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HomeMy WebLinkAbout0029 OLD TOWN ROAD - Health 29 Old Town Road' Hvannis r.A =,,267 070 e I 0 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Town Road M Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out q forms the computer, r, use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 03/18/2009 Inspe tor's Sign ure 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. Lb t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in-310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ ,broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑. ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): D C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/09 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is Y required for Hyannis Ma. 02601 03/18/2009 every page. Cityfrown 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 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 [j ® 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 T.below invert or available volume is less than '/day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. CityFrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® 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 tes absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zane II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section.D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts L. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis - Ma. 02601 03/18/2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage.-disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For,example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon septic tank,distribution box and 4 Cultes 330's. J Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2007:222,000 9 ( Y 9 (gpd)) 2008:62,000 Detail: 2007:608 gpd 2008:170 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 03/18/2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M •''V . 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 01 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed�(if known) and source of information: New leaching installed 2002 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction fine: 20'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through house vents. Septic Tank (locate on site plan): 1 Depth below grade: 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: 1000 gallon Sludge depth: 811 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. City/Town State Zip Code Date of Inspection D. System Information cont. Y (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 6 - Distance from top of scum to top of outlet tee or baffle 3„ Distance from bottom of scum to bottom of outlet tee or baffle 9„ 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.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is level.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-Cultic 330's ❑ 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.): Sandy dry soil.No signs of hydraulic failure.4"of water observed in leaching at time of inspection.No stain line observed. 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 l5ins-09/08 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 29 Old Town Road M Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. CitylTown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Map Page 1 of 2 Town of Barnstable Geographic information System Parcel Viewer Custom Map Abutters Map Size Zoom Out 'In b I! RJR IA��I1 ' l 9 •. 1 y es r ............. M`. y fix. wr 1U w37-- C' x... ;:.. 4 Feet .......................................... ..............._............................................_.................... Set Scale 1" _ 20 I Aerial Photos I MAP DISCLAIMER Cnnvrinhf OMF_9MR Tnuin MSZOMefohln KAA All rinhWraennn htt.n://www.towh.harnsta.hl e.ma..0 c/a.rcim c/anngenann/ma.n.asnx?nronertvTT)=267070&man... 2/26/2009 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M . 