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Home My WebLink About0690 OLD STRAWBERRY HILL ROAD - Health 690 Old S rawberry Hill Road. - ---Y - Hyannis A= 273 — 208 p F e a ° r Commonwealth of Massachusetts COPY Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is April Hyannis MA 02601 A 7 required for Y p � , 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: � T only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name r� PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 Cityrrown State Zip Code 508-888-2805 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority �!' �• '': April 8, 2009 �` InslsPctor's Signature Date o T' 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 4!; report to the appropriate regional office of the DEP. The original should be sent to the system owner - , C and copies sent to the buyer, if applicable, and the approving authority. 1 K. ****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. 690oldstrawberryhill-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 1 • r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is required for Hyannis MA 02601 April 7 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Property has been vacant since pumped Feb. 20, 2009. Solids and liquid measurments at tank were done at time of pumping. B) System Conditionally Passes: ❑ One or more system components as described in th °conditional Pass" section need to be replaced or repaired. The system, upon completio of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in e ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 2 ears old* or the septic tank(whether metal or not) is structurally unsound, exhibits su antial infiltration or exfiltration or tank failure is imminent. System will pass inspection if a existing tank is replaced with a complying septic tank as approved by the Board of/H Ith. *A metal septic tank t(pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indic ing that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, se ed or uneven distribution box. System will pass inspection if(with approval of Board of Health ❑ broken pipe(s) are replaced ❑ obstruction is removed 690oldstrawberryhill•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is Hyannis MA 02601 April 7, 2009 required for Y p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced / ND Explain: . ❑ The system required pu ing more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspa tion if(with approval of the Board of Health): El broken pi e(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of.Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environ.rf(e nt. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of apordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Kealth (and Public Water Supplier, if any) determines that the system is functiorng in a manner that protects the public health, safety and environment: ❑ The system has a septic�p k 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 sel}tic tank and SAS and the SAS is within a Zone 1 of a public water supply. / ❑ The system has,7�eptic tank and SAS and the SAS is within 50 feet of a private water supply well. 690oldstrawberryhill-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is Hyannis MA 02601 Aril 7 2009 required for Y p , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less th, fi 100 feet but 50 feet or more from a private water supply well". / Method used to determine distance: z "This system passes if the well water analysis/erformed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence o ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other fai re criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: s D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 690oldstrawberryhill-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is Hyannis MA 02601 Aril 7 2009 required for P every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate eit/rfn "t each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is withsurface drinking water supply ❑ ❑ the system is withtributary to a surface drinking water supply ❑ the system is loc-a sensitive area (Interim Wellhead Protection Area—IWPA) aY a mapped Zone II of a public water supply well If you have answered "yes"to a question in Section E the system is considered a significant threat, or answered "yes" in Section above the large system has failed. The owner or operator of any large system considered a signifi nt threat under Section E or failed under Section D shall upgrade the system in accordance wit. 310 CMR 15.304. The system owner should contact the appropriate regional office of the erartment. 