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HomeMy WebLinkAbout0077 MITCHELL'S WAY - Health 77 Mitchell's Way Hyannis P A = 290 154 y i k 1 F 1 D D a TOWN OF BARNSTABLE f_ _ M� G'`� .S SEWAGE # ` :LOCATION IRLLAGE 14!YA a`a L" J,�✓ rM 1S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J W ,� 1 aMC c� LEACHING FACII.TTY: (type) 3 � �+'t J S (size) NO. OF BEDROOMS 3 l aB-UMDER OR OWNER Ael ]t/S0I1 I PI.RMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachii g facility) Feet Furnished by /1S/ltAi Q 4� - O W I __ i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 M 77 Mitchells Way Property Address q Juan Marichal Owner Owner's Name information is 3 required for every Hyannis Ma 02601 4/28/18en5 page. City/Town State Zip Code Date of Inspection ) Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms It on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 S113522 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 Evaluatio by''the Local Approving Authority 5/4/18 nspector'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. 2 U p J� t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 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: System contains a 1500 gallon septic tank. As well as a concrete distribution box and two 500 gallon chambers. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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): El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 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 '/2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® An portion of a cesspool or privy is less than 100 feet but greater than y p p p y g 50 feet from aprivate water supply well wit h 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 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. 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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 bu It 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)] 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 89 gpd 9 ( Y 9 (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is Y required for every Hyannis Ma 02601 4/28/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not provided 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 L __ I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Mitchells Way 1y Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 1.5 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: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: , Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System_Form - Not for Voluntary Assessments M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. Cityfrown 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.): 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert level and at normal level 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 ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts u, W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 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 high ground water: 10 + 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: May 14 1999 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 L r 5/4/2018 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION �J� M .T SEWAGE N J VU.LAGE N4!JAA4 Lf ASSESSOR'S MAP&LOT 99 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /SW LEACHING FACILrrY:(type) 3' A+''t s (size) *I rro4k NO.OF BEDROOMS J B ER OR OWNER /q1n L�1�IZZO/I� PFMrrDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ' g facility) r Feet Furnished by_ ^SAon t'Er Pov►T Q fi A � A a • 3 J a a3 33,ti ys 4. http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=290154&seq=1 1/2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments �M 77 Mitchells Way Property Address Juan Marichal Owner Owner's Name information is required for every Hyannis Ma 02601 4/28/18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑' Inspection Summary D (System failure Criteria Applicable to All Systems)completed ❑ System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 77 MITCHELLS.WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA` 02601 4/8/13 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered im4hyR way. Please see completeness checklist at the end of the form. t Important:When filling out A. General Information forms on the computer,use 1, Inspector: / [� only the tab key to move your DOUGLAS A BROWN U U cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC' Company Name V�I P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code 508-420-4534 S14297 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 t� ection,1L§.340gf Title 5.