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. CityFrown 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: Bottom of leaching 23'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: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 29 Old Town Road Property Address Alessandro Adao Owner Owner's Name information is required for Hyannis Ma. 02601 03/18/2009 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information —Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE � = ,4 LOCATION Awe✓� � SEWAGE # . tot VILLAGE -t S9 0,n(N l S i ASSESSOR'S MAP & LOT (j 7 INSTALLER'S NAME&PHONE NO. t GC-e L SEPTIC TANK CAPACITY. t LEACHING FACILITY: (type) LPc o t ins [f eO Aer(size) _ � E 7X R)' ; C NO. OF BEDROOMS ��= (W) cu(kc 330Y BUILDER OR OWNER PERMITDATE: 0 COMPLIANCE DATE: 3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Z Feet Private Water Supply Well and Leaching Facility (If any wells exist j 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 CIA V► � JIEl W_ 0 �o c Ga �. N t r FEE o. 11 V t� Board of Health, �D�2 MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair, ``upgrade( ) Abandon( ) - ❑Complete System Individual Components Location Z E�OVJc1 Owner's Name j '' JJ Map/Parcel# C o Address A9 0(Cie QX-^lIS Lot# �� A it Telephone# Installer's Name Iv l 1dn Designer's Name l�l Can Jam` Address Address 3C{ Telephone# ISC08 ^8 — CL446 ITelephone# Type of Building � 5 A Lot Size G3 33a sq.ft. Dwelling-No.of Bedrooms c7 6e&cotiM Garbage grinder 0j .j j Other-Type of Building `5"eD No.of persons o;—Showers (V/ ,Cafeteria-(✓� Other Fixtures Lctiln::�4z , Design Flow (min.required) 3�3o gpd Calculated design flow 330 Design flow provided 3 3 gpd Plan: Date I as�00�, Number of sheets Revision Date Title o _ C Description of Soil(s) ice S \ EOCA\3c Soil Evaluator Form No. o Name of Soil Evaluato S ONY Date of Evaluation, DES RIPTION OF REPAIRS OR ALTERATIONS r The undersigned agreejpa jthe�t a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to t to operatio until a Certificate of Compliance has been issued by the Board of Health. Signed Date les CT ,. ,. .4 ... r � ; �. jv x�, '-a. r• ,.. yNo. r FEE 74, COMMONWLAITH OF r- ,- :Board of Health, S�CA�`P , MA. I APPLICATION FOR ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( Repair{�\\ O'Upgrade Abandon( - ❑Complete SystemAlndividual Components Location Z C�2'�"OWr '' Owner's Name I c� .t �)LQ (Y ri Map/Parcel# O p Address 2l G(dQ TOlyd'--)-AZ cA `^ ;S Lot# �� A r' Telephone# �! Installer's Name y„ t C�, ` C Designer's Name 0 U 1 n 4 Cs Address + j Address r Telephone# c3 _ C 1,(Q Telephone# 41 Type of Building w,t _ �C7-1 C�e C1&- G.\ Lot Size (3 3 30 sq.ft. Dwelling-No.of Bedrooms t-P c\C-00 rn Garbage grinder Other—Type of Building tk-\Ec No.of persons Showers (v�,Cafeteria (✓S e Other Fixtures Lr—,jC. �. 'T C��a �-, S t c 1rc unc\C:% Design Flow(min.req ired) 230 gpd Calculated design flow. O Design flow provided 3 '� I • lc gpd " Plan: Dated (�'� Number of sheets Revision Date k Title r U '�iC lJmckk ,b�c Descriptrorr of Soil(s) SailrEvaluator Form No. , �1 c� Name of Soil EvaluatorCAP_.Mt E,J SEa�lY Date of Evaluation I�� 1 DESCRIPTION OF REPAIRS ORALTERATIONS 7 ZO r The undersigned agree t- ' tall the a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to t to IS a the systAirill operatio until a Certificate of Compliance has been issued by the Board of Health. Signed Date / 1/2 U a 4 .�1 No. ��� - FEE' 5�2 pp,ILI Board of Health,, !� MA. - r � CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: AA, ke L ec,^t i has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. ),UJ 2-074r dated i ,A) 2, Approved Design Flow (gpd) Installer }o jq G-Pe P �J}( ,. —{'1--- ], ? Designer: Inspector: AJ � i �^ Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed.y 1 No.,ff /l!1 FEE COMMONWFA%O ETTS (} Board of Health, lISACIIUS DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair Up rad ( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No.A� A ated Provided: Construction shall be completed N,/O,�,Board three years of the date ofPeenditAll local condi ns must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date of Health Y I - -.'rat,'.,euu}:.. ..'......_. TOWN OF BARNSTABLE LOCATION SEWAGE # I VILLAGE I ASSESSOR'S MAP & LOT CO' 070 INSTALLER'S NAME&PHONE NO. t L SEPTIC TANK CAPACITY 0 `9 xF, LEACHING FACILITY: (type) rX LecG 1^1q'T Gc���`�(size) �:� l � 3 xa NO. OF BEDROOMS N Cal c 334S ' BUILDER OR OWNER , PERMITDATE: ® COMPLIANCE DATE: t ®� 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If,any wetlands exist Feet i within 300 feet of leaching facility) Furnished by / J C r (3 C i?e �„ TITLE V CALCULATION CHART (1995 Code); COMPONENT 3 BEDROOMS 4 BEDROOMS 5 BEDROOMS 6 BEDROOMS , Min. Required area for<5 nlpi soil (1995 Code) 446 sq. ft. 595 sq. ft. 743 sq. ft, 892 sq. ft. SEPTIC TANK 1500 Gallons 1500 Gallons. 