaching pits,number: 1000 GALLON LEACH PIT Y leaching chambers,number: ji& leaching galleries,number: _nLa leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: Wa Alternative system: Wit Name of technology: jiLa Y Comments: ` (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY'PIT HAD t'IN IT AT THE TIME OF THE INSPECTION NEVER MORE THAN 3, CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: Wa Depth of solids layer: n1a Depth of scum layer. n1a t { Dimensions of cesspool: WA , Materials of construction: n(a Indication of groundwater: n& inflow(cesspool must'be pumped as part of inspection)nLa °wv Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:Wa Dimensions;n1a " Depth of solids: nLa : Comments: . (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)JuLa ` revised 9/2/98 Page 9 of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 LOCUST ST.HYANNIS MAP 209-PAR'130 Owner: MARY A.NELSON Date of Inspection:4/23/99 F SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes.into house); n/a , k revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 LOCUST ST.HYANNIS MAP 209-PAR 130 Owner: MARY A.NELSON Date of Inspection:4/23/99 NRCS Report name: nLa Soil Type: nta Typical depth to groundwater: nLa USGS , Date website visited: n1a , , Observation Wells checked: NO _� £ •� Groundwater depth:Shallow _ Moderate _ Deep SITE EXAM _ Slope _ Surface water _ Check Cellar , _ Shallow wells Estimated Depth to Groundwater 12 Feet _ p Please indicate all the methods used to determine High Groundwater Elevation:° _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health , _ Checked FEMA Maps 4 Checked pumping records �. - P P 9 , Checked local excavators installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed), USGS MAPS AND CHARTS AND VISUAL t revised 9/2/98 Page 11 of 11 TOWN OF BARNSTABLE LO ATION 'OC Or SEWAGE # R�" VILLAGE ASSESSOR'S MAP & LOT 30R 1130 1:v9TALLER'S NAME&PHONE NO. >r1 . PT1C TANK CAPACITY SS CH FACILITY: (type) 1 C X�� (size) 0 NO.OF BEDROOMS BUILDER OR OWNER CA PERMITDATE: OMPLIANCE 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 leachi g facility) / J Feet Furnished by 'h. 00 a -i c -� J TOWIZ OF BARNSt'ABLE p OCATION_ � ���-a7�"� � � _ SEWAGE # C't VILLAGE --_6 — ASSESSOR'S MAP & LOT INSTALLER'S DAME & PHONE NO._ gffq� _�9A.1�. 2_.� ,-- SEPTIC TANK CAPACITY LEACHING FACILITY:(tyge) L�,e ci4s-*- NO. OF BEDROOMS ,�PRIVATE WELL OR IC: WAT • BUILDER OR OWNER CAVdZY YA&;LW%AA — DATE PERMIT ISSUED: _ DATE COMPLIANCE ISSUED________ VARIANCE GRANTED: Yes No ___ __ sue_ n W � 3 U o � f-1 r No...f.1. ..: � s p • •F. THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH Applutttiun fur Disposal nxk _C��ans rnr i n Fermi Application is hereby.made for a Permit to Construct ( ) or Repair ( r )*.an Individual Sewage Disposal System at: , ..............l_.._�.1�::.c� :u.5::t- - ��� --• ......................... ...••-• 1�-(( - •:5 ...... .................................... -Location.Address r Lot o. A d o t N ..-••-•--•--. P a_'_�'`�.-- -.�/ r.19 Y+/ k .............•--...... .....--------.•...S.YEVVT--...................................................... ' Owner a . •..... �/.._. .�:.L f M!!fn.-• _.l.k.0 .............. •----•........ k(fir!?Address Addr P ................._.................... Installer Address. Type-of Building 3 ,`. Size Lot............................Sq feet �., Dwelling—No. of Bedrooms.......................:...... ..•..:...Expansion Attic ( ) Garbage Grinder ( ) Other=Type of Building ..... No. of persons................ .__.. Showers — W YP g -------------•----...--- P --...