690oldstrawberryhill-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is Hyannis MA 02601 Aril 7 2009 required for p every page. Cityfrown 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)] 690oldstrawberryhill-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is Hyannis MA 02601 Aril 7 2009 required for _-Y P every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): 2007+2008= 526GPD Sump pump? ❑ Yes ® No Last date of occupancy: Sept. 2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): aeons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Titl system? El Yes ❑ No Water meter readings, if available: a� Last date of occupancy/use: Date Other(describe): s r 690oldstrawberryhill•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is required for Hyannis MA 02601 April 7, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Ready Rooter records- Pumped Feb 20, 2009 Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Septic tank installed 1988, age of house. D-Box and SAS installed 06/28/01. As-Built and engineered plans on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No 690oldstrawberryhill•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is required for y H annis MA 02601 April 7 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 2411 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: 11 X 5 X 4.5 1500 gals Sludge depth: 3"at time of pumping. Distance from top of sludge to bottom of outlet tee or baffle t Scum thickness .211 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape measure and dop tube 690oldstrawberryhill•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is required for Hyannis MA 02601 April 7, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Feb 20, 2009- Inlet and outlet PVC tees are in place. Liquid level at outlet invert. Tank pumped and cleaned. April 7, 2009-Tees in place, gas baffle in place on outlet. Tank empty, no leakage into tank. Risers bring covers within 6"of grade. Grease Trap (locate on site plan): Depth below grade: / feet Material of construction: r' ❑ concrete ❑ metal fiberglass ❑ polyethylene. ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: f� Material of construction: r ❑ concrete ❑ metal ❑ fibe/rglass ❑ polyethylene ❑ other(explain): 690oldstrawberryhill-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is Hyannis MA 02601 April 7 required for p �il , 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons � Design Flow: gall ns per day Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and, oat switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover; any evidence of leakage into or out of box, etc.): One inlet, one outlet. Very light solids carryover. No sign of high water staining over outlet invert. No sign of leakage into or out of D-Box Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ,� ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 690oldstrawbenyhill•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is required for Hyannis MA 02601 April 7, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ea w/ 4 stone ❑ 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.): SAS located and inspected with camera. Empty at time of inspection. No sign of past hydraulic failure. Hand probing around SAS found clean dry sandy soil with stone. No sigh of ponding. 690oldstrawberryhill•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is Hyannis MA 02601 Aril 7 2009 required for p every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwe inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hyd ulic failure, level of ponding, condition of vegetation, etc.): /r 690oldstrawberryhill•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 690 Old Strawberry Hill Road Property Address Anne Facchetti Owner Owner's Name information is Hyannis MA 02601 April 7 2009 required for _Y P every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. l � I , , I I I l i f t 1 I 1 , 1 690oldstrawberryhill•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 14 �s TOWN OF BAR�STABLE LOCATION.1090 0LJ7 SEWAGE # 260I VILLAGE_ ASSIESSOR'S.MAP & LOT Za j ' I INSTALLER'S NAME&PHONE NO. ,� C' ,c�C°p SEPTIC TANK CAPACITY CX�STj - ti4 LEACHING F:4 II ITY: (tyPet� Q 1 eG,W�!17�Y5" ze i a: ( )' ZS'"' �C 13------------ �..Z si NO. OF BEDROOMS _ BITILDER OR OWNER PERMIT DATE 6 C MP Q LIANCE DATE.. Separation Distance Between the:-.. - Maximum Adjusted:Grounwater Table to the Botto.m.of Leaching Facility Feet Private.Water Supply Well and Leaching Facility`. ,y wells exist on site or within 200,feet:of leactung facility) `.'' -~ Edge of V�`etland and Leaching Facility(If any wetlands east. Feet within 300 feet of leaching facility) Furnished by' Feet fj�r.NT of klo `—tII -29 l r 1 ° s. i ! I. r TOWN OF BARNSTABLE LOCATION (; \0 SEWAGE# OCg�- 319' VILLAGE y S ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) .