(310 CMR 15.000).The system: ©� ® Passes. r . ❑ Conditionally Passes ❑ Pis � O ❑ Needs Further Evaluation by the Local Approving Authority 4/8/13 �' fv Inspector gnature 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 flowof 10,00:0'gpd or:greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only described ponditloos at the time of inspection and under the conditions of use at that time.This inspectiprt,does iot addlress.how the system will perform in the future under the same or different conditions of-use. ' V 3 t5ins•11/10 Title 5 Official Inspe Vo : urface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts 471 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM , 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is MA 02601 4/8/13 required for HYANNIS ' every page. Cityrrown State Zip Code Date of Inspection ' B. Certification (cost.) 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. j Comments: SYSTEM MET MINIMUN PASSING REQUIREMENTS AT TIME OF INSPECTION, WATER USAGE WAS HIGH, SYSTEM APPEARS TO HAVE HEAVY USAGE, CAN NOT PREDICT FUTURE PERFORMANCE OF SYSTEM B) System Conditionally Passes: r ❑ 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. Check the box for"yes", "no" or"not determined" (Y, N,.ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 4/8/13 every page. Cityrrown State; Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes) 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 ❑ Y ❑ N ❑ .IVD(Explain below): ❑ obstruction is removed - ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): 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 0 Y ❑ N ❑ ND (Explain below): ❑ f obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 16.303(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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 -t Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form = Not for Voluntary Assessments v °M 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 4/8/13 e' every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) , 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 hasa.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 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: Aycopy of the analysis must be attached to this form. 3. Other: • P 'x 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 77 MITCHELLS WAY r Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 4/8/13 every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed p$e(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. 0 ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within'a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than,.50 feet . from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] EJ ® 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 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. 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 El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone Il 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. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form :Not for Voluntary Assessments M , 77 MITCHELLS WAY ° Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 4/8/13 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 ofitWOlowing: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Z Were any of the system components pumped out in the previous two weeks?' ❑ :;sHas#he..systemrreceived.m�ritrraal flows in the previous two week period? ❑ ® Have large volumes of water been_introduced to the system recently or as part of this inspection? ® ElWere 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? r ® ❑ 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)] D. System Information, Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts f Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name p information is required for HYANNIS -MA 02601 4/8/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 2 500 GALLON CHAMBERS WITH 4 FT OF STONE ,• Number,of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? . . ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: ` • , . 2011-= -=-----------435 2012---------------437 Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENTDate Commercial/Industrial FIowConditions: 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: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name- ' information is required for HYANNIS MA 02601 4/8/13 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date.. Other(describe below): fi Generallnformation Pumping Records: Source of information: 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) i ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of W Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 4/8/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of,information: 1999 Were sewage odors detected when arriving at the.site? ❑ Yes, ® No Building Sewer(locate on site plan): Depth below grade: 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: 1.25 feet Material of construction: ® concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate.of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: t 1500 Sludge depth: MODERATE HEAVIEST AT INLET t5ins•.11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 4/8/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) , Distance from top of sludge to bottom of outlet tee or baffle ; Scum thickness VARYING 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? WOODEN POLE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,. liquid levels as related to outlet invert; evidence of leakage, etc.): WITH THE HEAVY USE I RECOMMEND PUMPING AT LEAST EVERY 2 YRS 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 t5ins•11/10 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is IS MA 02601 4/8/13 required for HYANN ' 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.): 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 per day w Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: t Date Comments(condition of alarm and float switches, etc.): r *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins"11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P . , 17 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA'- 02601 4/8/13 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 011 . b• Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DEFINATE SIGNS OF SOLID CARRY OVER BUT LIQUID WAS FREELY FLOWING INTO CHAMBERS AT TIME OF INSPECTION Pump Chamber(locate on site plan): Pumps in working,order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No • 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: NO.RISER FOUND ON CHAMBERS t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA . 02601 4/8/13 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions:, overflow cesspool number: El 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.): THERE WAS NO SIGNS OF FAILURE IN AREA OF CHAMBERS THEY WERE NOT OPENED, BECAUSE'NO RISERS WER FOUND • s 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. H Dimensions of cesspool Materials of construction A Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 4/8/13 - - every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): a Materials of construction: .a Dimensions Depth of solids Comments(note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 77 MITCHELLS WAY Property Address NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 4/8/13 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal,System: Provide a,view 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. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form-Nof for Voluntary Assessments 77 MITCHELLS WAY - Property Address NOWAK Owner Owner's Name information is HYAN required for NIS MA 02601 4/8/13 every page. CityrTown State Zip Code Date of Inspection D. Sys'tbm Information (cont.) Site Exam: ® Check Slope ® Surface water' ® ,Check cellar ® Shallow wells Estimated depth to high groundwater: AT LEAST 5' fleet 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:y - You must describe how you established the high ground water elevation: 1995 CODE Before filing-this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection `Form r � Subsurface Sewage Disposal System Form Not for Voluntary Assessments a 9 P Y ry is wM 77 MITCHELLS WAY Property Address , NOWAK Owner Owner's Name information is required for HYANNIS MA 02601 418/13 every page. Citylfown , State Zip Code Date of Inspection E. Report Completeness Checklist ry ®µ Inspection Summary: A,1B, C, D, or E checked ® inspection Summary D (System Failure.Criteria Applicable to All Systems)completed ® System Information—Estimated depth to.high groundwater ® Sketch of Sewage Disposal System,either drawn on page 15 or attached in separate file . 3 t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 1 F - ^ TOWN OF BARNSTABLE LOCATION !� M S SEWAGE# VILLAGE ayA� ASSESSOR'S MAP&LOTa�o INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY v LEACHING FACII.II'Y:(type) 3, C.1AA%4teS (size) NO.OF BEDROOMS 3 /� J B ER OR OWNER Ian.�CiSc#,% DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ' on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist " within 300 feet of leac�g facility) } 'Feet Furnished by �/IS/JIl an P 4 d ' O q 13' ` 3 , 3 , 3a A 4 http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=290154&seq=1 4/8/2013 n YOU: WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$30.00 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.) Business Certificates are-available at the Town Clerk's Office, 1 a`FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) r +,r DATE: Fill i please: APPLICANT'S YOUR NAME/S. a Eaq? vrp tbh r s BUSINESS R E . r, ' <` /R YOU HOM ADDRESS: .44 TELEPHONE # Home Telephone Number NAM ON,, f r, . NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATION?.