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HomeMy WebLinkAbout0181 OLD TOWN ROAD - Health 181 ' OLD'-TOWNE RD. ,HYANNIS A= 268. 053 7� / 1 V I O Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 181 Old Town Road' _ Property Address F _ }, •.., x �'; Jean& Daniel Alger . . Owner Owner's Name ' information is Hyannis Y MA""` 02601- - - -• - April 14 2009 required for State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. - - Important: A. General Information. When filling out ✓ - ���� forms on the J computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspectoe use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills • MA 02648 �- - i (T State Zip Code Run City own 508-428-1779 Sl 12855 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 14, 2009 In ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official Inspection Form:Subsu ce Sewag Disposal Item•Page 1 of 15 09-60 Alger.doc•08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments w 181 Old Tow n Road Property Address Jean & Daniel Alger Owner Owner's Name information is Hyannis MA 02601 April 14, 2009 _ required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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: pumping Tank is not in need ofat this time, leaching system has no standing water or evidence of surcharge. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N,.ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank wili pass inspection if it is-structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break t a out b okenh static settled oater unevenl in the distribution box due distribution box. System will to broken or obstructed pipe(s) or due pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 0"0 Alger.doc•08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 181 Old Town Road — Property Address Jean & Daniel Alger Owner Owner's Name information is Hyannis MA 02601 April 14 2009 — required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. 09-60 Alger.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road — Property Address Jean & Daniel Alger Owner Owner's Name information is Hyannis MA 02601 April 14, 2009 required for y — every page. Cityrrown 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 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 ❑ ® 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. 09-60 Alger.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road Property Address Jean & Daniel Alger Owner Owner's Name information is required for Hyannis MA 02601 April 14, 2009 - every page. Cityrrown 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 09-60 Alger.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 181 Old Town Road Property Address Jean & Daniel Alger Owner Owner's Name information is required for y H annis MA 02601 April 14, 2009 every page. CitylTown 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 an of the system components pumped out in the previous two weeks? ❑ ® Y Y p p p ® ❑ 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)] 09-60 Alger.doc-09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 181 Old Town Road Property Address Jean & Daniel Alger Owner Owner's Name information is Hyannis MA 02601 April 14, 2009 required for — every page. Cityrrown 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 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? El Yes ® No Water meter readings, if available (last 2 years usage (gpd)): — Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied 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: Last date of occupancy/use: Date Other(describe): 09-60 Alger.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road _ Property Address Jean & Daniel Alger Owner Owner's Name information is required for y H annis MA 02601 April 14, 2009 every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate*age of all components, date installed (if known) and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 09-60 Alger.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road Property Address Jean & Daniel Alger _ Owner Owner's Name information is Hyannis MA 02601 Aril 14, 2009 required for y p — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 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: 10.5' long x 5.8'wide- 1500 gal_ •Sludge depth: 2° — ` Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 2 6" Distance from top of scum to top of outlet tee or baffle - Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Measured 09-60 Alger.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road _ Property Address Jean & Daniel Alger Owner Owner's Name information is Hyannis MA 02601 Aril 14, 2009 required for p every page. CityTrown 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.): Liquid level was found at bottom of outlet invert. Tees are intact and clear. — Grease Trap (locate on site plan): Depth below grade: feet Material of construction.- El 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 0960 Alger.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road Property Address Jean & Daniel Alger Owner Owner's Name information is y required for Hyan nis is MA 02601 April 14, 2009 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 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.): No solids or high stains present. Liquid level at bottom of single outlet pipe. _ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 09-60 Alger.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 181 Old Town Road Property Address Jean & Daniel Alger Owner Owner's Name information is Hyannis MA 02601 April 14, 2009 required for y 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: 3 Maximizers_ ❑ 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.): Interior of Maximizers were video inspected no standing water or evidence of surcharge was found. 09-60 Alger.