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HomeMy WebLinkAbout0018 PAWNEE COURT - Health 18 PAWNEE COURT, HYANNIS A=289 - 137 1, I i ,I i r 0 I� a� _ G G � r_ TOWN OF BARNSTABL,E c LOCATION � o A C"f' SEWAGE # , VU L,AGE 14V 01„n-.! & ASSESSOR'S 1bI,AP& LOT L INSTAi`. ER.'S NAME&PHONE NO. SEPTIC TANK CAPACITY. 1500_._ 4.4 1 L1E ACY-.IING'FACIt..ITY: (ty ipwe .L 4 ct� m b e I _ (size) C;� —�Eod S NO,OF BEDROOMS BUILDER OR OWNER. FEi'TDA71:1:`.. — _. :.,_COi+r 'GIlCE DATE: 14Q Separation Distmwe Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fee' Privtte Water Supply Well and Leaching Facility (If any rmlls ex6t on site OF wititin 200 feet of leaching facility). Four Edge of Wedand and Leaching Facility(if any wetl is exist � within3f30 feet if leaching i ci�ry) P@ Clow Furnished by �wvd fir'/o I° t d q 1 0 TOWN OF BARNSTA.BLE E C' LOCATION PAWnrEE SEWAGE # � VILLAGE 14yerMA15 ASSESSOR'S MAP & LOT l-Q# INSTALLER'S NAME&PHONE NO. \/V I III ISMS &1 1c 106 CO :;U-6300 SEPTIC TANK CAPACITY 1 50 CSC.. LEACHING FACILITY: (type) pl%e� (size) PQ NO. OF BEDROOMS BUILDER OR OWNER 11M W.M 1 b4-M PERMITDATE: c �7 IO(, COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on Bite 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 v. ----7I cC) — K) S LL) I Q ` V.. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Miopogal *pgtern Construction Permit Application for a Permit to Construct(d)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1(2� VA"i Owner's Name,Address and Tel.No. Assessor's Map/Parcel 113� 1,0 " Installer's Name,Address, land Tel.No. Designer's Name, Naaim�e,�Address /wand Tel. No.:PWF_S {Theole45 o'aA YV c, I(0�/�l( +� '�T" I-6�►y7��'te�M�"�//�'f—/��"!/. 7 7 Type of Building: Dwelling No.of Bedrooms Lot Size ":J sq.ft. Garbage Grinder(Alo Other Type of Building No.of Persons Showers./D) Cafeteria Other Fixtures Design Flow ZW gallons per day. Calculated daily flow Z24-1 gallons. Plan Date %2-,30-YA Number of sheets ! Revision Date Title Size of Septic Tank l 5bO 6.L Type of S.A.S. AEI-/-yr� E'-! ✓y1131�5 Description of Soil D�- Z ® 6� /G `Z`��t `0 P- of 2 G coACZZ 5'4.-Y G VcL fQ M- 7Z2 MQ luAiX- Nature of Repairs or Alterations(Answer when applicable) ..,co IkAl 1ST SUPM�S Date last inspected: ®E fG IN U.i3ON AND CERTIFY 11N STRbCT E. 4 C ill WAS INSTALLS Agreement: �^,G-;�.s-;�,.NCE TOP LAN- 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 o e Et ningntal C de and not to place the system in operation until a Certifi-cate of Compliance has been ' ued b t ' of al Signed a Date Application Approved by a Date Application Disapproved for the following reasons Permit No. Date Issued r.Noy t = Fee - ter:- Y L THE'COMMONINEALTH OF MASSACHUSETTS - Entered in co mpu Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppfication for Miopo�af *pztetn Construction 1permtt Application for ia Permit to Construct Repair( )Upgrade( )Abandon( ) 1:1 Complete System ❑Individual;Components Locat on ddress or Lot No. �ti-CL Owner's Name,Address and Tel.No. ',ri��S i�a Imo' t Assessor's Map/Parcel Installer's Name,Address,r(diar Tel.No. Designer's Name,Address and Tel.No.�2j F—s 1geor2� T r. (rV ' , (Ii 1 Type of Building: F' Dwelling No.of Bedrooms Lot Size �U rj�Z y sq.ft. Garbage Grinder�) Other Type of Budding No.of Persons Showers.(✓O) Cafeteria(V6 Other Fixtures Design Flow Zw gallons per day. Calculated daily flow Z2�2 gallons. ... Plan Date - -�� Number of sheets Revision Date Title „ Size of Septic Tank 7 5aO 6.4L Type of.S.A.S. Desc7r�iption of Soil D Z D ��/�iY/G�> 2- Ilo ,4 S�/�a /t� �2 N /LP p- 2fm " 3 �O�Yft lcJ. �n�,4►�CL /o A2 Ga Go 4C- C SAr✓fl r,,94 WE L /0 2 7 3 l✓O AA47Z:7.— _..� Nature of Repairs or Alterations(Answer wheti applicable) Date last inspected: 1 - "` Agreement: - - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system 4, in accordance'with the provisions of Title 5 ofthe ixon ntal lode"`and not to place the system in operation until a Certifi-. +. t cate of Compliance has bee ued by-lhis - d of 4 • Signe 0 Date Application Approved by / ! Date Application Disapproved for the following reasons Permit No. Date Issued ——————————————————————————————————————THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUUSETTS Certificate of Cote fiance THIS IS TO CERTIFY„that�the On-site Sewage Disposal System Constructed )Repaired ( )Upgraded( ) NSA' Abandoned( - )by T.M at i�� r-r' ` �- t. t ti .