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HomeMy WebLinkAbout0055 MELBOURNE ROAD - Health 55 PAELBOURR!E FtGl�►D; HYANNIS A i r .f n Q i � G f G { 2-0 { S E � n c`s cr car in S.McGlame 55 Melbourne Rd. HyWis,MA 02601 Above-Grade Building Sketch Borrowei/Client McGlame Sean&Stacey Pfoperty Address 55 Melbourne Road City West H annis ort County Barnstable State MA Zip Code 02672 Lender North American Mortgage Company Dimensions are Approximate Rooms are not to Scale 12:0' 10.0' Bath Dining Bedroom Bath Kitchen Area \ 24.0' 28.0' Living Room Bedroom Bedroom 14.0' 20.0' 24.0' M. 06-01-2009 a 01 = 30s:� (rz�00 PC) � DEED RESTRICTION 0 04 WHEREAS, Sean P. McGlame and Stacey J. McGlame, of 55 Melbourne Road, Hyannis, MA are the owners of 55 Melbourne Road, located at Barnstable (Hyannisport), Barnstable County, C_ MA (hereinafter referred to as Lot 49 and being shown on a plan entitled"Subdivision of Land >1 in Barnstable, MA for C.K.M. Associates", duly recorded in Barnstable County Registry of x Deeds in Plan Book 25.0, Page 143. a WHEREAS, Sean P. McGlame and Stacey J. McGlame, as the owners of said lot have agreed a, with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms �4 which can be included in any home built on said lot as a pre-condition to obtaining a disposal o works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title -° V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; v L, WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary o Sewage, and authoring the issuance_ of a building permit for the construction of a single family �4 home on this property, is requiring that the agreement for the restriction on the number of ra bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. NOW THEREFORE, Sean P. McGlame and Stacey J. McGlame, do hereby place the following 0 restriction on his above-referenced land in accordance with his'agreement with the Town of a_ Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 55 Melbourne Road, Hyannisport, MA may have constructed upon the lot a house containing no more than three (3) bedrooms. Sean P. McGlame and Stacey J. McGlame agree that this shall be a permanent deed restriction affecting Lot 49 located on 55 Melbourne Road, Hyannisport, MA and being shown on the plan recorded in Plan Book 250, Page 143. For title of Sean P. McGlame and Stacey J. McGlame, see the following deed: Book 12168, Page'245. Executed as a sealed instrument this 1st day of June, 2009. Sean P. McGlame j S acey J. AcGlaj&e i f� t COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, ss. On this ?%day of June, 2009, before me the appeared the above named, Sean P. McGlame, who otherwise was personallyknown be the person whose name is signed on the preceding or attached and acknowledged notaryned public, personally document was signed voluntarily for its stated purpose. O�'l dged to me that 0 me said J, John B. o kins, Notary Public i Co fission Expires: 07102115 COMMONWEALTH OF MASSACHU SETTS BARNSTABLE, ss. On this day of June, 2009, before me the undersigned not public, appeared the above named, Stacey J. McGlame, who,otherwise was person notary known to � ":_ be the person whose name is signed on the preceding or attached and acknowledgedpers me to onally said document was signed voluntarily for its stated purpose. to me that Notary Public My Commission Expires: r LO•C TION SEWAGE PERMIT NO. let% VILLAGE I N S T A LLER'S NAME & ADDRESS *Owl. Allot BUILDER OR OWNER j, 'K . DATE PERMIT ISSUED • � ��,� DATE COMSPLIANCE ISSUED_ _ .!y `.i G g ♦� � �I� . ,, ��- +�" I .� __ d �e '�� . � ` + � 'I F ��®I L i X u.. _ i .... - __ .,t,d�_..,. �... ,- .. .� No. '/ FEB...3..$.................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH `1.............OF......0,9 N.,ZT. !.: ------------................... Ailp iration for Ui4posal Workii Cnnnitru rtiun ranat Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: ...........,/ �...r�...... (F or3 ........ ...............�-�-••�-¢=9- --•--•------------------------................ Location-Address or Lot No. .. -e S s.........---•--•••......... .................. &.&� .......................................... Q/�/ ,O,w/ner Address a ............................. -W t....1.4.�°_ 5............. ...................... . e/2�/�s S .............