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HomeMy WebLinkAbout0180 MEGAN ROAD - Health .180 -Megan Road Hyannis F/R 291 262 i � I % J J �E f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General Information 3 0 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address s E. Falmouth MA 02536 City/Town State Zip Codt 508-495-0905 S13971 r= Telephone Number License Number ZI B. Certification q, I certify that I have personally inspected the sewage disposal system at this`address nd thatathe M. information reported below is true, accurate and complete as of the time of the inspe ion. The inspection was performed based on my training and experience in the proper function and maint nance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-27-09 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. L61 t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 .. I Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 -- every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or,not determined (Y, N, ND) in the ❑for the following statements. If"not determined,',please explain. F ❑ 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 t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 I Commonwealth of Massachusetts F Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 . every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ' ND Explain: ❑ The system required pumping more than 4 times a year due tolbroken 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 r ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. -1. System will pass unless Board of,Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, : safety and that ❑ 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 a Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level.in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑. ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/ day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the'SAS, cesspool or privy is below high ground water elevation. F ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is Hyannis MA 02601 4-25-09 required for H y ' every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis i and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure ❑ ®. criteria exist as described in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes"or"now to each of the following, in addition to the questions in Section D. Yes No - ❑ ., the system.is within 400 feet of a surface drinking water supply • ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply. ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form , " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 180 Megan Rd M Property Address American Home Mortgage Servicing ` Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health El ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 god x #of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (god)): Sump pump? ❑ Yes ® No Last date of occupancy: 12-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): 4 Grease trap present?.. a - r El Yes ❑ No Industrial waste holding tank present? t° ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No ""Water meter readings, if available: Last date of occupancy/use: Date 2 f Other(describe): t5insp official document-63108 4-- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 180 Megan Rd 5• Property Address American Home Mortgage Servicing Owner Owner's Name information is Hyannis MA 02601 4-25-09- required for H Y + every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information- Pumping Records: 'Source of information: N/A Wass stem pumped as art of the inspection? Yes No Y P P P P ❑ If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ' ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03M8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 180 Megan Rd Property Address American Home Mortgage Servicing - Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 7 , Depth below grade: 8 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet' Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 1" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal Sludge depth: 10" • „ Distance from top of sludge to bottom of outlet tee or baffle 22" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6 ' Distance from bottom of scum to bottom of outlet tee or baffle 16„ How were dimensions determined? Tape t5insp official document•031D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts " Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 180 Megan Rd Property Address American Home Mortgage Servicing ,Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' Comments on pumping recommendations inlet and outlet tee or baffle condition structural integrity, ( P P 9 , 9 Y, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. r. Grease Trap (locate on site-plan):' Depth below grader feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle M Date.of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete '❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts F Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is Hyannis MA 02601 4-25-09 required for y - every page. City/Town State - Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day' Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site plan): ` Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town. State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not�required): If SAS not located, explain why: Type: t ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ leaching galleries . number: ❑ leaching trenches, number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): - Leach chambers in good condition and empty at inspection: Stain line at 12" off bottom. t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) , Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 12 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Wluntaryy Assessments CG1,p , 180 Megan Rd Property Address American Home Mortgage Servicing " Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. g n G 3' 4 4 - -77 P' v A -► 7.3 ',6`r-96 t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 180 Megan Rd Property Address American Home Mortgage Servicing Owner Owner's Name information is required for Hyannis MA 02601 4-25-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no water at 12'. • t5insp,official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 16 TOWN OF AARNSTABL.E LOCp.nON ` 1kb A4e�rah �14e� SEWAGE # ,„ VILLAGE/ ✓� 4 ;, ASSESSOR'S MA.P&LOT- - i INSTALL.EWS NAME&PHONE NO. J$EMC TANK CAPACITY LI ACH NG EACILrff: ( ) C K>+.. -ei S (size) NO.OF•BEDROOMS. -3-- 13UILDER OR OWNER, P*0RMITDATIi;:,,__,_,,,,,._, CONMILIOICE DATE: Separation Distance Between tbe. Maximum Adjustul Groundwater Table to the Bottom of Leaching Facility Eeq Private plater Supply W'eR and Leaching Facility (If any wells exist an site or Within 2W feet of leaching facility) Fact Edge of Wedand and Leaching Facility(If any wetlands exist witiain 300 fs e leac4�i f�i � fee Furtaished by, O p y O G © IRZN � . n 1 ' W 6� ` v TOWN OF BARNS ABLE 6-C. LOCATION �A-%q A V SEWAGE # l� VII,LAGE �V�o A'Al /� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. J(6l�l/"JE0 SEPTIC TANK CAPACITY j 6 G--<✓ a a LEACHING FACILITY: (type) (size) _1 140.OF BEDROOMS E3UII,DER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching4Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by , t D; CPS . v 1/3 'TOWN OF BARNSTABLE �LOCAIIOI�' 180 10Ql a✓1 SEWAGE # VILLAGE 14!1*J AAIS ASSESSOR'S MAP& LOT o7°1 01�001 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY « GA 1 LEACHING FACILITY: (type) p.'r + 3 z.►1', ��a rbrs (size) S'rOASL NO.OF BEDROOMS 3 BUILDER OR OWNER —111erC5A PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility)- Feet Furnished by S_T_�n 3nccT�un 'S,Ford 51/9 001 ✓ iw, As,h t3a- 3q A3- 33 w - 33 33 O Alq- alo 1' y o 3 4 >, , I , t.' Ns. L "C L Fee$1 0 0.0 0 s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipptication for Ztgoar *p5tem Con.5truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 180 Megan Rd, Hyannis R. Fonseca Assessor's Map/Parce / � 21>. 180 Megan Rd, Hyannis Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco-Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich . Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder T10) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach system to plans of Eco—Tech. 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 Fed ions of Title 5 of the E ironmental ode and not to place the system in operation until a Certifi- cate of Compliance hasissued by this oar Health. SiA Date Application Approved b Date Application Disapproved for the following reasons Permit No.�'�.C�� -. vc-� Date Issued U Fee 1 O O.O O Entered in complier: THE COMMONWEALTH'OF MASSACHUSETTS — ` Yes PUBLIC HEALTH'DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZppYication for Mi5p0ar bpgtem Con5truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 180 Megan Rd, Hyannis R. Fonseca Assessor's Map/Parcel P 9 , Flo �0- 1 180 Megan Rd, Hyannis Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco-Tech PO Box 1089, Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3, Lot Size sq.ft. Garbage Grinder(no) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. plan..Date Number of sheets Revision Date Title . Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Install a new Title 5 leach system to plans of Eco Tech. 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 En ironmental Code and not to place the system in operation until a Certifi cate of Compliance has been issued by thi oar Id ealth. // Si tied lJ Date Application Approved by bateW Application Disapproved for the following reasons Permit No. C�G t—� 5 1 1 Date Issued CU Fonseca THE COMMONWEALTH OF MASSACHUSETTS .. BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired(X )Upgraded( ) Abandoned( )by Wm E Robinson Srt Septic Service at 180 Megan Road, Hyannis° has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ,)ud q'S dated 9/ 7/0LZ Installer Designer The issuance oil this pe l t shall not be construed as a guarantee that the sy tern ill, fiction a .€si neCd. Date -7 r Inspector Fonseca THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mqu al *p!5tem Construction Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 180 Megan Road, Hyannis 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: Constr ction^must be completed within three years of the date of` this perm.t. Date:_. 9 / /0 ,4 Approved b —� Town of Barnstable OFtHE r Regulatory Services v yP ti� Thomas F. Geiler, Director • BARNSTABLE, MASS. g Public Health Division 0390. `0 ArEo► ;�A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Desiener Certification Form Date: Designer: Eco-Tech Installer: Wm E Robinson Sr sPntic Address: 43 Triangle Circle Address: po Box 1089 Sandwich CentPrvillP 'On Wm E Robinson Sr Septic was issued a permit to install a (date) (installer) septic system at 180 Megan Road, Hyannis based on a design drawn by (address) Eco-Tech dated , (designer) y I certify that the septic system referenced. above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Z pAVtO (Insta r s ignature) GHp,NOWA �1093 0 (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form OWN OF BARNS ABLE LOCATION '. SEWAGE # VILLAGE_ 11VV N 11 Sr / ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. !fr-•4'C� ^I SEPTIC TANK.CAPACITY. •/�Gam✓ LEACHING FACILITY pe) ? - L (size) NO.OF BEDROOMS BUILDER OR OWNER I I'a A-. . PERMIT DATE: �"0�-'7"(5 9 COMPLIANCE DATE:. M Separation Distance Between the: Maximum Adjusted Groundwater Table Bottom of Leaching Facility Feet Private Water Supply Well and Leachin Facility (If any wells exist on site or within 200 feet of leachi facility) Feet Edge of Wetland and.Leaching Fac' ty(If any wetlands exist within 300 feet of leaching fa ' 'ty) Feet Furnished by l/ . j G Fi-�.°I ED INSPECTION 24 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION PARCEL - LOT . . .- _ TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 180 Megan Road P , Hyannis. MA 02601 Owner's Name: Franz Mattos Owner's Address: Date of Inspection: September 20, 2004 Name of Inspector: (Please Print) James M Ford j s Company Name: James M. Fordco t co Mailing Address: P.O. Box 49 to �; rn Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Need urther Evaluation by the Local Approving Authority ✓ Fail Inspector's Signature: Date: September 22, 2004 The system inspector shall subm' a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 180 Megan Road Hyannis, M4 Owner: Franz Mattos Date of Inspection: September 20, 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,1\D)in the for the following statements. If not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 180 Megan Road Hyannis, MA Owner: Franz Mattos Date of Inspection: September 20, 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 or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 180 Megan Road Hyannis, MA Owner: Franz Matlos Date of Inspection: September 20, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '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_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 180 Megan Road Hyannis, MA Owner: Franz Matzos Date of Inspection: September 20, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. - ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. I 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 180 Megan Road Hvannis, MA Owner: Franz Mattos Date of Inspection: September 20, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 550 Number of current residents: 6 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 6 months agoo-per 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 ✓ Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Infiltrators were added in June 1995 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 180 Megan Road _ Hyannis, MA Owner: Franz Mattos Date of Inspection: September 20, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 4" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal. Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: -- Scum thickness: Distance from top of scum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: -- How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Liquid was up to the cover and above both the inlet and outlet tees. 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: 180 Megan Road Hyannis, MA Owner: Franz Mattos Date of Inspection: September 20, 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: y-allons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -- 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.): The D-box was under water. 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 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 180 Megan Road Hyannis, MA Owner: Franz Mattos Date of Inspection: September 20, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000ga1.) leaching chambers,number: leaching galleries,number: ✓ leaching trenches,number, length: 3-infiltrators with 2'stone(per as built card) leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The leach field was under water and breaking out to the surface. The liquid was backing up into the septic tank The leach fields were in failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 180 Megan Road Hyannis MA Owner: Franz Mattos Date of Inspection: September 20 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 feet. Locate where public water supply enters the building. Q I I I a i a S —L3 O d y 3o ag 3 33 33 10 Page 1 I of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 180 Megan Road Hyannis, MA Owner: Franz Mattos Date of Inspection: September 20, 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 the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 25'+/-to kround water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 180 Megan Road Hyannis, MA 02601 Owner's Name: Theresa Lang Owner's Address: Same Date of Inspection: May 8, 2001 o Name of Inspector:(Please Print) James M. Ford ! ��, ll ® \ Company Name: ' James M. Ford Mailing Address: 'P.O.T Box-49 Map Osterville,MA 02655-0049 Parcel: 262 Telephone Number: (508)862-9400 Lot. 43 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditi nally Passes Need F her Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: May 9, 2001 The system inspector shall subm' 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_th6xdnnditions of use at that time.'-This inspection does.notaddress how the system will-perform in the future under the same or different conditions ofuse: x ,a - 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: 180 Megan Road Hyannis, MA Owner: Theresa Lang Date of Inspection: May 8, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: f i B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,u on coin lehon 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 followmg staternents. 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 of 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 of obstruct pip s e system will ass inspection if(with'a royal of the Board of Health): _............ ......._.__......_._.._._._ . .._ _.. p p pp .._..._. _. broken pipe(s)are replaced obstruction is removed ND explain: 2 I Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION (continued) Property Address: 180 Megan Road r Hyannis, MA Owner: Theresa Lang Date of Inspection: May 8, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water'Supplier;if'any)'determines that the � system is functioning in a manner that.protects the public health,safety and environment • : 1.�.,. .1.a. _.. .. .S ..... a....l :I.it ., J . �. ...... _�,. The system has a septic tank and soil absorption system(SAS)and the SAS is within 100'feet of a surface water supply or tributary to a.surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile.organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 t { w ' Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 180 Megan Road Hyannis, MA Owner: Theresa Lang _-__ -•_--. . .. _- . "_ :..: . .._. . ...-.... Date of Inspection: May 8, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/Z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged,or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ . Any portion of cesspool or privy is within 100 feet,of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool.or privy,is within a Zone 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.