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HomeMy WebLinkAbout0025 MASA'S PLACE - Health 25 Masa's Place- Hyannis A= 292-318 i i No. L Fee r V v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliCation for Misposal 6"tem Construction Permit nr ti, Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. A5 MA5 irj P)LAtE_ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a 3 1 9 ` Y .5MA nIMTVWS P 4 Y "i Installer's Name,Address,and Tel.No. 509 -4 71—$'FJT] Designer's Name,Address,and Tel.No. C�41V&us fDF C- 4eaps.Lsas j c2'50 OK iFNv 1RWMa"T3 c, Type of Building: Dwelling No.of Bedrooms 3 Lot Size Icy 1 0(It sq.ft. Garbage Grinder( ) Other Type of Building kCS 0P6&)Ti V!(_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 330 gpd Design flow provided gpd Plan Aate —4 aooc' Number of sheets Revision Date title -.#A5 MA36 5 IPG4-c� f4 NWAJ/S d� 2�a I Size of Septic Tank t 500 (aotL, Type of S.A.S. 0% Soo Gw�-L cAmtegi-A& Description of Soil A44Q)I(>o4L Nature of Repairs or Alterations(Answer when applicable) U54 CN`S C(&J& "r4W14 To 06W n-bok 'To fa) scow GiprJ L.64C A r4,6r c �S c T14 41 O � s > t2DUW L QCt Date last inspected- Agreement- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of �a Compliance has been issued by this Board of Healt SignC Date Application Approved by Date 10 Application Disapproved by Date for the following reasons Permit No. t — 3 0 Date Issued rpa No. S, �. �r�{ e` se ""-. :. Fee P' a �� Entered in computer: 4' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION ­TOWN�O`E:BARNSTABLE, MASSACHUSETTS Yes fttlflcation for MfApo8al�tt Eln c(Co strUctlon ertnit rIt i. Application for a Permit to Construct( ) Repair(A Upgrade( Y Abandon( ) El Complete System D4ndividual Components t Location Address or Lot No. C��{J� Owner's Name,Address,and Tel.No. 44,y(/ Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 509 -4'77-g$77 Designer's Name,Address,and Tel.No. �,q�r~w i0���45�s j kla . n aC: eNv IR t4t�t�J`rok. Y Type.of Building: Dwelling No.of Bedrooms '. Lot Size Ec), 0 lie sq.ft. Garbage Grinder( ) Other Type of Building Y,-R 11D #V- No.of Persons. Showers( ) Cafeteria( ) - � 1 Other Fixtures- ' Design Flow(min.required) + � gpd Design flow provided gpd Plan Date "•tc► .•. a Number of sheets Revision Date re-v�e � Title �.S l°I+&A`5 PL t 1`I v•wo! ;' c) Uo Size of Septic Tank Type of S.A.S. 0,) Soo L (:A,4sva?s . �. 1t�nS, t r�" Description of Soil _pi L�m t L,At s I1 0 _31,r J Sg@ aP4AJ ature of Repairs or Alterations(Answer when applicable) USA QU.S 1&X' K oo 64*1-1; 60 .75F, �l� To NEW D"bo k. "k1 lM Lid l-114 4 t OF 4n-t6CJQGGw4T9 :;ca�?%*J1>0JC7 Date last inspected: P Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordaie with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health., kt r fir,, Signed— /1 Date dby RT Applicatiop Approve � ' l Date R c- ~ J �tApplication Disapproved by Date for-the following reasons t } t4 ¢Permit No. 3 0 6. Date Issued 6 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( k Upgraded( ) Abandoned( )by C �Cl+e�tDE & A / NW at ;A - HASA �5 PLA4E HV 40J 1 S' has'beenconstructed in accordance �Q i p - 306 dated i d ' - with the provisions of Title 5 and the for Disposal System Construction Permit No. �� �. Installer 6064)roL GPX~- 416ES-/AAQ Designer DaC 6AjV11Q 4Ektr*4.- bisStGAJ #bedrooms Approved design flow 330 gpd The issuance of this permit shall not be construed as a guarantee that the system will function as-destg�. � a Date / / �f Insp �Inspector No. ?d 13 o b Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS/ Misposal 6pstem ConStCULtlon permit Permission is hereby granted to Construe( ) Repair( Upgrade( ) Abandon( ) System located at dLS M 4.5A S P((4-6 R V&)N j t-- and as described in.the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with � t Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. �y Date l`U' S l " 9`,,%`'. Approved by ,. y►nr fC vct. I Jvi0 j;UbrM No. 2601 P. 1 Town of Barnstable ILI Regulatory Services s Richard V. Scali,Interim Director NAM 06;9. Puiblic Health Division Thomas Mclean,Director 200 Ka in Street,Hyannis,MA 02601 Off ce: .508-862.4644 Fax: 508-790-004 Installer& lesigner Certification Form Date: _ Sewage Permits# 2 o I ,. 3 0 td ,Assessor's Map\Parcel Designer: TC C. Installer: Ca e.wt8e. enftr cfses i Address: 1b511 Cra.,b:y l' �i��1 WO1Y Address: 15 L Lomiyi rcfa► S�ree,� it EQs4 ' On (C) - J - 2�1 S 'a z.w i d e. L I�tf rfs eS was issued s ed a-�p Q permit to da � P install a ( te) (installer) septic system at 25 }'t a s R ' 5 Q a c C, based on a design drawn by (address) -S G Errl�tnQeci� Tv►C , dated —�j'o� PC (designer) v I certify that the septic system referenced above was installed substantially according to the design, which may include m nor approved changes such as lateral relocation of the distribution box and/or septic tan�lc- Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than I0 latera:l 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 fo 1 ow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system reference above was constructed ' e with.the terms of the M approval letters (if appli'able) aL�11 c JoHN L CHURCHILL it (In ler' Signature) C N ko teor i ( igner's Signature) (Affix Des' e amp Here) PL E RETURN AItNSTABLE PUBLIC HEALT DI SION. CERTIFICATE OF COMPLIANCE )ELL NOT BE (ISSUED UNTIL BOTH_THIS FORM AND AS- BUILT CARD ARE RECEIVED BY T1tIE B Ali NSTABLE PUBLIC HEALTH DIVISION. HANK YOU. QAScptir,T;3igner Certification Form Rev 8.14.13.doe . No. .