1500 Gallons 1500 Ga[lolls, DISTRIBUTION BOX Distribution Box Distribution Box Distribution Box Distribution Box SOIL ABSORPTION SYSTEM: Cultec Recliarger 330's (334-GPD) 6 (471 GPD) $ (606 GPD) 9 (674 GPD) OTE:5 are not enough- INOTE:7 are not enough- Cultec Rechargcr 330's(with 2'stone surroundingC-A-S) 34 x 8.3 x 2 p vides only 401 GPDI provides only 538 GPDI 71.5 x 8.3 x2 �x8.3x2 64x8.3x2 Cultec Rechargcr 330's(with 3'stone surrounding SAS) 3 (332 GPDI) 5 (490 GPD) (NOTE:4 are 6 (569 GPD) 8 (728 GPD) T 28.5 x 10.3 x 2 not enough-provides only 411 51 x 10.3 x 2 60x 10.3x2 GPDI 43.5:10.3 x 2 High Capacity Infiltrators 4 (394 GPD) 6(461 GPD) 7(598 GPD) 8(667 GPD) H.C.inriltrators(with 4'stone on sides,3'stone on ends and 14 inches underneath) 33 x 10.8 x 2 39.25 x 10.8 x 2 52 x 10.8 x 2 58 x 10.8 x 2 > [NOTE: 4'stone is not recommendeed,more infiltratorr units are recommendedl. ' Infiltrator 3050's 5(331 GPD) 7(448 GPD) [NOTE: 6 9(557 GPD) [NOTE:8 11 (665 GPD)[NOTE: 10 Infiltrators 3050's(with 2 ft.stone surrounding SAS) are not enough,only 399 are not enough,only 515 are not enough,only 631 34'x 8.2 x 2 GPD capacity] GPD capaci(y) GPD capacity] 47x8.2x2 59x8.2x2 71x8.2x2 Infiltrators 3050's(with 3 ft.stone surrounding SAS) 4(345 GPD) 6(445 GPD) 7 (550GPD) 10 (660GI'D) 30x10.2x2 39.5x10.2x2 49.5x10.2x2 60x10.2X2 Infiltrators 3050's(with 4 ft.stone surrounding S.A.S.) 3(335 GPD) 5 (443 GPD) 6 (551 GPD) 8 (665 GPD) [NOTE: 4'stone is not recommended,more infiltrator units 25 x 12.2 x 2 34 x 12.2 x 2 43 z 12.2 x 2 52.5 x 12.2 x 2 are recommendedl 500 Gallon Chambers 4 (395 GPD) 5 (477 GPD)'. 6 (560 GPD) 8 (724 GPD) 500 Gallon Chambers/Drywells(with 2'Stone) 31 x 9.1 x 2 46.5 x 9.1 x 2 55 x 9.1 x 2 72 x 9.1 x 2 500 Gallon Chambers/Drywells(with 3'stone on sides&ends) 3 (384 GPDI) 4 (477 GPD) 5 (574 GPD) 6(669 GPD) 31.5x11.1x2 40x11.1x2 483x11.1x2 57x11.1x2 500 Gallon Chambers/Drywells(with 4'stone on sides&ends) 2(355 GPD) 3(462 GPD) 4 (570 GPD) - 5(677 GPD) [NOTE: 4'stone is NOT RECOMMENDED,more chambers are recommended) 25 x 13.1 x 2 33.5 x 13.1 x 2 42 x 13.1 x 2 50.5 x 13.1 x 2 Flow Diffusors(with 2'stone surrounding SAS and 12"deep 4(343 GPD) 6 (485'GPD) 7 (556 GPD) 9 (698 GPD) stone on bottom) 36x8x2 52x8x2 60x8x2 76x8x2 Flow Diffusors(with 3'stone surrounding SAS and 12"deep 3 (340 GPD) 5 (506 GPD) 6(589 GPD) 7 (671 CPA) stone on bottom) 30x10x2 46x10x2 54x10x2 62x10x2 Leaching Trench 60' X 4' X 2' or(2) 80' X 4' X 2' or(2) (2) 48' X 4' X 2' or (2) 57' X 4' X 2' or 30' X4' X2' 40' X4' X2' (4)24' X4' X2' (4)28' X4' X2' Leaching Field 446 S.F. (330GPD) 595 S.F. 743 S.F. 892 S.F. ALL MINIMUM S.A.S.SIZE REQUIREMENTS LISTED ABOVE ARE BASED UPON TIIREE ASSU11'IPTIONS (1) No garbage grinder,(2)Class I Soil(0.74 GPD/S.F.),(3)No wetlands within 250 feet of S.A.S.and groundwater is greater than 14' below SAS 1:CHARTITV FORM 11 — SOIL EVALUATOR FOR Page 1 of No.: Date: 1/14/02 COMMONWEALTH OF MASSACHUSETTS Barnstable , Massachusetts Performed By: Carmen E. Shay Date: 1/14/02 Witnessed By: Waiver— Per Barnstable BOH Location Address or #29 Old Town Road, Owners Name: Paul & Rita Anglin Hyannis,MA Address: 29 Old Town Road,Hyannis Lot# Map 267 Lot 070 MA 02637 New Construction : Repair : X Telephone Number: 508-889-0446 OFFICE REVIEW: Published Soil Survey Available: No ❑ Yes ❑ Year Published: Publication Scale: Soil Map Unit: Drainage Class: Soil Limitations: Surficial Geologic Report Available: No❑ Yes❑ Year Published: Publication Scale: Geologic Material: (Map Unit): Landform: Glacial Outwash Flood Insurance Rate Map: Above 600 Year Flood Boundary: No ❑ Yes 57 o Within 500 Year Flood Boundary: No X❑ Yes ❑ Within 100 Year Flood Boundary: No Fx_1 Yes ❑ Wetland Area: None Observed National Wetland Inventory Map (map Unit): Wetlands Consercancy Program Map (map unit): Current Water Resource Conditions (USGS): Month Range: Above Normal ❑ Normal Below Normal ❑ Other References Reviewed: USGS Topographic Map DEP APPROVED FORM 12/7/95 FORM 11 — SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No.: #29 Old Town Road, Hyannis, MA On -Site Review Deep Hole Number: #1 Date: 1/14/02 Time: 9:00 PM Weather: Sunny,warm, 35OF Location (identify on site plan): Refer to Sketch Landform: Outwash Plane Position on Landscape (sketch on back): Refer to Sketch Distances From: Open Water Body N/A feet Drainage Way N/A feet Possible Wet Area N/A feet Property Line 25' feet Drinking