HomeMy WebLinkAbout0059 MEGAN ROAD - Health 59 Megan. Road
Hyanni51,P
' A = 292 '255
� e
,•m
0
o i
'I
I
I
I
9 TOWN OF BARNSTABLE
LOCATION' SEWAGE#o;I
VILLAGE ASSESSOR'S MAP&PARCEL cA•9,�- —�
INSTALLER'S NAME.&PHONE NO.
SEPTIC TANK CAPACITY
C asp GozET�
LEACHING FACILITY: (type) G.y.�l�l3.e¢G�.i' _ (size)
NO.OF BEDROOMS
OWNER �i¢ji�o®/�
PERMIT,DATE: —a 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) Z Feet
FURNISHEDBY
1
f
S7
r
rg� V1
®' vt 3
X.
rs ri
No. c7 Fee U(/ i
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 'Yes
2ppIitation for Disposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot No. 1,eL'4y,4 Al /�0� Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel A 5 o� — a .�S �y �.4AP o
In�ler4"g;s Name,Address, No. Designer's Name,Address,and Tel.No.25-
Type of Building:
Dwelling No.of Bedrooms C;? Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 4�!40, No.of Persons Showers( ) Cafeteria( )
Other Fixtures fo
Design Flow(min.required) c74 c�L 4 gpd Design flow provided 3" 9 gpd
Plan Date �� :X Zz`-% Number of sheets oz Revision Date
Title
Size of Septic Tank�X/,PT�Id 6r /000 "°Fype of S.A.S.
Description of Soil �4e-�r Zp
ell-
Nature of Repairs or Alterations(Answer when applicable) CPG��" ®r-',,�,d 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 Ith.
Signed Date
Application Approved by I, jK2 Date T=.2 7
Application Disapproved by Date
for the following reasons
Permit No. 2`' 7 Date Issued
No: Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
PUBLIC HEALTH DIVISION -`TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplicatlo4 for 33ispbsal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair(�pgrade( )-Abandon( ) ❑Complete System., ndividual Components
Location Address or Lot No. .40" 5 G6,4 N oOOP Q, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel I-) 9 oZ a� .'�r yy C�/*0 ev
12ler's�va Addre ,a iTel.No. Designer's Name,Address;and T 1.No.
Cr
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. 'o Garbage Grinder( )
Other Tye of Building
g .?,D' ) No.of Persons A Showers( Cafeteria( )
Other Fixtures
Design Flow(min.required) O gpd Design flow provided � gpd
Plan 'Date J� cX "-00'J Number of sheets - ,,, Revision Date
Title • -._ i
Size of Septic Tank d!:�-X/.�T��wG /DO® ype of S.A.S.
Description of Soil .J'4c'0' �o 6
Y
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
4
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 e lth.) -.01
Signed Date
Application Approved by , Date
Application Disapproved by Date _ J
for the following reasons
_� U
Permit No. 2-u `l S Date Issued /'2 -;?
-- --------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
tertificate'of Compliance
THIS IS TO CERTIFY,that the On site Sewage Disposal system Constructed( ) Repaired(s)) Upgraded( )
Abandoned( )by G -C�®ezoU,A_ kp4w,;,�'' �14--c
at S9 /V has been constructed in accordance f
with the provisions of Title 5 and the for Disposal System Construction Permit No. Nated
Installer�� ` "ZA!FO " ,47' DesignerD v/l� .B POA J
#bedrooms oZ Approved design-flow U gpd
The issuance of this permit shall not be cons �ed a guarantee that the system will functio des'gned.
Date \ Inspector
----------------------------------------------------- ----------_._ ______
No. h, - t Z Fee /00-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Bisposal .pste Construction permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( )
System located at 6-3;0 -A�44111"low �� A/
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:Constru tion mu b�_completed within three years of the date of this permiPit,
Date j� Approved by (p
DEC/30/2015/WED 03:07 PM FAX No, P. 001
Town of Barnstable y
SHETpy Regulatory Services
Richard V.Scali,Interim Director
aVARNSTABM x .
Public Health Division
° Thomas McKean,Director
200 Main Street,f[yannis,MA 02601
Office: 509-862-4644 Fax: 508 790-6304
Installer&Designer Certification Form
Date: � Sewage Permit# 0 �6Assessor's MaplParcel2q� 7'55
Designer: JAVLP �&. lk)N� Installer: 3 M-k
Address: �`''� � Address: �l
On —� `°�tiU' L � was issued a permit to install a ,
(date) (inst,.aclllerr)) �n, �`
septic system at� t`� '1` t5based on a design drawn by
(address)
.dated 1 Izz,6 1 j
(designer) .