> >f ha ee onstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N 9 Hated Installer Designer The,issuanc of this permit shall not be construed as a guarantee that the syst wi11 f nction as esi,gned. Date a�f U 2 Inspectorr� ` -------.----------------- 1� Fee , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopooa\\f//*p!tem Con!tructtott Vermtt ,O Permission is hereby granted to Construct Repair( )Upgrade( )Abandon( ) System located at f and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. I ll/Ii Date: It / f r /C Approved AP TOWN OF BARNSTABLE E'C- LOCATION P14 EE1 SEWAGE # cam" VILLAGE_ 14tt°fi'K)0415 ASSESSOR'S MAP & LOT:' # 3 INSTALLER'S NAME&PHONE NO. \A[ I I1"S & Ic 1 06 C 6 362-6;JL is SEPTIC TANK CAPACITY KOO 6 A-(- LEACHING FACILITY: (type) 0-4 (size) 4146 G PQ NO. OF BEDROOMS RZ- BUILDER OR.OWNER t1M LU 11164-M PERMITDATE: �1 �7 I�C� COMPLIANCE DATE: I f) a(. to Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility J?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. 3� � 3 � �A yL �fi _ 56 3 /� p10 AJ Bust ess Na e` � r2o f ht'�; fiib 1(�/ M e Car �Un it / k i ! suartee Dater , / ,77]Owner. SYDNEY,MILES proploc 18 PAWNEE COURT /�r 'x• x;-..' .:.: � „I' - fir, i w Am ' F r r rrt f, i SULLIVAN ENGINEERING INC. 7 PARKER.ROAD/P O BOX 659 OSTERVILLE, MA 02655 Peter Sullivan P. E. Mass Registration No. 29733 psullpe@aol.com phone 508-428-3344 fax 508-428-3115 . November 1, 2001 Board of Health Town of Barnstable 367 Main Street Hyannis, MA 02601 RE: Lot 3, Pawnee Court, Hyannis. Map 289 Parcel 137 Dear Board of Health, Per your request, I inspected the septic system at the above referenced property on October 25, 2001. I inspected the system prior to back filling and found it to have been installed in substantial compliance with the plan of record. At the time of the inspection, town water had not yet been installed. I trust this meets your present needs. If you have any questions, please feel free to contact my office. Very truly yours, . Peter Sullivan, P. E. A tF , Sullivan Engineering Inc. SU�idA;� �,t �f1V �0' L G7 Members of American Society of Civil Engineers, Boston Society of Civil Engineers TOWN OF BARNSTABLE �FtNEr�� OFFICE.OF 31asa9TSBL i BOARD OF HEALTH NAG& . 1639. a MAX 367 MAIN STREET E k' HYANNIS, MASS.02601 January 29, 1999 Robert Sydney 106 Athelstane Road Newton Centre,MA 02459 RE: 18 Pawnee Court, Hyannis Dear Mr. Sydney: You are granted a variance from the Board of Health Interim"330 Regulation", in order to construct an onsite sewage disposal system at 18 Pawnee Court,Hyannis, Massachusetts. The variance is ranted with the following conditions: g g (1) No more than two(2)bedrooms are authorized. Dens, study rooms, finished attics, sleeping lofts, and similar-type rooms are considered"bedrooms"according to the Massachusetts Department of Environmental Protection. (2) The applicant shall record a deed restriction at the Barnstable County Registry of Deeds with respect to the two bedroom maximum restriction. 3 The dwelling shall be connected to the public water supply. ( ) g P (4) The dwelling shall be connected to the town sewer line when/if it becomes available. This variance is granted because the applicant testified that the dwelling will contain only two bedrooms. It is the opinion of this Board that the construction and use of an onsite sewage disposal system for a two bedroom single-family home should not significantly alter the groundwater quality in the area. i Since ely y t1rs, DESIGN"" R MUST SUPERVISE } INSTAt `=RTIFY IN WRITING THE S „STALLED IN STRICT Ra p urphy, ;ACCOR- PLAN. Chairm ri Boar f Health Town of Barnstable SGR/bcs C rsydney { -TOW.11 t Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today,Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 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. A. General Information Inspector: p 1. Ins f Shawn Mcelroy Name of Inspector Upper Cape Septic Services t =` Company Name 29 Atwater Dr Company Address E.-Falmouth . . .MA „ .. 02536 City/Town .." State Zip Code 508-495-0905 d S13971 #' Telephone Number License Number f O' B. Certification .a -n . 