- c YF NO ADDRESS OF BUSINESS MAP PARCEL NUMBER 2 5 / (Assessing) When starting a 'new business.there are several things-you must do in'order to be in compliance with the rules and re g You MUST GO TO 200 ulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. . Main St. -(corner of Yarmouth Rd. & Main Streetj to make sure you have the appropriate permits and licenses required.to.legall-� .- era soness in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to thistype of business. Authorized Signature** W COMMENTS: 2. BOARD OF HEALTH r1 J. This individual has bee inf r ed-of;t� e it requirements that,pertain.to this type of business. Author zed Signature 11 COMMENTS CA 3. CONSUMER AFFAIRS ( ICENSING AUTHORITY) This individual hasen m 6r e f the licensing requirements that pertain to this type of.business. Authorized Signature* COMMENTS: Date: f TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: =� �3 rz� --•c BUSINESS LOCATION: �� LL4 Li-'L1 ; INVENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: CONTACT PERSON: 1 t ��2-n S ►�� +� EMERGENCY CONTACT TELEPHONE NUMBER: �T C)��-�� � � �'���� MSDS ON SITE? TYPE OF BUSINESS: fa i v, s INFORMATION/RECOMMENDATIONS: RAM-12/AI-5 66,U(,rti I`776i i t-C Fire District: T �tAte-r , , A_ Dr- � �i�./�7��ziAL� . LC Fi i A-) Ul GAr— TIC U( ! I< Waste Transportation: Last shipment of hazardous_waste: Name of Hauler: Destination: i Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use, storage and disposal of 111 gallons or more a month requires 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) Misc. 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 Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) i Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's 1 (w aj Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, "Lacquer thinriers (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel I j Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS � 1 I4-05 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIOX— RECEIVED JUL 2 9 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ��AP Property Address: 77 Mitchells Way Hyannis, MA 02601 PARCEL Owner's Name: Anderson Biazzola LOT Owner's Address: Date of Inspection: July 14, 2003 Name of Inspector: (Please Print) James M. Ford . Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Ne s Further Evaluation by the Local Approving Authority F is Inspector's Signature: r Date: July 15, 2003 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions,at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form '' 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM -'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 77 Mitchells Way Hyannis, MA Owner: Anderson Biazzola Date of Inspection: July 14, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.'If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year.due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of.Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 77 Mitchells Way Hyannis, MA Owner: Anderson Biazzola Date of Inspection: July 14, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than,'/Z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped' . Zone II of a public water supply well If you have answered"yes".to any question in Section E the system is considered a significant threat,or answered "yes"in Section D.above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 r OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 77 Mitchells Way Hyannis, MA Owner: Anderson Biazzola Date of Inspection: July 14, 2003 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 a ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is=unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 77 Mitchells way Hyannis. M4 Owner: Anderson Biazzola Date of Inspection: July 14, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 . Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 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): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: . Design flow(based on 310 CMR 15.203): vd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: New system-never pumped Was system pumped as part of the inspection(yes or no): No If.yes,volume pumped: _gallons--How was.quantity pumped determined? Reason for pumping: TYPE OF .SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system.