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HomeMy WebLinkAbout0262 MITCHELL'S WAY - Health 262 Mifchell;s wWaYA , , , 'Hyannis :F/R f _. 1 TOWN OF BARNSTABLE LOCATION L11 CA i) SEWAGE # 2G()y'6 y VILLAGEIANi QA,csk5 con ASSESSOR'S MAP& LOT a U-- f INSTALLER'S NAME&PHONE NO. S lG—Vsa A e_o D e. SEPTIC TANK CAPACITY I O© Gc,i Iot1S LEACHING FACILITY: (type) '(✓eJ i i 2G 3 ®'S (size) 310�LA 1XIJ Q OF BEDROOMS 4 ¢EJUILDER OR OWNER i 1 PERMIT DATE: 12—2— U-1/— COMPLIANCE DATE: j 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 l►5 S+ J � tilt TOWN OF BARNSTABLE LOCATION Meg, M its�i t,5c.��1 SEWAGE # VILLAGE H�Q- 0,,1 -e, -n-j ASSESSOR'S 0 OTI U I INSTALLER'S NAME&PHONE NO. PE SEPTIC TANK CAPACITY 1-,5'00 @a//off LEACHING FACILITY: (size) l 4& NO.OF BEDROOMS 14 9LTILDER OR OWNER f ,:!X('C.0 {� INSPECTICNN 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„_ � � s d lK i -------------- LWAV0",`d VdLI,A,GF�, SIGyO t-3 ASSESSOIZ'S'lti 'Al AMR!'. �tA &P�atdE ivC1 - LEACIING= Ac .tt ) %� I} 33o scsgl S xo.op�snoors Separat►on Distance Between Ehe Maxunum Adjusted Gz�andwater Tale to the Bottom of Leaching Fatity. Fee€ PnYate,fitater,supply4te11 andsLeacduttg paciltty { aaY ws exut an site or.vn n 2t34 feet of lead R.far. ty) G Edge of We#daad and"Leaehug 'aaaci3Ziy(Ff ariy wettarids exist witk�un 3 Feet. IG Furntsi3ed iay.> -_ - -- lV \ 1 , 1 F.:z- bs C W W v �� � .— U-A Commonwealth of Massachusetts a= Title 5 Official Inspection Form 0 . Subsurface Sewage.Disposal System Form-Not for,Voluntary Assessments rro� 262 Mitchells Way Property Address Poliana Milagre; Owner Owner's Name information is -.� required for every Hyannis MA 02601 7-12-17 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. A. General Information �� aW4 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name i P.O. Box 73 , Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that 1,have personally,inspected the sewage disposal system at this address and that the information reported below is true,.accurate and complete as of the time of the inspection. The inspection was performed based on my training,and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)'The system:' " ® .Passes ❑. Conditionally Passes ElFails ❑ Needs Further Evaluationrby the Local Approving,Authority 7-12-17 Inspector's Signature " ` Date The system inspector shall submit"a copy,of this'inspection report to the Approving Authority (Board of Health or DEP).within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or'greater, the inspector and the system owner shall submit the report to the'appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer; if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �o I/S Commonwealth of Massachusetts :a=1 (,,z Title 5 Official Inspection Form a it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,_�_;3!✓ 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts laa Title 5 Official Inspection Form ' it Subsurface Sewage Disposal-System Form -Not for Voluntary Assessments 9rY 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 } page. City/Town 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 sewagd'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 replacbd ❑ 'Y ❑ N ❑ ND (Explain below): ty ❑ 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 ❑ 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 F 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 l Commonwealth of Massachusetts al Title 5 Official Inspection Fora f Subsurface Sewage Disposal System Form Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 17 r Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form =Notfor Voluntary Assessments , a/ `� �.;!✓ 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name z information is required for every Hyannis c;t.". T MA 02601 7-12-17 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: r❑ ®; :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 Y ❑ ' ® '`tributary to a surface water supply. ' ❑ ® r> 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 ' R 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.", y The's stem fails.)shave determined that one or more of the above failure El ®- : � ? 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 15,0,00 gpd.. x 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 ❑ A 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 s Area-�IWPA) or a mapped Zone II of a public water supply well r 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 �I,. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 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 built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts 1a=1 Title 5 Official Inspection Form 11' � Subsurface Sewage Disposal,System.Form =Not,for Voluntary Assessments 262 Mitchells Way t J' Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 page. City/Town State Zip Code Date of Inspection D. System Information Description; Number of current residents: 4 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 years usage (gpd)): Detail: Sump pump?- ❑ Yes ® No Last date of occupancy: 7-2017 Date Commercialhndustrial Flow Conditions: i Type of Establishment: ,.Design flow (based.on 310 CMR 15.203); „ Gallons per day(gpd) C, 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 ai Title 5 Official Inspection Form �N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is Hyannis MA 02601 7-12-17 required for every y 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: Owner--pumped 5-2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ cesspool Single 9 ❑ 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 Commonwealth of Massachusetts f Title 5 Official Inspection Form . W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre 4 Owner Owner's Name information is required for every Hyannis r'' MA, 02601 7-12-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) f Approximate age of all components, date installed (if known) and source of information: 2004 ;, _ U .- Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan);'r, Depth below grade: ~� ,' i 30,.feet Material of construction: • r ❑°cast iron 0'40PVC` .'` D'other(explain): v, Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan):. Depth below grade: 24"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: 1500 gal Sludge depth:. 4" t5ins-3/13 Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts :aa z Title 5 Official Inspection Form EI 1I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 page. City/Town 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 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: P 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-Fage 10 of 17 Commonwealth of Massachusetts �+ Li Title 5 Official Inspection Form �., Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments -�_,�!�% 262 Mitchells Way Property Address . Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 City/Town/Town r State Zip Code Date of Inspection page. Y P P 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.): 4 . " 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 ,a=1 Title 5 Official Inspection Form f, ' 1A Subsurface Sewage Disposal System Form Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 page. City/Town 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. 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•Fage 12 of 17 Commonwealth of Massachusetts l� Title 5 official Inspection Form �f;�, Subsurface Sewage Disposal System-Form -Not for Voluntary Assessments 262 Mitchells Way , Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis '. : "' MA 02601 7-12-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type ❑ leaching pits number: ® leaching chambers number: 5-Cultec 330's El 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.): Cultec leach field in good working order and empty at inspection with no sign of back-up into d-box or observation port. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts �aa Title 5 Official Inspection Form f i,-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 page. City/Town 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 a=1 P Title 5' Official Inspection Form Subsurface Sewage Dis osalS stem Form'-Not for Voluntary Assessments 9 p Y rY v 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name ; information is required for every Hyannis '. MA 02601 7-12-17 .' 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 4 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 , - Ct JLIJ f f ,t -7 3.7 P f y5 f7 .r 14 ; t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts ia=1 Ll Title 5 official Inspection Form f Subsurface Sewage Disposal System Form Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show groundwater at greater than 12'. 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 Commonwealth of Massachusetts :a= o Title 5 Official Inspection Form 1 �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 262 Mitchells Way Property Address Poliana Milagre Owner Owner's Name information is required for every Hyannis MA 02601 7-12-17 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 i ' I I { t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 fi B I yDate: © n /Q /0 TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: A,9 C-7 C(l S CC CA L' J & BUSINESS LOCATION: 2C2.2 Ai i tc i-1 C'.C.L S EVI y M MAILING ADDRESS: 19 Mail To: TELEPHONE NUMBER: � 36- 9S I Board of Health Town of Barnstable }�V,r CONTACT PERSON: C r D L O o o V ZA P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: S0 a 7Z� - ab ; y Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic hazardous materials listed below, either for sale or for you own use? YES NO ( This form must be returned to the Board of Health regardless of a es or no answer.y y Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or ) coolants stems Drain cleaners systems) NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners + Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor & furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS F-ALED INSPECTION COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION IvAP � O LOT TITLE.5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: a(„Q, ('fl _ Owner's Name: �, Owner's Address: Flo� • rn kG 11 tJ rxy i4jan ni-6 f`nc � RECEIVED Date of Inspection: 1 i i 4S id 4 Name'of Inspector: (please print) NOV 2 4 2004 Company Name: ° iS�S L•l `Mailing Address: P,O, 56)(. TOWN OF BARNSTABLE -3 HEALTH DEPT. Cen�rer:�;l��i � � Telephone Number; 60q--q 45-- HG 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 Needs Further Evaluation by the Local Approving Authority Fails .Inspector's Signature: 6—S < Date: .145 JD i4 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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 ' r Page 2 of 11 OFFICIAL INSPECTION FORM'--.;NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAOYSTEM INSPECTION FORM' PART A CERTIFICATION(continued) Property Address: Cad fi) �G11,ej6 ,J;�y Owner: nlrrt-t;® Date of Inspection: 111 i q IOLA Inspection Summitry: 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 aipproved 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: J omObservation of sewage backup or break out-or high static water level in the distribution box due to broken or scted 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(;)awzeplaeed. 