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank- 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 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but is accordance with State&Local Regulations_ Plan revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in c iiance with the terms
of the RA approval letters (if applicable)
UFi�,�S�s
[)AVID < e
81
taper's e) ��SOPI
's"NITAI{<
estgner ignature) (Affix Des1 �VVV- p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTE'ICA,TIE
OF COMPLIANCE WILL.NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASepticlDesigner Ceitificakon Form R.a'v 8-14-13.doc
net
L
Town of B rnstable t
VIE
Departiment of Regulatory Services
Public Health Division Date
MA9,q
200 Main Street,Hyannis MA 02601 I
TEl)MAi A Q1
Date Scheduled Time Fee,Pd.
-{!=` :,
Soil Suitability Assessment for Sewage Disposa '
Performed By: Witnessed By: n%LOCATION& GENERAL INFORMATION
Location Address S"9 f�� ��Al Ot O �y Owner's Name CA o/moo l✓
Address
Assessor's Map/Parcel: Engineer's Namc `a�!l?1�f'o� .
NEW CONSTRUCTION REPAIR `� `7-d-, /���
Telephone# G tr�j�/iC/f
Land Use Slopes('Yo) Surface Stones G�
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well {t
Drainage Way ft Property Line ft Other ft
SIM7CCII:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes)
• 1 .
Parent material(geologic) Depth t4 Bedrock
Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL kIIGT WATER TABLEMethod Used:
Depth'Observed standing in obs.hole: In, Depth In soil mottles:
Depth to weeping from side of obs.hole: Ili
0bt, Groundwater AdJutatment Index Well gt,
Reading Date: Index Well IeYol Add,11lCtOr�_ Arij.Groundw6ter Level
Observation
PERCOLATION TEST Dule_______. Iri mb
Hole 1t Tlmn at 9"
Depth of Pere
• Time at G"
Start Pre-soak Time @
r"—'— Time(91,41)
End Pre-soak
Rate Min./Iuch
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 notify the.
Barnstable Conservation Division at least one(1) week prior to beginning.
Q:\S EPTIC\PERCFORM.DOC
DEEP'.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Sdil Color Soil• Other
Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders.
onaiatcncy,96 aravel)
2
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency, ra
DEEP OBSERVATION BOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Boll Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stotir4 Boulders.
Consistency,
e
Flood Insurance Rate Mal?:
Above 500 year flood boundary No Yes
Within 500 year boundary No files _
Within 100 year flood boundary No.. Yts.,,,_.,,,_
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring per i u titeriai exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of ha rally occurring pervious material? _.
Certification
I certify that on. �� (date)I have passed the soil evaluator examination approved by the
Department of Environinendl Protection and that the above analysis was performeo by me consistent with .
the required training,ex rtise e e 'ence described in 10 CNR 15.017.
Signature Date
Q:\SEPTIC\PERCPORM.DOC
COMMONWEALTH OF M-
ASSACHL SETTS
N EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
WC DEPARTMENT OF ENVIRONMENTAL PROTECTION
iO,9M 5 9 r
9d, ass zo ,01
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: S9 �G pi l _J
N, o 160/ U
Owner's Name: o
Owner's Address: $ 2 N
tia hn,S ._ oZ 6 0/
Date of inspection: /9//07
Name of lnspector:.(Please print)� A✓�1' /O�S���
Company Name: 1--&k1 p
Mailing Address:
Telephone Number:lTpj�> ) S— f
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-r�y
training and experience in the proper function and maintenance of on site sewage disposal systems. i am a QEP
approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The system,: C--
C_-
11�Passes
ri
Conditionally Passes �.
