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HomeMy WebLinkAbout0317 MEGAN ROAD - Health 3 17 Megan Road / Hyannis A = 291 255,1 i YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for,4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you . must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this format 200 Main`St., Hyannis:, Take the completed form to the Town Clerk's Office, 1 st Fl., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: I� f Fill in please: ~ APPLICANT'S YOUR NAME/S: Z�D.A)A -e S' _V A SS YOUR HOME ADDRESS: S ' 0` 3 009 TELEPHONE # Home Telephone Number NAME OF CORPORATION: C-2 AAJ- NAME OF NEW BUSINESS v TYPE OF BUSINESS C eA✓Vi-n IS THIS A HOME OCCUPATION? YES NO 0 ADDRESS OF BUSINESS 1 /V�5 MAP/PARCEL NUMBER a l [Assessing] When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. MUST COMPLY WITH HOME OCCUPATION 1. BUILDING COMMISSIONER ISX0FFI E , RULES AND REGULATIONS• -FAILURE TO This individual has been ' f any r t requirements that pertain to this type of business. COMPLY MAY RE$QLT IN FINES. Aut orized Si re* COMMENTS: 0 2. BOARD OF HIJALTH This individual informed o the permit requirements that pertain to this type of business. MUST COMPLY WITH ALL HAZARDOUS MATERIALS REGULATIONS Authorize Signature** COMMENTS: i ten)- 2Ss 2S f 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: •- Date: I I TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: -` �S CLe A i BUSINESS LOCATION: ' fW ` OC R - f✓/V.` INVENTORY MAILING ADDRESS: N `S TOTAL AMOUNT: TELEPHONE NUMBER: SZK- 0210- MS CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: CLe INFORMATION / RECOMMENDATI S: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with"poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes �21 c6/ofax Laundry soil &stain removers (including bleach) 1 Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Appl ant' Signat re Staff's Initials 41 :F Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information ` When filling out forms on the computer,use 1. Inspector: `+ only the tab key d to move your Patrick M. O'Connell — cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. f Company Name .p 189 Cammett Road Company Address MA 02648 Marstons Mills — renm City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Ev ation by the Local Approving Authority I Ckq —�.. January 20, 2010 In ector'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. Title 5 Official Inspection Forms Subsurface Sewage Disposal System•Page 1 of 15 10-09 Kenniston.doc•08106 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Cerny 317 Megan Road - — Property Address Deana Kenniston — Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for 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: ® 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: Tank is not in need of pumping at this time, leaching system had no standing water or evidence of surcharge. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: D 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 i ❑ obstruction is removed 10-09 Kenniston.cloc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road — Property Address Deana Kenniston — Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 — required for y State Zip Code Date of Inspection every page. City/Town 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 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: 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 heallth, 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. 10-09 Kennislon.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page:3 of 15 r Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for y every page. Cityrrown 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_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. 10-09 Kenniston.doc•08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road — Property Address Deana Kenniston _ Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for y rY — every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence! of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 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"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection 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. 