[This system passes if the well water analysis, performed at.a,DEP certified laboratory,for coliform bacteria and,volatile organic compounds indicates that the well is free from pollution from that facility and the presence.of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 180 Megan Road Hyannis. MA Owner: Theresa Lang Date of Inspection: May 8. 2001 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined.?(If they were not available note as.N/A) ✓ Was the'facility or dwelling:inspected`for'signs of`sewage backup ',Was'the site inspected for signs of Greak out? _.._..... "✓ ` Were all system components,excluding the SAS,located-on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 180 Megan Road Hyannis, MA Owner: Theresa Lang Date of Inspection: May 8, 2001 - FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or,no): No_:[if yes separate jnspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2000-128,250 gals.; 1999-123,750 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow,-(based 9n 31-0 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: Pumped on Jul. 1193,Aug. 23194 and Jun. 14195-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pump�i: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach.a copy'of the current operationand;maintenance contract,(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval + . r ''Other describe - , Approximate age of all components,date.installed(if known).and source of information: - Infiltrators were added on Jun. 14195 . Were sewage odors detected when arriving at the site(yes or no): No 6 I Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '.SYSTEM'INFORMATION (continued) Property Address: 180Me an Road ,.:...;,•. .'vi :...., z>. •, a, ._,, g Hyannis, MA Owner: Theresa Lang Date of Inspection: May 8, 2001 BUILDING SEWER(locate on site plan) Depth below grade: r Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line-- Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 4" Material of construction: ✓ concrete _metal _fiberglass__polyethylene""__ _other(explain)If tank is metal list age:-- -----..Is age confirmed.by_a_C.er.tificatc,ofCom'pliance.(yes or no):, (dtta&a copy,of certificate) Dimensions: 1000 rra1. Sludge depth: Distance from top of sludge to bottom,of outlet tee or-.baffle:. 30 Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): The tees were present The liquid level was even with the outlet invert. There were no signs ofleakage. Recommend pumping every three years 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 mtegrgy;,liquid=levels as related to outlet invert,evidence of leakage,etc.): .7 , r Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ , ;S,YST.EM-INFORMAT-I.ON (continued) Property Address: 180 Megan Road Hyannis. MA Owner: Theresa Lang _.. . _ . . .. ..: .. Date of Inspection: May 8, 2001 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): ...)• ..:Y-. __.....�) .. 1.. •x''.._.,._ ..,t t '.! F11'f .4..f). ..-5 .} .ail..� ..f 1,.1., ��i�� , DISTRIBUTION:BOX:, ✓. (if present must.be opened).(locate on site.plan) .-,. , f" ...Depth of liquid level above outlet-invert: " Even 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.): The D-box was level and there were no signs of leakage. 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.): i p 8 r Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO`RMATION (continued) Property Address: 180 Megan Road Hyannis. MA _..__..._.._...__...__. . _.._. .. : _w.._. Owner: Theresa Lang , Date of Inspection: May 8, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: e Type ✓ leaching pits,number: 6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: ✓ leaching trenches,number,length: 3-infiltrators with 2'stone(per as built) leaching fields,number,dimensions: overflow-cesspool,number:---- ......-.-Innovative/alternative stem------T a/name-oftechnolo Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The original pit had 1'ofwater on the bottom:''The scu»i'hne ivas'aiiprozimdtely S'up from ih"e bottom.`The bottom to grade was approximately 7' The infiltrators were added in 1995 and were not dug up. There were no signs of failure in the D-box. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan){ Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: - Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs'of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART C , ` ;:`SYSTEM.IN.FORMATION (continued) Property Address: 180 Megan Road } Hyannis, MA Owner: Theresa Lang Date of Inspection: May 8, 2001 Map:,291 Parcel: 262 Lot: 43 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �A y 0 AI- as 3 Aa- 30 ga- a0 A3- 33 83- 33 to 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a k PART C ' '' SYST'tM-`INFORMATI.ON (continued) Property Address: 180 Megan Road a Hyannis. MA Owner: Theresa Lang Date of Inspection: May 8 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: ' You must describe how you established the high ground water elevation: The bottom ofthe leach pit to grade was approximately 7'. Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing'approximately 25'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or implied, relating to the system,the inspection and/or this report. 11 TOWN OF BARNSTABLE •�3 OCATION /c SEWAGE # gam"yd29 VILLAGE 1A4Ar4V)5- ASSESSOR'S MAP &LOT—!! 9/—A .Z INSTALLER'S NAME&PHONE NO. 'N-lCX-ecc 62MT `77/ V/ZR SEPTIC TANK CAPACITY 1 006 LEACHING FACILITY: (type) bz'-V� (size) �Z-/ -S"'ZWL NO.OF BEDROOMS 3 BUILDER O�:- = ,+ PERMITDATE: COMPLIANCE DATE: 6//Y/9-r- Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 14k°�� Caur: 50- _ � X A�yy T�� �A V �� d�_ 4 �w k 'S d , t �� ! � W I�i f s _ � 7 fj y � � ti: j 1 ' ✓ p t L _ _. r .J _ jM �- �q I P ►le 1. 1 No.. .............. /FEz... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applira#ion for Disposal Works Toustrurtinn 1hrutit Application is hereby made for a Permit to Construct ( ) or Repair (� an Individual Sewage Disposal System at: -W.VA .................. 4 ! .......-----------------------------.....-----•-•---....•--------...•..--..•..---••...........--- Location-Address or Lot No. •--•^. ....... ....�!!!-�-------•----------------------...........--------- Owner a Address kFcewr `36 2 ? ......----- n-,�w� ----------------------- ...--------------....•• z......... , ' .__....••-•-.....-•-----••--•----•--•--•-._.._...._..... Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PL4Other—Type of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures -•---------------------------------------•---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width....................Total Length.................... Total leaching area-..-_---------------sq. ft. Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 4 Percolation Test Results Performed by......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•-•----••--•-----------------•-•-••-•-•-•--•-••--•-•-•-•---•-•--•-••-••..............-•••-••--••-•.......................................................... 0 Description of Soil...............................................................................----------------------------------------------------------------------------..........-- W U ••••-•-•---•---•-••-••--•-••-••-•--.....••---•••••-••-••---•----•••-•-•--•---•-•••-•--••••-----•---••....----••-••-•---••-•-•-••-••-----•-•--••---•-•---•-••-•••---•-•-•-•-•--•--•-•--•................. -------------------•-------------------•--------------------------------------------.... ---------------------------------------------------------------------------------------------------...._ U Nature of Repairs or Alterations—Answer when applicable..: ........#.'4 ........P'P!r.....'.�� �.__...�"...... - ---------------- --- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Cer ' 'cate of Compliance has been issued by the board of health. / Signed ... , "".... ..... ......... j.2 - Date Application Approved By . �� //�j d Date Application Disapproved for the following reasons- ................................... .......... ----------------- -------------------- .......... .. .. ...................".-"-"-"""---""----.....................................". .- ... "....Date..."....-...-..." Permit No. s...l"... sued - ... . rr -- -- ---------------------- to got f`J---------- U`) VFEB _ ..... { THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t TOWN OF BARNSTABLE Appliration for Dispooal Works C> onstrudion 1hruti# Application is hereby made for a Permit to Construct ( ) or Repair (3c:57) an Individual Sewage Disposal System at: 1�O M�G,PnJ �4�4�JlS ................-_..___...................................................................... ---•-•------...---••---------•---..._......••------•--•--••-----------.._...._..................-- e� L 1 � ,,,, L ovation-Address or Lot No. .................._l_"_................(.�_�.._.__.....----------_------------------7--�-------------L ---------- _--•----------------------•--•-••------------------- ._.......................... ----•- W "kC�t.k Cb, lJ-- - Owner e3g 2OS.hV=-1 �.�N1t� 'f.