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HomeMy WebLinkAbout0079 PEACOCK DRIVE - Health 79 'Peacock-Drives ? _v Hyannis F/R j A - 269 212 I}. i I I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION err ' TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS4ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM`'z� PART A ; CERTIFICATION f} -79 C-D g . Property Address: Peacock Drivecc rest' Hyannisport MA kr r b Owner's Name: George Etre Y Owner's Address:: Same Date of Inspection: June 9,2005 Job .05474 Name of Inspector: PATRICK M:O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO: Mailing Address: . 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on m,Xi tttotttiq� training and experience in the proper function and maintenance of on site sewage disposal systems. I am OF approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: � • G� _X Passes P R C :cn s_ Conditionally Passes = M. :� Needs Further Evaluation by the Local Approving Authority y Fails ,O• lor O � Inspector's Signature: Date: June 9,2005 • num uu�� 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 r DER The original should be sent to the system owner=and copies sent to theT buyer, if applicable,and the approving authority.. ` Notes and Comments: Observed 1-2 standing water in leaching chambers,tank not in need of pumping at this time.Recommend pumping tank in one year and every,three years. ****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. R -Title.5 Inspection.Form' 6/15/2000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 Peacock Drive West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: • r, 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 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 distribution box is leveled or replaced ND explain: a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Titla Tncnartinn 2. Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 Peacock Drive West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 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 t 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Titlo Inenorfinn Fnrm 411 v)nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 Peacock Drive - West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X_ Static liquid level in the distribution box above outlet invert due to'an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation_. —X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No_(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ 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 lI 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. T;tla C Tncna�t;nn P—m 4/1 Vlnnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 79 Peacock Drive West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner;occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _ _X_ Have large volumes of water been introduced-to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? ' _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _X_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no < _X_ _ Existing information. For example,a plan at the Board of Health. - X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Titlo G lnanontinn Anrm 411;/innn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 79 Peacock Drive West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)):.'Two years consumption: 171,750 gal.=235 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: No pumping records. Source of information: Homeowner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped:_0_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system - _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date June 6,2003 Were sewage odors detected when arriving at the site(yes or no): No Titla C incnartinn Fnrm 4/1;i,)nnn 6 i Page 7 of 11 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 Peacock Drive West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 BUILDING SEWER: XX (locate on site plan) . Depth below grade: 1' Materials of construction:—cast iron _X_40 PVC_other(explain) a Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_concrete—metal_fiberglass—polyethylene _other(explain) If tank is metal list age: . Is age confirmed by.a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 8.5'long x 5.2"wide- 1000 Gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,liquid level at bottom of outlet invert. GREASE TRAP: No (locate on site plan) Depth below grade:— Material of construction: concrete—metal_fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T41.9 Incn f;^n v^—411 ci,)nnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 Peacock Drive West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:'XX (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 hieh stains. Liquid level at bottom of single outlet. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Titlo C Tnenartinn 17nnm 4/1;/Innn 8 I Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 Peacock Drive West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: —X_ leaching chambers,number: Two 500 gal drywells. leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: r 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.): Observed 1-2"standing water with no high stains CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: , Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): Tit1a xnenortinn 17^ m 411 Vnnnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 Peacock Drive , West Hyannisport MA 02647 Owner: George Etre Date of Inspection: June 9,2005 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. Peacock Drive #79 32 5 39 26 52 30 Title G tncnortinn T7nrm Ali;nnnn 10 Page 11 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 Peacock Drive West Hyannisport MA 02647 Owner: George Etre - Date of Inspection: June 9,2005 x SITE EXAM Slope None Surface water None _ Check cellar Dry Shallow wells None r Estimated depth to ground water: More than 25 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within.150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_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 below el.20 and topo map shows property at el.50. Land A el. 50 4.5' ,- Leaching Chambers a >25' Groundwater below el`20 Tit1P C inanantinn Rnrm 411 VIM) 11 3 � U Fee 5 d No. j THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migooar *pgtem Construction Permit Application for a Permit to Construct( )Repair( V)/pgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. rlq PSjN&0C _ v a— Owner's Name,Address and Tel.No. t}t1�►NtS PoR� KTGUI� ME'122�1-`t��+ Assessor's Map/Parcel f}P S44 PC, ZI Z C 4,K- L $"N 1J t S Pox-r Installer's Name,Address,anq Tel.No. Designer's Name,Address and Tel.No. 1 ox. ?02 f"*96TVW6 rVil" f Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 O gallons per day. Calculated daily flow 341 gallons. Plan Date i 8► 0 3 Number of sheets Revision Date .IJ Title Size of Septic Tank 1000 GArt, Type of S.A.S. a-X 9b0 644- L45Ac4 C Whbe" Description of Soil SLR SOIL & Nature of Repairs or Alterations(Answer when applicable) Date last.inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this Board of He t . Sign Date , 3 Application Approved by Date a 3 Application Disapproved for the following reasons Permit No. 3 Date Issued (o 1 c; r x Fee J ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for �Digpogar *pztem Construction,,Vermit Application for a Permit to Construct( . )Repair( 4upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. �Ci P 4.0 GK„ v IZ. Owner's Name,Address and Tel.No. -�`, ►-}H"N t S P 09.:"r 1CO V l a M 12 21 Tl-E Assessor's Map/Parcel • f}P 2(0� C. 21 v t✓Ik eouL 14 A-N 01 S PaLT Installer's Name,Address,anq Tel.No. 47o, dZ�o Designer's Name,Address and Teel.No. JP,mFs ROO-45- E� [ANC f l t3ox 70Z M A 2$roNS M f LLs $fig� 02-9 Type of Building: I Dwelling No.of Bedrooms 3 Lot Size sq.ft. ,* Garbage Grinder( ) Other , Type of Buifding No.of Persons " Showers( ) Cafeteria( ) Other Fixtures Y Design Flow 3 3 D gallons per day. Calculated daily flow 3 `4 1 gallons. Plan Date 5, 1 6 , 0 3 Number of sheets 1 Revision Date N 11 A Title J Size of Septic Tank 1000 G A L. Type of S.A.S. a-X 9_00 6.41- L-_lc 4 C14PV'1(C_a-S Description of Soil 5�E Solt_ o� f Nature of Repairs or Alterations(Answer when applicable)/ ( t 1 • t Date last inspected: "t br 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- &ate of Compliance has been issued this Board of Hea4q. Sig Date 3 - 3 Application Approved by`-�z_ Date a 3 Application Disapproved for the following reasons 1' M1 Permit No. i 3 Date Issued -------------------- — ----- ----------- THE COMMONWEALTH OF MASSACHUSETTS .c BARNSTABLE, MASSACHUSETTS � Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( ),Upgraded( E) Abandoned( )by ? c n r at Q�tco r- 14 S has been constructs in ccordance with the provisions of Title.5 and the for Disposal System Construction Permit No.Z003- 20D dated_ t� Installer Designer The issuance of th/ir pe it shall not be construed as a guarantee that the system eon o as - g efd. Date �! ) Inspector 1 es No. goo, 3_�YU -------------------^--------Fee © �— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogar *p!tem Construction Permit Permission is hereby granted to Construct( )Repair