Water Well N/A feet Other N/A feet DEEP OBSERVATION HOLE LOG Depth From Soil Soil Soil Soil Other Surface Horizon Texture Color Mottling Structure, Stones, (inches) (USDA) (Munsel) Boulders, Consistency, % Gravel 0" — 5" A Sandy 10 YR 3/2 None Friable Loam 5" — 35" Bw Sandy 10 YR 5/6 None Friable Loam <5% Gravel 35" — 168" C1 Sand 2.5 Y 7/4 None Med-Coarse Sand, 5% gravel/cobbles, Loose Parent Material (Geologic): Glacial Outwash Depth to Bedrock: N/A Depth to Groundwater: Standing Water in the Hole: None Weeping. From Face: N/A Estimated Seasonal High Water Table 168"Assumed DEP APPROVED FORM 12/7/95 I FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No.: #18 Byron Place, Hyannis, MA Determination of Seasonal High Water Table Method Used: ❑ Depth observed standing in Observation Hole: inches ❑ Depth weeping from side of Observation Hole: 168" inches assumed ❑ Depth to Soil Mottles: inches ❑ Groundwater Adjustment: None feet Index Well Number: Reading Date: Index Well Level: Adjustment Factor: Adjusted Groundwater Level: N/A DEPTH OF NATURALLY OCCURING PERVIOUS MATERIAL: Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system: Yes CERTIFICATION: I Certify That on September 17, 2000, (date), I have passed the soil evaluators examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature: Date:_, FORM 12 - PERCOLATION TEST Location Address or Lot No.: #29 Old Town Road COMMONWEALTH OF MASSACHUSETTS Hyannis , Massachusetts Percolation Test Date: 1/14/02 Time: 9:53 AM Observation Hole #: #1 #1 Depth of Perc 36" Start Pre-soak 9:53 End Pre-soak 10:00 Time at 12" Will Not Hold 24 Gallon Presoak Same Time at 9 Time at 6' Time (9-6") Rate Min./inch < 2MP1 Assumed @ 36 " Same * Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Performed By: Carmen E. Shay Witnessed By: Waiver per BOH Comments: Would Not Hold 24 Gallon Presoak - <2 MPI Assumed 0- 36" Site Passed X Site Failed DEP APPROVED FORM 12/7/95 SKETCH OF PERC TEST & DEEP HOLE LOCATION Property Address: #29 OLD TOWN ROAD Hyannis,MA Owner: Paul Anglin Date of Perc Test: 1/14/02 POOL Test Hole #1 12' 4�� Existing House Foundation 3 Bedrooms 45' OLD TOWN ROAD Sep-20-01 13: 52 BARNSTABLE HEALTH DEPT 5087906304 P • 02 5/ZSrol !NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. i PERCOLATION? TEST AND SOIL EVALUATION EXEMPTION FORM [, E� hereby certify that the engineered plan signed by me dated 1 'l. concerning the property located at C9-1 C) C� ©�e� oA 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. • '['he soil is class!:ed as.CLASS I and the percolation rate is less than or equal to 5 nrunutes per inch. The applicant may use historical data to conclude this fact or may conduct prehrrun.ary tests at the si,e without a health agent present. • There is no increase in flow and/or change in use proposed • There are no vanances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14, feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable) Please complete the following: ,A) Top of Ground Surface Elevation (using GIS information) B) Q.W. Elevation 10 O + adjustment for high G.W. 57,_(4._ _ _ LS • 140 DETFERENCE. BETWEEN A and B O�O yO S I G NE D _ D ATE: � oa NOTICE Based upon the above information, s reoair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in t1e future without engineered sepuc system plans. a:h ziih fr„dcc pcccczmp i Permit Number: Date: Completed by: HIGH- -G—ROUND-WATER LEVEL COMPUTATION Site Location: 2S ©t& \(3W C� Qf1V Lot No. '`- Owner: ? n •n Address: C;?Q �T+C�CrC�11�� Contractor: 5"Pi'2 U � R 1E0#4tt- LAddress: 3y (�f�kt^In9C`S LN C� 4��0 �MA Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ............. ....... Date 10.0 .......................................................... month/0 y/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... N1tt.sL9 OB Water level range zone..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to oa O n p, water level for index well........................... moot /year 1 STEP 4 Using Table of Water level Adjustments for index well (STEP 2A),current depth to water level for index well (STEP 3), and water-level zone(STEP 2B) determine water level adjustment .