Needs Further Evaluation by the Local Approving Auth S2I x
Fails :Z,
Inspector's Signature:
Date: 6 i9 O r`' rn
The system inspector shall submit a copy of this inspection report to the Approving Authorit`-(Board o Health or
DEP)within 30 days of completing y this inspection. If the system is a shared system or has a design flo� 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 I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: ph
Date of Inspection: / p
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
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
in 310 CMR
Comments:
B. System Conditionally Passes:
41Sy 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:
Patre 3 of 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORXI
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
T4 Conditions exist which require further evaluation by the Board of Health in order to determine if the system
s failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CNIR 15.303(1)(b)that the
systein 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:
Page 4 of 1 1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
a.•r.�i s �1 Z 6 0/
Owner: /�✓�� � po
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes'or"no"to each of the following for all inspections:
Yes j��Discharge
ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
or pondinQ of effluent to the surface of the around or surface waters due to an overloaded or
,,c4ogaed SAS or cesspool
41- Static liquid level in the distribution box above outlet invert due to an overloaded or clogg, eesspool ed SAS or
C _ quid depth in cesspool is less than 6"below invert or available volume is less than './ day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
,,,,,6f times pumped
ny portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion .f 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.
�y portion of a cesspool or privy is within 50 feet of a private water supply well.
_r/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.)
(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•
XThue
indicate either"yes'or"no"to each of the following:
wing criteria apply to large systems in addition to the criteria above)
he system is within 400 feet of a surface drinking water supplye system is within 200'feet of a tributary to a surface drinking water suppl\e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped
one 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 an lard v
significant threat under Section E or failed under Section D shall upgrade the system in accord nstem considered C�IR
15.304. The system owner should contact the appropriate regional office of the Department.
Pase 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:9&q
e Q N OQ�
Oe2 60/
Owner: Vr
Date of Inspection:
Check if the following have been done. You must indicate"yes'or"no"as to each of the following:
Yes —
Pumping information was provided by the owner,occupant, or Board of Health
J 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 art of this inspection
P p on .
/ 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 C/
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
1 , sting 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 1 5.;02(3)(b))
III
T41.
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Sq- /%fe al,^ RC
Gbi GO/
Owner: p H g
Date of Inspection: 6 /9 d
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): c� — Number of bedrooms(actual): 02
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): c�d�
Number of current residents: O
Does residence have a garbage grinder(yes or no): /vV
Is laundry on a separate sewage system es or no):IW[if yes separate inspection required]
Laundry system inspected(yes r no):
�
Seasonal use: (yes or no):
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):_�
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): o d
Basis of design flow(seats/persons/sg ft.etc.): "p
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:
Was system pumped as part of the inspection es or no):
[fees, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYP STEM
Septic tank, distribution box, soil absorption system_
Single cesspool
_Overflow cesspool
_Privy
Shared system (yes or no)(if ves, 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 info ation:
Were sewage odors detected when arriving at the site(yes or no):�Q
i
i
I
I
Page ?of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA
PART C
SYSTEM INFORMATION(continued)
Property Address: ��
�>^
Owner IA-0
Or�6ol
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade: '
Materials of construction:t iron _4f_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)
Depth below grade:
Material of construction:—c�ete metal fiberglass—polyethylene
_other(explain) —
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no :certifcate) —(attach a copy of
Dimensions:
Sludge depth: a
Distance from top f sludge to bottom of outlet tee or baffle: C2 /
Scum thickness: ess/
Distance from top of scum to top of outlet tee or baffle: G
Distance from bottom of scum to botto�of outlet tee or baffle:
How were dimensions determined: /5-/
ce
Comments(on pumping recommendations, inlet and t tee or b�condition. structural integrity. li
as r�Jated to outlet invert, iden� e,etc.): _ quid levels
/
GREASE TRAP:k0ocate on site plan)
Depth below grade:_
Material of construction:—concrete metal
(explain):_ — _fiberglass
_polyethylene_other
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 integriv, liquid levels
as related to outlet invert, evidence of leakage, etc.):
'r4I.- C 1._.._..__._._ r• - .
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: oNC'c,
Date of Inspection: 6 9 0
TIGHT or HOLDING TANK:/I("-(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: /t (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 3 0 or out of box, etc.):
G.r 6&1 x-o-te Lvc�Leo/
PUMP CHAMBER:/f (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.):
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOR-MATION(continued)
Property Address: -j 9 ��f� " /':;�/
&n2 n4it />—�¢�0ot60/
Owner: A.14 o-
Date of Inspection
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits, number: 6j ' ,� ��� _ �S 7�
leaching chambers, number: /
leaching galleries, number: / J'A
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.): q
L�Ht J
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids laver:
Depth of scum laver:
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: eoocate on site plan) `
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of pond ing, condition of vegetation. etc.):
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT
PART C
SYSTEM INFORMATION(continued)
Property Address: �!e GH
Owner: �"Cjj
�4 Oot6 0/
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposa! 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
Ad,
/Sj 02 0 ,
30 '
O
f
Page I 1 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: `j g
Owner:_ 004
Date of Inspection:
SITE EXAM
Slope
Surface water /0
Check cellar '
Shallow wells ' Q
r� Nr'
Estimated depth to ground water 1
v
Please indicate(check)all methods used to determine the round water high
�
o elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Olj�semed site(abutting property/observation hole within 150 feet of SAS)
Necked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high round water elevation:
a oa •t
_ �oH H �' of o r` 7ui ci are J..�
DATE; 5/21 /02
PROPERTY ADDRESS:59 Megan Road
Hyannis ,Mass .