�4�piy$ .................. •------- Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms........................:..................Expansion Attic ( ) Garbage Grinder ( ) at n Other—Type Type of Building --- p ding ------------------ ------- No. of persons............................ Showers ( ) — Cafeteria ( ) at Other fixtures -------------------------------- . W Design Flow............................................gallons per person per day. Total daily flow.....................:......................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 04 Percolation Test Results Performed by.......................................................................... Date........................................ a 1_4 Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ fit Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P ---•------------------------------------•----------•----.....--•--------.........-•---------..•..---......................................................... 0 Description of Soil........................................................................................-.......................................................................... x ---------------------------------------------------------------------------------------•-••--------------------------------------------•----...-------------•---------------------------......_......... U Nature of Repair or Alteration—Answler when applicable ....._..'! ?fl_......�?�-_._.'..�k uoo ...h.... I-�A_Q �� -`-�......._... `=`-'-- -=Z- 5 TO Ki� --' (( .moo�, � ---�---- I-`-�-N%'r�._�_..... 4 s,Z 7 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental`Code—The undersigned further agrees not to place the \ system in operation until a Certificate of Compliance has been issued by the board of health. Signed ..--- --".. 1.....----- --------- --------------- ........... _ 7 vDa - ApplicationApproved By ----- -- -- .. J -- -----°-----------� -� ?Jr/1� _-.................. ........................................ Application Disapproved for the following reasons( --------- ---- ----- - at ��.... ' -- y�.... ........................................... .......-... .... Date Permit No. ....... - 7................. Issued -------------- /.....--/. .-.'.::------ to THE COMMONWEALTH OF MASSACHUSETTS I _ BOARD OF HEALTH TOWN OF BARNSTABLE (gextift ate of C antyliance I r THIS IS CERJ'IFY,-That the Individual Sewage Disposal System constructed ( ) or Repaired (� ) ltic�L:� 6) r by--------------------------------------- -...................................------------------------------------------------------ -------------------------------------------------------------------------------------------.................. (.8o . C-.kN 'Q'�_-- A44P�N ta ller at -------_-- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--......----------. .------------...---- has been installed in accordance with the provisions of TITLE 5 f The St at $ vi onmental Code as described in the application for Disposal Works Construction Permit No. .. ..".� dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTRUED �S A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ Inspector --------------t�..�` ................................................. .........��`""----��-: �--�4------------------------ ...-.... ----... ..-..- C� i]� I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No... ................. FEE-- `... Disposal Works Tona#rurtion f rrutit Permission is hereby granted.... «. .......-0`�� to Construct ( ) or Repair c( ) an Individual Sewage Dispo�tts�l�System at No....... ....._... Nr.Y .i. . Street as shown on the application for isposal Works Construction P it No . ............... ated........ o ......... _ r U� � t' Board of ealth DATE.................. FORM 38508 HOBBS&WARREN.INC..PUBLISHERS • i x_ HYANNIS• MA " 3 - ram* ` S s .< H ROAD 4 m� FAL `> r `- 0 49 �PLICIP ROP � e E 5/ LEGEND 174.35 EXISTING 52 \. 2 1000 GALLON o 0 52 - - LOT 43 r 1 SEPTIC TANK — — \ `k - 0) N w ��t ocvs m 1 AREA - 13652 s f 1 o N D-BOX TEST PIT ® ' LOCUS MAP TER LSE m ± �� f 1�P\. \ 48 WATER m--i 2 NOT TO SCALE � X . EXISTING > \ '� � p0 — EACH PIT m > m L � � `� o I71 _{ o // m ^� �'m C— o Z w � — �+ PLAN REFERENCE A_ o, rE DRAIN ® w w- Z ` G> � � LAND COURT PLAN 27099-B Z 1, ' !