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 i cticol� was performed based on my training,and'ezperience in the proper function and maintenance of �'te sewage disposal systems. I am a DEP.approved system inspector pursuant to Section 15.340t'e# Title 5(310 CMR 15.000).The system: ` i (l ® Passes ;, ❑ Conditionally)Passes. ❑ Fails ❑ Needs F rt Eval on by the Local Approving Authority 10-7-10 I 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.. •.t y k - II Title 5 Official Inspection Form:Subsurface Sewa Dis osal 2JP]gebf 1t5insp official document•03108 p p 5 F l r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s` M 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure and operating at about 75% of capacity. Recommend pumping tank and chambers now and every 2 yrs for maintenance and to prolong life. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. Tne system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the ❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp official document-03/08 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes.(cont.): 0 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 boraering vegetated wetland or a salt marsh 2. System will fail unless tl e'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: t ❑ 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. { t5insp official document•03/08 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 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less 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. t5insp official document-03/08 Title 6 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 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today,Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont): Yes No ❑ ®, Any portion.of a cesspool or privy is within a Zone 1 of a public well. ❑ _ ® Any portion of,a cesspool or privy is within 50 feet of a private water supply well. ❑ ®. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform'bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 1 t. , The system fails. I have determined that one or more of the above failure 0.' 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`fifes"or"no"to each of the following, in addition to the questions in Section D. Yes No" _ .. . 0 _ ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system.Js within 200'feet of a tributary to.a surface drinking water supply. El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document•03/08 Title 5 Official,lnspeclion Forms 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 �qM r 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] t5insp official document-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts 1 Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 18 Pawnee Ct Property Address Bank Owned (Contact David Holt@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis, MA 02601 10-7-10 page. City/Town , state' Zip Code Date of Inspection D. System Information P Residential Flow Conditions:, 'a Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 Number of current residents: « 0 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No i Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)):, , Sump pump? El Yes ® .No Last date of occupancy: F 9-2010 Date Commercial/Industrial Flow Conditions: -Type of Establishment:, Design flow(based on 310 CMR 15.203): • . x r Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft:, etc.):. ; Grease trap present? ; ,: f ,, - ❑ 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:, ti Last date of occupancy/use: Date Other(describe): T t5insp official document•03/08 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 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A 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 tar k.