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: Page 3 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3�fa f(1,tGhzil JCL» Owner: Date of Inspection: 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: n Q Cesspool or privy is within 50 feet of a surface water DA Cesspool or privy is within 50.feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: (A 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. (A The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well,water analysis,performed at a DEP certified laboratory, for coliform be a ter'is and vo latile organic compounds g p ds indicates icates that the well is free from polluti on ion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: f Page-4 of 11 OFFICIAL INSPECTION FORK—NOT-FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DIFSPONAL SYSTEM'INSPECTION FORM . PART.A . CERTIFICATION(continued) Property Address: h N�j�n�S 1fYlc� Owner: .M[2Mc> �1� Date of Inspection: i i I 195 1 O0 i D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ Backup of sewage into facility or-system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less.than 6"below invert or available volume is less than day flow Required pumping-more than 4 times in the last year NOT due to.clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface P P �'Y urf ce 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.-IThis system passes if the well water..analysis, performed at a DEP certified laboratory;for caUform 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 Sppm,provided that no other::failure criteria are triggered.A copy of the anal ysis mustbetiftclied to this form. �(2a(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as. described in 310 CNM 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E. Large Systems: To be considered a large system the system must serve-a facility with a design now of 10,000 gpd to 15;000 gPd. You must indicate either"yes"or"no"to each'of the following: (The following criteria apply to large systems.in.addition to the criteria above) 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 waterisupply — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply 1 well If you have answered "" es to any y 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. F ' Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: M i�ahe-ILG Owner: AP�^e,i� Date of Inspection: it h4S ipil 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? 1� 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 mamtenance of subsurface sewage disposal systems? II 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 toe Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approxiination of distance is unacceptable)[310 CMR 15.302(3)(b)] v i Page 6 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ( SUBSURFACE SEWAGE:I)ISPOSAL SYSTEM INSPECTION FORM PART C ... SYSTEM INFORMATION Property Address: M .j!C p tic; )a CA Owner: 110 f'1'o 1 Date of Inspection: . j 1 )t'7 jo FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Imo_ Number of bedrooms(actual): 14 DESIGN flow based on 310 CUR 15.203 (for example: 110 gpd x#of bedrooms):�_ Number of current resident s: Does residence have a garbage grinder(yes or no):00 Is laundry on a separate sewage system(yes or no): f)a [if yes separate inspection required] Laundry system inspected(yes or no):Jam; Seasonal use:(yes or no):'y , Water meter readings,if available(last 2 years usage(gpd)):jamr,- Sump pump(yes or no):ny' . 30 Last date of occupancy:jp jOLi COMMERCIAL/INDUSTRIAL Type of establishment: . Design flow(based on 310 CMR 15.203):_ Qnd 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: (� Q Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ASeptic tank,'distribution box,soil absorption system .r Single cesspool Overflow cesspool —ivy _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: l Were sewage odors detected when arriving at the site(yes or no):fj l Page 7 of 11 OFFICIAL INSPECTION FORM—NOTYOR VOLUNTARY ASSESSMENTS (� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: Owner: Mar-j!X,_) .Date of Inspection: it l j 5loL BUILDING SEWER(locate on site plan) Depth below grade: : r j- 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: Material of construction: concrete—metal--fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance es or no : attach a P (Y )._( copy of certificate) Dimensions: Sludge depth: ) Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _ Distance from top of scum to top of outlet tee or baffle: H'�. Distance from bottom of scum to bottom of outlet tee or baffle: D(� . How were dimensions determined:_jpS i f' tica 'Ye-1.0 e✓ Comments(on pumping recommendations,inlet and'outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Oki' GREASE TRAP:Mlocate 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 l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:A M.kK albWay Owner: Siluc' Date of Inspection: i 11 Ia'1©o TIGHT or HOLDING WANK:jak(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.): i' DISTRIBUTION BOX: (if present must be opened)(locate.on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,'etc.): ' PUMP CHAMBER: O (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):. Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM (C PART C SYSTEM INFORMATION(continued) Property Address: 6 liyann�• ;�.� Owner: 0)CxEes Date of Inspection: 1f!