------------------------
02601
------------------------
On the above date, I Inspected the septic system at the abo a@ �% D
This system consists of the following: IL
1 . 1-1000 gallon precast H10 septic tank . JUN 0 4 2002
1-1000 gallon precast leaching pit.
TOWN OF BARNSTABLE
HEALTH DEPT.
Based on my inspection, I certify the following conditlons:
3 . This is a title five septic system. ( 78 Code ) ��
4 . The septic system is' in proper working order
at the present time .
S. Waste water is 42" below the invert pipe of MAP
the leaching pit .
PARCEL • Z
LOT
SIG NATURE;J,
•�-
Na me :
_�_�._ Macomber fir,_-----
Company: Joseph_P _ Macomber-& Son , Inc .
Address : Box 66
__Centerville , Ma_-02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
LJOSEPH P. MACOMBER & SODINC.Tanks Cesspools•LeachfleldPumped & Installed
Town Sewer Connections
x 66 Centerville, MA 026
775.3338 775.6412
(• � ,per
-\ COMMONWEALTH OF MASSACHUSETTS
= EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
Ui
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 59 Megan Road
Hyannis ,Mass .
Owner's Name:Constance Madden
Owner's Address: 16 Huckins Neck Road
Centerville , Mass . 02632
Date of Inspection: 5/21 /0 2
Name of Inspector: (please print) Joseph P.Macomber Jr .
Company Name: J. P .Macomber & Son Inc .
Mailing Address:Box 66
Centerville .Mass . 02632
Telephone Number: 508-775-3338
CERTIFICATION STATEMENT
1 certify that 1 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 Section15.340 of Title 5(310 CMR 15.000). The system:
4/ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Q
Inspector's Signature: Date: t�. OV-0/1
The system inspector shall Vubmit 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
I
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 59 Megan Road
Hyannis , ass .
Owner: Constance Madden
Date of Inspection: 5 21 02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S�Passes:
I have not found any information hich indicates that any of the failure criteria described in 310 Ctv1R
15.303 or in J IV UMK I 37UT—exist, Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order "
at the present time .
B. System Conditionally Passes:
_,4)b 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.
4V6 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 is[r ion bo ue to broken or
obstructed i e s p p ( )or due to a broken settled or uneve
n distri
bution 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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 59 Megan Road
Hyannis ,Mass .
Owner: Constance Madden
Date of Inspection: 5/21/0 2
C. Further Evaluation is Required by the Board of Health:
A,lb 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:
AA 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.
Ab The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
40 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
..46 The system has a septic tank and SAS and the SAS is less than 100,feet Wt 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
f
Page 4 of I I
4
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Add ress:5'9 Megan Road
yannis , ass .
Owner: Constance Madden
Date of Inspection: 5 21 02
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes No
_ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
10Cischarge 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 isrribution box bove outlet invert due to an overloaded or clogged SAS or
` - esspool 1_4 jZp� 66 V,3 I
Liquid depth in�erspeeI is less than 6"below invert or available volume is.less than 'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
/of times pumped Q.
V 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,
y ponion of a cesspool or privy is within a Zone I of a public well.
�y portion of a cesspool or privy is within 50 feet of a private water supply well.
y 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 qualiry 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 forma
V (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 now 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)
des 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 11 of a public water supply well
1f you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
,�es" 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
304 The system owner should contact the appropriate regional office of the Department.
4
__ I
Page 5 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:59 Megan Road
entervi e ,Mass .