��� ` 0 9 Fee [ 6-1) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Ztpplirattou for �Digotal *p!tem Con0tructton Permit Application for a Permit to Construct O Repair('grade O Abandon Complete System ❑Individual Components Location Address or Lot No.oZ �/f S� '�GE` Owner's Name,Address,and Tel.No. Assessor's Map/Parcel O Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. tT�iyl GE���i� �j1--o�o7 1&1rili(JbAll, 07f Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building ' J' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided -3 '4 U gpd Plan Date —e5`09 Number of sheets Revision Date Title Size of Septic Tank 0 I-�qQ C- Type of S.A.S. 7? at.3`XA Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sign Date Application Approved by V - Date Application Disapproved by: Date for the following reasons q Permit No. go ( q®j Date Issued t X l 4—0 No. .or-00� IO I N*a ��r„ � Fee /61) Ed inuter: THE COMMONWEALTH OF MASSACHH U.SETTS Entered computer: Yes PUBLIC HEALTH DIVISION - TOWN OF:BARNSTABLE, MASSACHUSETTS j Application for ai5po!9al *plte* Congtruction Permit Application for a Permit to Construct O Repair(grade O Abandon O X.Complete System ❑Individual Components Location Address or Lot No. S �y�fi4 �` dGE Owner's Name,Address;and Tel.No. Assessor's Map/Parcel .2 3/op 4 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) I Other Fixtures d Design Flow(min.required) 3 3 gpd Design flow provided 3 q U gpd Plan Date Number of sheets / Revision Date Title Size of Septic Tank 43-,00 19A e. Type of S.A.S. .7�2 6`^-<,,9 /3Xe3T5(A ; a Description of Soil __Nature of Repairs or Alterations(Answer when applicable) a, Date last inspected: Agreement: _ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signeda -0 F., Date /aT --may 0.9 P T. Application Approved by Date Application Disapproved by: ` Date for the following reasons Permit No. �O�� qq 1 Date Issued I L.( C9 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaire d ( X) Upgraded ( ) Abandoned( )by ✓ at /�9��/'�'�,1' ��,{e�" �S/J'N/r'/y 1,P has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. q ?09^ yb l dated Installer 0//Yj C�C'.�nEy�' Designer 464,.� .0"&—rq, •^. 1 #bedrooms 3 Approved design flow gpd The issuance of this it s la11 not be construed as a guarantee that the system wil fu do s designe . Date 0 )r J Inspector /tv f or — -----u---. -- ---------------------/(--} -- No. l Fee t y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS ' 1=igpo!5a16pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at A- T, ..11�"C$ 1J' ®."Ic G" -12-1113"IX t« and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. ((�� n Date a "r '— d Approved by -•---� (/ D�- rt f Dec 15 09 03: 30p p. 1 'rown of Barnstable Regulatory Services 'Thomas F.Gciler,Director BAh i �m Public Health .Division Lb,xa Thomas McKean,Director 200 MAW Street,layannis,MA 02601 Office: 50s-962-4644 Fax: 508-790-63M Imstaller& Dwsiguer Certification Form Date: Designer: ��i'� � Installer: ' --- .. Address: a6f5 wl Address: 14q.%A4 L-F Tr On was issued a permit to install it (date) (installer) septic system at: A46& used on a design drawn by �V\V c dated (designer) "' 3 certify that the septic system referenced above was installed substantially according to }he desim which may include minor approved-changes such as later:': telocation of the distribution box and/or septic tank- I certify that the septic system referenced above was infftzRed with°major changes O.e. greater jb n: 10, lateral relocation of the SAS or any vertical r4ovation of any compoxic�t of the septii;,.system)but in accordance with State &Local Regulations. Plain revisnorl oT certified as-built by designer to follow. 'cHOFMas DAVID Onstaller'S ignaturt,) LIASON r`n � �q�Ho.1066� sgN1TAw��`� _ {I) er s Signature) (Affix a gncr's St F ere) PLEASE RETURN TO BAMSTAVLE4MAC HEALTH DIVIISION, C RTMC 'X'-P,' OF CoUpLIANCE 'INII L NOT BE ISSUED,KnIL,.-BOTH;TMS,FORM AND AS- BU'ILTCARD ARE ItF,ClEIi VED��.TIiF:.BA STSTABLF.PUBLIC HE&M DMSX17K T7El.A:NK YOU. - Q:FlrieltYJScyticlhcsigncr Certification Four: of Town of Barnstable P#. 1 9 7V -------------- Department of Regulatory Services '• t MAE& Public Health Division �ttias. �, `Date ' ,.200 Main Street,Hyannis MA 02601 {rF4 MAC Date Scheduled i z ) �. Time -�1 Fee Pd, Soil Suitabilit--Ass ssment fog S`ewa e j�''^^__ ,, 0 g Disposal Performed By: �+' �'!