10-09 Kennislon.doc-08106 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 M 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is required for y H annis MA 02601 January ,20 2010 - every page. Cityrrown 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 ❑ ® 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)] 10-09 Kenniston.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 0 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for y y 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 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 99,000 gal. _ 9 ( Y 9 (gpd)),. 136 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 10-09 Kenniston.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is required for y H annis MA 02601 January 20, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None available Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? — Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: Leaching system installed: 1/22/02 Were sewage odors detected when arriving at the site? ❑ Yes ® No 10-09 Kenniston.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 I Commonwealth of Massachusetts I Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for y y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 1 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.): Septic Tank(locate on site plan): - Depth below grade: 2 — 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) El ❑ N -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 27 — Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 — Distance from bottom of scum to bottom of outlet tee or baffle 12 — How were dimensions determined? Measured — 10-09 Kenniston.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for Y Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in need of pumping at this time, Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Scum thickness — Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 10-09 Kenniston.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for Y 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 11 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.): Observed a small amount of solids carryover, liquid level was at bottom of outlet pipe with no high — f stains. r Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-09 Kennislon.doc•08/06 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 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for y ry every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: — ® leaching chambers number: 4 Infiltrators ❑ 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.): Interior of infiltrators were video inspected no standing water or evidence of surcharge was found. _ 10-09 Kenniston.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is required for y H annis MA 02601 January 20, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 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.): 10-09 Kenniston.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts . . Title ���� OfficialOfficial I'nspectionForm orNNN Subsurface Sewage Disposal System Fmnn ' Not for Voluntary Assessments 37 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 03801 January 3U 3O1D required for - S��-- Zip Code Date n,mopou/on every page. ,..'..,_, D. System Information (cont.) Sketch Of Sewage Oiopon*8 System: Provide a sketch of the sewage disposa| oynhom including ties bomd least two permanent reference landmarks or benchmarks. Locate all wells within 100hnm Locate where public water supply enters the building. MOW A"Foad 35 35 ' ' / I Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 317 Megan Road Property Address Deana Kenniston Owner Owner's Name information is Hyannis MA 02601 January 20, 2010 required for y Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 15+ 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: Elevation of pond at opposite side of abutting property is considerably lower than SAS. _ 10-09 Kenniston.