__ ( ) Cafeteria Q Other fixtures . ........................................ ... - W Design Flow..•..._....._._.•......::..:.........gallons per person per day. Total daily flow..........-.�N.....C:._................gallons. , Septic Tank—Liquid capacity •gallons Length................ Width.... Diameter................ Depth................. W Disposal Trench—No...................... Width.................... Total Length.....................Total leaching area....................sq. ft. 3 . Seepage Pit No.......I........... Diameter......ID....... Depth below inlet..;...6.......:... Total leaching area..................sq. ft. Z Other Distribution box ( ° ) Dosing tank ( ) Percolation Test Results .Performed bY••------------•----•-•----••--•----•..............:..••......•-•---. Date ►.7 . Test Pit No. ................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........................ a' = .........................................:...................................... ............................................. 0 Description of Soil..............................................................................................----••-....-••••----•••••--•-••------=--•--•--•............__.............. W *. ..... -------------------------------------------------------------------- .-------------------------- ..-..-----•-------...: ----:--------------•-----_.......-. x ---.....•••••••.••••-••-•--•-•----•-•-••••--•••-••-••----•---•-•-••--------••---••••...--..._......••-••--•-••-••-- -------- =-•----•-•---....•••---•--••-•--•-•-•.....•••--•-•-•...............•--••••- U Nature of Repair or Alterations—Answer when applicable._-_.. ........ ....=.G�,�.�.�P.Q..`- P � . :�C_ess--�- -------------------------------- 1�- ......................... Agreement: , . .1 ° r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:I i LE 5 of the State Sanitary Code— The undersigned further agrees.not to place the system`in operation until a Certificate of Compliance'has been issued e b iealt ig l Sned . 0 . cl-' • ' �J . .... , Date Application Approved BY }--•-- ...... $- . ------. � .. -Date t Application Disapproved for the following reasons:----......................----------------------------------•----------------•----------------......:......:_ . _ --------------------••---._.......-•--•---------......------'--------•--.......------.........----....---•--•-••-----......-_...-•---------------=---•--------------------------••-=-••-•-......••-•••--- t r Date PermitNo. $_.... -------------------- Issued....................................................... - '. Date i t No.: .rs.._..���`� a�c 3 7 Fmc...�a�..-.r--............. THE COMMONWEALTH OF MASSACHUSETTS BOARD --OF HEALTH Appliration for Disposal Works Tontrnrtion 11rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............• ........... .................. .A- = . _........ ........................... Location-Address or Lot No. ..........................V�k w: ........................................................ Owner Address W wn I'l tL ' H rt,4-1 ..................................................... ................................................ � Installer �. Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .............. No. of ersons............................ Showers a YP g -------------------------------------------P--�- ( ---)--- Cafeteria ( ) d Other fixtures . W +Design Flow...:.a.._�`�............................