Upgrade( )Abandon( ) System located at 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 dat• of th`i �`e- it. Date:_ (0 I�3 Approved �— TOWN OF BA.RNSTABLE LOCATION r7 1 SEWAGE # 3 �' VILLAGE LL ASSESSOR'S & LOT ' INSTALLER'S NAME&PHONE NO. ti:/Pe K /U/l 2b ''D 2-9,a 11 SEPTIC TANK CAPACITY /M) 6A LEACHING FACIL=: (type) ��:Ali (size) NO.OF BEDROOMS' BUILDER OR OWNER Vl PERM T DATE: °� - COMPLIANCE DATE: v, Separation Distance Between the: Maximum Adjusted3Groundwater Table andBottom 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 e p J&t i �r 32-6 ., Z 39 -� 3 q4 2, 29-ID gCts .3 33—a 5/25/01 'Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only . PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, C A?L L I-\PJTE_.P,`! , P.L_ ,hereby certify that the engineered plan signed by me. dated S- 1 Y) -�Y5 ,concerning the property located at \w'F- /1'\ 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. i • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may.use historical data to conclude this fact or may conduct preliminary tests at the site without a,health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five 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) G.W.Elevation)\/- +adjustment for high G.W. — N- DIFFERENCE BETWEEN A and B J, SIGNED ,.DATE: � C� NOTICE . w Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:pereexmp COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ' CERTIFICATION Property Address: 79 Peacock Drive West Hyannisport, MA 02672 RECEIVED Owner's Name: Linda&Kevin Merriheu Owner's Address: Same MAY 1 2 2003 Date of Inspection: April 11, 2003, TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map:269 Mailing Address: P.O. Box 49 Parcel.212 OsteryUk,MA 02655-0049 Lot: 12A Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal,system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5910 CMR 15.000). The system: Passes Conditionally Passes Needs FHrther Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: April 14, 2003 The system inspector shall submi 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 sett to the system owner and copies sett to the buyer,if applicable,and the approving authority. Notes and Comments ****This report'only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION, (continued) Property Address: 79 Peacock Drive West Hyannisport, MA Owner: Linda and.Kevin Merriheu Date of Inspection: April 11, 2003 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 the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)'in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank, failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank 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 - 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: 2 y Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 79 Peacock Drive West Hyannisport, MA Owner: Linda and Kevin Merriheu Date of Inspection: Apri111,2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiirther 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 m accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and.SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method-used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and ' the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 79 Peacock Drive West Hyannisport, MA Owner: Linda and Kevin Merriheu, Date of Inspection: April 11, 2003 D. System Failure Criteria applicable to all systems: You must indicate either`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 i/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped— ✓ 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 coldorm bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must.be attached to this'form.] Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 151303,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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`ryes"or`no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 79 Peacock Drive West Hyannisyort, MA Owner: Linda and Kevin Merriheu Date of Inspection: April'11, 2003 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.disposat systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at 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(3)(b)]. ` 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 79 Peacock Drive West Hyannisport.MA Owner: Linda and Kevin Merriheu Date of Inspection: April 11, 2003 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No . Water meter readings,if available(last 2 years usage(gpd)): 2002-69.000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):a gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 4 years azo-per owner. Was system pumped as part of the inspection(yes or no): 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: Approximately 1985 Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM`INFORMATION (continued) Property Address: 79 Peacock Drive West Hyannisport, MA Owner: Linda and Kevin Merriheu Date of Inspection: April 1. 