�./ 1 Lr1t I. LJv`% Witnessed By: QU, ty.. LOCATIO & GENERAL Location Address . P INFORMATION ti ee Owner's Name Address Assessor's Map/Parcel: Gl (� Engineer's Name NEW CONSTRUCTION REPAIR Telephone# T Land Use 12 �C 't 5lopes,(%) Surface Stones Distances from: Opcn Water Body _fr possible Wet Area Dunking Water Well fr Drainage Way ft Property Line Other ft STCHt (Street name,dimensions of lot,exact locations of test holes&.perc tests,locate wetlands I / n proximity to holes) �2 Parent material(geologic) 00f 100 Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Pace Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH'WATER TABLE Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: in, Depth to Sall mottles: Index Wells# In, GroundwaterAdj6stment tn, Reading Date: Index Well level fr.. --- .� AdJ,factor AdJ,Groundwater .Level TEST Observation PERCOLATION Dili � Time Hole tt Time at 9" Depth of Perc - '; Time at G" Start Pre-soak Time Time(9"•6") End Pre-soak Rate Min./Inch � ' Site Suitability Assessment: Site Passed ' Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be COmpleted on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notifythe Barnstable Conservation Division at least one (1) week prior to beginning, Q:\SEPTIC\PERCFORM.DOC 8 DEEP.OBSERVATION HOLE LOG Depth from Soil Horizon Hole# Surface(in.) Soil Texture .Soil Color Soil (USDA) (Munsell) MottlingOther (Structure,Stones;Boulders. J on isle c % ravel J Z -�- , s C) , DEEP OB Depth from SERVATIONHOLE LOG S (M Soil Horizon Hole# L ff. --— Surface(in.) Soil Texture Soil Color (USDA) Soil Other unsel]) Mottling (Structure,Stones,Boulders, onsisten `Yo Grayel)___ f y Depth from DEEP OBSERVATION HOLE LOG Soil Horizon Hole#Surface(in.) Soil Texture Soil Color -- Soil (USDA) (Munsell) MottlingOther (Structure,Stones,Boulders. Co i to c %a Rye]) Depth from DEEP OBSERVATIO Soil Horizon N HOLE LOG Surface(in.) Soil Texture Soil(M Color Hole# Sol! (USDA)' Other unsell) Mottling (Structure,Stones, Boulders. Consistency, l Flood Insurance Rate-Ma Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes T Within 100 year flood boundary No �! yes . Depth of Naturally occurriin Pervious Mein 'a l Does at least four feet of naturally occurringF pervi u ma erial exist in all areas�observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurrin Pervious g p material'? Certi----ification lO �L I certify that on l (date)I have passed the soil evaluator examination approved by the ` Department of,Enviro ental Protection and that the above analysis was performed by me consistent with . the requir training, exper ' e a x e nce described in 310 CUR 15,017. Signature f2 & �D . D ate QAS13PTlWERCFORM.DOC ECOJECH Environmental www.eco-tech.us THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Masa's Place Hyannis MAP Owner's Name: Deborah Sylvia - Owner's Address: 236 Main Street PARCEL North Harwich,MA 02645 Date of Inspection: July 24,2004 Name of Inspector: (Please Print) David D. Coughanowr,R.S. Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the info tion worted'-' e below is true,accurate and complete as of the time of the inspection.The inspection was perform ased on ay training and experience in the proper function and maintenance of on-site sewage disposal system`� am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system; U�l X Passes `V Conditionally Passes r Needs Further Evaluation By the Local Approving Authority rri Fails Inspector's Signature �0 - � ^-- QS Date: 14Y 25i 2000 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 NOTES AND COMMENTS Inspector's Note—> A septic 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. ****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: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24, 2004 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR 5.303 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,or 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 breakout or high static water level 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 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 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 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: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24, 2004 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 and 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 by 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: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24,2004 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no" to each of the following for all inspections: 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 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 X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of 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.