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Y * COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS t DEPARTMENT OF ENVIRONMENTAL PROTECTION Se TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION _ Property Address: 317 MEGAN RD HYANNIS Owners Name: PACHECO Owner's Address: ems, Date of Inspection: 10/23/06 Name of Inspector: (please print) Douglas A.Brown < ! Company Name: Douglas A.Brown Septic Inspections - Mailing Address:P.O Box 145 Centerville,MA 02632 Telephone Number: 508-420-4534 ` ~' C r.a rn 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature, 123/06 The system inspector shall submi 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 SYSTEM MEETS MINIMUM PASSING REQUMMENTS AT THIS TIME ****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 Revised on 10/31/2060 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: PACHECO Owner's Address: Date of Inspection: 10/23/06 inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: HOUSE HAS BEEN VACANT SINCE JANUARY 06 WHAN I LAST INSPECTED THE SYSTEM. B. System Conditionally Passes: one or more system components as described in the"Conditional Pase'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 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 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 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: PACHECO Owner's Address: Date of Inspection: 10/23/06 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 15.3030)(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: r Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: PACHECO Owner's Address: Date of Inspection: 10/23/06 D. System Failure Criteria applicable to all systems: You must indicate"yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes" or no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 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 y8§'m 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 317 MEGAN RD HYANNIS Owner: PACHECO Date of Inspection: 10/23/06 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks ? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection-? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding,the SAS,located on site? X _ 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? _ X 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 X _ 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 s Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 317 MEGAN RD HYANNIS Owner's Name: PACHECO Owner's Address: Date of Inspection. 10/23/06 FLOW CONDITIONS . RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NA Seasonal use: (yes or no): NO 0tl- 01bv Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: 1/06 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): _ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): _ If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _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: INSTALLED 122 02 ELLIS BROS Were sewage odors detected when arriving at the site (yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: PACHECO Owner's Address: Date of Inspection: 10/23/06 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: 0" Material of construction: X 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 gal Sludge depth: TRACE Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: TRACE 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- TANK LOOKS STRUCTUALLY SOUND AT THIS TIME GREASE TRAP:_(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.): Page 8 of 11 Y OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: PACHECO Owner's Address: Date of Inspection: 10/23/06 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): 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: X (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.): PUMP CHAMBER: (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 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: PACHECO Owner's Address: Date of Inspection: 10/23/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: ACCORDING TO AS BUILT FOUR INFILTRATORS NO OBSERVATION PORT INSTALLED SO I WAS UNABLE TO LOOK INSIDE Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: X 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.): 4 HIGH CAP INFILTRATORS 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 or 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.): Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �AMEEGAN RD Owner's Name: PACHECO Owner's Address: Date of Inspection: 10/23/06 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. �3D-3S r -�-I�( -b F- C, r, Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ) INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: PACHECO Owner's Address: Date of Inspection: 10/23/06 SITE EXAM Slope: Surface water: Check cellar: Shallow wells r Estimated depth to