Owner: Constance Madden
Date of Inspection: 5 21 0 2
Check if the followine have been done. You must indicate"yes"or"no"as to each of the following:
Yes NXpumping
information was provided by the owner, occupant, or Board of Health
/
Were any of the system components pumped out in the previous two weeks
t/ _ Has the system received normal flows in the previous two week period?
t/ 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 note as N/A)
lz _ Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
4z_ Were all system components,**eluding 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/
t/ Existing information. For example, a 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)j
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 59 Megan Road
Hyannis ,Mass .
Owner: Constance Madden
Date of Inspection: 5/21 /0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): J_ Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms):
Number of current residents: I _
Does residence have a garbage grinder(yes or no): 4A)
Is laundry on a separate sewage system_(yes or no):� [if yes separate inspection required]
Laundry system inspected(yes
Seasonal use: (yes or no): AZ
Water meter readings, if available(last 2 years usage(gpd)): 2000=20 , 250 gallons=55 . 48 G P D
Sump pump(yes or no): 2UU1—Z1 , UUU a l l o n s=5 7 . 5 4 G P D
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment: ,tfi9
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):Ay
Industrial waste holding tank present(yes or no):/J�A
Non-sanitary waste discharged to the Title 5 system (yes or no):4/
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): _
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping: �fi9
TYKE OF SYSTEM
J/ Septic tank,dtstiefl-beer soil absorption system
Single cesspool
W,,P Overflow cesspool
Privy
VShared system(yes or no)(if yes, attach previous inspection records, if any)
o Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
/2 ob ained from system owner)
Tight tank /J�Attach a copy of the DEP approval
Xk1ther(describe):
Appr imate awe of all comp-one ne ts,date installed (if known) and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 1 I
s
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 59 Megan Road
Hyannis ,Mass .
OwnerConstance Madden
Date of Inspection: 5/21/0 2
BUILDING SEWER locate on site Ian U G ( plan)
Depth below grade:
Materials of construction:—cast iron Z0 PVC N/tother(explain):
Distance from private water supply well or suction line: li';A
Comments(on condition of joints, venting, evidence of leakage,etc.):
Joints appear tig�ht . No evidence of lea'-kage . The system is
vented through the house vents ,
SEPTIC TANK: Zoocate on site plan) 1"Of/6405
Depth below grade:
Material of construction: �;/—concrete.e/d meta WO fiberglass.W polyethylene
&t)other(explain) A)p
If tank is metal list age:1V,4 is age confirmed by a Certificate of Compliance(yes or no):-tl (attach a copy of
certificate) I! ` J� ,
Dimensions: 6" �'/�i
Sludge depth:'� �
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:t� ----
Distance from top of scum to top of outlet tee or baffle/
Distance from bottom of scum to bottom of outlet tee sr baffle:
How were dimensions determined: , 7,,1Abk iW
Comments(on pumping recommendatio s, Inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of-leakage, etc.):
,Pump the septic tank every 2-3 .years . Inlet & outlet tees
are in place .The tank is structurally sound and shows no
evidence of leakage .
GREASE TRAP, locate on site plan)
Depth below grade:d1
Material of construction.t/0 con crete/P/�metal.t19 fiberglass/1�/�polyethylene4/4other
(explain): A)W
Dimensions:
Scum thickness: A0
Distance from top of scum to top of outlet tee or baffle: },.I
Distance from bottom of scum to bottom of outlet tee or baffle: 44�9 _
Date of last pumping: A),
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 is not present:
7
i
Page 8 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress59 Megan Road
Hyannis,Mass .
Owner: Constance Madden
Date of Inspection: 5/21 /0 2
TIGHT or HOLDING TANKA6Ie• (tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: AM
Material of construction: A4 concrete A1,4 metal e,4 fiberglass polyethylene,1,?A._other(explain):
,to
Dimensions: A114
Capacity: WX gallons
Design Flow: W4 gallons/day
Alarm present(yes or no): ��
Alarm level: N0 Alarm in working order(yes or no):
Date of last pumping: AM
_
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX4h&(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: AM
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
leakage into or out of box, etc.):
Distribution box is not present .
PUMP CHAMBERS 6 (locate on site plan)
Pumps in working order(yes or no): /Q
Alarms in working order(yes or no): �1JH
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump chamber is not present .
8
I
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 59 Meagan Road
Hyannis ,Mass .