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.......J------------ Diameter....../..10....... Depth below inlet......k-r....... Total leaching area..................sgrft Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY........................................................................... Date........................................ ,.a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---------------------•----------------------------•--....--•---....-----..........--•••-----.....---......................................................... 0 Description of Soil.......................•-------------•-----.................---••-------•-----•-------------------------------------•-------............------................••-•.--••- W V ..............••-----.......•-•-•.........-----.....-•----•---•----•-••----.................-••-•-......-•--•--•-•--••--•-•-----......•••---•-•----------••-----------------•••••---.-------------------- W ....-----•---- -•--••••.....-•••-------•--••----•--•-------------••-•--••••-----•---•--•••-------•--•---------•-••-•--•-•----------•--•--•---•••••••---••••-•---•••••••-•--•---•••......•.............-- U Nature of Repairs or Alterations—Answer when applicable__..... !1� ........✓ n......�'. :t. _;J a•L::_-••-• ---7.s�l l�(.R.._... a `P.. �� G �?..../3 tiC ae�• 'x ��A 'oJ P e c Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z- 5 of the State 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. ----------••...--- \ sl I /' J Date — Application Approved B � ,. . • � Date Application Disapproved for the following reasons:.................... -------------••--------------------•-----•--•--...------------•---•---------------------....-•-------------•-•......--••----------•----•-•-•---------------------------------------•----- Date PermitNo....... _:_..y. ........................ Issued....................................................... w Date -----------------_—_.,..------.-._-_------------------------'1----- ----------------- d THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r 1�+N...-........OF.................: (Irrtifiratr of Tontpliattrr r THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired bY------------------------------------4�- �,_t :,w ... -p"I A .................-------------------•-------...........-•------•------------ . Installer at _. --------------------------- ..---------. 40.1......--•- •-•••-••••-•-------------------------•------.._...........---••-•-•-- has been installed in accordance with the provisions of TI T LZ j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._...�8.-__114 ......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................... ............................ Inspector.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH __...T__d...t OF.....-...... :!la"al. 3-± ._.Y. .a" No ................ FEE..:-:1�2.......... Disposal Works Tonotrwtion J Prmit Permission is hereby granted........ V)------- f C -----------•...........:. ---------------------------------------- ir to Construct ( ) or Repair (tom—an Individual Sewage Disposal Systemy� . atNo.................................................................. - -------------------••----- -----------------------------------------------..........---- Street as shown on the application for Disposal Works Construction Permit.No.Y�1�����_ D'ated.......................................... _ --------------------------•-•-•-•-•- ................................................... - ISoard of Flealth. 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PROPO SED SEPTIC SYSTEM M UPGRADE PL AN Engmeenng Works, Inc. , —2o P.T.M. 253-21 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. 