-.......................... Installer Address 70 Type of Building Size Lot. ___ --------------------Sq. feet ,V._,.. Dwelling—No. of Bedrooms......... ..............................Expansion Attic ( ). Garbage Grinder ( ) pa ' Other Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) `I" Q' Other fixtures --•------•---------•------ ----- ¢ O a 330 W Design Flow.........1................................gallons per lef.san per day. Total dajly flow.............................................gallons. WSeptic Tank—Liquid capacity/®®®.gallons Length..-.C,.. Width.4-e 0._ Diameter................ Depth:.i;E-.-%-.. x Disposal Trench—No. .................... Width...;............... Total Length.............1....... Total leaching area....................sq. ft. Seepage Pit No......./_........... Diameter---lO__._...__. Depth below inlet.....Cam............. Total leaching area:...Z19�2.sq. ft. Z Other Distribution box (JC ) Dos i tyk )/J '-' Percolation Test Results Performed by _------ --------- ................................. Date...�:?12 � � .. aTest Pit No. i._. _Z.._.minutes per inch Depth of Test Pit--- ...... Depth to ground water------- __-------. f= Test Pit No. 2..4 Z....minutes per inch Depth of Test Pit._1.44`.._.. Depth to ground water....... ............. f- -------• --------------------------- -•----------- -•-- ---------------- O Description of Soil T �J ------ -•• •-------2--------•-----.. _`. - � ®/L x ............................. c., ---------------••----------- ------••--•---------------------- � afr W ----••-----------------------------:-------•--------------------------------•------- --•-•---•----------•-----•--------------•---------------•-----------------•---........=......-•----------•---- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T`:1,ZJ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b�eeied by the board ofgielth. Sld.._. ....... . ................ .............. . Application Approved By. --------------•-------------•-------•-----------------------------. ...;.`_ 7 Date Application Disappro d f t e following reasons-----------------------•--------•------------------------...---------------------•---•---•------............._... . ................................ ..... ..... ...............`...-----•-----------------------...•----...-------------•---------•----•-----•-•-----............................... --•-----...... Date PermitNo...................................-------...-----------_ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 3s BOARD f�OF HEALTH /.v....................OF...... :................................ Appliration for Dispnstal Works Tnnitrnrtinn Vamit Application is hereby made for a Permit to Construct ()( ) or Repair ( ) an Individual Sewage Disposal System a_t:. % .._.............. ..EZr..----•-•-� O `'�� ................ Location-Address or Lot No. ..................._.--•:_ ........ it. :_l._�_................................................. ... Owner a � aress L!�- NJ: � ......•_------J , , Indaller Address UType of Building 2 Size Lot_j...Z.............70 6/........Sq feet �., Dwelling—No. of Bedrooms............?_..................._..........Expansion Attic ( ) Garbage Grinder ( ) a`k Other—T ype of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ................................. rats --•-----•--•--------•------------------------------- ----------•--•------_........ .. W Design Flow........lb____________________________gallons per been per day. Total daily flow...............9__3.G gallons. WSeptic Tank—Liquid capacitylO��.gallons Length_i6_-4_._ Width4"1��_. Diameter................ Depth_ x Disposal Trench—No_ ____________________ Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......I............ Diameter._l . ........ Depth below inlet....--�'J____......... Total leaching area....15�l2_2.sq. ft. Z Other Distribution box ()t ) Dosing. tank '-' Percolation Test Results Performed byfC- ('/ F/I.vN 1AIC___________________ Date___ .___�Z�� Z` a ••••• ------....e_•---• .............. Test Pit No. I._.G_...._..minutes per inch Depth of Test Pit___.r'��^ ____ Depth to ground water........-_ ........... 44 Test Pit No. 2..4 t_....minutes per inch Depth of Test Pit._f_ ____. Depth to ground water...... 04 ........... -----------------------------------------•--• •-•-•................... O Description of SOiI_.7 z z ..... . . �-�/ Q F�50/C... T3 S®i ---.._._.. ............. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--••_.... U Nature of Repairs or Alterations—Answer when applicable----_•......................................................................_.................. ...-----•---------•••••-•-•-••----...---_-•--••--•--•-•---•----------•--•--•••------••••....---•---•-••-...•-------------••-••--••••------------•---•••-•••---•--••-• .................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the T provisions of T ': :; p 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 Si .tied _. Da{e Application Approved By__., .._ �.._/� Da Application Disapprgmved or he following reasons---------------•----------------•-----------------------------------------/-----•---------------Y-�-----...------ II -----•-•-------------------------------------------------------•-------.._Date .__..------- PermitNo......................................................... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f !�+ .I.......... .. . .......... F/ (9rrtirirate jai nrnt �ittnrr HIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ) or Repaired ( ) c..Me/..,--•-by -- 5e-k-•6/a6.H•'-5...........................................................................................------•--- •-----.......------------•--._._....._ ,�+ �} Installer has been installed in accordance with the provisions of TITLE j of The State Sanitary Cc e s described in the application for Disposal Works Construction Permit Nov ,___:/1r.___________________ date :__ __ . ....................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G GRANTEE THAT THE SYSTEM WILL FUNCTION SATII /ACTO,,RY. DATE... -------••-•_-•-_.. Inspector............. •--- R-- : --------------•------••-•----•-------•---____- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH ......... F 'r�:''"................ Obip sal Workii TUnntrnrtion frrutit Permission is hereby grantedt to Construct ) or Repair } an Individual Sewage Disposal System at Nq<..,o- •-----..?------ Street / as shown on the application for Disposal Works Construction Permit N :__2._ Date. ...............................................................----._...---....--------•-----•....__... DATE................----- Y-Sfx....-------._...--------.....------ • •-•-• Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS SOIL ', TEST INVERT ELEVATIONS NOT.Es= ~, DATE OF``SOIL:; TEST 3 /2 8 Z INVERT AT BUILDING io/� FT ALL . WORKMANSHIP: AND MATERIALS WITNESSED BY INLET SEPTIC TANK FT. SHALL CONFORM TO D.E.Q.E TITLE ' S PER_COLATION RATEL=- MIN./INCH OUTLET SEPTIC TANK /ao.3 FT. AND .THE TOWN OF-8���✓�-ad--- RULES INLET DISTRIBUTION= BOX %�� / FT. AND REGULATIONS FOR SUBSURFACE OBSERVATION HOLE I OBSERVATION ' HOLE 2 DISPOSAL OF- SANITARY SEWAGE ELEVATION=/o/• oo ELEVATION= /o% / OUTLET DISTRIBUTION BOX FT. pa INLET LEACHING PIT .93.7 FT. Top f BOTTOM LEACHING PIT ,9.37 FT. DESIGN CALCULATIONS NUMBER OF BEDROOMS . . . .. . . . . . . . . . . . . . 3 ' i s� GARBAGE DISPOSAL UNIT.... TOTAL ESTIMATED FLOW (1LGAL./BR./DAY x,7- BRA.. •33� GAL./DAY �JEo/CaA•eSc �� REQUIUD SEPTIC TANK CAPACITY.... . ¢ GAL. ACTUAL SIZE OF SEPTIC TANK TO BE INSTALLED.... ioaa GAL. LEACHING AREA REQUIREMENTS ' gg g _ 14 ��^ S9 SIDE WALL AREAde_,�GAL./S:F. ) BOTTOM AREA L2 GAL./S.F. /% ,�/z 6 �i✓cavn�rE2,EoJ LEACHING CAPACITY ( BOTTOM SIDEWALL 7 GAL. �.3•i¢ x S z x /> �• �3/¢ x Gx/o x.2•S� S�9�7 GAL. RESERVE LEACHING CAPACITY.. . . . . . . . . . . . . . . . . . . . . . . T O P OF FOUND. ELEV.=/C?3.S CONCRETE 4�' SCH. 40 CLEAN SAND COVERS MI C "PITCH CONCRETE N 1/8 PER. FT. COVER w` �� Ui � �, 2% MIN. PITCH 12 MAX. a -:�, '/'' 1Cs� i v _=r 4, 2. .LAYER OF I/8- I FLOW LINE �. p .w 41 _ WASHED STONE ,.:: ao f r i n _L z ' o n o' u u �cnlz Y•-c�:� ''c�`�iC., /� 4 CAST IRON — /9 0 3/4- 1 I/2 PIPE - MIN. PITCH 'o w va WASHED STONE I/4�� PER FT DIST. v n �_- o ' PRECAST LEACHING ' BOX . o� caw n o BASIN OR EQUIV. n �— - �.., 0 O w 0 /aoo GAL MASS, SEPTIC T R. J. 0 EAR INC. RLS RS TANK. o fr ¢'C H . N, . •� _.. . . :. 1346 ROUTE PROFILE OF GROUND WATER TABLE EAST DENNIS, MASS. SEWAGE DISPOSAL SYSTEM JOB No: cLIENT.�ffy�y„�. NOT TO SCALE [DATE ��G SHEET,- OF,,-- - I - I Mi ,� I3 i L OT -,4eE3 `. r I � Q o Q/ � � h \ �,� H2O� \�\ • oe��.