(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): . Approximate age of all components,date installed(if known)and source of information: May.13/99-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7.of 11 i OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77 Mitchells Way Hyannis, AM Owner: Anderson Biazzola Date of Inspection: July 14, 2003 WELDING 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: 2' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: S" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs ofleakage. Recommend pumping every three years for maintenance. GREASE TRAP: None (locate on site plan) Depth.below grade: Material of construction: _concrete. _metal . fiberglass._polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc:): _ Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77 Mitchells Way Hyannis, MA Owner: Anderson Biazzola Date of Inspection: July 14,�2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level. No solids were present. There were no signs of failure or backup from the leach field PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77 Mitchells Way Hyannis, MA Owner: Anderson Biazzola Date of Inspection: July 14, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 2-500 gal. chambers with 4'stone-per septic plan 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.): There were no signs of failure from the leach field. The bottom to grade was approximately 5. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow.(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) . Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 �c Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77 Mitchells Way Hyannis, MA Owner: Anderson Biazzola Date of Inspection: July 14, 2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A a � 1g ag a 3 - a a3 3� �S 3 � 3a 10 f Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 77 Mitchells Way Hyannis, MA Owner: Anderson Biazzola Date of Inspection: July 14, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15 +/- feet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic'and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately 15'+/-to ground water at this site. r i This report has been prepared and the system inspected and,passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE CATION � �(�(i v Y� c.���g � 7v SEWAGE # `diI LAGS .� ASSESSOR'S MAP & LOURQ— f7c,( p�1STALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 49- NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: a— l /-r-'' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �c��: _ )-� )s ca ho f " 7 TOWN OF BARNSTABLE ,L'OCATION L l r �'•` . SEWAGE # q7� VILLAGE ��I�� % t ASSESSOR'S MAP& LOT r ,- INSTALLER'S NAME&PHONE NO. S 5e`�'A j, 0', - SEPTIC TANK CAPACITY J LEACHING FACILITY: (type) ` m' r (size) ' NO.OF BEDROOMS - b'UII.DER OR OWNER PEF:MITDATE: 6 /Cj COMPLIANCE DATE: :I-) Separation Distance Between-the:'' t' Maximum Adjusted Groundwater Table to the Bottom.of Leaching Facility Feet Private Water Supply Well and'Leaeliing Facility (If any wells exist on site or within 200 feet ofr leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 4 M � � .. �Y e, - No. /��] �T Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zippfication for ;Digpogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) L_1 Lomplete System O Individual Components Location Address or Lot No. Owner's Name,Address and 1Tel.No. 00. 1 a 9. 1 S)S Assessor's Map/Parcel Gi® '�L, Installer's Name,Address,and Tel.No. 0© 3 Designer's� Name,Address and Tel.No. et- RT f' 61 I' � Id `l�ly�av`t-�. �U i�ek �,35 �1Da�*a�tOr+,` I19 o a5�/ uZ s `3 1rn IA D�S 3 z� Type of Building: Dwelling No.of Bedrooms Lot Size /®-4 sq.ft. Garbage Grinder( ) Other Type of Building rM yn-C No. of Persons Showers Cafeteria( ) Other Fixtures /y Design Flow 33 gallons per day. Calculated daily flow '7 gallons. Plan Date 16 Number of sheets Revision Date Title Size of Septic Tank 0 S OO Type of S.A.S. a,-M Lei, Cz S0� Description of Soil 6 0 o-me- `,0 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ens thtBd on and m 'ntenance of the afore described on-site sewage disposal system in accordance with the prov' ' ns of Titleviron tal Code and not to place the system in operation until a Certifi- cate of Compliance has bee issued b i a Signed -Date Application Approved by Date — Application Disapproved for th foll ing reas s Permit No. �' 7 Date Issued TOWN OF BARNS TAB LE LOCATION SEWAGE # VILLAGE f����: ASSESSOR'S MAP &ff LOT INSTALLER'S NAME&PHONE NO. �x c - l ` wc-> SEPTIC TANK CAPACITY l LEACHING FACILITY:.(type) (size) NO.OF BEDROOMS BUILDER OR OWNER j PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by y `v a / •�is. �I.fiii .c. ` �i .•_ 16 -. ,r No. �` » y i x. Fee THE COMMONWEALTH OF MASSACHUSETTS' ; Entered in computer: F PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS Yes Apprication for Mi5po5a[ *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. '7-7 kr 1 Te�(,1 1 WWI- Owner's Name,Address andvTel.No. 00--' Z IG1. 'I )S Assessor's Map/Parcel 0 I d P-M" r4L H'0110% i oagpI to ' -0 5oK b3S (U1areErn, ,tinA Installer's Name,Address,and Tel.No. goo. w3 15 Designer's Name,Address and Tel.No. So k S-V (sY Tan P% 40,'nOLI kot'.cl SwvI 'Y" N-lox &35 wayokam,�1)c} 0,�--S7/ b b t7 Id . �- Type of Building: Dwelling No.of Bedrooms Lot Size 10'A7 sq.ft. Garbage Grinder( )' l Other Type of Building rt-''CA rnC.. No.of Persons Showers Cafeteria ( Other Fixtures Design Flow . 