(This system passes if the well water analysis, performed by 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 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 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: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: , July 24,2004 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? including Y _ Were all system components,exeleding the SAS. located on site? Y Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y _ Existing information. For example,Plan at the Board of Health. Y _ 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: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept. Number of current residents 1 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection requiredl Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two year's usage(gpd): 211 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd 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: System not pumped in recent past(Owner) 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: X Septic tank,&6-ib ftien box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternate 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: I I+years Certificate of Compliance for new leach pit issued 4/20/93 (BOH permit#93-163) 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: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24, 2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:—cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting,evidence of leakage,etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_ SEPTIC TANK:Yes (locate on site plan) Depth below grade: 15 inches Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 10 in Distance from top of sludge to bottom of outlet tee or baffle: 24 in Scum thickness: 8 in Distance from top of scum to top of outlet tee or baffle: 6 in Distance from bottom of scum to bottom of outlet tee or baffle: 10 in How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Pumping strongly recommended at this time and maintenance pumping is recommended every 2 years. Liquid level at outlet invert.Tank and tees appear structurally sound and functioning as intended.No evidence of leakage in or out. 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: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24, 2004 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 inlet tee, 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 is 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 FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24, 2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located,explain why: Type: X leaching pits,number 2 _leaching chambers,number _leaching galleries,number _leaching trenches,number,length _leaching fields,number,dimensions _overflow cesspool,number —innovative/alternate 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 leaching pits appeared unsaturated.No evidence of surface ponding,breakout,lush vegetation,or other evidence of hydraulic failure was observed. New leach pit was opened and found to be drv. CESSPOOLS: none (cesspool must be pumped at time 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: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24, 2004 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'(Locate where public water supply enters the building) 1 I S'MA A PLACE LOCATIONS S A B 1 23.5 ft 31.5 ft 2 27 ft 34.5 ft 3 16 ft 48 ft LEACH PIT W z LEACH O y PIT Oo SEPTIC 3 W a TANK <I ' 3 A g EXISTING DWELLING # 25 NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 Masa's Place Hyannis Owner: Deborah Sylvia Date of Inspection: July 24, 2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 25+ feet Please indicate(check)all methods used to determine 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: _ Checked local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Barnstable GIS department records indicate that property is over 25 feet above groundwater table. 11 TROY WILLIAMS y �� SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection "I T0HHor 99� (508) 385-1300 19 Hummel Drive o �� 414 South Dennis, MA D2660 �3 COMMONWEALTH OF MASSACHUSE 9 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS COFV DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET. BOSTON, MA 02108 617-292.5500 WILLIAM F.WELD TRUDY CORE Govcmor Secrctan, ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: o-)S A' S"S rt., 9� 1-7 jy 7 y Address of Owner: Al H h cr L ���c ic « !n Date of Inspection: (If different) c r i EXc Name of Inspector: Troy Williams 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.0 Company Name: Troy Williams Septic Inspections ��) Mailing Address: 19 Hummel Drive, South Dpnnis , MA 02660 / zza.