-)-S'0o C. t cam. NO.OF BEDROOMS OWNER PERMIT DATE:./9 Jg ( COMPLIANCE DATE: 6%?J® I 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 1 7 i b � v o ALJ �r °0 TOWN OF BARNSTABLE1 LOCATION IP9 0 OL19 ��W. �/?ll�Y �f� SEWAGE # ZGC1 ^,3�� VILLAGE �� /� yOx--f � LESSOR'S MAP & LOT '�� INSTALLER'S NAME&PHONE NO. ��.� C �4AAPQ SEPTIC TANK CAPACITY G�X'S71:cX-4 LEACHING FACEL=: (type�e '�W 4L'4 I C�1wtl 6v;',S (size) ZS' 13 tX Z 1 NO.OF BEDROOMS n BUILDER OR OWNER PERMTTDATE: e-— /2—A-/ COMPLIANCE DATE: b-Zt'8) 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 t 4 r � �,d � �, \ �X /` v �. �+. ' �'' O '1 �Q . .: C ' � �_ � ; a.e .�` � ' yd.. h' d1 -Y '� , ,p z , x $. � #� jib, � ; .- -. i'. - :. r No. Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for Mie;pooar 6psstem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual.Components Location Address or Lot No. &go d er F Owner's Name Address and Tel.No. Assessor's Map/Parcel a'7 3^Ot C A P;,5 0,k Installer's Name,Ad*Sao IM"CQ Designer's Name,Address and Tel.No. 350 Main Street W. Yarmouth, MA 02673 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alte ations(Answer y hen ap licable) _07S/A. Od e�evo ChArvJ /'S 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 o e th. Signed e., Date 4' l Application Approved by Date Application Disapproved or the following reasons Permit No. Date Issued ` Q e No. 9 Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS a = _ ZIpprication for Migogat *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. l 9v tjlCkl Z'4jt) e P NcOwner's Name,Address and Tel.No. Assessor's Map/Parcel /- r0 Installer's Name,Address, 1 l,'WOCA 6 ! Designer's Name,Address and Tel.No. 350 Main Street W. Yarmouth, MA 02673 Type of Building: Dwelling No. of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) _ Other Fixtures Design Flow gallons per day. Calculated daily flow ? i '�`j' gallons. Plan Date Number of sheets Revision Date f - Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alte ations(Answer�qyhen applicable) S/A.l� c� 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 o . e th. Signe _ �l 1 / i,_.. Date 4 I Application Approved by i i `�� li� ��l /1� J ;> Date Application Disapproved for the following reasons vU i Permit No. ^cw Date Issued IzvIllul THE COMMONWEALTH OF MASSACHUSETTS n BARNSTABLE, MASSACHUSETTS Certificate of (Compliance o:HIS IS TO CERTIFY,th the On-site Sewage Disposal System Constructed( )Repaired (/ )Upgraded( ) Abandon )by - ,W vU U at�O S�IIAI.1�2!1t��: -2d� P� i .ha e�dconstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No �"ldated fr Installer Designeh y. The issuance oft 's a "t shall not be construed as a guarantee that the sy to will f �tio designe . Date y1s, Inspector�w i Y: No. Fee s'V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogai *pgtern�0 gtruction Permit Permission is hereby ranted toonstruct Repair U/pi2ra ( >Ab�nd�on System locate d9 aZ / a wIC /;i ) and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions Provided:Construction mufst be cowithin three years of the date o ' Date: // I/M Approved by iv) ( f i / i 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED.PLANS) I, C64 x,V-4 v\ , hereby certify that the application for disposal works construction permit signed by me dated �� , concerning the property located at 6?0 d`�S�/ c�/! -w �� meets all of the following criteria: / This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. / The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed /There are no variances requested or needed. ' • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] )� If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation .0 +the MAX.High G.W. Adjustment. DIFFERENCE BETWEEN A and B SIGNED : V Y CDATE: c l [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert a — �6F 1 t 1 � .t "'n (/� fi _.l tt �: fir' TOWN OF B.ARNSTABLE LOCATION 0 S r fvJ 10 ,r s- U SEWAGE # VILLAGE ASSESSOR'S MAP & LOT I_ INSTALLER'S NAME & PHONE NO. f CApq., S9 99 -7 SEPTIC TANK CAPACITY I J' OO LEACHING FACILITY:(type) 1 (size) /OC C' NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERJC�t��% BUILDER OR OWNER oN lJ°i•9. G, - ;►l\ DATE PERMIT ISSUED: '2 —a ZZ DATE .COUPLIANCE ISSUED: VARIANCE GRANTED: Yes No } a� -` ASSESSORS MAP NO: `27 _'5 � PARCEL NO: - 3---0 Fxs...2 ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OOF....................................................................