ground waterer 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: s 1-��►�� rr�i 200 k — 76 `� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE'QF ENVIRONMENTAL AFFAIRS Y jl w DEPARTMENT OF ENVIRONMENTAL PROTECTION A� t i• TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 317 MEGAN RD HYANNIS Owners Name: SOUZA Owner's Address: k Date of Inspection: 1/5/06 f r Name of Inspector: (please print) Douglas A.Brown >* Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.0 Box 145 , 'eMn. C-- Centerville,MA 02632 Telephone Number: 508-420-4534 �, C M CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and tha the inf& Iatio�jeported below is true,accurate and complete as of the time of the inspection. The inspection was p rformed(b5hsed on my training and experience in the proper function and maintenance of on site sewage disposal systems'"I'am DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). T e system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatur . Date: 1/5/06 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving, authority. Notes and Comments SYSTEM MEETS MINIMUM PASSING REQUIRMENTS AT THIS TIlylE ****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 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection: 1/5/06 inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 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 Pase'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 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 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 o ' Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection: 1/5/06 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: Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection: 1/5/06 D.System Failure Criteria applicable to all systems: You must indicate"yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surfacematers due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed 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 3 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes" or no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 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 yeVin 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 317 MEGAN RD HYANNIS Owner: SOUZA Date of Inspection: 1/5/06 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks ? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding,the SAS,located on site? X of _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ X 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 X _ 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: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection. 1/5/06 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN How based on 3 10 M 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: A�zT Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NA Seasonal use: (yes or no): NO 4 4— 10 0 7 3 G P D Water meter readings,if available(last 2 years usage(gpd)): , w— 'q3. 11 G� Sump pump(yes or no):— Last date of occupancy: 06 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) 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: INSTALLED 122 02 ELLIS BROS Were sewage odors detected when arriving at the site (yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection: 1/5/06 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: 0° Material of construction: X 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 gal Sludge depth: TRACE Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: TRACE 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- TANK LOOKS STRUCTUALLY SOUND AT THIS TIME GREASE TRAP:_(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.): Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection: 1/5/06 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): 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: X (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.): PUMP CHAMBER: (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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection: 1/5/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: ACCORDING TO AS BUILT FOUR INFILTRATORS NO OBSERVATION PORT INSTALLED SO I WAS UNABLE TO LOOK INSIDE Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: X 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.): 4 HIGH CAP INFILTRATORS 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 or 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.): • Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection: 1/5/06 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. 