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 115 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road Property Address Jean &_Daniel Alger Owner Owner's Name information is Hyannis MA 02601 Aril 14, 2009 required for y P every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 09-60 Alger.doc-08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts . r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road Property Address Jean & Daniel Alger Owner Owner's Name information is Hyannis _MA 02601 April 14, 2009 required for �— — — every page. City/rown 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. Old Town Road Water Service ♦ , 2 O • r r , , 15 2 32 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 181 Old Town Road Property Address Jean & Daniel Alger Owner Owner's Name information is required for y H annis MA 02601 April 14, 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 ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 20 and topo map shows property at el. 40. 09-60 Alger.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF B STABLE LOCATION �V 0/ ®�rl�f� SEWAGE VILLAGE ASSESSOR'S MAP& LOT 2�9 6 ri INSTALLER'S NAME&PHONE NO._ l � ICO/,�5r= 7 7� 2 SEPTIC TANK CAPACITY /Soa ga./ LEACHING FACILITY: (type) L,-a,,ti F:',,Jd Y en qx;--Z,-r's (size) 99 'x It � NO.OF BEDROOMS 3 BUILDER OR(,O�) r2r/ LI t/ PERMTTDATE: //7 9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by B/ 5+rcc.4 Aa Bz '3a' A3 3M ' B.3' Yo' Fr� 900% ALI 'S3 By 'Gr ' A Q I � 3 y TOWN OF B STABLE LOCATION ���r� SEWAGE # � VILLAGE y5 ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO.& Lo ?6;r` 7 7/—&Q1 SEPTIC TANK CAPACITY /4000 c/ct_/ LEACHING FACILITY: (type) LeaA F'yd 2 MAxi­eZeM (size) 29 'x 11 NO.OF BEDROOMS 3 BUILDER OR(� I PERMTTDATE: r/7l9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet " Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200,feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .BI '0p8, - 5-Frccf Aa BZ °39' A3 " sy� .83° �o' - Rca►r Of Ho"E ALl By M 3 y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for Migogal *pgtem Cougtruction permit Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) MComplete System ❑Individual Components Location Address or Lot No. / �� ®�/�� r Owner's Name,Address and Tel.No. Assessor's Map/Parcel f� Ll'r/rl/.5 Installer's ame,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms� Lot Size sq.ft. Garbage Grinder Ke Other Type of Building /Q�SI B!?Ge 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./_ ��P' Description of Soil / �/,X `Z� Ot Nature of Repairs or Alterations(Answer when applicable) 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 d e t Signed thi Date Application Approved by ® Date Application Disapproved for the following reasons Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION ---TOWN OF BARNSTABLE., MASSACHUSETTS Application for-- gpozaf *pgtem Congtructton Permit Application for a Permit to Construct( )Repair( )Upgrade(/)Abandon( ) X-Clomplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel L f Q,�`/�'�5v �Q��°' �`5�✓ Installer' ame,Address,and Tel.No. Designer's Name,Address and Tel.No. far Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(16P Other Type of Building &5) "ef No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 5O0 Type of S.A.S. Description of Soil / �/1)(79 Nature of Repairs or Alterations(Answer when applicable) 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 Environme_ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued t i d ' .Heat I` Signed Date Application Approved by ® / Date Application Disapproved for the following reasons Permit No. .�— Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIFY,that,tthe -site Sewage Disposal System Constructed( )Re aired ( ) Upgraded Abandoned( )by /f at ` z7 BG� een constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of thispe t h ll n2�Oe construed as a guarantee that the system will function as designed. Date •.•�t / Inspector -�) No.-------------------------------- ---- Fee '-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigozar *pgtem Con�tru ton Permit Permission is hereby granted to Construct( Repair Upgrade Abandon( ) System located at g� o/� ��'!5 1� Yl/� , y 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:Cons ctioti must be completed within three years of the date of this pe t t Date: .Approved by � Z4__ Y//U s aS �a 6 Do w TAL+�-C� rr/ C,L,6 7Z(,JIIJ i 0 I 10/9/97 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 ENGINEERED PLANS) hereby certify that the application for disposal works. construction p g Y me permit signed b dated hp ,concerning the , located at l r / d /��� �v'"' meets all of the property to l following criteria: V/ here are no wetlands located within 100 feet of the proposed leaching facility ere are no private wells within 150 feet of the proposed septic system flow and/or change in use proposed '•/There is no Increase to g :11f ere are no variances requested or needed. the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the proposed leaching facility will pQj be located less than fourteen (1 t1 feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) Z. B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED: DATE: 117 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:halth folder.cent j. i r; 1 ASS ORS MAP N0: /�/L/• 12 D � F�s.....7u�......-_ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ' .......... ........................OF.............................-.......................................................... Appliration for Bi"vital Workii Tnnitrnrtinn rumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...- :.....� �..Q� ../.. .�� ....kh:_ at_7 c;�............. ............................................. ocatio Address or. -No. WA Owner e s a --•-••-------•---------=` ' .... �--- �.,.----------- ------- ......... a....... !_ o%.._.. ......... Installer Address Type of Building Size Lot.. ��--------Sq. feet U Dwelling—No. of Bedrooms.-_--------------------------------------Expansion Attic ( ) Garbage Grinder ( ) A`4 Other—Type of Building --•_____--__•__------------ No. of persons............................ Showers ( ) — Cafeteria ( ) Aa Other fixtures .................................. W Design Flow_.........................................gallons per person per day. Total daily flow............................_...............gallons. GG Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest 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-------_................ •-••-•-•--•-------------------•-----•-•---.._..-----•-•--------------...._......._._....-----.