� jC)J4 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): C + _.fi me_ e4 Both p i+_'C he'd (y1or4p. m 'rYvan Se.p�%c; E-2n Slui0 1itl� - - p o ,CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 0 Page 10 of 11 OFFICIAL INSPECTION FORM=SNOT FOR VOLUNTARY ASSESSMENTS t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 9,(G Owner: 'Date of Inspection: I1 �p 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. ko 4A > 3 i i Page 11 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: a(a), M i t-G n e fly; W6LI V Owner: M a rno A j)r?,0 Date of Inspection: ��i i4S iCSf SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system;design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: • 11 No. U�t'{ ( 4 Fee /UU— THE COMMONWEALTH OF MASSACHUSETTS Entered in compute Yes PUBLIC HEALT161VISION -TOWN OF BARNSTABLA, MASSACHUSETTS 01p plication for ;Dfopooal Opotem Cottetruction Permit Application for a Permit to Construct( . )Repair( upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2 6 Z Al iTL1iG1(S 04 r Owner's Name,Address and Tel.No. Assessor's Map/Parcel a Gj M Aa Co R 6 rev z4 Z Mi.Tc4e%% cszay Aay!S 11� jej Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. R►Ga rd i4 �06`�L8—`�c2 S `y(.>723f e e�rvt� o$ - fu, ,3,, x �3 / o�. EST 6�OQ-e. S �.c 6 x-- Al K1 V 43 N Type of Building: Dwelling No.of Bedrooms q _ Lot Size sq.ft. Garbage Grinder( ) Other TI pe of Building 5i ail e- F-h-n No.of Persons Showers(✓f Cafeteria( ) Other Fixtures Design Flow V gallons per day. Calculated daily flow yV a gallons. Plan Date 12-4-c `{ Number of sheets Revision Date Title MAreoR rev Size of Septic Tank Type of S.A.S. Ceath �'��� C�ifiCf_ 33o Rec4*-ITP Descri tion of Soils S 4 /®. ��� C. $ e o V /L 3(.off got., ►2 y�o y r 1 ��- e_ S /Ccac�rs �td o Nature of Repairs or Alterations(Answer when applicable)_ u 0 crr A-�,c t te4a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date i Z - 7—Zda'� Application Approved by N Date 1.2- 7 `p Y Application Disapproved for the following reasons Permit No. 0i!j— / Date Issued No: U��1 r s Fee �U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. 'PUBLICHEALTH, ... �n Yes t *DI�/F�ION -TOWN OF BARNSTABLAoMA,SSACHUSETTS ZppYicatiou forlDizpool *pztem Cou.�truction Permit Application for a Permit to Construct( ` )Repair(1/J Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 2 6 Z M iT L t.,G'1 l S L4 A�/ Owner's Name,Address and Tel.No. Assessor's M ^ap/Parcel C M(A2Co A 6 re d�� //I ! 2{O Z M� TC�vPI/S /wJ�Y fll9NiS /`7A pZ,Gol , Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Ov 1 314-C.IC E/')i.1 e e r r✓PMAO q }�� -`�/6,•`23( to try®S-r G r S 7 I s. 2-- d 2 d L 3 N t Type of Building: Dwelling No.of Bedrooms q Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 5i-1.11 c. F4ri r( __No. of Persons Ll Showers(✓1 Cafeteria( ) Other Fixtures Design Flow �yt) gallons per day. Calculated daily flow �IY� gallons. Plan Date..f 1 Z-q-o c( Number of sheets / Revision Date TitleF� eo A rev Size of Septic Tank /Pao C�IfiF 330 Re p Type of S.A.S. Cc n. c(, F, cad �w;rrrr Description of SOO) LQ4�IA.�, S&,Cj /o./t?!jb �3, C-OAA!, 5avl d �o c.i it Gf 3 C.QMC e S'rQ A /O YX 7/fit !Nature of Repairs or Alterations(Answer when applicable) u nc I a�e. o� Ge%1C�, ,he Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certify- C cate of Compliance has been issued by this Board of Health. - Signed Date t Z -7—Z oc Y U Application Approved by Date 1.2 7.: Application Disapproved for the following reasons Permit No. :2 i N f,N Date Issued 2 - 7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(✓) Abandoned( )by L e at '7 6 2 M,4,_kullf F4,7-"4,1 m has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2 uo q-6 `�G/ dated /.t -'7-b Installer Designer The issuance of s rmit shall not be construed as a guarantee that the system wil a ion as desi ned. Date 2 Inspector _ _ .._ ,. .. 02 U�`T -- —----------- ------- — . . u_ - . . No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=i$po!5al *pgtem Construction Permit Permission is hereby granted to Construct( )Repair Upgrade( )Abandon( ) System located at a(n 2 kv) -I-cAc //l wt-L, 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: Constructi n must be completed within three.years of the date of � uu Date: i ° �' Approved by r Town of-Barnstable �o RegulaxEory SeI-vices snrtrte;>g�sa Thomas F. Geiler,Director Public Realth Division Thomas McKean,Director 200 Maiu Street,Hyannis,NLA,020U:I Office: 508-8 52-4644 Fax:-508-790-6304-— Iustaller& Desi er Certjfrcanion orzn Date: _ ". �, 0 Design.er: C. _4 I Address: V"��'- - )T Address: J. ►3 ox 7�3 �C1-Z(03 z On was issued a trrzut to install a . septic system at 2-62 Mt based on a design drawm by c� (address) �L c� ►c. del C>jv d JtiC daccd (desi�zer) , T cezti£y that the septic syster.'n referenced above was.inst?t1ed, sul�rtanti.3l:i:y accorciit�.g to the design_, which may iu.c:lude minor approved Q}jaages ,-11c as Iattauteial iel�icataox� of tine distribution box and/or s.:PGiq.tank. T certify that the septic system re:feroriced above was installed wi1I1 major changes (i_e_ greater than 10, lateral TelocatiQv of the SAS or a:ay vertical relocation.or an.y Certified as comps}vent Of the septic system)but in accordance with State&Local Regulations. i'laxz revision or __--built by designer to,follow— -_T - - (Ins ez's Sign . pre). ' ' JANIES A PAVLIK QViL481 A c ,n (/S (Desa cr's Signature} (Affix D xnp Tier ) EASE RET LTRN TO BARl` sTABLE4 I'ITBLIC -TH DM_910N. CERTMCAT]E OF C"OMPI,IA CE ,I, NOT BE ISSUED j7N 1501�A HIS �ORM AND AS- UARD. RE REv.,DBY LI �aLNISrABE Y�u�T } a cT �rrA nxs �z _ Q:FZasith/Sc-pticlDe.4i�ner Ccl�catinu Penn - i a• TOWN OF BARNSTABLE LOCATION i lae e 11®5, L'I Ct ai SEWAGE # 2bo y.