•--••-----............ Appliratiou for UWpatial Workfi Tumitrurfiota Vamit 'L Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...Q _. � ...... 'e nh r/e .• ..7� _`.�=---------------------------------------- n catio -Address /1 or �7N yy� .en AIJI+...................................... ...l u/ _.../.._l.Q S:�C................ a y��q�' � Owner Address....L..`� ..............................•----------.._.......-----........................... ........................ ---.....•.................................. Installer Address UType of Building Size Lot.._z---oo®--_-` --Sq. feet ,..., Dwelling—No. of Bedrooms..........06�----------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Otherfixtures -------------------------------------------------------------------•--...----------------•---•-------......--------------••-•--••-------.......------ W Design Flow...................................57A�.gallons per person per day. Total daily flow.___` . ..._......._.. ...........gallons. WSeptic Tank—Liquid capacity/67 gallons Length..rBr-65.". Width--- °_4 Diameter----- Depth.. �_. x Disposal Trench—No..................... Width.................... Total Length.............. Total leaching area.........--.........sq. ft. Seepage Pit No........../-------- Diameter.._._ .......... Depth below inlet-----10............. Total leaching area... .....sq. ft. Z Other Distribution box (K Dosing tank ( ) aPercolation Test Results Performed by.. Ll__CA n ............... Date...,� Z7.......... a Test Pit No. 1 46�_Z__minutes per inch Depth of Test Pit---- Depth to ground water..... GL, Test Pit No. 2...... ........minutes per inch Depth of Test Pit-----/_,4.`__-__- Depth to ground water--------- �........ Q+' ------------------------------------------------------------------------------------------------------•------------- ---- ----------------.....---------- O Description of Soil------- !��" �I/_% --------ts -•L;�r!1�, 'S� .. T® � `� ?�fJ�l_ ✓` x x -------•----•------------- ........................................................................... --------------------------------------------------------------------------------------------••--- U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI:?:;•. 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss by the d of health. Signed . . a�— I... Date Application Approved By........... .... .............. ...2--7 Date Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------•-----•-•--•-••--- ----•------------------------------•---------------------------------------------------------------------I----------------------------------•-------------------......---------------------------•--..... �p Date Per0-mit No.----•-.. ..7:=... .2L.6--•----•----•------- Issued_....................................................... Date D-0 Fx$... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ... .............OF.......................................................................................... Appliration for Biipnaal Works Tomitratrtion prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at f-cat'op•Address f / or jr Nfp. / sry 'a., f n h. .. tl.�.r .. /C.l? (O i1 ......../ ...................................' 'lG- ................. -- -... .. Owner Address -Z ............................... ...------.................................. Installer Address z�� U Type of Building Size Lot... .a........_...-...Sq. feet Dwelling—No. of Bedrooms.__....................................Expansion Attic ( ) Garbage Grinder ( ) pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures -------------------------------- . W Design Flow............................. .`r_�_..gallons per person per day. Total daily flow____333�............................gallons. WSeptic Tank—Liquid capacity/ +'a gallons Length..!:�?.Z,,.". Width___'.A:`.. Diameter----- "....... Depth_9'4.'.. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No---------,l-------- Diameter.....-Z.'---..... Depth below inlet....4............ Total leaching area... ......sq. ft. Z Other Distribution box (✓") Dosing tank ( ) '~ Percolation Test Results Performed by._ t�.. �?� .=_../Z� 11Z1 11� _______________ Date--- �`� .......... , Test Pit No. I&r�,._.q__minutes per inch Depth of Test Pit_._.�_�_'' .. Depth to ground water....... . _ Test Pit No. 2...............minutes per inch Depth of Test Pit----- ......... Depth to ground water.................... P' ---•--------------------------------------................ •------•-------------•------------.------------•--••----------•----------------------------.------ O Description of % 3..'.. ..11................................A.'�_!"_:....... r f.. ....•••f/�°'f�r, ri?7__5,.,%7 x U .-----------------------•----------------------------------.....................---...------....-----•......-----------------------------......---------•-----•-•-----•----------- W --------------------------------------------------------------------------------------------------------------------------------------------------------------•-•..................-------•------------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... •--................ -•--•••-•------•-------•--•••-----•••--••---------------------------------•---------------------------------•-------•-------------------.....-----••---------.............--- Agreement: The-undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code�The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss e by the ld of health. Signed-- ........ . ................................ Date Application Approved BY �'1 4- ---•' `` •--•------••----•-•----•--- --•-•----•---------------•--•---•••-••-- Date Application Disapproved for the following reasons-------------••-••--•--•--•--•-••-----------••-•-••-•---••-•---•-------------•--•-........--------........_....._ -------------------•-•----._...-----------------------------...---•---•--•••--------------------•-................_........-------------------------------------------_...----------------- ............ Date Permit No........19-7-.....V aZ la _ ..................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH EGG: ............OF.... ........................... ................. . Twgrtifirtttj� of T antpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by-----------------------•------------.-----•----.-•---------•--•--•---•--.-.------------•------------•-------------------------------------------------------•-------------------------•------------- ��^ �/ Install/er ` y Q at.......`�.f.�•-..=f 1 ..ICE. ............. . L.._...K C= �_ n---------•---•-----•---•. has been installed in accordance with the provisions of I'II LW 5- of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------.c2__7_v.__4(_r�_.4....... dated.__.___________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....................a..-• `� .56 .................. Inspector.----- -Z• ................. Zy THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ./..�.SG�:. rl............OF....... re. +. g1 . No.2l: �/cz�..6 ........... FEE....-7`�.:.... Disposal Workii T-nni#rndion amit Permission is hereby granted....................-......................................................................................................................... to Construct (�e or Repair ( ) an Individual Sewage Disposal System- at No....... G'T V....... /e,� ��c tC -> -= ._l �_lL---- --•••- ce--�-......... _..........e=.................... J Street as shown on the application for Disposal Works Construction Permit No.?7_.��_ Dated.......................................... ------------------------------------------ ............................................................ Board of Health DATE................................................................................ • FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS t -4 .,Pot S # I-6 'x 6 100 % r-N wl l 14tone 2 7 3. 7 £ P' �- 20I 4 �3. rvl 427 9pd 4® to,. 3Z PRO POSED . , 1 od, Z R. tot il 29,000'-S 9 0 F o' Otd Q r- 1 D R 1 V S hyd #523 ld i,�,C bo P.t 42.3 3 9 0 _ , o.a .oad 3.oe 2 3 7.9G 4 40 wide Xo,t 3 } Scale 111-40 ' bate 6-9-87 jq& Cape £nc�ihke�' 49 l4aabo t 12oad ldyaviv , Ma. .02601 j 4_ c. No J4" No Scale ------ .__l_�'a 7 r IBC r 2�i✓� T'N E SQ E ' 1 Stow De4.icarc _ 1 1&i t. itow V0 qpd R., 1500 r ' .(each az 201 �ea a� C -i3 � I�tn� � pit u�,rj r yleae�u�a " 201 C 427 gpd , W 1 ' 4.tone No �ac�e d-i,i. 32.0 �r�r Sketch ptan o f Xand in lJyarua ins:, Ma. 1 9o�t Lazy & Anne Curham , i3e .Cot 4 a4.. 4hown on a ptan tecoaded a.n - }- book 350 pare.44. Cteaatiori cue on an ad4ww-d datua. S Z - ---Agent: Ia� Zecrd o ldea7,th , . i t Seat Pit #p-649 3 , ! Made 5-28-87 :No water e-ncountehed - Pezc. te" than 2, nun.p et 1 " t_ 9P1 9P2 -top & a°'2 4e.7 -top & ; 4-Z 4zib t 3k.z -M-7 coa,m.e coa4.e 4 and 4GndOf 11W.4 4tAney a Loney OF o� �yv�Y �AA' �, V JOHN. u o K ARf,-Y. k1 .. *12606 M [n E 4.and rar✓cLi um 9fClSIER 4C U A`At taNQSJ 1 . Z7.7 1 27,71