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site STEP 1 . C..ape Cod Commission: USGS Well Data - December 2001 Page 1 of United States Geological Survey Observation Wells As a service to Cape officials, engineers and other interested parties, the Cape Cod Commission publishes monthly groundwater data gathered by its Water Resources Office. The water level measurements shown below are taken monthly from United States Geological Survey (USGS) observation wells and compiled during the last week of each month. They are published as soon as possible thereafter. Listed below are nine out of the 61 wells measured across Cape Cod by the Commission's Water Resources Office. These nine are employed as index wells to be used with Technical Bulletin 92-001 to predict high groundwater levels. For your convenience, we've also provided links to USGS national and state data. See the I ist coIninn in the table and the footnotes below. For further information, please contact Hydrologist Gabrielle Belfit at the Commission offices (508-362-3828). December 2001 Water Record Record Departure from LJS(:S Site \�utriber--, Location Well No. Level* High* Low* Average" (111116 to I-SGS n itional Monthly Overall wmer-level ( atabase) Barnstable 230 26.3*** 20.5 26.6 =-2. -2.6 413956070164301 Barnstable 24w 27.0 20.5 28.6 -1.8 -2.5 414154070165001 Brewster BMW 21 12.8 6.9 13.3 -2.3 -2.7 414518070020301 Chatham CGW138 25.7 20.9 26.6 -1.3 -1.7 414100070011101 Mashpee MIW 29 9.9*** 5.6 10.0 -1.0 -1.4 IF 413525070291904 Sandwich SDZ 47.8 45.9 48.2 -0.3 -0.5 414418070241601 Sandwich SDW 53.1 45.8 55.1 -2.6 -3.1 414124070265901 Truro TS W 89 12.8*** 10.2 13.0 -0.6 -0.7 420206070045901 Wellfleet WNW 17 12.3 7.3 12.8 -1.3 -1.9 415353069585401 * Measurements are in feet below land surface. ** Measurements are in feet above mean sea level. *** New monthly low. USGS national water-level database provides historic data, hydrographs, and site maps. The USGS compiles the above data and other water levels into a monthly, online Water Resources Current Conditions Report that covers all of Massachusetts. http://www.capecodcommission.org/wells.htm 1/28/200 TO ALL NEW BUSINESS OW NERS DATE:Fill in please: ,, APPLICANT'S �ti � �a YOUR NAME: 60kNDR0 BUSINESS YOUR OME ADDRESS: Zq OL-D Tow 14 R9 TELEPHONE - Telephone Number Home 5b9 " 3Go 5 '"� NAME OF NEW BUSINESS - VI-0% �iRV-_nOi`J TYPE OF BUSINESS CptQ T .k;Ct►O N �Y VV(k ll,--�_,_ IS THIS A HOME OCCUPATION? YES La:-NO Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS MAP/PARCEL NUMBER When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. Once you have obtained the required signatures, listed below,you may apply for a business certificate at the Town Clerk's Office (Ist floor-Town Hall). You MUST go to the following office to make sure you have all the required permits and licenses.. GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) and you will find the following offices: 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual ha been i rm d f teperMLroquirements that pertain to this type of business. Authorize Signature** COMMENTS: -- 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in the town (which you must do by M.G.L. -it does not give you permission to operate-you must get that through completion of the processes from the various departments involved. **SIGNIFIES APPROVAL FOR A BUSINESS CERT/F/CA TE ONL Y. Date: c2 06 w— •l� TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: _5P(L+ok) CONS�IPC1(ON — �_I�- Vit'ru BUSINESS LOCATION: an &ZID MAILING ADDRESS: , O2O� Mail To: TELEPHONE NUMBER. O • � _ S Board of Health Town of Barnstable NTACT PERSON: ��/ CO P.O. Box 534 EMERGENCY CONTA T TELEPHONE NUMBER: -S - �'� Hyannis, MA 02601 TYPEOFBUSINESS: C/ / 's-V Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO /V This form must be returned to the Board of Health regardless of a yes or no answer. 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 Q _ Antifreeze(for gasoline or coolant systems) _ Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid _ Disinfectants —(2— Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) 0 Gasoline, Jet Fuel _ Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, 1 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 Paint brush cleaners —� Any other products with "poison" labels Floor& furniture strippers (including chloroform, formaldehyde, 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 LOC AT LON _- SEW.&.C;E_PERMIT Q 0.- _ v G-a-S �/II..LhGE - -���-'_cam/�.✓-a O?d --- - IWST-ALLER'S- IJ&ME ADDRESS _ - - y - - - ' �S� L_ �'o ,. r b.