1 LOCUST STREET HYANIS MA (508) 477-5313 9/27/21 P.T.M. 1 of 2 Prepared for: Robert Healy, 1 Locust Street, Hyannis, MA 02601 J* NOTE: TO PREVENT BREAKOUT, THE PROPOSED Ek§T/NG DECK_ FINISH GRADE SHALL NOT BE <98.10 xHOUSE&1) zz 0 FOR A DISTANCE OF 15' AROUND THE SEPTIC TANK PERIMETER OF THE S.A.S. T.O.F.=102.5E CO INSTALL RISERS & COVERS OVER INLET & PROPOSED D-BOX FF=103.,3f� o OUTLET AND SET TO 6" OF FINISH GRADE PROPOSED S.A.S. � INSTALL.WATERTIGHT RISER & INSTALL RISER & COVER OVER ONE CHAMBER AND Q 2 COVER SET TO 6" OF GRADE SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT WQ TOF=101.3f(HOUSE) '' Q c F.G. EL.=101.0E F.G. EL.=101.2t F.G. EL.=101.5t F.G. EL.=101.7t N 0 INGROUND CL z L = 36' SWIMMING Q Q a ® S=1% (MIN.) ` L = 18' L = 23' 2 DOUBLE WASHED STONE POOL = +; 4"SCH40 PVC s" �4"SCH 0(PVC) �4"SCH40(PVC) (OR APPROVED FILTER FABRIC) GARAGE `� W as as to^I 14" ` s 2' EFF. as®aa®a 3/4" TO 1-1/2" DOUBLE \ p INV.=98.45 48" LIQUID DEPTHL aaaaaaa WASHED STONE `Sid }- W LEVEL ADD 4' 4.8' 4' ,� INV.=98.02 PROPOSED \ GASH INV.=97.85 EFFECTIVE WIDTH = 12.8' INV.=98.20 D-BOX No U o Aft eim .. . r• H-20 INV.=97.60 N 5p �• _ SEWER CONNECTION PROPOSED SEPTIC TANK 3-500 GALLON LEACHING CHAMBERS LA S / `1 L V) INV.=99.Ot HOUSE SURROUNDED WITH STONE AS'SHOWN N .01 6 LIJ H-20 RATED t (V N (� NOTES: I T ^7 0 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP CONC. ELEV.= 98.7E I I Q 0 N INVERTS, PRIOR TO INSTALLATION. BREAKOUT ELEV.= 98.10 I 160 W L INV. ELEV.= 97.60 co 0 v 2) SEPTIC TANK & D-BOX SHALL BE SET LEVEL & TRUE aaaaaaaaaaa r- TO GRADE ON A MECHANICALLY COMPACTED STABLE aaaaaaaaaaa 0 BASE OR SIX INCH AGGREGATE BASE, AS SPECIFIED BOTTOM ELEV.= 95.60BE Q_ L_ IN 310 C M R 15.221 2 .- 4' 3 x 8.5' = 25.5' 4' �-----33.5-------) ( ) 4' OF NATURALLY OCCURRING 0 a 3) INSTALL INLET & OUTLET TEES AS REQUIRED. PERVIOUS MATERIAL EFFECTIVE LENGTH = 33.5' Of 4) A GAS BAFFLE SHALL BE INSTALLED ON OUTLET TEE- 5' (MIN.) ABOVE G.W. PROPOSED S.A.S. AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. LEACHING SYSTEM SECTION 3-500 GALLON CHAMBERS BOTTOM OF TEST PIT, EL.=90.5 = SURROUNDED W/4' STONE N i z SEPTIC SYSTEM PROFILE S.A.S. LAYOUT o; rj W 0 N.T.S. ; o N V) 04 i 2 Y 3 c,> SOIL LOG DATE: SEPTEMBER 26, 2021 PT-21-267 ®®®® 0 ®®EO E3 uj \ DESIGN CRITERIA SOIL EVALUATOR: PETER McENTEE, SE-1542 ®®®E ®oE ®Ea '. w WITNESS: DONALD DESMARAIS RS HEALTH AGENT w ®®®®®® ® ®®EO® 37 N z o rn NUMBER OF BEDROOMS: 4 ELEV. TP- 1 DEPTH ELEV. TP-2 DEPTH N Z E@ SOIL TEXTURAL CLASS: CLASS I (LOADING RATE=0.74 GPD/SF) 0" 0" 101.7 101.5 DESIGN PERCOLATION RATE: <2 MIN/IN FILL FILL o 100.7 12" 100.5 12" �• DAILY FLOW: 440 GPD A A 1 102 DESIGN FLOW: 440 GPD SANDY LOAM SANDY LOAM 10YR 4/2 10YR 4/2 .618 18 GARBAGE GRINDER: NO-not allowed with design 100.2 100.0 - 9 B B r 4" KNOCKOUT LEACHING AREA REQUIRED: 440 GPD = 594.6 SF SANDY LOAM SANDY LOAM -' ( ) 10YR 5/6 10YR 5/6 20" DIA._COVER S o .74 GPD/SF 99.0 C 32" 98.5 C 36" PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY L PERC 4" KNOCKOUT / 4" KNOCKOUT 58" C o PROPOSED D-BOX: 1 INLET, 3 OUTLET (MINIMUM), H-20 RATED 36"/54" USE 3-500 GALLON LEACHING CHAMBERS IN SERIES 2.5 SAND M-C SAND .5Y 6/6 2.5Y 6/6 y SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES 4 KNOCKOUT .rLo N M SIDEWALL AREA: 2(12.8' + 33.5') x 2 = 185.2 S.F. BOTTOM AREA: 12.8' x 33.5' = 428.8 S.F. o 90.7 132" 90.5 132" 500 GALLON CAPACITY, H-20 LOADING ` C TOTAL AREA:......... .................................................... 614.0 S.F. PERC RATE <2 MIN/IN. "C" HORIZON CHAMBERS v+ c 3 o DESIGN FLOW PROVIDED: 0.74 GPD/SF(614.0 SF) = 454.4 GPD NO GROUNDWATER ENCOUNTERED w W