------............................................................. 0 Description of Soil-------------------- ----------------------------------•-•---.....-•----•-----------------------------------------------------•---------------------------------------•- x c, ------ 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 Ly t L.:' of the State Sa rye de— undersign furtheyragrees not to place e system in operation until a Certificate of Complian ce " sssuat� .VoarEE� %d/ �i 4�KD �FA_- Signed v AGG[ .... .. . ......................./... ...Dat . Application Approved BY...........-�-s�,.,.�---•--�-acc.�,'�-Y'-z�-...... ---.................... ........................................ Date Application Disapproved for the following reasons---------------••----•-••-------•------------------------------•-------------•--•---------------------......_..-- ---------------------------------•--------------------------•----•---------------.......---•----......-•----------------------••-------•-•--•-----•--••--------------.....-------------•---------•----•- Date PermitNo...... ..-... .c1/---------------------- Issued_....................................................... Date —--- -mom i ENGINEERING 749 Main Street O Suite B O Box 266 ASSOCIATES OF Osterville, Massachusetts 02655 (617) 420-2223 O(617) 420-2224 OS Reg. No. S-32442 Reg. No.C-24700 July 21 , 1987 Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 RE: EAO FILE # 87-109 Lot 3, 181 Old Town Road, W. Hyannis Port, MA SEWAGE PERMIT #: 87-391 APPLICANT: Barbara Grimes Gentlemen: Please be advised on -July 17, 1987, the referenced project was inspected for compliance. The bottom of the referenced system was placed (1 ) one foot higher than that of the approved project dated April 23, 1987. This elevation change will not affect the design flow. If you have any questions, please feel free to call our office. ENGINEERING ASSOCIATES of OSTERVILLE By: A. Paul Simard, P.E. P APS:ekh si E:u ` �; �jj c� � L cry 4 g o 470a cc: Mrs. Barbara Grimes 526 Winter Street I Issf m�� Framingham, MA 01701 t�r Consulting and design engineers O Civil and structural r No....%r :.x��1r.`.` Fps.... ..` .....::.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --- -- .._. ....................OF..........................------........ ApplirFa#ion for Uiipoiiaal Workii Tomtrnrtion thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ......-•----....----•-----------------------------------------------------------------•-----...... -••--------.....---...-----•------••-------------------........--•---......._....-----......----•- Location-Address or Lot No. ............................................•-----•---------•--•------............................ ------------•-------------------.......---...---•--•--.............._...._....--••--............-- Owrer --------------------------------------------Address --.- --Address ---••------•--•--.....r a 'i� .....�...> '-- - Installer Address Q Type of Building Size Lot...............:............Sq. feet U Dwelling No. of Bedrooms................................ .....Ex anion Attic a g— ------- p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther 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.---_.---____-__-__-___. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R.' 0 Description of Soil.........................................................................................................................-•-•-----------------------.................. W U w UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------•-----------------------------------•-----------........-----------•----------------------------------------------•------------------------------------•----------- Agreement; The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of i i !.,,.. j of the State Sa,y ar. Code—"he undersign d furti agrees not to place the system in operation until a Certificate of Compiiar ee'$ ssu oa ,,i4th?' G� Signed..................................................................................... ................................ Date Application Approved By........... ---- ................. Date Application Disapproved for the following reasons:................................................................................................................ .............-•---•---•-----••••----•--•-----------•--••--------•-•....•-------•-•••--------•---•-•----•---•-----------------•------•----•---•-•••-•------............................................ Date r Permit No......1,, . 7= /-----------------••••.. Issued........................... ,-------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ..............OF......� ems! r!__.r i_4S.tr.......................................... Trrtifirtttp of Tontph atta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed X) or Repaired ( } by................... G. .� ,m.e�=-------------•---------------------------•--------------•-•------------------------------------------------------------ Installer at.---------�a 3-- ! l > f>ram` - -tom �x -------a :------ �'l n has been installed in accordance with the provisions of T-.r'!~; j of The tam t Sanitary Code as described in the application for Disposal Works Construction Permit No---- 7.-•_..a.?._!_......... dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... .-----........------. Inspector-------. ---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7 �'~t.I..._......OF.......... - ............... llispomt Works Tonirudion an it Permissionis hereby granted.............. ,�........... ............ v----------------------_. ....... ............................ to Construct (,V) or Repair ( man In ividual S Di posal st / at i\'G. 7. 3. -- ---•------ ---------------- as shown on the application for Disposal Works Construction Per `' No.5 1 r.l__! ated.......................................... DATE........ ...... .......................................... Board of Health FORM 1255 HOSES & WARREN. INC., PUBLISHERS _ _ - _ i` fI t I L _ �KI gT/6lli I ram' � tia E � N) III ------ --- � Ii ILI f CAS dfQy,, Wt t of OFSNOW N i �- , C'�• 1- r I�t���ovti� rGyIrt ^ �t 10 � z r 'I jlIil S'` _ N 1 R_C, LC)" u yx e I —'c— _ 3�, f Z `^ � " o ARCHITECT _ > m > I • L. F. 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