� �c,�_ �a�h 1•S del r� � ,� _ _ _ - -BUILDER'S -Q &MF- ADD.RE SS - DATE PERMIT 15SUED - D ATE COMPLI-AMCE ISSUED ; �. ��.J � = �� C. d � �� ;, . �' `�� s r �•---•---•--• � �` - Fss..,02..::..............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F JL H -----------OF....... ........................ , pphratinn -fur 4%ip at Workii Tnntrurttnn Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 1 ..............�---....�...--------•............./...w~--- ............................... w�1 Location•/Address S or Lot No. 'a ---•.............'----•--•-------•--•--•..................•....... \\ caner Address Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms...._---------------------------------------Expansion Attic ( ) Garbage Grinder .( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic.Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth---------------- x Disposal Trench—No. .................... Width.................... Total Length.-_._____-__.._-__.. Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------------------------------- ................................. Date--------------------------------------- Test Pit No. 1----------------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-..-.-.-___--__--_-_---. P4 ------•---•--------------- -•-----•----------------------------------------------------------------•-------------------------------------------------------- ODescription of Soil----•------------------------ ------'----•--•------•----••-•-•----- ------------------------------------------------------------------------------- ------------------ x W ----------------------- ---------------------------------------------------------------------------------- --------------------------------------- --------- ------Nature Repairs or Alter. 'ons—Answer when applicable..-_,h ��.Yr? -►r.._.-_�-.--____/a_ _':/ '--. .. ........ -' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. t Signed. ate Application Approved By................. -------------- Date Application Disapproved for the following reasons:................................................................................................................ --------------------------------------------------------------------------•------------------•-•--'----•-•-------- -------------------------------•---------------------------------•-•-•-------------- Date PermitNo......................................................... Issued........................................................ Date �S No......................... F>�a...,,�.:................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F � L ;t'rM._.. O F........ ... ............ .......... ................................ Appliration -for Uhipoiittl Workii Tonstrnrtion Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----------------...............................................................I•-•---•--•-•--•-- •-•-••-••-••••----••••-•-•••-•-----•---•---•--••---•-•----•-•------••--•--••---------•-----•••--. Location-Address or Lot No. "41 e/"4 s ............................................... •••••••-••---•-----•------•••••••-••••---•••-••••••••-----•••---••••--••---•••.................... Address a Installer U Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms------------------------------ --•-.-----_--Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No- -------------------- Width-------------------- Total Length.................... Total leaching area---_--_---..-__--_sq. ft. Seepage Pit No..................... Diameter____--__---.-----_-- Depth below inlet.................... Total leaching area--.-.--.------__-_sq. it. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY-------- ............................................................ Date---------•--------------------•-------- a a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water....---..-.---..__.--__- 0-4 ( Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.............-..-----._. 9 ------------ ---------------------------------------------------------•----------------------------...................................................­­­ 0 Description of Soil---------------------------------------------------------------.........................................------_---------------------- -------------------------------- x U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- ------ ---------------------------------------------------------------------------------- ---�----- U Nature Repairs or AlteraLjons—Answer when applicable._-.. ^cf......................