��' ASSESSOR'S MAP: 291 TREE ��`1'� + 11 I ` \ LOT: 262 -PJUMBEP. REFERS TO DIAMETER I , ' �;1 , 1� °\ 11 1 18-P „� � I +� , O NCI-ES. LETTER DENOTES TYPE 0-OAK M-MAPLE H-HGLLY CONTOURS \ — — — — — — . EXISTING — 50 \ 1,W MINIMAL GRADING PROPOSED 5tp BENCH MARK — so TOP OF DRAIN GRATERIVEWAY9 ELEVATION - 50.45D' D {iUSGS DATUM ASSUMED 00 55� �` 17 24ftx12.5ftx2ft LEACHING GALLERY kOF PLAN DAvro tiN D. COIJGHANOWR OW PROFILE sCALE: i In = 20 ft 4 1093 y FL 9 0 TOP OF FOUNDATION RAISE COVERS TO WITHIN '°N��A 1% 6 in OF FINAL GRADE - 53.35 +- - �J EL N INSPECTION CTION RISER FOR ONE S E LEACHING GALLERY , /WIN 200+ F I/ " 2 LAYER O 8 D-BOX I/ ''ST N 2 0 E E - 3- DROP FLOW LINE TEE SEWAGE DISPOSAL SYSTEM PLAN, 10 14 ;.'. ':.. :... -TO SERVE EXISTING DWELLING -.. PRECAST Sys ,�- 3i4'-I 1�4- 48 BAFFLE ( h'Y'N? +X �RYwELI ;,YYr .r JOSELITO 'ABRANTES STONE p ry `, , 6 in A SoLTABSORPTION 180 .MEGAN .ROAD "HYANNISMA m "� Exlsrric, BA�EE 46.13 LEf�CHING_ _ SYSTEM - ExISTING - _ _ . - - , _ .. _ a : EN+TP;: L -� R 4 s 46.30 GALLERY.',,- y ECO TECH ENIRONM r < XI TING i _. . - > ,.. E S _ 5.00 r, 43 TRIANGLE CIRCLE 'SANDWICH MA 0256' E XISTING ,[� N Vf C _ •:�," ... aw. e- ..J:➢'I•. an„rua. r— • '.fY'.O' ,w' �. 000 , ..� .£ �, .a.. f .. ..�-&,. _W .. -.�, 'a,-.�. •r1 . '. ,.. ,.,.. . 4`. L A N ._. 8 9 4 ,. a;. EXISTING ... . .�,_ 43.5 f ::. PTI -TANK SE C �n _ 12 : ) 14f � S T "18 I T 0 :x.� NALADJUSTED�HIGH PLAN IS TO ;A DRAF .. ,., Aso - BE.CONSIDERED .;�.: :•\ �.7 r - C a.. . `33 70 M _.... a,e.;:> .t. ,.: ..dik.., �. >.a-t.r....:, *x .._..,.. +(":^.� ,. r•,..-., ,,., .x c :.te. ;,,_..s, 7 Y a wAT R- � r�. �� DESIGN ENGNEER O - � S�TFE`STAhP-A xOF��THE� "a� .r,. ?''. ...,�.... ..s+ A. .• ..d .. ,. y. �' ,. r. � ,�-•r:. t;� y,.„r.';;:•.t�. < ,"t y..k..GR. D E :$.� '.,.c• '.--� > SIGNATUR TIE'BoARD 0 GNAL"PLANS NTENDED.;;FOR SUBMITTAL. TO,. ¢, . _ E,S STAMPED3N:RED. r.,. U� ,.. _ . cu ) OF HEALTH WILL"B IGPIED�N BLUE'AND re. -_ ,. zi` .. .: .., .: .s:'. ,.; -. - ,-.:f4.. r...�...: •-_..:..�- : ..: .•a..r:. Y -' is .. .. �1'.+. .4�-. ,'�,,,.—ti �K-c4 rt e ` - SOIL TEST �L`OG :� DESIGN CALCULATIONS . - DATE OF TEST: SEPTEMBER 21. 2004 - SOIL EVALUATOR: DAVID . D. COUGHANOWR. RS >- WITNESS REQUIREMENT WAIVED - NO .VARIANCES _SOUGHT, - DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD = -NO GROUNDWATER ENCOUNTERED TEST PIT I PARENT MATERIAL: PROGLACIAL OUTWASH SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS PERC AT 58 in 2 MIN/INCH IN C SOILS ELEVATION - 49.2 USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING DISTRIBUTION BOX: USE 3 OUTLET D-BOX, 0-6 Ap LOAMY SAND 10 YR 3/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 f t x 2 ft LEACHING GALLERY CAN LEACH Abot - ( 24 x 12.5 ) - 300 sf 6-36 B LOAMY SAND 10 YR 4/4 NONE FRIABLE A s d w - ( 24 { 2 4 12,5 { 12.5 ) x 2 - 146 sf Atot - 446 sf 36-120 C MEDIUM SAND 10 YR 46/3 NONE LOOSE. 15`i STONES Vt 0.74 x 446 - 330.04 GPD USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED GROUNDWATER ADJUSTMENT LEACHING GALLERY EXISTING GROUNDWATER LEVEL BASED ON BARNSTABLE GIS DEPARTMENT RECORDS CONSTRUCTION DETAIL INDICATED GW: 28.0 DRYWELL UNIT INDEX WELL: AIW-230 STONE ZONE: D 8'-6"x 4'-10'x 2'-9" READING: AUG 2004 2 fi. EFF. DEPTH LEVEL: 24.8 24.0 ft ADJUSTMENT: 5.7 ft \ c ADJUSTED GW: 33.7 NOTES � f Ln u� N N _ 1) GARBAGE GRINDER NOT ALLOWED WITH. THIS DESIGN M 2) ALL LINES TO BE SCH 40 PVC .AND. PITCH AT 1/8 INCH PER FOOT MINIMUM. _ 3.5 8.5 8 A' 3) ALL COMPONENTS INS.TUCED SHALL MEET THE MINIMUM REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 24.0 fr NOT ro _ SCALE 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. 5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 6) ALL STONE TO BE- DOUBLE WASHED AND FREE .-OF IRON. FINES AND DUST IN PLACE -° 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN ` 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF--LOW FLOW_--FIXTURES SEWAGE DISPOSAL SYSTEM .PLAN # . } AND APPLIANCES AND -BIANNUAL PUMPING :OF THE SEPTIC. TANK _ WE G TO SERVE EXISTING D LLIN :�.. 9) SYSTEM . IS NOT DESIGNED _TO -WITHSTAND •VEHICULAR` LOADING. DO..NOT PARK .OR DRIVE `,VEHICLES" .OVER.;SEPTIC „SYSTEM - aaE : x _ � _ - JOSEL-ITO _ ABRANTES 10) INSTALLER TO' OBTAIN -DISPOSAL WORKS _PERMIT BEFORE STARTING WORK. I80 AN ROA YANNISMA .. 11) .SEPTIC TANKS :.SHALL_ BE,'INSTALLED, LEVEL AND:;TRUE :TO GRADE ON fR"- LEVEL - -STABLE-'BASE THAT,,.HAS BEEN=-„MECHANICALLY`COMPACTED AND,: ON';TO ':•WHICH; SIX INCHES OF CRUSHED STONE HAS BEEN-PL`ACE6"17 MINIMIZE "UNEVEN SETTLING '`.. ,- , ��H NV RONMENTAL E -> SYST M REPAIR AND CHECKED, 12J S PTIC.xTANK ..T..O.,.BE PUMPED -.DRY_AT ;TIME =OF., . ,E . _ � -�s �t� �» .: _- E Y� r:: - Y�.;:. w.; , HMA-0256344 -. FOR STRUCTURAL�rINTEGRIT�Y _INSTALLPVC :OUTLET= TEE• FITTED.WITH ,G.AS,$AFFLE. 43 .TRIAN > _ < t... a... : '.w:."w _ i.:. ..w .,..:._�_ - .ty. • u. �• ,. PT tip. ... fit.< ••�,.�-3;�'�.� �-..+, 2 n a� x /2 3 2 66412 - T 1801 SE �- _ q