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction lines Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan). Depth below grade:. 16" Material'of construction: ✓ concrete _metal _fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 1 Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: 6" { Distance from top of sum to top of outlet_tee or,baffle: 8" Distance from bottom.of scum to bottom of outlet tee or baffle 10" How were dimensions determined: ' - Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. Theliguid level was even,udth the outlet.invert.- There were'no signs of leakage. GREASE TRAP: None (locate on site plan Depth below grade: Material of construction: •concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: , Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): R 7 • Page 8 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 79 Peacock Drive West hWnnisport, MA Owner: Linda and Kevin Merriheu Date of Inspection: April 11, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day. Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 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.): The D-box was located Liquid was backing up from the leach pit. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 79 Peacock Drive West Hyannisport, MA Owner: Linda and Kevin Merriheu Date of Inspection: April 11, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'with 2'stone(1000 Qal.) leaching chambers,number: 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.): The pit was full. Die liquid level was up to the inlet pipe. The leach pit was in failure. The bottom to zN*was 10'. The cover was Y below grade. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): I PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 79 Peacock Drive West HVannisport, MA Owner: Linda and Kevin Merriheu Date of Inspection: April 11, 2003 Map:269 Parcel:212 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 12A 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. Ott C. A A 6 I � 13 / (0 3.3 a 0 3 3a yb 10 Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM_ PART C SYSTEM INFORMATION (continued) Property Address: 79 Peacock Drive West Hyannisport, MA Owner: Linda and Kevin Merriheu Date of Inspection: 'Apri111,2003 SITE EXAM Slope Surface water Check cellar Shallow wells. Estimated depth to ground water .30 +1 feet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,.date of design plan reviewed: Observed site(abutting property/observation hole within 156 feet of SAS) . ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours may,the maps wre showing approximately 30'+/-to ffound water at this site. This report has been prepared and the system inspected and failed of.the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future, There have been no warranties or guarantees, either expressed,written or.implied, relating to the system,the inspection and/or this report. . I1 . r99. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION ' DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500, P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAULCELLUCCI DAVID B.STRUHS Govemor r Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 79 PEACOCK DR.W. HYANNISPORT L 12A y Name of Owner n/a Address of Owner: BRIAN BEARDSLEY;603 MYSTIC DR.MARSTONS MILLS MA.02648 Date of Inspection: 1/27199 Name of Inspector:(Please Print)JOHN GRACI ' I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: John Graci Title V Septic Inspection ' Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 Telephone Number: (608)664-6813 CERTIFICATION STATEMENTS 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,inspection.The inspection was performed based on my training and experience in the proper function and- maintenance of on-site sewage disposal systems.The system: X Passes t, z Conditionally Passes Needs Further Ev ua n By the Local Approving Authority Fails Inspector's Signature: -Date:2/2199 The System Inspector shall s mit a copy of this inspection report to the Approving Authority.