4 Ac A �� 35' h 3c A - 30 0 L a 'BD- F [ _ 0 Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 317 MEGAN RD HYANNIS Owner's Name: SOUZA Owner's Address: Date of Inspection: 1/5/06 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: TOWN OF BARNSTABLE LOCATION I 1 � c.� S��-# VILLAGE l/ i S ASSESSOR'S MAP&PARCEL IN8+A+&V46S NAME&PHONE NO. SEPTIC TANK CAPACITY 1(0O LEACHING FACILITY:(type) r'Iirtoi S (size) NO.OF BEDROOMS OWNERY-0-A &IOn PERMIT 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 leachin i ) Feet FURNISHED BY • J ! ! f r / ! f f f f r f f ! ! f ff F i f f 'r:r.:z f . -'f,/,ii f ! F ! f f rJ•i f f i f�J f F f ! ' 4 \ \ \ k t t \ \ ♦ 4, \ 4 4 , \ \ ♦ \ \ 4 ♦ \' 4 4 4 t ! r / J ! ! / J ! r r r ! r r ! f i.J ! r J • \ 4 4 \ \ t \ 4 t \ 4 t t \'4 4 \ ♦ 4 \ \ 4 33 2 orb . .. r 35 35 TOWN OF BARNSTABLE CC 317 r� , / / :3Cik'i C N ��1 �G°l �•1 SEWAGE #a ocl '7tv-3 VAGE 9 n n 1-5 1n ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.. r 111S &'071'PrJ Cch SJ"• Cd {SEPTIC TANK CAPACITY 1 d 0 O Gi4-6Lo+m T rLeCllu'l' 3 (09 LEACHING FACILITY: (type) _ I/J C>t-P -7- l A IV.- (size) bw 30 K Z NO.OF BEDROOMS3 3 W0 vtocnl"DeSi.L-✓t 00 BUILDER OR OWNER PERMITDATE: I a`15 OI COMPLIANCE DATE: . Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility b f 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) IV IA Feet . �IFurnished by er-N*n�%-LA—( k_ I "ML c C4 WK � O s � . i i G ' No. ���` ! �V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS s 01pplication for �Dizpogar bpztem Cow5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel � mqp aqp err *1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size a� sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S%--e So i i l-o Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of Xe Enviro ental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued t ' oard of th. Signed Date70 �df Application Approved Date Application Disapproved for the follo g reasons Permit No. i-10`1-- Date Issued 1__1 _�o d w^^� r. .. ..",N y � s q, r �i I' r•< n - lrtiiw+ - ^. - . . -- ... L"�4. :..,"�'Y°� .�a, ."tn.,-._.,.•�,. n t , ^f"e.vAr r....ix,...�4.r •1,«.r.1'.,,,Ji.t....�,,,.'ia,.'7.-,r+"- No. Fee 4 02-71 i Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4 0 01pplication for Migooar bp$tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. J 3 —� cI,� /1c y rrj Owner's Name,Address and Tel.No. r 7 l�1 Assessor's Map/Parcel f '+ , off` �,'(�1 aSf w� � (6-(H ,- Installer's Name,Address,and Tel.No. 1D\e�signer's Name,Address and Tel.No. V Type of Building: Dwelling No.of Bedrooms Lot Size�sq.ft. Garbage Grinder(A � 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 .P'° S c L c Nature of Repairs or Alterations(Answer when applicable) s S Y,o . C ��✓t Date last inspected: iM 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 a Enviro ental Code and not to place the system in operation until a-Certifi- cate of Compliance has been issued by th• oard of th. _ Signed Date Application Approved b _ Date Application Disapproved for the following reasons - Permit No. f as Z," Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comptiance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at 3 t-2 L-) -r �ci n 0 c ci d �� i ,�.� ; ( has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Perm 04'/i�dated`.W 4F` Installer I- f i l�i t,, r 1 C, C Designer j.)r C k,,n Clj „ ?- 1 r;f r> ( _ / The issuancq of this permit shall not be construed as a guarantee that the systemwill junction as designed. Date z z Inspector ----�%—l— e--------------------------------- No. ��e es '"" / Fee 6�51 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wi5po5ar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at t `? M -e t �n 1 c -1 c'f, 11 ,, rj i ( M j v _ 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 Mowing local provisions or special conditions. Provided:Construction"must be completed within three years of the date of t A ermit. '" 61/Date: Approve y� i u w `7 I TOWN OF BAR^N,STABLEL. LOCATION '3 J�I ��� �/ SEWAGE #a Oar --7t-3 i VILLAGE `� ? w) n 1-5 ASSESSOR'S MAP & LOT-2-1 1 ,2 SJ INSTALLER'S NAME&PHONE NO. r l 1s bC07;-aCS CCh SO" Ca SEPTIC TANK CAPACITY O C1n-11,0'm -P1LCC'W 3 LEACHING FACILITY: (type) 4 //C-erp NO.OF BEDROOMS-1 PO BUILDER OR OWNER —T7Ave d �- - PERMITDATE: .l a`15 0�_COMPLIANCE DATE: 2a Separation Distance Between the: iMaximum Adjusted Groundwater Table and Bottom of Leaching Facility 6'S t. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) I A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) IV IA Feet Furnished by<-- ntaay fi 44 Pyj U ,. T �10 CATION 3 SEWAGE PERMIT NO. t-: ►�� 4 A-�� LLAGE INSTA LLER'S NAME i ADDRESS ( .. Y o# ) l)P v 9 S^7 IV�1Ah41 S BUILDER OR OWNER DATE PERMIT ISSUED '— 77 DAT E COMPLIANCE ISSUED _ 7 r° s _ II � � , � � � o � s w � _ -� �' c ��.`" � '�' x c L' . I� t <;.� �,� �� __ _�� No..:........f...y .. Fps.. ......................... t THE COMMONWEALTH OF MASSACHUSETTSj BOAR® OF HEALTH t' B - .._Town..................oF.............. arnstab7;� . ...........------...................................................... A;tVfiration for Uhipulial Works C om4rurtion ami# Application is hereby made for a Permit to Construct (X) or Riapair ( ) an Individual Sewage Disposal System at: ................--..................QZ n-..Road----•-•--•••--•-•-------...... ...........................Let..9---.....•--•••-------•--•--•----•--•--......------........ LocCr2A; Address Io/-�N�o./ ............................... aca�.-_ .L...... �Cp.................... .......... ----��Z....Y �y/er Address ..................... . Installer Address 13 5 9 d Type of Building Size Lot_.__._....2.................Sq. feet Dwelling—No. of Bedrooms..........................................Expansion Attic ( ) Garbage Grinder (n,) �'4 of,'Building _____-- No. of ersons____________________________ Showers Other—Type .,,Bildi g ------------•-----.._ F ( ) — Cafeteria ( ) P4Other fixtures -----------------------•--...------------•-•---------..•....-----------•---------------------.....-----------------------------••-•-----•-----•---••-- Design Flow................55......................gallons per person er�iay. Total d ily ow..........33�....................... _ W Septic Tank—Liquid capacity1000 gallons Length_...t b... Width_...10.. Diameter-----._.._____. Depth Q... Disposal Trench—No.................... Width................._ Total Length........ _ ^;Total leaching area... . _ .. sq. ft. Seepage Pit No.....1............. Diameter....0. -------- Depth below in l _..___ _ Tot leaching area.Z6 ........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) d Percolation Test Results Performed by.CaPP_.__Gad---Silo' Tay--Z10-nault'agtPate-__---/2-317-9--•---.•------. Test Pit No. 1........2......minutes per inch Depth of Test Pit___-_-2.1....... Depth to ground water....... pn49..._._ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................. a ..........-................................................................................................................................... �S>i.OF Mq O Description of Soil..p.rIIm.,.-0---J.eam_&--- uhsadl-,--1,0- 2,0---mad-,-brown---&a-nd---w -``�--.--_-- ss9oy �4 . ___REN.. N c.� oab. •��� B. -- ---------------------------•----------------•-------_-_-----------•--•-----.--------------------------------•----•---------•-----------•----------------•- v �'1(APMAN �a U Nature of Repairs or Alterations—Answer when applicable..................... .. ........�--- - ...__.________........ A te.-g7654vp .. -•-•------••••-•-••••••••---•----••••-------•--------•-•---•-••-------•-•••-•------------------•-••............------ •--•-•- ----- -----------------•- -.-•- Off. "QJ-STE � Agreement: lONALENG\ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordanc the provisions of TITT.; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. c� Signe ••.. ••. •.•--............................................................ -•••�..4.2 ..7_./_. Da e Application Approved By.......... i . •.... ... ...... ! --�----------------- --- Application � ,�- �7 Gj Date Disapproved for the following reasons---------------------------------•-•--••-•-.--•-•-......--••---•••-•-------------------------------....------ .......................................----------------------...------......----------•--•--------------•••-••••-•-••-••-•-•-----•----•••-•---••--------•-••---••-••---•--•-••--------•••••-•---_..... Date Permit No......................................................... Issued--- . :::�Z�.............. Da ,J No.