-c,ls c3n.y � it/lu Telephone Number: T5 0 8�)--3 8 5-13 0 0 CERTIFICATION STATEMENT Z S 3 .2 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: asses — Conditionally Passes Needs Further Evaluation By the Local Approving— PP 8 Authority Fails c Inspector's Signature: v/�1i Date- `j //7 I�J 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: 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: BI SYSTEM CONDITIONALLY PASSES: Al 119 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 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. — (rovisod 04/2S/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ( A,� / CERTIFICATION (continued) Property Address: �S /"`�''S �^ S �' Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) 11114 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled 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 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 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 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 APPROPRIATE) 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 to 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 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 is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,. CERTIFICATION (continued) Property Address: 1 "`— 5 c- S �� Owner: Date of Inspection: D) SYSTEM FAILS: IVIA You must indicate ei, ,er 'Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of 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 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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 Well Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: . /"( C" 3 1" S Owner: �� �V, ti S Date of Inspection: /i -2 /G , Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ 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 water have not been introduced into the system recently or / as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. JZ _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. -Z _ 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: The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. ✓ _ 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)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C w� SYSTEM INFORMATION Property Address: °Z S ✓" G,S 5 ��� t Owner: Date of Inspection: 7 `'7 FLOW CONDITIONS RESIDENTIAL: Design flow: 33'1 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no):N Laundry connected to system (yes or no): y�r Seasonal use (yes or no): /VO Water meter readings, if available (last two (2) year usage (gpd): / 6 ��`' cc //.a S`- 70').df aik, s Sump Pump (yes or no): No Last date of occupancy: d C— COMMERCIAUINDUSTRIAL: A/M Type of establishment: Design flow:_ gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title S 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: cA System pumped as part of inspection: (yes or no) AN If yes, volume pumped: gallons Reason for pumping: TYPE 9F SYSTEM _ V Septic tank/e}iv.ibat+m. btrx/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. Copy of up to date contract? Other APPROXIMATE AGE of all components,.date installed (if known) and source of information: t. S -�-a..k' r_ �; a4rr y 5 ►� BuH. Lc��� :� new s3 sCPO 4- r~ O✓;f; 4 5elw2g.edors detected when arriving at the site: (yes or no) /Va 04/25/97) Fag* 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: D Date of Inspection: J�7 / 7 7 BUILDING SEWER: Al/ l (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: (locate on site plan) Depth below grade: /8 Material of construction: t✓oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: S l.r 5 /X G /o 0 o K Sludge depth: J Distance from top of sludge to bottom of outlet tee or baffle: 2/ Scum thickness: O S c '..'&" Distance from top of scum to top of outlet tee or baffle:_N6 •S `'� Distance from bottom of scum to bottom of outlet tee or baffle: A/0 S �- How dimensions were determined: be_ 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.) AAla S�� - c C G�i C- 4. f-C�- �+►�>� c C o c r. A ­7—,a GREASE TRAP: /A1 ell--I (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.) (zavimad 04/2S/97) Pay 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �2 s /Vl ',.s A S /dlc�- c c Owner: « S Date of Inspection: TIGHT OR HOLDING TANK: OW (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 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: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: /Al (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 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �S /V Owner: I 4 o k.w S Date of Inspection: 7112 6 , SOIL ABSORPTION SYSTEM (SAS):_z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: Dec to XG Lhc {�- L./i )J 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, condition of vegetation, etc.) c ✓ c/C-4-cr U c� % r w✓ �c ro L�w ti s CESSPOOLS: —&119 (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: (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 04/25/97) Page a of to Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r7 ,r SYSTEM INFORMATION (continued) Property Address: o M—s 4 5 /�C` C, <.