Owner: Constance Madden
Date of Inspection: 5/2 1/02
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
1-1000 gallon precast leaching pit . ( 6 ' X 10 ' )
If SAS not located explain why:
Located see page 10
Type
,;?�Sleaching pits, number: j
A.)d leaching chambers, number: 6
leaching galleries, number:
AF leaching trenches,number, length:
�Q leaching fields, number, dimensions: O
overflow cesspool, number /�
1 innovative/alternative system Type/name of technology:%k A) L 7F &A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of-vegetation,
etc.):
Loamy sand to boney sand to fine sand . No signs of hydraulic
failure or ponding . Soils are dry Vegetation is normal
CESSPOOLSe{AVf-'(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: 140
Depth of scum laver: 14/iQ
Dimensions of cesspool 1W
Materials of construction: _'4A
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools arp not present
PRIVY4;jj,r—(locate on site plan)
Materials of construction:
Dimensions: A40
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PfiyV is not nrecant _
9
Page 10 0(11
OFFICLAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 59 Megan Road
Hyannis ,Mass .
OwDcr: Constance Ma en
Ditc of Inspcclim 5 21 02
SKETCH OF SEWACE DISPOSAL SYSTEM
Piovidc s sketch of the se-itc disposal system including tics to it least two permanent reference landmarks or
ocnc"Liks. Locitc ill Wclls Within 100 (cct. LDcitc where public water supply enters the building.
.y;
i"
i
10
Page I I of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 59 Megan Road
Hyannis ,MaSS .
Owner:Constance Madden
Date of Inspection: 5 21/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 1u feet
Please indicate (check)all methods used to determine the high ground water elevation:
44 o?Obta' ed fro System design plans on record - If checked, date of design plan reviewed:
,g bserved site (abuning ro a bservation hole within150 feet of SAS)
t3Checked with local Board of Health-explain: 14-1
T- /.d hecked with local excavators, installer(an, ch documentation)
Ise Accessed USGS database-explain: ,/n a
You must describe how you established the high ground water elevation:
Used ; Gahrety & Miller Model Ground water 1 vels ahnve RAn 1pupl
12/16/94
Used ; USA; Observation well data 11rna 1999
Used ; US . 92-000-1 Plate #2 January
range o'f'ebound water elevations . .
Leaching
Pit ` :eet
CroundwateJj Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
Of the leaching pit and the adjusted groundwater table is
feet.
ll
I
y-rr.-r•r.-n:rs—,1-err'-mr•ntrr�.n as-rrrr.:•.�*+rvrr:m:-e:•mnnn•aa*�asr.sr.r+�+
1 � Barnstable '•"� '� • `�••
TOWN OF BOARD OF HEALTH
-.^-T••_••*--•'--SUBSURFACE
••9FHACF DISPOSAL SYSTEM IN�gI�'F,C*TION FORM - PART D^- CERTIFICATION
r�• '•
-TYPE OR PRINT CLEARLY-
PIWERTY INSPECTED
STREET ADDRESS 59 Megan Road Hyannis ,Mass . ,
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAMEConstance Madden
PART D - CERTIFICATION Y
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P.Macomber & Son Incw:w '
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City Stat• LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 _ 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
omplete as of the time ofeinspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one ;
System: PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
he-alLh or Lhe. environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which I have con lcted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 3.10 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
f �I�iG��
Inspector Signature Date
ne copy of this ce t.ification must be provided to the OWNER, the BUYER
( where aPpl icable ) and the BOARD OF HEAL7'it.
* If the inspection FAILED, the owner or"" perator shall upgrade
he ayate
within one year of the date of the inspection , unless allowed ortrequiredm
otherwise as provided in 310 CPJR 16 , 305 .
partd .doc
TOWN OF BARNSTABLE
LOCAT`ON Agme � SEWAGE #
VILLAGE YGt/y��� /�/� �I� ASSESSOR'S MAP & LOT `
INSTALLER'S NAME&PHONE
SEPTIC TANK CAPACITY / b _ -'}
LEACHING FACILITY: (type) /" � h '" (size`)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:-?
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Le ¢hing Facility ( any tlands exist
within 300 et cility) Feet
Furnished b '
e.
i
t
\ 9 �Vp
v
THE COMMONWEALTH OF MASSACHUSETTS
!� BOARD HE
J 1
.........OF........... ........................................................................
A:P:Pjiratilan _fur Ubipoiitt1 Workii Towitrurtion Vrruiit
Application is hereby made for a Permit to Construct ( ' or Repair ( ) an Individual Sewage Disposal
System at:
a
------. / -�...•. ---------- --------........................
Locati ddress or Lot No.