-b I VILLAGE 11ctAN 'T _ ASSESSOR'S MAP & LOT o� U- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACrrY 1 5O® Caci LEACHING FACILITY: (type) 3 3CJ'-e, (size) 3(o,L A J, tJ )(aN Q NO. OF BEDROOMS l-I BUILDER OR OWNER PERMITDATE: /:)--`7--& COMPLIANCE DATE: 1� 0 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 Furbished by �a. m tC- ,-���� Lime14 a - Cs 1 1 i COMMONWEALTH OF MASSACHUS TTS ENTAL AFFAIRS EXECUTIVE OFFICE OF ENVIR DEP ARTMENT OF ENVIRONMENTAL PROTECTION F Z n J V TITLE 5 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS BSURFACE SEWAGE DISPOSAL SYSTEM FORM T SU pART A CERTIFICATION ` Property Address- owner's MITCHELLS WAY 14YANNIS,MA 02601 ate► a- ��� � p TOM,GUSCIORA A 02601 Owner's Name: 262 MITCHELLS WAY.IIYANNIS,M Owner's Address: REGEIVED Date of inspection: 5/29/01 JUN 2001 lease prin JOHN GRACI Name of Inspector: (p t) SEPTIC INSPECTI ONS 02536 Company Name: P.O. BOX 2119 TEATICKET,MA. TOWN�LTH DEPT. Mailing Address: Telephone Number: 508-564-6813 FAX 508-564-7270 .below is CERTIFICATION STATEMENT (lisp(sal system at this address and that the don my training a reported n and ersonally inspected the sewageinspection was performed based on my roved system 1 certify that I have p ection.The true,accurate and complete as of the time of the inspsewage disposal systems.I am a DEP approved ro er ectifunction 15.340 of Title 5(310 CMR 15.000). The system: experience in the p p inspector pursuant to Section . }( Passes Conft aluation by the Locses al Approving Authority _ Nee Fai Date: 5/29/01 Board of Health or DEP)within Inspector's Signature: roving Authority( d or greater,the f this inspection report to the App n flow of 10,000 gpectorshall suY stem or has a desig final should be The system insp office of the DEP.The origs of completing this ine s stem is a shared syro riate regional 30 day applicable, and the approving authority. inspector and the system owner shall submit the buyer, report f pp app sent to the system owner and copies sent to the buy TWO YEARS Notes and Comments CTION.RECOMMEND PUMPING NOW AND EVERY ONE TO THE SYSTEM PASSES TITLE V INP TO PROLONG THE SYSTEM'S USEFULL LIFE. at that time.This or different conditions of use. ie time of inspection and under the conditions of use ****This report only describes C.oue systemdiollS tw II perform in the future under the same inspection does not ad dress Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information 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: THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: , _ One or more sY stem comp onents 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. n/a 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: n/a n/a 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:n/a n/a 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: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 E 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply.or tributary to a surface water supply. _ The system has a septic tank,and SAS and the SAS is within a Zone 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 n/a "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. i 3. Other: n/a I� I Page 4 of 1 1 4� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or,"no"to each of the following for alLinspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. " _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X An portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. y p P P vY p X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well X Any portion of a cesspool or privy is.less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or` less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.[ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 � X the system is within'400 feet ofa surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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.II lie owner or operator of any large system considered a significant tltre�t 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. n Pa'ge5 of*II OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 262 MITCHELLS WAY HYANNIS, MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period'? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? i X _ Were all system components,excluding the SAS, located on site'? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? , X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example,a plan at the Board of Health. X _ 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)], Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 5 ' 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)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL ' Type of establishment: n/a ' Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,•date installed(if known)and source of information: I 1996 i Were sewage odors detected when arriving at the site(yes or no): NO Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 BUILDING SEWER(locate on site plan) Depth below grade: 30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: 24" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate). Dimensions: 150OG L 10' 6" H 5' 6" W 5' 811" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: n/a Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STURCTURALLY SOUND. RECOMMEND PUMPING NOW AND .EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete,metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 DISTRIBUTION BOX IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on,site plan) Pumps in working order(yes`or no): NO Alarms in working order(yes or no):NO Comments(note condition of,pump chamber,condition of pumps and appurtenances,etc.): n/a i Page 9 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits,number: 2 n/a leaching chambers, number: n/a n/a leaching galleries,'number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name9Y of technology: n/a Comments(note condition'of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PITS APPEAR TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a y PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 1 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. llsi_I leek. . g n � AC 3 c Fl n S° ❑ s l}C qo U11 33 E 51 F t { I P Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 262 MITCHELLS WAY HYANNIS,MA 02601 Owner: TOM GUSCIORA Date of Inspection: 5/29/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 19+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) YES Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED FROM ENGINEERED PLANS-19+FEET 4 4 TOWN OF BARNSTABLE LOCATION _'c�k4 � t &19A�fZj .l yc� .� SEWAGE # VILLAGE ASSESSOR'S MAP&LOT P0 - INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) - 1haq Q\-E� (size) X. l NO.OF BEDROOMS Lk B-TJ-TLDER OR OWNER )fR10 X� kT-f►-& ,N CJ PERMTTDATE: �16 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility -`CA Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) y\ Feet Edge of We and Leaching Facility(If any wetlands exist within 300 feet of leachingfacility) Feet Furnished by 14ctLC P v s3� 6s 75 o Li to Os ASSESSORS MAP N0: No. �` PARCEL Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2ppitcation for Mi5poai *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. `�-(D �li`I��5 w� C�o�'�'� fl►,�x. �o..5a>�o uAp �lYi�cl,�ll's Gv� ,�;5 Installer's Name,Address,and Tel.No. 2/ '1.Q�23 Designer's Name,Address and Tel.No. 010i N4L17-7 �}urc, i �/Y Vita,ti��b�� IZic, ��e�f+�C� i 3 t 4r b<.o(sfO Type of Building: i/Dwelling No.of Bedrooms. Garbage Grinder( ) Other Type of Building (tilditYlAl No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow W gallons per day. Calculated daily flow 7'(/ gallons. Plan Date Number of sheets Revision Date Title l-ItZ Description of Soil A Nature of Repairs or Alterations(Answer when applicable) 0.1 5 TlG roAk o J14flUiv, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment 1 Code and not to place the system in operation until a Certifi- cate of Compliance has been issue is Board o t Signed Date 2 114 Application Approved by — Application Disapproved for the following reasons Permit No. Date Issued ---------------------------------------- �,.'�iw� Lt+4}Xw ;h�=ws�...::a«c.^�v_' .F.,..: .�v..xw'+.,» w-,;w.�R"'caY.,�).hri u'.7;�� .w�`:f:.^n+-cr�h�_assl"r(.:^'-w'�',..i^ .., at.,rti.�:.% .I��r.n fir,••..,:>�u:.+:::i"`vw..'-+sir i.' .. , to Fee _ U� e THE COMMONWEALTH OF MASSACHUSETTS 1 PUBLIC.HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS 01pplicatton for Digpogal *pttem Con5truction Verrnit Application.is hereby made for a Pem-it.to Construct( )or Repair( )an On-site,Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. �(v ,l�li�d���� w� �Lo��� OAv� �-5a>^� 2�� �7c�eI�L G.v�� �ya>1n►5 a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � 7/ Gjq 13/ sy►'�r hays �,s,�vfl -Type of Building: ADwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building I e i No.of Persons Showers-(- ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow q (/ gallons. Plan Date Number of sheets Revision Date iLn•c... Title_ ' time t110-k 0�al\ Description of Soil Nature of Repairs or Alterations(Answer when applicable) Md, 15,60 4 S &, a>n k to t�p)I i� f r,.U l'u'p, o fW0 co,yl ra �rsgj am Date last inspected: t, Z.,{ Agreement- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment I Code and not to place the system in operation until a Certifi- cate of Compliance has been issue is Board o t G Signed Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION'"%BARNSTABLE, MASSACHUSETTS Certifirate of Comphance . f THIS IS TO CERTIFY,that th n-site Sewage Disposal System`stalled( )or re aired/ placed( )onb by --' for as <G' has been constructed 'n accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. / dated Use of this system is conditioned on compliance with the provisions set forth ow: No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS D gpo$al *pgtem Cow5trurtion Vermtt Permission is hereby granted to 152/P to construct( )repair(?-'San On-site Sewage System located at zi 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. All construction must be completed within two years of the date below. Date: Approved b �•� r Town of Barnstable • Department of Health, Safety, and Environmental Services 1 59.CAB ' Public Health Division 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health January 23, 1996 Carl Currie 14863 Evergreen Detroit, MI 48223 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 262 Mitchells Way, Hyannis was inspected on October 31, 1995 by Robert Bortolotti a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 daily flow. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health � I! [Installer letter] TO: a �lw ORDER TO COMPLY WITfI 310 CMR 15.00, THE STATE ENVIRONMENTAL c CODE, TITLE 5. � �;t; ¢�' ��f/�'�1 The septic system owned by you located at Q � � was inspected �� �� ��'� a Massachusetts licensed septic on AO inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: � � '0" v i411 C.