- Owner: —1-2� S Date of Inspection: 9/,7 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) � �r�a1- . 38iGlr �L ,/ rl ; /dvo yc.!l„�, ' r // l 1 (zaviaad 04/25/97) Pag• 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,t I SYSTEM INFORMATION (continued) Property Address: s M c. S /�ICt e t Owner: 01-'&t a Date of Inspection: 5 /7 7 Depth to Groundwater _ Feet adjusted high groundwater level Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record t/Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) /�41 ` /era C e, +< d( O r. 4/ / LJ ; f—L, /✓'.f ✓ / e l,.moo`O .., 9 rw k L / Q r.� , ) Gt T /o c. u..�—t M • �, 4; c, 4 —o- c`Jl w cam. C— u I G✓e- (•, (revised 04/25/97) Vag* 10 of 10 p TOWN OF BARNSTABLE LOCATION MA-SA'5 P Lkcj97 SEWAGE#. 24 i 8 _30(p VILLAGE 44 Yi' N W(S ASSESSOR'S MAP&PARCEL A9' 3 INSTALLER'S NAME&PHONE NO.(�APiEtn)iDG E0TQPQISCS f Q1Jn 417�c� ��ss"17 SEPTIC TANK CAPACITY Ca A (ed4-S LEACHING FACILITY:(type)Cx) ©%� CiL,4���t (size) l 3tX o�5 r NO.OF BEDROOMS OWNER -Te)SIJC, P I M) PERMIT DATE: J 0 -!5 s a 0 i 2 COMPLIANCE DATE: i P% —1019 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N14. Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) N Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) MIA Feet FURNISHED BY QAK-uJf 06 E—AiTC_AP 1�(�: NJ W a� w A dP B TOWN OF BARNSTABLE LOCATION � '�`fjB J SEWAGE# VILLAGE �' ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. �� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: —'p9 COMPLIANCE DATE: 4X 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)) F/ Feet FURNISHED BY Oc Ob a M 00 �o 0 b �� a � � � N -1 C A`t ION SEWAGE PERMIT NO. �C % VILLAGE y /Uru�'S ST L R'S NA i ADDRESS N A L E NAME BUILDER OR OWNER ' J- Pa �-s DATE PERMIT ISSUED 9 DATE COMPLIANCE ISSUED � _ _ � _.,_ -� , . . �? . _. i +. �'' w 1 � . l ' � � . � � � r _. r_- .. ;_, . c �r • ' Is N0. dl �J '�.. PARCEL 3 J `� f ; CATION SEWAGE PERMIT NO. V LLAGE IN TA LLER'S NAIMEa ADDRESS 3 U I L D E R OR OWNER DA T E,,�E�A`MIT I S S U UD DAT E COMPLIANCE ISSUED o � � x No 6*7 .. n _ Fizz.............. •'_�'`� THE COMMONWVKALTH-, F MASSACHUSETTS BOAR® OF� HEALTH _ ... ...........OF...�.?1 1'II ? f��.... � -s /)J 5)............ Aopltration for Elinpnsal Works Tonstrnrtinn rrrmit Application is hereby made for a Permit to Construct (k-j'or Repair ( ) an Individual Sewage Disposal System at- -- -------------- ---=�-_n-�, � %r_� LotNo................... ..••.. .. ;. ••-- ?A5�dress ...... `: ......----Installer Typ f Building e Lot.../Q,t. .......Sq. feet V Dwelling—No. of Bedrooms____________ __ Expansion Attic ( ) Garbage Grinder (jl/o) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures .d W Design Flow..............jJ0.....................gallons per �r day. Total da it flow................3 ............... ons. WSeptic Tank—Liquid*capacity.I. ..gallons Length.. ........... Width��_ �_.. Diameter-------_-------- Depth,._ ----I�_ - x Disposal Trench—No.-.-----•---___--.--- Width................... Total Length............_ Total leaching area....................sq. ft. � cr f ;P. Seepage Pit No._4--------------- Diameter...f�.:G?_..... Depth below inlet....6...�___._. Total leaching area....2.62.sq. ft. z Other Distribution box (i.� Dosin tank �, J „� '-' Percolation Test Results Performed by.. r .. i. � � __ �4�fT1.5.. Date........ �_7 . ------..---- ,aj Test Pit No. 1U41y' .minutes per inch Depth of Test Pit..1�_'.- °�....� Depth to ground watere.en4�.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to gro OF A9 ................... OV .Description �lof �S oil..6JC6_I�_I.1 - � .....__... _........1-. N W a McKECHNiE -----------------------------------------------------------•-----------------.......-------------------••-------------•--•-••-......-•----............ ----...... UNature of Repairs or Alterations—Answer when applicable_________________________________ ____________ _ ��N--1---- .y s Agreement: �Q 1 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System i ccordance with the provisions of TL I A'ILE 5 of the State Sanitary Code- ThXu signed further agrees not to place the system in operation until a Certificate of Compliance has been issued b rd of health. S Sig •. •-- ,Date Application Approved BY �.:_L:�E• (.r - - . --........................ �� - Date Application Disapproved for the following reasons---------------------------------••----------------------------•-------------------------------------...-•••-•--- --------------------••--••------------••-•---._...-------------------------------•---------•--------•-•-.--------------------------------•------•----------------------••-----------••-•--••------------ Date -•----------------------- Permit No............................... Issued---�..�.