(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies.sent to the buyer,if applicable,and the approving authority. n NOTES AND COMMENTS r SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING'SYSTEM NOW AND RAISING COVER TO MAINTAIN SYSTEM EVERY YEAR. a revised 9/2J98 .f Page 1 of,11 6° f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: n/a Date of Inspection:1127/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. ND The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. NO Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced NO The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 1 t revised 9/2/98 Page of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: n/a Date of Inspection:1/27/99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nta..•(approximation not valid), 3) OTHER ' nLa revised 9/2/98 - Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: n/a Date of Inspection:1/27/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. ^ X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: . You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is.a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: n/a Date of Inspection:1/27/99 Check if the following have been done:You must indicate either"Yes,or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. t revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: n/a Date of Inspection:1/27/99 FLOW CONDITIONS RESIDENTIAL: `S Design flow:.. .:g.p.d./bedroom 3?)C) Number of bedrooms(design): 3 Number of bedrooms(actual):nta Total DESIGN flow: Number of current residents:nLa Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO. If yes,separate inspection required Laundry system inspected(yes or no).,M Seasonal use(yes or no):M ' Water meter readings,if available(last two year's usage(gpd): Wa Sump Pump(yes or no): NQ Last date of occupancy: 1/6/99 COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: nta gpd(Based on 15.203) Basis of design flow: Wa Grease trap present:(yes or no):J9Q Industrial Waste Holding Tank present:(yes or no): 1�LQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:Wit Last date of occupancy: Wit OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information:' nLa System pumped as part of inspection:(yes or no):NQ If yes,volume pumped nLa_ gallons Reason for pumping: nLa TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEh"VVAS INSTALLAED IN 1985 PERMIT 85-358 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: n/a Date of Inspection:1/27/99 BUILDING SEWER: (Locate on site plan) Depth below grade: V Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: 1 Material of construction:X concrete_ metal Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO nLa Dimensions: L R'6"H 6'7"W 4'10" Sludge depth:,li" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) MAIN CESSPOOL AND ALL COMPONENTS ARE ST-- ALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY YEAR, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:i3La Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: nLa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nLa . revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A. Owner: n/a Date of Inspection:1/27/99 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: NQ Alarm level:.nLa_ Alarm in working order:Yes—No—: NQ Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nta A it DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:nta Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) , y PUMP CHAMBER: NO b (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa b revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: n/a Date of Inspection:1/27/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: 6'X6'LEACH PIT WITH 2'OF STONE leaching chambers,number: -n& leaching galleries,number: jiLa leaching trenches,number,length: n& leaching fields,number,dimensions: nLa overflow cesspool,number: n&' Alternative system: n& Name of Technology: sda ' Comments: (note condition of soil,signs of hydraulic failure,level of ponding;damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY PIT HAD 4'IN IT AT THE TIME OF THE INSPECTION CESSPOOLS: _ (locate on site plan) Number and configuration: n&. Depth-top of liquid to inlet invert: nLa Depth of solids layer: ilia - Depth of scum layer. nLa Dimensions of cesspool: n[a Materials of construction: Wit Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc) nLa ' PRIVY: (locate on site plan) Materials of construction:Wa Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 Page 9 of 11• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: nla Date of Inspection:1/27199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or,benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a , �ac� to �1 Ac revised 9/2/98 Page 10 of 11 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 79 PEACOCK DR.W.HYANNISPORT L 12A Owner: n/a Date of Inspection:1127/99 NRCS Report name: nLa Soil Type: Wa Typical depth to groundwater: n& USGS Date website visited: nLa Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 13 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions X Checked with local Board of health _ Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) ? GROUNDWATER OBTAINED FROM A SEPTI C INSPECTION PERFORMED 10/20196,AND USGS MAPS M. revised 9/2/98 Page 11 of 11 s TOWN OF BARNSTABLE L�,CAT10N/ IC `fir SEWAGE # . r�P��.'