��"15 ller to submit a You are directed.to hire a licensed Town of Barnstable septic f HealthaDivi on Office sketch diagram of a proposed system to the Town of Barnstable (Town flail, 367 main Street, flyannis) that will bring the septic system into compliance with 310 CMR 15.00 00 The Slate Environmental Code, Title 5 within (14) fourteen days of , receipt of this notice. compliance within thirty (30) days of septic is system into p d to bring the y You are also directed g P receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Town of Barnstable BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A IESSORSMApN CERTIFICATION VARCM t Property Address: Date of Inspection:/O- /-qS Inspec or's Name. Owner's Nanicand Address:_�72:zc JP(y &.7 ;2 Z i CYCRTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes Needs Further Ev luation By the Local Aproving Authority Z Fails : Inspector's Signature: Date:_ r// `�� The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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. INSPECTION SUMMARYo. A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. F Indicate yes,nor,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,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved b The e Board of PP Y Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken 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): -1- 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)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 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 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply 1 well,unless a well water analysis for colifonn bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYMM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SU SURFACE SEWAGE DISPOSAL SYSTEM IINSPECTION.FORM PART A CERTIFICATION(continued) 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 I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with.no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a.system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is'withun 400 Feet of a surface drinking water supply The system is within 200 Feet of atributary to a surface drinking water supply The system is located in a nitiogen 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 bring the system and facility into full compliance with the ,y, groundwater treatment program requirements of 314 CM R 5.00 and 6.00. Please consult the local regionaloffic e of the Department for further inform a i ' .t SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PA RT B CHECKLIST Check if the following.ownng have been done: kPumping information was requested of the owner,occupant,and Board of Health. !-None of the system components have been pumped for atleast 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 obtained 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. k The site was inspected for signs,of breakout. . L�,All stem c system omponents,excluding the Soil Absorption System,have been located on site. ' _,, The septic tank manholes were uncovered,opened,and the interior of the septic tank was in m spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, �epth of sludge,depth of scum. e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- . 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) ✓The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: // Design Flow: allons Number of Bedrooms: y' Number of Current Residents: Garbage Grinder: /0 Laundry Connected To System: Yes Seasonal Use: �7 Water Meter Readings,if available: Last Date of Occupancy:COMMERCLAi t NDUSTRL4, :/V/0 Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informati u:L?-C-1�2111111 6System Pumped as part of inspection If yes,volume 'Pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System i Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PROXIMATE AGE of all com nents,date installed(if known)and source of 'nformation: Sewage odors detected wh n arriving at the site: D -4- i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade:p g Material of Construction: concrete metal FRP Other (explain). -- Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.) GREASE TRAP: Depth Below Grade: Material of Construction: concrete metal—FRP Other (explain) — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: 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.) TIGHT OR HOLDING TANK: Depth Below Grade: Materia l of Construction concret e me tat FRP r Oche (e xplain) 'n— _ _ ( xp at ) Dimensions: Capacity: - gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float.switches,etc.) DISTRIBUTION BO.X: Wd Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: /�-6 Pump is in working order: -- r Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) -S- I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):,/Q (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool, number: Comments: (note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation, etc.) CESSPOOLS: Number and configuration: f Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer-. Dimensions of Cesspool: 0 l P Y P Y �—� Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failu , level of ponding,condition of vegetation, etc)ZzS (� / - �s o k Q6 e ss VA .f t PRIVY: rl('e � Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -6 TOWN OF BARNSTABLE LOCATION' SEWAGE# h VILLAGE i� llA S ASooESSO ' MAP &LO'19d/W SMs7 NAME&PHONE NO. /O '2221 � 02 S7PTIC TANK CAPACITY / LEACHING FACILITY: (type)d.S dd���� (size) GOO 4b.OF BEDROOMS T BUILDER O OWNER ��/�'7PS PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tab't and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 11114 Feet Edge of Wetland and Leaching Facili (If any wetlands exist ' within 3 of 1 achin fac' ' � Feet Furnished b ) U� � � �_ � J ,(� I Lr i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. . 