................ --Q _..._.__ ...... ........... -------•-•----'--•--=-•---•-----•--------•••-----•............-•----............................--
ner Address
W
Installer Address /
Type of Building Size Lot...1, LG�..Sq. feet
U Dwelling—No. of Bedrooms----------_______________________Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ------------ -------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- --
W Design Flow...... _-e --------------gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank— iquid capacity_ _________ga ns Length---------------- Width......._.._..... Diameter... ------Depth_._.______._....
x
Disposal Trench—N h____________________ Total Length-------------------- Total leaching area.:-OZ0 sq. ft.
Seepage Pit No____ ______________ Di eter__..........._____._ Depth below inlet.................... Total leacltittg<trea_____._.____.____.sq. it.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by---------------- ----------------------••---•------------------------ Date........................................
aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.--.---..-----.--.-____.
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._.-.----_---.----------
O Description of Soil---- '•-'
x
-----------------------------------------------------------------------
V
W -------------------------------------------------------------------------------------------------------- -------'------------------------------------------------------
VNature of Repairs or Alterations—Answer when applicable----------------------------__--.------_---._--_-_.-__--f q __�$._-.-._. _____-.---__....
----------------------------------------- ---------------------------------------------------------------------------------------------------------------------1----------- -------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article YI of the State Sanitary Co —The ndersi furthe agrees not to place th system in
operation until a Certificate of Compliance has been e boa f healt
igned-- .. • ....... ------------------------••-- - •-• --
te y�
Application Approved By------------- ......... ----------- --- ----- ---- ---- '-c " ---- Da- :-
Application Disapproved for the following reasons--------------------------- --------- ---------- ------------------------------------------------------
------------------------------------------------------------------------- ------------------
Z_
--••----•--••----._...-•----•.............•--•----------------•--•-----...--•-•-•-•----•--• Date
Permit No......................................................... Issued.....{ ••-�
Date
No.._. yB.. FsE ... :..................
THE COMMONWEALTH OF MASSACHUSETTS
� OARD F HE
...........---OF .................... .. ...-_..
ppliratiuu -fur 43itipu.ittl 10orkii Tomitrurtiou Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at °
- - L- ----------------------•----------
Locati ddress or Lot No.
........y`.. - - . ....... -- --•---•----- ....................................------•-----..................................---.............
ner Address
W
Installer Address //_
Type of Building Size Lot---1 f-�6r___Sq. feet
Dwelling—No. of Bedrooms-.-__-_--.-�________________________Expansion Attic ( ) Garbage Grinder ( )
p-, Other—Type of Building ---------------_----_-____ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P-4 Other fixtures ----- ----------------------------------------------------------------------------------------------------------
W Design Flow.... gallons per person per day. Total daily flow----•-------------••--•---------------------gallons.
WSeptic T.tnk—. iquid capacity_ _g ns Length-----------_--- Width_--------- ._.. Diameter---------.------ Depth_--------------
x Disposal Trench— t11-_-•---------------- Total Length_-----_-_._.___-__. Total leaching area....:.!�0;Z-sq. ft.
Di eter____________________ Depth below inlet_.__.______....__... Total leaching trea._____._________sc it.
Seepage Pit No____ ___________ P g t 1
Z Other Distribution box ( ) Dosing tank (; )
aPercolation Test Results Performed by------ ----------------------------------------------------- Date----------------------------------------
a Test Pit No. I----------------minutes per inch Depth of "Pest Pit____________________ Depth to ground water----------------------_
4, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-._-.--_-_-----------_
P+ ------- ---- - - -----------------------
Descri Description of Soil--.___ _.__.
P = ; ; -
--- - --- - - --
x -�::::::::::::::: :::.........................................................
W
UNature 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 Article XI of the State Sanitary Co —Th ndersi ed furthe agrees not to pla4thsystem in
operation until a Certificate of Compliance has been ssued e bo f healtSlgne A lication A roved B
---*--- -- Dat,
Application Disapproved for the following reasons:----------_....................-.......................................:_.._____________________.__...._._._____
--------------•--...-_-------•--------....._•..-_......----------------------'------•------------------..•.....---------- ---------------------- :... --••------------- ---------------
ate
--- •----
Permit No......................................................... Issued ------------- ----- ------�-t-1-------
Date
THE COMMONWEALTH OF MASSACHUSETTS �C �J� ���,✓
BOARD F HEALT / J
.........OF. ...................................................................................