�o► VI-LAGS h✓1224nt 2 ASSESSOR'S MAP & LOT ,2 �LN= R-'S NAME&PHONE NO �r�'�k ®n�wl� 2�i� SEPTIC TANK CAPACITY 1'QQ LEACHING FACILITY: (type) ( =� �(�rte��5 (size) 13 X Z$� NO. OF BEDROOMS 3 BUILDER OR&�1E 1 PERMIT DATE: EE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by N 6` Ct� r ' • C11 Cry _ _-. <A r• l TOWN OF BARNSTABLE ` ' LOCATION -SEWAGE # : `D&3 7- D VILLAGE- iTN"wis PDk:r ASSESSOR'S & LOT is INSTALLER'S NAME&PHONE NO. t/Pe'�2aGL��Z .� ��� SEPTIC TANK CAPACITY /ODD 6A-b LEACHING FACILITY: (type) SbQ (Ai 8 (size) 9— NO.OF BEDROOMS M BUILDER OR OWNER --`( ') PERMITDATE: " Z" COMPLIANCE DATE: (O 1 0 Separation Distance Between the: Maximum Adjuste$6roundwater 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) 00m,6Feet Edge of Wetland and Leaching.Facility(If any wetlands exist ���,y within 300 feet of leaching facility) �66 Feet Furnished by 3z -9 q 52- 1 22_:� y�cs� Z 2-1_-o 3 .33—Z> 31 -� TOWN OF\BARNSTABLE LOCATION P64 L0Lk !J r SEWAGE # VTLL;AGE �/ � A/t1hSA'a ASSESSOR'S MAP & LOTa(9 a�a1 INSTALLER'S NAME&PHONE NO. L- l SEPTIC TANK CAPACITY /OM LEACHING FACILITY: (type) /"+� �o !o� WO (size) a r '�- NO.OF BEDROOMS BUILDER OR OWNER �t n�� �ey+mot •M Crr-1�\ey PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leac, ng facility) Feet Furnished by W Sb o 1 CA w � c� , TOWN OF BArN5TABLE LOCATION �C����-� / SEWAGE # VILLAGE `'.'n �A'SSESSOR'S MAP & LOik INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any well mist within 300 feet of leaching facility) /� , Feet Furnished by y� I „� S' O G! '}� rJ� �s� V�13� ��-.c � � . � l .+. � +� TOWN O,FIBA,R/N�STABLE _Q 7 LOCAON 7` �cG Ef� //r SEWAGE # VILLAGE GJ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:y�a�S Sr COMPLIANCE DATE: ���KZ 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 leeaching/facy it ) Feet Furnished by— ( p [N �i a i C] + a c ,V .. i (� a (�x� M s � � � • � • L0 C,A•T ION 7 Je S E W A G E tj RMIT NO. 4-0 c o c .VILLAGE I N S T A LLER'S NAME ADDRESS T pr L5co11esQ 0 U I L D E R OR OWNER DATE PERMIT ISSUEDg DAT E COMPLIANCE ISSUED 4 r Q a� •.t J � �. Co. THE COMMONWEALTH OF MASSACHUSETTS �- BOARD OF HEALTH ..........'1....................OF.....! ...............---------------........------...................... Applirati.an for Uiip.aaai 19orkii Tomitrnrtinn Prrutit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: .........� 1. ..... ec ......��?112C............. ....................................../J):...I ............................................. -Loc ion-Press or Lot No. -•••- ......................... -...........................•-•--•--••......-----••-•- Ow C Address a ..... ��..�r f------------------------------------- ........................d:s� Address UType of Building Size Lot............................Sq. feet Dwelling-No. of Bedrooms......... .............................Expansion Attic (A.) ) Garbage Grinder (AJ) Other—T e of Buildin ? '!.... No. of persons....... _ Showers a YP g -------- -------------•------------- `,�------------------ (� — Cafeteria (� Otherfixtures ......IV Lr 7 .• •--••------•••--••••--••-•-••.....-•--•-••--•---••-•--_...• ••••---••-•-•-•.............•--•----- W Design Flow.......... 5 ....................gallons per person per day. Total daily flow.......... .X.0......................gallons. 04 Septic Tank—Liquid*capacitykP.�A._gallons Length_-/.a........ Width---4........... Diameter---_- --------- Depth...k......... W Disposal Trench—No.__/ _. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter..............._.... Depth below inlet.................... Total leaching area....1.4-__-_sq. ft. Z Other Distribution box (,) Dosing tank ) Percolation Test Results Performed by.____f ....____ t?�,.l.0� Date........................................ W - Test Pit No. 1.....L_2.minutes per inch Depth of Test Pit.... ........... Depth to ground water/v :....... (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ••-•-•-••--•-----------------•-•----••-•--••-•-•••••---•-•-••-----•-...-•--•---•..........._._..............------------••-•--••••-•--•--••-•••---••--•••---. 