6(0 DEPTH TO GROUNDWATER: Depth to groundwater: /5� Feet � YOX������iO/f7 � f� � Method of Determination or Approxim 'on: -7- y St;��.c.'T lc�n� ,. ��Lows . BENCH MARK: TOP OF FND. _ ELE.= TAT r W>4 i (SAS) SHALL BE t4 S MANHOLE COVERS TO EXTEND TO 35,Z5LONG WITHIN 6' OF FINISH GRADE L.2.,33 WIDE Y L h1 2' DEEP tA " 2X BAFFLE.REQ'D t 33.85 Esc�sT 1161 Io t X EL=33.91 57 t,00O 3 _. D.B. -- - - ^% 2' PEASTONE TOPPING GENERAL NOTES: T A IJ K CAP ENDS .. - ELEVATIONS SHOWN BASED ON U.S.G.S. DATUM.SYSTEM PIPE SHALL BE EITHER C.I. OR SCHEDULE 40 P.V.C. :`- 3/4- DOUBLE WASHED - THE BOARD OF HEALTH SHALL BE NOTIFIED EL- -- STTONE ALL AROUND SEPTIC SYSTEM. ' } 3o/9� - SAC TSYSTEEM STRUCTURAL COMPONENTS rj —I SHAH BE CAPABLE OF WIIHSIKNDING A 20' MIN. H-10 LOADING. UNLESS SPECIFIED OTHERWISE - 2.0SO(L TEST —31• 0 -SEPTIC SYSTEM UNDER DRIVEWAYS SHALL COMPLY WITH A H-20 LOADING. PERc �` z '/l"`�` PROPOSED SEPTIC SYSTEM - USE FIVE(S) 4uc.TEC -THE DESIGN AND COMPONENTS OF THE SEPTIC MODEL NO.`3$O. REGidAaveJE; c Pj SYSTEM SHALL 8E IN COMPLIANCE WITH THE DE.M ELLY.— .'35 o 5(o NO .SCALE WITH 4.0' OF.STONE O: SIDES Zc LoA►�y Salvo co YR 4�T & 2.0' OF STONE O' ENDS STATE OF MASSACHUSETTS SANITARY CODE ,. °T.o P!~y SR�►D IUy,c L TITLE V. AND SHALL 13E IN COMPLIANCE WITH /3 NO STONE AT BOTTOM THE LOCAL BOARD OF HEALTH RULES AND z4 .33"56 E'L = 2 5 • I d REGULATIONS. THE CONTRACTOR SHALL BE RESPONSIBLE FOR c' CoP(ZSE 51��►� �� � SST IkDc.E LOCATION OF ALL UNDERGROUND UTILITIES AND 16 y IL -j l8 i SHALL NOTIFY DIG - SAFE PRIOR TO CONSTRUCTION. /7a -.NO GARBAGE GRINDER 132 :ZS•.to ' :►4OF, DESIGN CRITERIA: / V - NAMES A, yJ, TEST 3b 7. ?ptIiLl�� P.E. o PAVLIK DESIGN FLOW O s Z 7 A G RES �' CIVIL m 4 BEDROOMS AT 110 G.P.B. / DAY 440 G.P.D. 12, 1 2 1 o4 N R� ',cI O / C.ct i l 1 q I QUIRED SEPTIC TANK Qo WXTM o RSEf-V i R� - I to ° USE x 15 ,600 c�Rc- TA�►rc \ ( To REOAir O �ss6/ T Q SEPTIC TANK PROVIDED 11 t E DESIGN PERC RATE <2 MIN/INCH . ) 1 ls, b =: 3(p SIZE OF REQ'D (SAS) AREA = 440/0.74 595 S.F. � - � ti �1 Ile\ r SIDEWAIIZ 2 3 S�qb BOTTOM �12 39 C35:25 :434.,(, '17 3F �x SIZE OF LEACHING FACILITY PROVIDED: 116.3t + S.F. _ 4-z3 _ S.F. G.50 EFFECTIVE DEPTH: 2' , LEGEND: c�', i EFFECTIVE LENGTH: 3S• 25 "r ti �k DaSTING CONTOUR EFFECTIVE WIDTH: 12.33 ————— �g 1 \.�- �'� A v - , WATER SERVICE NF-1M— F \ I EERING » 106 STREET TEST HOLE WEST GRdVE GAS SERVICE G—G— �' \ MODLEBORO, MA 02346 BENCH MARK rdBN K : WS 946-9231 S .oT t t.EJ 3 '� ��y PROJECT: SEPTIC SYSTEM REPAIR ¢fife F �• .#s`�{fJ��` ;r4-aa:a:s . ?:`--r,r `I'�E L. WAY jp ' irk 3 AS SHOWN onyx►r NOTE: E�q I 6 Z �- MAP 2QQ/ LOT I I .n PRIOR TO INSTALLING THE NEW (SAS) THE 1` G \ ` OWNER. �`R G o A (L E(.t, CONTRACTOR SHALL PUMPOUT ALL LOCO PoTS� � AND BACK FU WITH CLEM MEDIUM SANG G` ITS ARE MCOUNTERED IN THEc-.� Z Z VA T G t4 u,S. W A Y (SAS) ANFA THEY SHALL BE RELOMED ' I �. 1 _ 1\1 � � • NyRrJN ISM � p2�o( �` = to _ . � - ---- Z' - — ,. _ ., -, . - _ .. „ . , . _ , � , - i:, :,: 3 -::: ., :;`T ., , , ..,- - .., x - #': I - ,.:'. - /• :vN t : , .. "'t - ' r, -. , - 9 , , - ... , .. : _ i (. Y ". :.r r ,,. , ",: ta i - , - - r r :: , : ,.. .`: , ". .< x .� , - ,. ..::.. , t ... v; '. ., , r .. - .. ..- ..r :, . ..:. ,x , , „ , - , :'. :,. .. : ,. , .: , .. ,: .: , • , i c, , :`. ,:. >: ,., , _ ... , ,. - .'. -..:' t .Bier ,. :... +, , ,,: r J. .:.. r.. r :,} ,; is . , ,, , ::, . a : r , n - _ •t - ` ' , :>, ., .-' , .. • i _. .: y.', ,.< - Vk r• r :, : :' ' a} `< ,. ., r '- .-; , r" - -. .j . .. _ --- - .. - .- _ - - .. : ''.: , .- " . s'1 .. - V :. - . , Z j 9• " `S c `~�- 29 6 A 13 , 7 ' - f :, EXISTII� 1. I ; - 1000 SAL. , LE a{bA9 PIT , ,' III, , . .. Z . 9 . . 23. . _ 26 O P19GalOSED ' - p , 12 EX p �� �o eox LOCATION MAP �, o - . N .► ,, o „ ,,., z¢ S m�, o CAL E. 1 2000 Q , , 3 1 r . , m -.. �+aAaaFc , , . p ,w _,. 1 an , N aoo'eAL. . i ,. 9en is Tuvt >' W , .1 r.< EXISTIMS . 1000 SAL. ' � NOT a , L"a rW P17 REVIS PLAN QN MA Y 2 LOT s Ev. 1. s99e : p ., c� 25• TO sm* Ea?STXAW LEACHING"PI TS . 9454 S.F. , . ", . AAV PROPOSED:IWO 6AL. SEPTIC , o ,, • h TAAAYS AND'D-BOXES FQA.RIEPAIR T �c �. O - p . ,, AN EXISTING SEW✓ 6E•DISPOSAL SYSTEM ` ` , N • 11 r:I' iIi�;�"""I I"I"I � I I� Z S 7649 50 E h , 11 -: " „ ; . 120. 44 W a ,. . , . is 7 _. , EXISTIAe6 1.✓ p , N ,. 00O BA .17 f✓ t L. PACWOSED s ;, " CEAaIIMS ' T PT 1J00 6t�L. 1� H `; •. . . f SEPTIC TAnK O .. p , .- ..,--r Q f f, ZZ N ' • !� / f 1n , �- W u- s 11 n a ,.F'' "ox EXISTING . ., ' �. HOUSE yY a4O - I. V .~ " m / N , - H . rw, �,., I . L - ,I—__' -_ . � / _ ,• ,. (� , J ✓' EXISTING //� t000:BAL. 9 u, .. / LSo'MIM4 PIT II I II D ,/ I , A . . I . L L I I I I I I I - A, I '✓' . . . � 30• LOT 2. - . �/ ,� y 9210 S.F. . {`%9 s� „ ,, B . .� a 1 5 , . 2 5 - , 0 2 83.'34 1 ,. N 76 49 50 M II -~ - . / - . , y; . MI TCHEL L 'S WA Y l • , PLAN REFERENCE. BARNS TABL E REGISTRY OF. DEEDS 1r- . PLAN BOOK 243 PAGE 45 - Z . I. . 0 0 - . PLOT PLAN F 3 0- O LAND 4 �. , r L - , OCA ED IN >T w - O NREFERENCE. , , 'ASSESS SS 'ORS S MAP 290 _ _ BAf�NS TABLE h�YANN S I MA• ; PARCELS 119 6 12O . PREPARED FO R �; o+ . PARCELS '119 6 120 � . I. -„ .. , . I K. SCALE. 1 — 20 FT. N. B. - NO. 120 RICHARD x, CA - FERRE�RA � DA TE.' MA Y 6 1996 FILE -NO. MIWHC/P 20 10 0 20 40 r 60 No 31309 ,� PLAN NO. 05066PP DISC NO. 119 ,., SCALE IN`FEET _ FERREIRA ASSOC T IA ES 131 SPRING BARS `R OAD , : FALMOUTH — `MASS.� 02540 -.__ ___ _ . _ ,