•---•• .l Y. Fizz ...mod.................. xw. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH t` _._........'Town.................OF..............Barnst aba l0------------------------................... Appliration for Disposal Works Tonstrurtion pamit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: .............. -- ...... an load.--•--•-•--•--••....---••••... ....................................--•--------_...Lot-•-9-••---•-----•-•••-•••----•----•-...._..........--•--•----- Location-Address or Lot No. r}"' r"F, 7 r n x_....rr 7 , ("!f ne .4�,j G........................--..... ` f`.... .... Owner " Address (� Installer Address dType of Building Size Lot._J)_i'59Q-------Sq. feet U 1Dwelling—No. of Bedrooms............. _....Expansion Attic ( ) Garbage Grinder (nOj '4 Other—Type of Building No. of persons............................ Showers Cafeteria PaOther fixtures ------------------------•-----------------------------'-----------------------------------------------------------------------......-•.......---•--... d W Design Flow................5 'j�d© gallons per person g Tr nay. Total dT yflflow.. gallons. WSeptic Tank—Liquid capacity_"r_---:--••. allons Length.__.t......_..... Width......._._... Diameter________________ Depth....__.......... Disposal Trench—No. .................... Width_.................. Total Length.....___ _ Total leaching area--- _ ...... sq. ft. Z Other Distribution box ) Dosing tank ( ) d /; f' t- `" Percolation Test Results Performed byC&pe..Zod---Sur.V4y_..Cojjj;Ujtantd)ate.....]�/2 /.79.............. a Test Pit No. 1.......a......mmutes per inch Depth of Test Pit-----12_r....... Depth to ground water......AQne._.__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------- G4 -------- •--•• ----- --- •----.. ................................ iili.9F_nasV D Description of Soil.Q.0"I.0...loam-.&--3uh ,1 r .E�-� r0 >1 ,� 8 o ...s and-- . •----•---• 9�ti RENWICK G ---------------�Obh3e .. B: W � . x -------------------------------- - a • c� 1-TAFIVI AN cn U Nature of Repairs or Alterations—Answer when applicable_______________ ___ ........ ... ....................._. ..A.,�_}yo-._ _•-•---••--••---•------•-•-••----•-------------------•----•--•-•-••-•-----•--•-----------.........._......•......... --- ........... •:----- ..................... POFFOr�S,� Agreement: Z���` �SS�ONAL ENG\ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in actor the provisions of TITi E 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. f _.::- -•. :r Date Application Approved B ............:... ;*° f.S` _. PP PP Yti - ,� Date Application Disapproved for the following reasons; ------------------••--•----------------- l .w .. ....................................................................... �.------------------------ Date Permit No... - Issued ._ -----------•------•.._. Issued------------------- --- - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ .. ............OF...................g6_4 .. ........... ............................. Trrtifiratr of Tomplianrr THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) t Installer f r }g has been installed in accordance with the provisions of T T ra 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..'� ......4+ da.ted_.3.__/J_.._ 7rf____________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. . DATE...............••-•---•-•---.........------------.......---•-•-•--••---..._-----• Inspector.............................. t THE COMMONWEALTH OF MASSACHUSETTS 1' BOARD OF HEALTH " i . . .. ...........0F. q r�... ,, NO............ .' y ...... FEE.2J. . ...... Disposal Works Tonstrnrtion rrmit Permission is hereby granted----------'r- r ( _ i. •-•---------------•-----------------------•-•--------------------------•----------:....--•-•.. _. to Construct ()( ) or Repair ( ) an Individual Sewage Disposal System !` ................. r. Street as shown on the application for Disposal Works Construction Pe t No..l:_ .... . .......•. ........... ................... a oar d of Health DATE " �.. r ..........................