0 Description of Soil........................................................................................................................................................................ W ------------------------------------------•------------------------- --•--••-•••-•----••••-•-••-•••----•-•••--------•-------•••----•-•-••--••-----••••-•-••-•-•••-••------•......••-••---•••••----•--•- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-----....-•------------•------•----------------------------..._...---------•----------------------------------------------•--------------------------------•-•----••---••-. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in e tion n it a certificate pliance has bee issued by the board of health. `��t :d ....'E —... ----------------•---ication Approved By-----••-••-?Signed •-••-•••--_•-•- •-••••••-•--------•---_... ��� � �- __.................•--------•- DateApplication Disapproved for theing reasons---------------------------------•--------------------------------•--•-----------•------••-......•-••••....-••••- -•-------------------•--------•--------•----•---------------••---•--------•--------------....------------I••----•-•--••••----••••••--•-•••••--•--•••-•-••-••-•-•-••••-----•-----••--••••---••--••--•----- Date PermitNo......................................................... Issued-....................................................... Date ............................ ,rs am" ,TTS n, 1i A .� w No...� .`3.5$ FEs....... �--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f.C�ZCl .. ................0F....',a`. 7.........------.---------------------------------------------------- ApplirFa#ion for Disposal Warks Tonstrnrtinn "amit Application is hereby made for a Permit to Construct k) or Repair ( ) an Individual Sewage Disposal System at: ........ ,. }'" / ......�.. : �r. r..l:...... 12<.l'r............... -..--------- ------�a.A.............................................. Location-4,ddress ........ — X a: 1 ... /13..... / .......................( 4 /!_7 r Lot No. Ow Address Installer Address UType of Building Size Lot...........................Sq. feet a . Dwelling—No. of Bedrooms........... ..:...........................Expansion Attic JU Garbage Grinder (�) p-I Other—Type of Building _WG ....... No. of persons.......�✓._------•..-__----- Showers (�`) — Cafeteria (�J) PL4 Other fixtures ..-- W Design Flow........�S.:......:...................gallons per person per day. Total daily flow.........7_:3i.-4D......................gallons. WSeptic Tank—Liquid capacityl4!•f-,,D---gallons Length./,,2......... Width.. ............ Diameter.... Depth... ........... x Disposal Trench—No._ lJ V ... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..,9.4_.V.._.sq. ft. Z Other Distribution box Dosing tank ( ) W Percolation Test Results Performed by..__1'lc a --.-.2 i sr�r, r.. ._.__. Date........................................ Test Pit No. 1....�— minutes per inch Depth of est Pit. ................ Derth to ground water/-L/1);.�.0......... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._.................. P1 .... •----------------------------------- •••••••-•...... ... 0 Description of Soil........................................................................................................................................................................ x V ...•••-•--••••---•-------•-•••-•--•-••••-••-••••••....---•-•---••---•-•-•••-•-----•••••--•--•...•-••......•-•••--•---••-•--••-----•---•--•--••.....•••-•-•-•-•••-•---•--••--••-••......--••-••----•••---- W x ---- •-- ------------------------------- ---------------------------•---- U Nature of Repairs or Alterations—Answer when applicable__-_•-•.............:....:..................................................................... -•-------------------•----.....---------•------------------•------••--------•-----..........---.....---------...-------------------------------------------------------•-----•---•••--••...----••-•-••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in p tion it a Certificate pliance has bee issued by the board of health. lication Approved By............ ... .................-----------------------------------•-- S--------- Application Disapproved for th f Mowing ate reasons----------------------------••---•-----------•----------•------•-------------------------•-.... -------••-•--- ----------••-------•------•---...--•----------------•---------------------........-•------...---•-...-••••--•--•-------•••--••-•-••---•-•••-•----••-••••-------•-----••......-•••••......----- Date PermitNo....................................................... Issued•....