°_.:''._ '!'_... `-_._.._ . >. _ -�----------------------------------------•--------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.. l - ..................................................'y ..L / ! -------- --------------------------------------- Date - Application Approved BY------------------------------------------•-•------------- ---------------------•--•----•-------- --------- Date Application Disapproved for the following reasons:-------•------------------------------•-------•--------------•----•-••----•--------------------•--------------- -----------------------•---------•-----------.-----------------------------------------•------•--------------.------------------------------------------------------------------------•-------------•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -1 ..................OF.......... ...................+............ .. .......................... QVIertifirnte of ITOmpliaurr TICS I,S' O GERTI Th the.Individual Sewage Disposal System constructed ( ) or Repaired by ----- ---------------- •--------------••--••-.....---••-•-•-••... --------- ------- ---- �j er staller / at............ �� - G/ ( _.41/✓_'._ P �I��Y-h P /C .�..r� __.._.._.. has been installed in accordance with the provisions of!fir ' XI o The State Sanitary Code as described in the '� s application for Disposal Works Construction Permit No------........� _--___-___-__--__. dated.-..--/�-.:'__�_-__ZJ�__.......__. TOLE ISSUANCE OF THIS CERTIRCATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------------------------------------••--• Inspector................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEAL--TH I- /-/�o }......fi ....,......OF....... ................... No......................... ........... .. FEE.__"-................. rk,q LIT o iitr rtion rrntit Permission is hereby granted-- G%�/-- �r� "_ ---------- ---------------------------•- --------------------.---- to Const u t ) r Repair ( n Individual g isposal S s em I�il l= at No.. r . .�..__ U_. 5- 2.M. w-.. t` Street 1 � as shown on the application for Disposal Works Construction P it i Dated---- /7 f / 7J~' F' oar d of He � DATE...... ---------- i FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 10' thin. from �F house to septic tank *MOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. Existing Foundation s.attc tank covers must be 4� Wide '9iQS,�S in a In. a frashed grade r - ' Orade over Septic Tank- 00.00 Ora&over D-8ox- 9e.75 / over 5A5 - e8.73 .9 , f/ I 2" of 1/8--1/2- Washed Stone u^4 S - 0.02 3 HOLE H-20 S=.005 a\\G¢ A� aj a DISr. BOX 3'YsMm 24' 4 N x. Ei¢sT. a,a� n 10• . EXISTING S-0.v1 4 Perforated P.V.C. 2'-1/8"-1/2" washed Stone �►+a �C FROM F KMATZIN SEPTIC TAANNK foot- eInvert H-10 i / Qo� p s3/4'-1!ti" Woehed Stone 4 / SI E v c„ 8fq FULL raUNOA 'v 1 Bottom of Leach Facility E]ev.-95.75 3/4"-t ' Washed StoneCONCREIt •D d v, 28� 4" perforated P.V.0 Pipe ��\y S ¢ qA e In.ot 3/4"-1 Note: All leach lines to be capped at ends w/PVC cape. sky Qi\t� a SYSTEM to PROFILE compacted LEACH TRENCHES CROSS-SECTION �o, Scale So LOCUS MAP LEACH TRENCHES NOT TO SCALE Bottom of Test Hole 1 Elev.-84.75 E In.of 3/4•-1 1/2" compacted stone GENERAL NOTES 1. Contractor is responsible for. Digsafe notification and protection of all underground utilities and pipes. 2. The septic"tank ar$ distritlu$ion box shall be set _ level on 6 of 3/4 -1 1//2 stone. 3. Backfill should be clean sand ,or gravel with no „U amEt PM FROM 7Ne NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE stones over 3" in size. asTReu•non cox SHALL BE 4. This system is subject to inspection during installation LEVEL tE FOR AT LEAST 2 rr. ,�' - 001 ``'E 001,01FROM THE EXISTING LEACH PIT TO BE DISPOSED by Carmen E. Sha 2-18"DIAµ. ACCESS MANHOLES y - Environmental Services, Inc. s 3- S"apt 2 5. The contractor shall install this system in accordance a KNoc+wuls OF AS PER BOARD OF HEALTH SPECIFICATIONS. with Title. V of the Massachusetts state code, the approved plan 4 ACCESS COVERS OF SEPTIC TANK TO BE air 12, KXT and Local Regulations. ounEr RAISED WITH THE APPROPRIATE RISER TO MATHiN .