Owrrtifiratr of mvpompliaurr
THIS IS-TO
TIFY, T the Indiv al Sewa Dis osal System constructed ( or Repaired ( )
by----------------------- -----/------------
Installer------ ...�....... .....�_�i
.......at • ' ---- --------- 7 � !%���.t3. -9
has been installed in accordance with the provisions of Article XI of.The State-Sanitary ode as described in the
application for Disposal Works Construction Permit No.................. dated _.__.., Zo
_.__.
r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL F TIO SATISF TORY.
2?�
DATE--------------- f.,� -- 7..:-�-�---_- Inspector.- ----------�----------- ---------------------------------•--------
THE COMMONWEALTH OF MASSACHUSETTS
r BOARD ZQF HEALT
No....... --: i FEE........................
�i��u��tl�� urk,� C�uu�tru�r#uit erutit
Permission is he granted___.. .-. ° �" . ____. ... ,- .�'
to Construct ( R i��) an Individual Sewage Di po System
atNo.......... ---- ----•-. �1 r' - ----------------- ------- --------
Street
as shown on the application for Disposal Works Construction Per.-mit No.._______ -._ Dated_.. f A�r !....
------ -
�,.-''. Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS # +
ASSESSORS MAP : -#ZgG TEST HOLE LOGS
PARCEL: i I) The installation shell cojnp kvith Title V and Town oflfN"hoard of
Ue) �S FLOOD ZONE: ��j/� ,� ;IG' 1 SOIL EVALUATOR:
[[ealth Regulations.
2) The installer shall verify the location of utilities, sewer inverts and septic
REFERENCE: tJ� '
� � t �?� 1j DATE: ��. components prior to installation and setting base elevations.
NESS :
-_ PERCOLATION O's 1 ` N RATE:_.4_ 'Z, 1 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first
-- - 2�.�-/_ -- Pq
\je ( ` yv ` two feet out of the d-box to the }caching shall be level.
/-/DT /Z 7__ TH- I TH-2 4) This plan is not to be utilized for property line determination nor any other
--- -- ---- n purpose other than the proposed system installation.
�l tl 5) All septic components must meet Title V specifications.
IS
b (0 ` 6) Parking shall not be constructed over 1110 septic components.
�•'D 7) The property is bounded by property corners and property lines.
h r),% Z , 8) The property owner shall review design considerations to approve of total
LOCATION MAP design flow and number of bedrooms to be considered for design. Receipt
/ of payment for the plan and installation based on the plan shall be deemed
,/� approval of the design flow by the owner.
C/ ►/ , 9) The existing leaching or cesspools shall be pumped and filled with material
I I ��l per Title V abandonment procedures. Those within the proposed SAS shall
J be removed along with contaminated soil and replaced with clean sand per
/3 '� �yp ?j Title V specs.
1 Dc5 Lam- �� U 10)System components to be 10 feet from water line. Sewer !fines crossing the
g�'dT water line shall be sleeved with 4 inch SC1140 PVC with ends grouted if
1 applicable. The proposed SAS is being installed below the water service
PP � p p g
line. The line is to be sleeved as aforementioned and maintained in place.
SEPT IC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
J FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such
exists.
`_BEDROOMS AT 110 GAL/DAY/BEDROOM - GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer
lines exiting the dwellingprior to the installation.
SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting
- Title Vrequirements. -
� �� GAL/DAY x 2 DAYS - ti GAL .
USE �= GALLON SEPTIC Ttg&
> 1W •�'! 6r
ABSOR�I ON SYSTEM
o b 2 N20 L, G
SIDE AREA: ZX Z,ot;),i, r, 'K �� I� �� AAVID
B. c.
BOTTOM AREA: 7jej ?% ��� c MASON m .
I F77
SEPTI C SYSTEM SECT I ON
0
0 . /OPOFDNS
►� bF oQ, 1•=i fi �
D-
GAL w n d J, '7
SEPTIC TA �Zp ����� .� l�J �I �' •, c
It
SITE AND SEWAGE PLAN
L)�
LOCATION :
�< WALJ�J-ebi MIA
op �� PREPARED FOR : TI ftlnx:�_ w
!n ..
o - SCALE i
DAV I D B . MASON RS DATE: VZ
DBC ENV I RONMEN�AL DESIGNS
W DATE HEALTH AGENT
EAST SANDWICH . MA
W ( SOS ) 833- 2177