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Selvage Disposal System-Page 8 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal S stem Form-Not for Voluntary,Assessments - _9 P Y 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Hyannis MA 02601 10-7-10 required for every H y ' page. City/Town State .Zip Code Date of Inspection D. System Information (cont.) t Building Sewer(locate on site plan): _ - • Depth below grade: .. ,.. a< r 24" 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.): Good condition. Septic Tank(locate on site plan): .f Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of,certificate) ❑ Yes ❑ No -- - --------------- - ------- --- - - ------ --------------------------------- Dimensions: 1500 gal Sludge depth 16" Distance from top of sludge to bottom of outlet tee or baffle , Scum thickness, 2.. ' S.. Distance.from.top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or.baffle 14" How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments on pumping recommendations inlet and outlet tee or baffle condition, ( p p g I n, structural integrity, , 9 liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Recommend pumping for solids. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 9 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) on) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis. MA . ' 02601 10-7-10 page. City/Town 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)As copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate:on,site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.):: Good condition with water at working level and no sign'of back-up from chambers. Pump Chamber(locate on site•plan): Pumps in working order: ❑ Yes ❑ .No Alarms in working order: { ❑ Yes ❑ No t5insp official document•03/08 Tige 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500'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.): Leach chambers in good condition with 6"of water at inspection with stain line at 5"below inlet invert. t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 Commonwealth of Massachusetts -, W Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis l MA 02601 10-7-10 page. City/Town r. 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, 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.): t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 10-7-10 page. City/Town 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. F N t5ins official document p ocu ent•03l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official InspectionForm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM ' 18 Pawnee Ct Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Hyannis MA 02601 10-7-10 required for every y , page. City/Town State ' Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10, feet. Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed- pate ® Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health explain: Checked with local excavators, installers-(attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 10'. t5insp official document•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 tFfQ D TE t _ FEE: • tiAR MA" ! ' Town of_Barnstable REC. BY �f0 � Board,of Health 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kauflnan,M.S.P.H. - Ralph A.Murphy,M.D. VARIANCE REQUEST FORM LOCATION Property Address: C--Ov+- A—` . k r.•^:S Assessor's Map and Parcel Number. P,SOL 1 3 7 Size of Lot: p, S-a 0 Sa.-4. Wetlands Within 300 Ft. Yes Subdivision Name: L ,; No Business Name: C> a— APPLICANT CONTACT PERSON Name:_M; Ie-S S..clr.e•( Name: Rote. a �? I�a=� :... h:✓.... a 10 fo A+t-.Q Address: © 66 Address: ►���,�e� Lr.�.� N1A p24S�1�.,cK.Q -. _ �S8 Phone: _( -01� as— of toL3 Phone:���C,17� T FAX: FAX: C�l7 7 a7— b©N VARIANCE FROM REGULATION(Gst Reg.) REASON FOR VARIANCE(May attach if more space needed) p 1 Vn Ov%nQ -j:}L% -a y 0N-S:4e- DeZi-e� ; 2 gQ % Set%-►MZ: e- CL:Sp�OSzI SvS`fe Checklis (to be completed by ojice staff-person receiving variance request application) Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) Variance request application fee collected(no roe for lifeguard modiriadon renewal,game trap variance rentwala[a.me oweernea+ee only),outride dining variance renewal tome ovmcrneasee only),and variances to repair failed sewage dlapoaal a ems yet (only it no apwion to the building propoaed)) Variance request submitted at least IS days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. ` REASON FOR DISAPPROVAL Ralph A.Murphy,M.D. Q:/WP/VARIREQ r 1-4 Ll $a tu IbA I �` �0', �� � r , � � \ � • � `� � `� o• �� I�� � J �?V c�F,� tits .` .l � t N � t � -y/yj r / N 3 Nam, 111 u, °✓W�o �¢+? -� rJ •� hE ram; �YoxO. ,4 F .1 f1 ,j Ul y 4 � � cam. � � � •W � A. 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