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......./...L� !t1.................OF........2r..t< ....................:........................................ (9rdif irtt#r of Twom rlianv THIS IS TO CERTIFY,,T1 at the Individual Sewage Disposal System constructed ( ) or Repaired byt1 .-------------------------------------------=------------------------------•-----------------------......---....-•..........------------... er Install has been installed in accordance with the provisioi of TITLF. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.. Z..��.... ... .......--.. Inspector...---.---•- ------------------ ................. \� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f..( ' Jli4...........:`......OF..... ....................... No......................... FEE........................ Dispo.o al Worko Sono nr�ion pranit Permission is herebyranted......%._. to Construct or Repair ( ) ali Individual Sewage Disposal ....., 5-ystem atN --•-•--• ....:: .........•....14:j 1ri .IVA" - ----- Street as shown on the application for Disposal Works Construction.Permit No..................... Dated.......................................... �.. ¢ ._.........•' '; ..------ Board of Health DATE .. y FORM 1255 A. M. SULKIN• INC., BOSTON - a QQ v I)e�► o k; r. tom.. ---G'x 4E- r- i /OaG�q` o e , e,.1 f zap R �Tr � o1 z v . S T-t GKS �1 A 9SvM Gib ,".Lr7T �F��N A;gsS�Q� `�v PR C AL.BERT r r , C C o �r ZZT Si A. `r ! 0 f EhT « ' MORSE. G!...L'E,E7(aE 1 J NGl V LEGEND �w IONALEa �r�, L Ldl4�`� . EXISTIN0 SPOT ELEVATION OAO ___.. ,- :EXISTINS.. CONTOUR --- 0 — CERTIFIED PLOT PLAN FINISHED SPOT ELEVATION ,Lor 1.2 2rv4 111141.SHED, CONTOUR O NOTF- The location of any. existing under ound ,seweragep ' Pities sho wn on .t} is plan is a rox IN . �. r other uti wells o P PP Amate�`only as determined from records and/or verbal SA A TASLAJAASS • information. The contractor, is responsible for the , verification of the existing locations in the field. SCALE DATE 1 04DREDGE ENGINEER/NO CO. lIV CLIENT.AUsib_ I CERTIFY THAT THE PROPOSED POISTERE REGISTERED JOB 1 088 BUILDING SHOWN ON THIS PLAN CIVIL LAND � ��t}t CONFORMS TO THE ZONING LAWS ENGINEER V RV DR.BY� OF - B RN.STABLE , MAS 712 MAIN STREET CH. BYE C �! </ 8� H.YANN I-S, MASS. ,' R SHEET.._ OF ._ A E — REG. , LAND SURVEYOR i•� lk C} U �►` \ h yam. °� ? Q., �. �Ww wok wj 1. � � � gym : Zw w V � w �tAV ti p� q, 4!ti o . 4� �►o ° a o J , O p A �( .. � t� p� (� ►J . � �Z r,� ft lb � . oa Co. Ot IN �UU 14 16. W Q w � �. �. • 4 e �c=sr O Q Oc � W v o U w N w . v QFill o 00 IK pQv f�� w <tA j'Ln ` V) 'Gej Id- st CO i L: i oz o �v�Sr My'�J To�o� 1n1AL� RF MovE_ AS NEEDED 8 , 91r4.G1� EC too.o MATE t,NkL 5 5 AROVND { txl S� 1 r�G 6Z- EL -2SLOpE SySTEM To LL.-97,p ` _ ° �6 o� 6 M I N V EA_ -/3'M AX C ov — ��-1 �, 04 g � 8.0 I (CX1S�tNG� I I �I2o-►EST /_\CcES5 PbVTS o T I ,"i— 1DMM rI L1 I1 1 TArti x CH 1e)� I7. o'er S:�t `�6.5 G.a c¢V .moo. • O o � J a Ob b a ,,.. �--C"CRuSr+><D ��N� �P c0-Pt�r:%t1� 3/4'i of�'2 A'xlF3-t WIvf,�� si�E - LOc U s Dew►=. �� �. tq ,� -4 �'r �r�_ � I a ram►� . 14LEr TE-t Wry - ip }-� D F3LLo\✓ EL SS- DOTES: /. Dl5P05AL SY57E-M CLIIVSTRUCTED try STRI CT JNCCDF?DANC` ot_ COMIM. of I`'IASS . ElWlRDI•q'. CODE- - T I!L ST ,'�1 ,�' 2- 5 U RVE`/ DA T/\ rR0PA PLAN 0P LANE) , W LST I `/ANN 115 P0PT _------ _ B A t�NSTAZ3LE r-a� BIsy _ (Now ro scF•'_C) RL CC�RlDE D (c� Bl\P.N ST11BL� iREC3. [3© 390EpDR9�D rl 3. CONTZ.ACTo� ATE t)T t> CALL D) G S LEP\ST 7E HRS. BF -o- ��� �` S TART/VCG CON ST—P. JCT'I ON. CHECX L_OeA IC)M oi- WATER LINE. . 20 „� 5_ B N C I1 M A�X. CCSRJJ C� aT- BULK N Ef�� - EL=1 oOd EASSUME ] \,� EXISTING PIT aSG'�� EXISTING TANK 6- A SS L- SS C)R . M AP Z 69 Pe Z 1 Z. ( O BE ABANDONED) 5 fig. e" �' (TOP OF TANK ELEV. = 98.3) T_ U S E Z - 3'x 5'x ? ' P C _ C o N C. LEA CN C MA M 13E R S w IT>t -q o`r 31A."?1 I ► /z'' DOU�L� WASt•J ED 5►ONE ALL AROUND I � a vvv 17 1-) 2." WRSI-1r`D P�AS� � l IN L _ 535013'08"`N _ I°° C �A 'K �'T 's At�;� G �\S BA�rtL il� LxISTI �J � S PT IC c 2 x �vM� S ` LOT I IA T A PLACE TBM: OUTSIDE CORNER OF t FILL \ BULKHEAD CONCRETE. Y2F'�cP'i S 1 oar,, 6 ELEV. = 100.00 (ASSUMED DATUM) COVIFFED St1ED DECK /PORCi1� x I I; No:79 p ;: GAR. 1 I/2 STY. /' No 6' WOOD PRAMS - - - -- — CP LOT 1 3 A BIT. CONC. 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LE �GN C13Fl gI R5t 4 STOr�1� ,�-- �o coNTQv j «: i \ "s`1 ' C1=1= FCTIOE Dti = 2, .- I WEST )-iY XNMI; PORTS � h z Ca+27 X L) - sew e�/Ay I L I ADVAMED T-CH SOLUT) ONS Z 4 x 13 x 0.Z 4 3 I c,, 8 8.5- J 10�)z o rle 14 �2.o TOT 14, C A�:�,C 11 _ - .. F1t�M CND TcST"ED*.+/e9Jo3 C0NSUCT EIgG'r?_ E ,-SP,AlL), MA _,- 9 1 GA L S . 7 , A otLE�, DATE. 5 --18 . 0.3 Dw G:� S u(32 L 4 3