- 6. if, duringinstallation the contractor encounters an E" of THE EXISTING GRADE As PER TITLE V. EXISTING LEACH PIT TO BE PUMPED DRY & soil conditions or site conditions that are different Y from those shown on the soil to or in our design, THE ACCESS COVERS FOR THE SEPTIC TANK, ta5• 4• - scH. 40 r ,.73• i 9 DISTRIBUTION Box AND LEACHING COMPONENT REMOVED TO FACILITATE NEW LEACH TRENCH. installation must halt & immediate notification be 1. SET DEEPER THAN 1 FOOT BELOW FINISHED PLAN SECTION CROSS-SECTION r made to Carmen E. Shay. . `� % GRADE SHALL BE RAISED TO WITHIN 12" OF - y _Environmental Services, Inc. -- FINISHED GRADE 7. No vehicle or heavy machinery shall drive over the INSTALL TUF-TiTE GAS BAFFLES OR EQUALS 3 HOLE H--1Q DISSTRIBUTION BQX septic system unless noted as H-20 septic components. a-•+4; -'R`T'' 8. Install Tuf-rite gas baffles or"equals on ail outlet tee ends. STEEL REINFORCEDREINFORCEDPRECAST CONCRETE NOT TO SCALE 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. PLAN VIEW - 10. All solid piping, tees & fittings shall be 4" diameter, 3-24•REMOVABLE cavrns-\ Schedule,40 NSF PVC pipes with water tight-joints. jr 11. Municipal.Water is Connected to The Residence and Abutting mh'uNvaace ,a" w.cT•r',' ® Properties Within 100 Feet. _ min, 2•min. Not to out!*! , ,, 4•-0•min 5• -r THE PROPERTY ED LINES & HOUSE LOCATION ARE APPROXIMATE AND .", ,N ,� COMPIL FROM THE SURVEY'PLAN GENERATED BY N 8 35' 30 ll 121McGLONE ENGINEERING OF WEST BARNSTABLE,'MA �; 67.824' ENTITLED " PLAN OF LAND IN HYANNISPORT, BARNSTABLE, MA" • BRB DATED: AUGUST t, 1974, PLAN BOOK 286; PAGE 88 � r-o- r-1a• �� � 9$.92 . '�• �FND � . AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN '41fir IT SHOULD BE USED FOR NO PURPOSE OTHER THAN -CROSS SECTION END-SECDON \\ Q x C 41 o O Rk THE SEPTIC ,SYSTEM INSTALLATION. USEEXISTING1 00 A L - 0 SEPTIC TANK �' '_a ' : LOT . S 0 GALLON H 1 T "A", -- - - `1`,. '��,- / ,, r 13,330 Square Feet NOT TO SCALE LEGEND / . SLAB D� FOUNDATION 9$.24 !y I W J DENOTES PROPOSED , PERCOLATION TEST .' `` x �,L G �o4x� SPOT .GRADE bD_� DECK w BRB. TE Dote of Percolation Test: JANUARY 14, 2002: •' TING �Q° FND X 104.46 DENOTES EXISTING 99.02 SPOT GRADE. Test Performed ,8y.. CARMEN E. SHAY, R.S., C.S.E. X �i 3 BRDROO�Y J Results Wltnessed .By. WAIVER 1 Excavator: Shay Environmental Services, Inc. I SOUSE PL PROPERTY N Percolation Rate: Less Than 2 min./inch it It O 98.36 PER LINE DECK " r>1ES9 x 9SF PROPOSED CONTOUR . • 8 , Foiled l 'i i n ASP R A - 9 97-._. - ---97 EXISTING CONTOUR I. Test" Hole teach Pit 8.88 HALT D IVEW Y _ PROJECT BENCH MARK No. 1 i I >• l X \ TOP., OF ,.FOUNDATION L - DEPTH SOILS ELEV. , ELEV. 100 {assumed) " DEEP TEST• HOLE & o 91175 TEST HOLE 11 l i ,.' ELEV.- 98.75 r-',r. PERCOLATION TEST LOCATION Loamy Sand ,a YR 3 l EXI 1000 gal. , 1 n , Septic ank j ' - -.-. 6 FOTO STOCKADE FENCE o•-g- A ore zs o' i 98.69 J h ,'. sandy Loam - M, I, co 10 YR 5/t 1 , 5"- ;W er 95.73 i Tea Q�+ POOL 98.69 Sand SHEp 2a,r 9 X ; I. J �.o0 1 P LOT PLAN, . , • 3s'-1e8• A $4.75 OF PROPOSED : SEPTIC SYSTEM , UPGRADE- 1 U ADE Perc`#1 9 , S PREPARED FOR 98.78 1 7.81 Depth to .Perc, 38 :to 56" 1 ; 1 _ 1 Perc.Rate=<2 min./inch (Assumed) X x, - PAU L & RITA :-AN GLi N Groundwater Not Observed �1 y 06.978 AT No=Observed:ESHVYT r x_.. _ • ` D H2O Elev. _ e....... __ � ._.:..� .}.�,.* .___ .�,_.. _.�•.�, _.e.... _ ....,;.,... ;__._,, .._ n...:.t �• ADJUSTED No #29 OLD TOWN ROAD W N 88d 35 30 ll I ' HYANNIS MA l Design Calculation = cof. PREPARED 8Y Number of 8edrooma 2 E utvalent to 220 Gal./Da 330 Gal./Da Goi./Daj Min. per Title VOF tfAR Garbage•Grinder. No sy � o . • Gal./bay Leachin Ca ci Pr 330 Minimum Mtn. Per:Title V Septic.Tank --` x` 20 Gcl: - S 1 0 A i Tank. Sep 2 2 /Day 440 , USE ,S 0 GAL Septic NVIRONWRNTdL SERVICES <INC. 501E;ABSORPTION AREA. •:;.Usin colation rate of vC2.anin, nch _, : o , Pro ed Leochin Trench Dimensions: 2 Trenches 4. Wide b -26 Lan b 2 Depth.)Pas g t Y. 9 y P $� 34 T AT R i H CHE S LANE,. . _ .. 0 0 40 , . l Bottom Area. . 0.74 al ft•. x ;208 s 154 gallons . 2 50 . , _ Stdewaii.. rea. ;. 0. 4: a! s . ft. 2 , ft. 177.8 lone' EAST F LMO A 7 9 / q >< ao eq �a F R A UT#-f, ,MA 02536. „Y sa _. / S Provldln 33L6 dlons g 9 _ . . , , _. .. _ \.P TEE' 508 54g _0796 !. n «J „ Ise. ., 2-TRENCH. ES 28..b :# x 2..LEACH TRENCHES SEPARXTED.A5 $hIOVMN :> u r .,' I . ,., . . . . . _ :.. D W CES ATE. JAN.. 22 •2002 t N ., :;. , '.,SEPARA"rlbPj OF ]LEACH tt E5 .AND WASHED STONE.;AREA AS'SPECIFIED •. ••,• . . _ ., -. ,; .,,• SALE. . 0 , • � / (:P �(/' INS ; . ., - .; E CH. IELD >]ETAJLS. . .�. , _ _. _ .. . _ .Ir _. . .. . . , , . •:. . :. .. - , . . . _ _ _ OJE T SD28 . . ILENAME. ,SD287PP,DWG , SHEET:1 `'0�'.,1 .. 6.,"; • A - a ` 7