� �O rC 4/47E^ 1 i Q �•r/1�� �� � V � 4 \� : r r � a LDT SO /✓o,TES: _�: .G''o�lo,CiAivG,F wiry Locq,C Zocii�uC ' Q. JJ;vnE:i cn � ' O'HE/ _'N `J 0'Fs-hi�iJ No.All LEGEND EXISTING SPOT ELEVATIONS OAO 1 EXISTING CONTOUR--- 0- -- FINISHED SPOT ELEVATIONS FINISHED CONTOUR 0 PROPOSED PLOT PLAN APPROVED: BOARD OF HEALTH MASS. DATE AGENT R. J. O'HEARN, INC., RL S, RS 1348 ROUTE 134 EAST DENNIS, MASS. DATE: 9 SCALE' JOB N0. r9k`aS-A5- CLIENT: s� DR. BY SHEET-L OF Z rAsBuilt Page 1 of 1 J LO j TION �hA SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS F4*1.3 �..�e 's S��wsa� _ 3!�► G...� 1.1. u_,A.1, BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED_ I 16 L-7j4y„�►K 11�.1�. http://issgl2/intranet/propdata/prebuilt.aspx?mappar=268247&seq=1 6/4/2013 COMMONWEALTH OF MASSACHUSETTS 7 EXECUTIVE V C E OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 0 00 0 6, t^ C a� T Q UDY _ to, �c9 Secreta iyy ARGEO `g .Govenior UL CELLUCCI .. _ VID B. Co�n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Z "Ab si ri PART A CERTIFICATION Property Address: 55 Melbourne Road, Hyannisport, MA Name of Owner: Anna Gentile Address of Owner: P.O. Box 136 Date of Inspection: .Febr,iaq 8.- 1999 Worcester, MA 01613 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: _P.a Box 49, Osterville, MA 02655-0049 Map; Telephone Number: _(508)862-9400 Parcel: Lot: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accur(' F and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function andmaintenance of on-site sewage disposal systems. The system: PassesConditionally Passes Needs Further Eval tion By the Local Approving Authority Fails , Inspector's Signature: Date: February 9, 1999 The System Inspector shall subrz a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page IofII Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -, PART A CERTIFICATION (continued) Property Address: ,, 'SS Melbourne Road, Hyannisport, MA Owner: t?Anna Gentile Date of,Inspection: "February 8, 1999 INSPECTION/SUMMARY: Check A, B, C, or D: t / • A. SYSTEM PASSES. III `✓- I have noffound any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria no 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. Indicate yes,no, or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due tobmken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) 4 broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 rk i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: SS Melbourne Road, Hyannisport, MA Owner: Anna Gentile Date of Inspection: February 8, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. - 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE ENVIRONMENT: The system has aseptic tank and.soil absorption system(SAS)..and•the SAS is within 100 feet to asurface water supply or tiibutary:to a surface water supply: _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public.water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: SS Melbourne Road, Hyannisporl, MA Owner: Anna Gentile Date of Inspection: February 8, 1999 ' D. SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged.SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than'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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a`cesspool or privy is within a Zone 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. If the well has been analyzed.to be acceptable,attach copy of well water analysis for colifotm bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safetyand the environment because one or more of the following conditions exist: g 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 The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 55 Melbourne Road, Hyannisport, MA E Owner: Anna Gentile Date of Inspection: February 8, 1999 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: f '«, • y Yes No ✓ _ Pumping information was provided by the owner, occupant, or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built'plans have been'olitained and examined. Note if they'are'not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened, and the,interior of,the septic tank was inspected for conditions of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge;depth-of scum.'' The size and location of the Soil Absorption System on the site has been determined based on: ✓ . Existing information. For example, Plan at B.O.H. . ✓ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)l• ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 P 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 55 Melbourne Road, Hyannisport, MA Owner: Anna Gentile Date of Inspection: February 8, 1999 " FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 Total DESIGN flow n/a Number of current residents: 1 Garbage grinder(yes or no): Yes Laundry(separate system) (yes or no): No ; If yes, separate inspection required Laundry system inspected(yes or no): Yes Seasonal use(yes or no): Yes Water meter readings, if available(last two yearg,usage(gpd): 1998-2,800 gals.; 1997-3,700 Aals. Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIALANDUSTRIAL: Type of establishment: Design flow: gpd(Based on 15.203) Basis of design flow 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: OTHER: (Describe) , .. Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: None on file-per treatment plant System pumped as part of inspection(yes or no): No - If yes, volume pumped: _gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 1982-per as built card. --Sewage-odors detected when arriving at the site: (yes or no)-- -No.---.- revised .9/2/98 Page 6of11 f i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Melbourne Road, Hyannisport, MA Owner: Anna Gentile Date of Inspection: February 8, 1999 BUILDING SEWER: (Locate on site plan) Depth below grade: . Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting,evidence of leakage, etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 14" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age s Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8' x 5' x 4'6" (1000gal.) Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" _ Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How dimensions were determined Measuring stiek Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) The inlet tee was present. An asphalt walk covers the outlet cover. There was no scum in the tank. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) x Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and.outlet.tees or baffles, depth.of liquid.level in relation to outlet invert, structural integrity,, "evidence of leakage, etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Melbourne Road, Hyannisport, MA Owner: Anna Gentile Date of Inspection: February 8, 1999 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: Comrrtents: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The D=box was under an asphalt walkway and was unaccessible. PUMP CHAMBER: None (locate on site plan) Pumps in working order: (Yes or No) Alarms ii working order: (Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page8ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Melbourne Road, Hyannisport, MA Owner: Anna Gentile Date of Inspection: February 8,.1999 - SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan,if possible; excavation not required,'location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number: I -6'x 6' leaching chambers, number: leaching galleries, number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.) The pit was dry. The bottom to grade was 9'. There were no signs of failure. - CESSPOOLS: None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Continents: (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.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION (continued) Property Address: SS Melbourne Road, Hyannisport, MA Owner: Anna Gentile Date of Inspection: February 8, 1999 skETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) IA btck �a to 304 revised 9/2/98 Page 10ofIt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 55 Melbourne Road, Hyannisport, MA Owner: Anna Gentile Date of Inspection: February 8, 1999 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 25 +/- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record ✓ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Hand augered down to 12'below grade and no water was observed. Using the Cape Cod Commission Technical Bulletin, and the Barnstable Water Table Contour Map, the adjusted high groundwater level for 12'at this site (MI W 29, Zone C) was 4.9'. 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. revised 9/2/98 Page 11 of 11 l ¢ w ¢ f ZK h ; a > a ¢ w II � II II I p m LOT-' 0 1 W . ot .01 J W oZ 1 I • I II � .� � � fI R ' i I i — LIB a I z I 3 ' � J li I l i � I i If g I)f a Ty —I I � � 1 mil'V P V I' _ I I I — t i , I . --- --.�. ------ --- --� — -- — -ice ' li i, � { I � a � z I I • I� I I I , I a I 13 gg 1 I ' E R 1 ' i _ 109ZO MH`s!uae-CH VH aumoglow SS aWBIDONi-S 1_Li rn tr) I �j V LLL ^\ , 0-.Z, V ' j 1 - 1 I ' � k I, / V