� ..._7�.................... Date / .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF WEALTH wli?...................o F...�� rtr.� .�?� .... 11 v.:t.t?.1. ......------ f .� �rfirtt#iaan for Dwpos al Works Tonstrartuan thrmit Application is.:hereby made for a Permit to Construct (vT or Repair ( ) an Individual Sewage Disposal System at: ......... —. 1° .. ...12km—g:........................................ ......................-.......�:z......••-----------•-•--•-•--------•-•-•--.................. Location-Address or Lot No. _ ',........, .,-.^--•--•------------------------ ----------------•----.----.----------- Owner "// dress s^ ...... ... ........................... —Installei TypTif•, Building Size Lot...1U� f ......Sq. feet U Dwelling—No. of Bedrooms._.......... Expansion Attic ( ) Garbage Grinder (!t/q) Other—Type of Building No. of persons............................ Showers — Cafeteria p•i Other fixtures ----------------------------------- ' ---- W Design Flow..............Z/O...................._gallons perw"pgrday. Total daily flo ................. ...............gallons. WSeptic Tank—Liquid capacity./.gallons Length...8'........ Width.4.....a... Diameter__-__-__-____- Depth..:�._�?.... x Disposal Trench—No. .................... Width..................... Total Length...........�....��. Total leaching area....................sq. ft. Seepage Pit No._:: ______________ Diameter...} ' ..... Depth below inlet...... t�:_.._ Total leaching area.....`0I 7.sq. ft. Z Other Distribution box'(a--) Dosing tank ( ) ~' Percolation Test Results Performed by.. _ rl '....fly..........:.. ...__ ?� f_..... .. Date........: _......... . ............ Test Pit No. I OD&Y..�,mmutes per inch Depth of Test Pit...j' ..... Depth to ground water.VZ!7_e_C:!X4 . .----,,,,,,Test Pit No. 2.............._minutes per inch Depth of Test Pit.................... Depth to g V -------------------- Q+' ......-----••...... .........•-•----.....-•-•-••--••-••-_ .....:.........-•••-••...••................... tea`.. ......--•-•q. . ..........•. 0 Description of Soil-- -� .. is _!2_c �.�' �r t�w�3 �=?t'sv'�Serif ......D'Am.......ti.. ............ ••-•----W..... . N ........... v0 ........................ McKECHNIE... y W ••-•---•--------------------•-••--••-•--------•---•-•--•-•--.............---........-•-•----...----•-----•---•------------------...--_...........---• .... -p-.6a ............ x 7Vo:Ya7U4- U Nature of Repairs or Alterations—Answer when applicable...:......................... .............. ° � ..... .. --------------------------------------------------------------------------------------------•--------------•-•---------..... = - ... Agreement: The undersigned agrees to install• the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?is 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. Sigd-� .1z ................................ lea ApplicationApproved By .... ............................................. .............................. Date ,,'.DAPPlication Disapproved for the following reasons:.........................................................---......•---•---•-•----•-••.......................... ......................................................--------------------------------•---•--------•----...---------------------------------------------------------------•••............-----•......-_- Date PermitNo......................................- - Issued-....................................................... Date _ y THE COMMONWEALTH OF MASSACHUSETTS g BOARD OF HEAL J ........... . .........O F...... :....:. �` (�rr#ifixtt�e f f��am��itt�trle T _ IS C the,�Indivi enrage isposal S' `ucted ( ) or Repaired ( ) 1 Insta r ,/f ► �I�6�i ila��+�''�i at. �------------•-- .................... :'.....---- -------- --------- --------------------- has been installed in accordance with the provisions of T , he State Sanitary � a dd f6ribed in the application f'or Disposal Works Construction Permit No........:................................ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / .-.7 G DATE.... 1.....:........... .f........................................... Inspector.....-. ...................................................... ti -THE COMMONWEALTH OF MASSACHUSETTS BQARD . ✓ .............�M � ........OF.............................................. ......... ........................ _. 1� r." FEE ..................... r Permiss'on i ereby granted .._....: �.... -----.... . .............. ... .. to Cone If di ll S e a st at No..YL .. {... __..... .............. x eet " lGGf t as shown on the application for Disposal Works Construction Pe . t No, . ate ..........�-__ -------- --------- ........-- � � �- -:-- ------------•-••-•-•----------- �_ Board of Health% _. DATE..... / �O----------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS I ��,�,��;�.j­ ___11��-,_v-,- , - - -"I - --- - .