----------- -5`�` FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ' TOP FNDN, AT EL. 36.6` SYSTEM PROFILE TEST �-IQLE LOGS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) - ACCESS COVER (WATERTIGHT) TO F.NGINEER:_ AH OJALA, PE /--ACCISS MINIMUM .75' OF COVER OVER PRECAST / WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM D/ STANTON 34.0 WITNESS 2' DOUBLE WASHED PEASTONP,; NOVEMBEF' 6, 2.001 I %. ELEV. 33.6' RUN PIPE LEVEL DATE, z x t FOR FIRST 2' 31.0' 2 MIN/INCH 1 JWE PERC, RATE EXISTING ooa GALLON SEPTIC 32.2't I 10099 C 30.5 -- -- _ - �, 2' @ SIDES CLASS � SOILS P# TANK <H-- 10 > GAS ` MITCFBAFFLE 14� 30.6 4 c, (ADD) 0.77 �, - S; CONNEMARA > 6' CRUSHED STONE OR MECHANICAL 14` COMPACTION. (15.221 123) MIN >`c� o�`t'a c '. 28.5- O ✓ E )LEV `"�~ locus DEPTH OF FLOW = 4.-.....-.--.. MIN 1 ..� 34 ' TEE SIZES % SLOPE) ( % SLOPE) 3/4' TO 1 1/2' DOUBLE WASH'-,"D STONE INLET DEPTH 10'l 6„ FILL h OUTLET DEPTH 14 16.5' B. LOCATION MAP NTS FOUNDATION--- EXIST. LEA THING} 5 l�S SEPTIC TANK 17 - D BOX 3 FAC III rY 1 ASSESSORS MAP 291 PARCEL 255 Z2„ 1 pYR 5/6 Cl F 22.0' 2.5Y 6/3 (? 31.5 34y3 BENCH MARK - CTR. OF C.BASIN C<". ELEV. = 32.6 (ASSMD G.I.S•) pe,C34 Ix M/F SAND 'k333.7 10YR 5/6 \ + 32.9 -144" 22.0` _ 1 , LOT 9 \ NO WATER ENCOUNTERED � NOTES: � -13,591 f SO. FT. \ .7 0.31 f ACRES S+�'PTIC DESIGN. A BF.GF DISPOSER IS d 1 l., W ) 1 J)Aj,UM IS APPROXIMATED FROM QUAD G _ S 1'GN FL❑ J a - -- --- pp DESIGN ? B D ' 1C1M a ( L U j� b') �w,� GP I_. -- _ 3 s M U NTCj P A L W��� I f= i 34.9 � USE A 330 GPD DESIGN FLOW __.. �\ 3. MINIMUM PIPE PITCH TO BE 1/8' PER FOOT. / _ TANK: 330 GPD C ) = 660 4, DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H-10 -+ 34•i SEPTIC T :��....W 5, PIPE ,JOINTS TO BE MADE WATERTIGHT. USE A 1000 GALLON SEPTIC TANK (UX'ST) 36.6 6, CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.34•6 LEACHING: ENVIRONMENTAL CODE TITLE V, �. \ '~� W SIRES; 2(30 + 9.83) 2 (.74) = 117�9 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT Extsr. DWELL. �� �` 30 x 9.83 74 > ICI BE USED FOR ANY EITHER PURPOSE, TH �o "1- 32.7 BOTTOM: (') = 218. _ � r -- B, PIPE FOR SEPTIC SYSTEM TO SCH, 40-4 PVC. + 34. 33'3 TOTAL: 454 S.F. 336.1 I5PD 9. COMPONENTS NOT TO BE BACKF 1-LED OR CONCEALED WITHOUT S INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED •`-� .�. �`� 3 . 33.a 3 USE (4) HIGH CAPACITY INFILTRATORS WITH 3.5 STONE �:i�(.�M BOARD OF HEALTH, 34. 33.6 AT SIDES, 2.5' AT ENDS AND 14" UNDER 33.E pF`, 3 / - .Y. 10, PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING LEACH PIT <\ A�'p 32.9 SHED / ti 33.3 _� l> ND �` �' + 100.0 TITLE 5 S11L PLAN- PROPOSED SPOT ELEVATION OF p 328 �33.4 LP / 100X0 EXISTING SPOT ELEVATION � _ IN THE TOWN OF; 1 00 PROPOSED CONTOUR ( HYANNIS ) B A R i V S TA L E 4- 100 EXISTING CONTOUR PREPARED FOR: DAUI v GlLL R +`3218 32 /4 �33,5 20 0 20 40 � 60 BOARD OF HEALTH M- 33" __ APPROVED Y DATEDATEMA SCALE. 1" � 20' DATE: NOVEMBER 7, 2001 -F 33.2 off 508-362-4541 r fax 508 312-98,90 r {H OF . dawn cape engineering, Inc, A CIVIL.. ENGINr'ERS ARNE LAND SURVEYORS ��'�� LA1 939 rain st, yarmouth, rya 0267 - ti � _. --_-_ -__---__._._:........ rrrrr �rwrrriryrrrrr rr rrrwrrrnrrr irnrrrrrrarrrrnirn�urrr.rnr rwYrrrrrrri- .-.-•'•_ I � SOIL LOG L 22."PEASTOME LOAM S fILL � _ i22�MAX- - a S —/ ' 4 Sor4 wadi.o e • I /i 4'C. I. DIST LBOX I;.o• I 1000 GAL. ° D • I �� �I I000 I a G I 7 u 10'MIN. • F` 24" -T GAL. _ _ �e..•o. PRECAST OR ;�• ° ,_Qfr Yr i SEPTIC I'• • • '. BL0C-K ` . c e � MIN p TANK 6' SEEPAGE /� J ! I"�°moo.• ° I �-'� aQ�S�tS PIT • ° ° 20' MIN ----- ---- {•: - - - - - - - • f FOUNDATION �o I /I 2" WASHED STONE I � I .No tom.,)A'K•It; I ELEVATION SKETCH 10' PERC. RATE tc.4.0 .•-v/._.. �'•.;AL F 4 TEST BY : — TOWN INSPECTOR : .+,r fa4r- BACKHOE OPERATOR :..ct •4-�° 1wfsAeC►.5 T E S T MADE ON Its ra oQ � 0 99 9 a ! r 1 ~�/ o4 r9c.r >ts T � oll GZ'C R o I►CY �. .. 1. 06-31s(�VoG,v&g.efi•.r C�B.�✓Da�'t}+• reo e,..�c��©III. '33���''`� ', Z Z —�cs� { I� 2•//l7�X ,U�.,,�,�se,dL caiL y f'Y�r.1 F.�,� Trri s .sYS re`,"') . `�'''�- .�. . �..., `'.`' Si0£-�v'�L+:. iE3R S•F. ,•1.5 G:r?,�S.r $ 47a 6�o.�0i4y Bo 77o i 79 S, F / o Go��S� T �J.Vc�'Agy• 3)'TawAe -'0 4T8� •yv/4/Lr�CS[.df 7s '�'Nf L:�T i u a I',p a Idc�S L L7' Ca i�Tbu.e. r E L E VAT I ON SCHEDULE PROPOSED SITE PLAN I I N V AT FOUNDATION SEIINAGE SYSTEM DESIGN 2 INV INTO SEPTIC TANK - ON 3 1NV OUT OF SEPTIC TANK = —Llr ` `� � 9' ��� ��� ���•y� 4 INV INTO DISTRIBUTION BOX = 7 SCALE I"=2o' e ', 1979 5 INV OUT OF DISTRIBUTION BOX = /':) 6 INV INTO SEEPAGE PIT = y.aG CAPE COD SURVEY CONSULTANTS ROUTE 132 7. BOTTOM OF PIT = 00 HYANNIS ,MASS.