0 gallons per day. Calculated daily flow gallons. Plan'-"Date !b -a 5•V Number of sheets Revision Date Title Size of Septic Tank 1500 Type of S.A.S. QYn bel- Cam) 0 8 Description of Soil 0 01 Y'S C 1 0'` r 1'1 ej't LPVYN q 1r dC 4-4 r Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees;to ens a the constru on and in 'ntenance of the afore described on-site sewage disposal system in accordance with the prov ns of Title nviron tal Code and not to place the system in operation until a Certifi- cate of Compliance has bee issued b is B rdo f a Signed Date Application Approved by Date Application Disapproved for th foll ing re as s Permit No. 91— a 7 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site S ge Disposal System Constructed(, )Repaired( )Upgraded( ) Abandoned( )by ` at 7hi jSAAOA 111091 has been constructed in accordance with the provisions of Title 5 and the for Dis o al System Construction Permit No. a- dated Installer Designer The issuance of this pe all. of trued as a guarantee that the syst ct n s tgted G Date �TT Inspector �1 Lj------------------------------/— No. � 7 � -Fee THE COMMONWEALTH OF MASSACHUSETTS �G PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mizponl *pgtem Construction Permit Permission is hereby granted to Construct(,,4�Repair(\)Upgrade( )Abandon/( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: -- T = `� Approved by l � U / r f t . y 85. 00 S.A. S. RES. -J 201 min. UM PA SE� o . T. LOT 4 10717f S.F. 0.96 THE FOUNDATION SHOWN ON THIS PLAN WAS LOCH TED BY AN INSTRUMENT SURVEY ON 5110199 AND EXISTS ON THE GROUND AS SHOWN. DA TE "PROFESSIONAL LAND S RYEYOR 9 `z PLOT PLAN_ - LOT 4 . MI TCHELL S WA Y, BARIVSTABLE, MA SCALE 1 " = 30 ' MA Y 10, 1999 CANAL LAND SUP YYEYING 306 OLD PL YMOUTH ROAD, BUZZARDS BA Y, MA PROJECT NUMBER 99-040-04 9 ` r� GENERAL NOTES. ou-2 -r .r�� SOIL TEST ST PIT DATA J. THIS PLAN IS FOR THE DESIGN AND INVERT ELEVA TIONS.' �" ' Z '0 T.P. -1 T.P. -2 CONSTRUCTION OF THE SEWAGE DISPOSAL OR/ EL EV. GRND. ELEV. FACILITY ONLY. INVERT AT BUILDING 5,p b G. W. ELEV. G. W. ELEV. 2. ALL CONSTRUCTION METHODS, MATERIALS AND INVERT IN AT SEPTIC TANK`' q. 5 MAINTENANCE FOR THE SEPTIC SYSTEM SHALL 26.DCi CONFORM TO MASS. D.E.Q.E. TITLE 5 AND LOCAL INVERT OUT AT SEPTIC TANK 2��5� ACCESS COVERS MUST BE WITHIN6 ' OF FINISH GRADE. BOARD OF HEAL TH REGULA TIONS. INVERT IN AT DIST. BOX 2 3 F I i� �' 6 �E INDICATES pv�,�- 5.� •S , 3. ALL SEPTIC SYSTEM COMPONENTS SUBJECT TO ` INVERT OUT AT DIST. BOX 2 .20 'O� 7 L �� S� PERC. TEST • 23.?10 r VEHICLE LOADING (I.E. UNDER DRIVEWAYS, ETC. INVERT IN AT S.A. S. .. 0 - MIN. 2 OF SHALL BE DESIGNED TO WITHSTAND H-20 LOADING. 5 ,00 1/B'-1/2' DIA. BOTTOM OF 'S A S. 21 .0 -- 4 YIN. WASHED STONE INDICA TES 4. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR OBSERVED GROUNDWATER Q ID z,y,rp OBSERVED [3�tz APPROVED EQUAL. !0 , EPTH DIST. Z GROUNDWA TER ADJUSTED GROUNDWA TER N v 3/4 1 1/2 DIA. p 5. BEFORE STARTING CONSTRUCTION CALL DIG SAFE �n1 - 1 rD 0 0 GAL. BOX W cWj WASHED STONE - 1-800-322-4844 FOR L OCA TION OF SEPTIC TANK � 1-.Ob INDIT P TES IT � UNDERGROUND UTILITIES. SEPTIC TANK 6 D-BOX TO BE SET Q A p� 6. DA TUM IS It r 55 M 4j 6' BED OF COMPACTED CRUSHED STONE. CONTRACTOR TO WA TER TEST D-BOX TO PROP. S.A.S. 7. NO OETERMINA TION HAS BEEN MADE AS TO COMPLIANCE SHOW LEVELNESS. WITH DEED RESTRICTIONS OR ZONING REGULATIONS. IT SHALL REMAIN THE OWNER'S RESPONSIBILITY TO OBTAIN ALL REQUIRED PERMITS, SPECIAL PERMITS, S o 11. DA TE.' VARIANCES, ETC. FOR THIS PROJECT. N O N O. 1 TEST BY' 8. , IT SHALL REMAIN THE OWNER'S RESPONSIBILITY , 2�. Z d TO HAVE THE PROPOSED DWELL ING FOUNDA TION ' DESIGNED TO ACCOUNT A r,►►.� I 1-r)h it rJ / Z .L WITNESSED BY.' FOR THE EXISTING GRADE I) �AND SOIL CONDI TIONS A T THE L OCA TION OF THE 5 013 5') ' PROPOSED DWELL ING. ll ` 2 4, L z _ PERC. RATE MIN./ IN. � , `r��' ,► z I,3 _ DESIGN CRITERIA: GUUp SF_ i i� � AA �i - 5 r), DESIGN FL OW 11 U, A P 1 V I .__ BEDROOM DWEL L ING 8 110 GAL/DA Y PER BEDROOM ', ! ,I it3 3 _ EQUALS 33�_ GALS. PER DAY. 9 SEPTIC TANK REQUIRED. lU b-BOX 336 GPD XZ04x - G CRO GAL. SEPTIC TANK PROVIDED I ErO 0 GAL. 12 SIZE OF LEACHING FACILITY REQUIRED 0, Z 13 j 2 t N _,.. s:, _._ _ y _-__.. �.DES?F1/ F'EAC �,l 7',­ - Z, f MTNU'F9 NCN 14 30 GALLONS PER DAY PERC IESI R E S U l I S 4 \ srzE of' LEACIIING FACILrrY Ao IDED PERC R A Z E ; 2_ r 1 I.�4/ i� I I -�-- o _ o a t✓t.vG C p, C, �-r`� Cr W N I 1 rJ E U � SS BY . _. SIDFW,4LL 1 � S.F. X0-_1Y - ►tip GPD Y'6 n,rz0s rr, R LE__ BOARD OF HEA1111 BOTTOM ga�;' S.F. X(23L) = z4a GPD R A 1 E : '_Z- i- U� TOTAL S _ S.F. GPD i o 85. 00' REVISIONS, o ' ----- -i \ \ NO. 21'TE REVISION RES 1 20 ' min gQ T. �o LOT 4 a �'f��L k, PLAN SHOWING THE DESIGN OF A PROPOSED 10717f S. F. g8 "" � i . �` - o• > f day FACL- SEPTIC DISPOSAL SYSTEM No. SUBSUR _ LOT 4, MI TCHELL S hA Y BARNSTABLE, MA ' ., SCALE 1 " = 30 MAY 14, 1999 CANAL LAND SURVEYING 1 306 OLD PL YMOUTH ROAD, BUZZARDS BAY, MA — -- -