�-_ .V, I , __'­4�,- Im- " -,"- � I �� I,"t- ��- r i�, , , . "--k, I . 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I �_ -�,�_____.___ I 2 .... 7A,- �, _ . 1, I, , -- - _ I I � � - I " �- _... ., - ,- ASSESSORS MAP : TEST HOLE LOGS PARCEL : � 1 NOTES: FLOOD ZONE: �/� �� 'v�C� L-- SOIL EVALUATOR :301 Q�� WITNESS : 14,q I 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: � � - � (f�pe C DATE: �i Health Regulations. -� PERCOLATION RATE: .0 7i1M-1 ) 2) The installer shall verify the location of utilities, sewer inverts and.septic ___�� � �L, �(�,,.� � �,,�• components prior to installation and set ting base elevations. ~—� 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first TH- 1 TH-2 two feet out of the d-box to the leaching shall be level. .. �1 (-E) ,4),kj t2ID I-V 1p y 4) This plan is not to be utilized for property line determination nor any other tb purpose other than the proposed system installation. LO 5) All septic components must meet Title V specifications. I P- 2\ & b 6) Parking shall not be constructed over H10 septic components. LOCATION MAP �j'L �3' �3 Z\ 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt _T of payment for the plan and installation based on the plan shall be deemed V 10 approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per o t 0. Wes; wa rust - -� - ' Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DES I G N applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. FLOW ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. 4 BE �d -� 12)The installer is to take caution in excavation around the gas line if such DROOMS AT GAL/DAY/BEDROOM GAL/DAY exists. 13 The installer shall verify the location,SEPTIC TANK ) �Y n, quantity and elevation of the sewer ---- -- -"- -� — ----- lines exiting the dwelling prior to the installation. �CAL/DAY x 2 DAYS - 6&0 GAL - USE l�00 GALLON SEPTIC TANK 1 OIL ABSORPTION SYSTEM 1 to 4. �" I LS 4 SIDE AREA: Z�C 4 )-?; x2x �_�? ��,5�. (� �AS�t� BOTTOM AREA: �F, Y� ZJ1 n •STS ` TIC SYSTEM SECTION ivj 0 ,np ct% vul�1 M V</ wItUU GAL D BOXY � - SEPTIC TANK v � 7 o 7 I _ ov l3�. 1.c? CS I3X4 ZO !2oc }g� SITE AND SEWAGE PLAN �_ u sue. o� a f, �� �t��� � ►2,o Pad c,.s� . , L OCAT I O N : � 2 5 �(-T PREPARED FOR o SCALE: I�i 0 DAV I D B . MASON IP,!5 DATE: (Z (, .l DBC ENVIRONMENTAL DESIGNS ,z EAST SANDWICH . MA Z DATE HEALTH AGENT ( 508 ) 833- 2 177 � AssEssoRs MAP : TEST HOLE LOGS PARCEL : 1 NOTES: FLOOD ZONE: LZ SOIL EVALUATOR: IM�GjG(�L !T ESS : )�( 1) The Installation shall comply with 1 itle V and Town of Barnstable Board of REFERENCE: U ��/� ace (f,,4PE- ems, DATE: Health Regulations. PERCOLATION RATE': 2 Wf) 1 2) The installer shall verify the location of utilities, sewer inverts and septic CDT G �� �.,/ components prior to installation and setting base elevations. - _-- --�-- -----__-_-- --- � �L. � 3 ��--- -�---�tom? '`�' 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The First A I TH-2 two feet out of the d-box to the leaching shall be level. t IAV��i�2� �� � to Z 4} This plan is not to be utilized for property line determination nor any other �b purpose other than the proposed system installation. WA4JAVY) t0 l.0 5 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over H10 septic components. LOCATION MAP 1�� �3 �'} �3, 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt 2,c41 6 C 215ZI-T lb of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. { 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean sand per I p UO 0. C'L-- in1C? @.�1 _ �_�� �, Title V specs. +'r 1:,1_� 12'�gjD 10)System components to be 10 feet from water line. Sewer lines crossing the ----- water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DESIGN applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW t_ST)MATE owner to ensure such. / Z2 BEDROOMS AT 1� GAL/DAY/BEDROOM -� GAL/DAY 12)The installer is to take caution in excavation around the gas line if such y exists. 13)The installer shall verify the location, quantity and elevation of the sewer r, SEPT]'-' TANK lines exiting the dwelling prior to the installation. �1)0 GAL/DAY x 2 DAYS - U00 GAL � . ""- -— USE 1 ADO GALLON SEPTIC TANK a�' l� KI� 1 S t�wc �cx e0e)W� 1 OIL .�BSORPT I ON SYSTEM i /! \ _ 10 O - l 1 ��X � ��L�`�1 �QLI '���GJ •� 'f � i O O -�- _--' ��;; Imo_ Mi - n 9 , wl'I t--�-- ;- TVW� � �� f.�K�f ,� a Mfg u�� �, ` . `i., ` I� l COX Ot� f" � j ; &IAS-iti f j"t Tecl�;"d r SIDE AREA: Z� -1. 1'� _ } `�. ,vo. :LSs . BOTTOM AREA: Z x �� x O t1 - Z�o��J �\ �,�f' ;,,r --- __ _- T I C SYSTEM SECTION j • ,W� q wi� ib14 � 3�� 4�v O PL/ h tat'GAL uO D _ D-BOX w SEPTIC TANK �c�- I,G�l�t.u�ij 3 ov wars w. � I /.op, Z D � Q, oP0� v��D S SITE AND SEWAGE PLAN _ ,q _12- �_ Usr o ___`fin 11L. Lr ,+2 !� _ 1'1JQPr �J_ - LOCATION GO/ PREPARED FOR : _J Io�u� So7nC. SCALE: 0 DAV I D B . MASON `j DATE : IZ DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA DATE HEALTH AGENT ( 508 ) 833- 2177 W 3 W z