HomeMy WebLinkAbout0135 PITCHER'S WAY - Health 13 5 Pitchers Way
Hyannis
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1. Article Addressed to: If YES,enter delivery address below: ❑No
Ms Wendy Treash
135 Pitchers Way
Hyannis, MA 02601 3. Service Type
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(Transfer from service label)
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
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.PUBLIC HEALTH DIVISIC-*+-----"M-0-1S�!AJ0
TOWN OF BARNSTABLE
200 MAIN STREET
HYANNIS, VTIASSACHUSETW 636WJ I AON 30OZ
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COMMONWEALTH OF MASSACHUSETTS'
Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
h �
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
�9,N eke
350 MAIN STREET
WEST YARMOUTH,MA
r—O 508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
MAP 289 PAR 011
Property Address: 135 ;'ITCHERS WAY
HY,JFINIS,MA 02601 _
Owner's Name: TRf ASH,WENDY
Owner's Address: 135 PITCHERS WAY
HYF.NNIS,MA 02601 ��
Date of Inspection SEP'(EMBER 9,2005 1.
Name of Inspector:(please print) JAMES D. SEARS
Company Name: A& B Canco
Mailing Address: 350 ✓lain Street
Wes Yarmouth,MA 02673
Telephone Number: 508-'.175-2800
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 prober'16 _i1on and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Dative: -1 'f d✓� p
The system inspector shall suenil�,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 systeni or has a design flow of 10,000 gpd
or greater,the inspector and the zystem owner shall submit the report to the appropl:ate regional office of the DEP. ' =:e;
The original should be sent toil.e system owner and copies sent tot he buyer,if applicable,and the ag,roving authority. _
Notes and CommentsC)�
to
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....This report only describes k nditions at the time of inspection and under the conditions of u.e at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
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Title 5 Inspection Form 6/15/2000 1
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Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 9,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: N/A
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: N/A
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 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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 9,2005
C. Further Evaluation is Required by the Board of Health: N/A
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 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 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 welly*. 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:
{
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Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 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
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
N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in pit is less than 6"below invert or available volume is less than%z day flow
N/A 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 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 CUR 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: N/A
To be considered a large system the system must service 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 I1 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 is failed. The owner or operator of any large system considered a significant
threat under Section E or failed wider 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.
Title 5 Inspection Form 6/1512000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 9,2005
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
�I 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,including 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)has been determined based on:
Yes No
Existing information. For example,a plan at the Board of Health.
J 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(3Xb)]
Title 5 Inspection Form 6/15/2000 5
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 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: 4
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
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: AUGUST 2005
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 copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1990 PERMIT#90-478
Were sewage odors detected when arriving at the site(yes or no): NO
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Title 5 Inspection Form 611512,000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 9,2005
BUILDING SEWER(locate on site plan):
Depth below grade: 2'
Materials of construction: Cast iron 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan):
Depth below grade: 32"
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: 1,000 GALLON PRE CAST
Sludge depth: 1"
Distance from top of sludge to the bottom of outlet tee or baffle: 29"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 18"
How were dimensions detetnuned: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
TANK AT WORKING LEVEL.INLET TEE,OUTLET BAFFLE.TANK AT 32"BELOW GRADE WITH
INLET COVER AT 4"
GREASE TRAP(located on site plan) N/A
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.):
Tide 5 Inspection Form 6/15i2000 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: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 9,2005
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of constriction: 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: J (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.,):
NOT OPENED.NOTED ON ASBUILT,PIT FULL.
PUMP CHAMBER: N/A (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.):
Title 5 Inspection Form 6/15/2000 8
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 9,2005
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: 1
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.)
LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT IS 50"BELOW GRADE WITH COVER AT 8".
PIT IS FULL,NOT LEACHING.NEED TO REPLACE LEACHING.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXlocate 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: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
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Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 PITCHERS WAY
HYANNIS,MA 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 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.
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Title 5 Inspection Form 6/15/2000 10
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 135 PITCHERS WAY
HYANNIS,I4A 02601
Owner: TREASH,WENDY
Date of Inspection: SEPTEMBER 9,2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 14 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:
Observation 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:
TEST HOLE AT 14'.TEST HOLE 4'BELOW BOTTOM OF PIT.BOTTOM OF PIT AT
10'BELOW GRADE.
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Title 5 Inspection Form 6/15/2000 11
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E .G• So/
�- TOWN OF BARNSTABLE
LOCATION ✓ /'`/6A e� iA—W4 SEWAGE#6g�QJ oil ]
VLLAGE ASSESSOR'S MAP&LO 0
INSTALLER'S NAME&PHONE NO. t� b � /
SEPTIC TANK CAPACITY C:-X{rr�"-
LEACHING FACILITY:(type)w (size) `>?sG X,
NO.OF BEDROOMS
BUILDER OR OWNE
PERMIT DATE:JW COMPLIANCE DATE: '
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist'
within 300 feet of leaching facility) Feet
Furnished by
9 .3 - 3 7
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TOWN OF BARNSTABLE
LOCATION j 7C-lr f V-5 4`111 y SEWAGE#
VILLAGE ✓ ASSESSOR'S MAP&LOT,,?-
/R T�� NAME&PHONE NO.
SEPTIC TANK CAPACITY s ���- /�S�£C /-/0 A—
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER L4, EA-13 y f
PgRAW DATE: -f 'O 3� `CO DATE:
Separation Distance Between the:
!�
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
WM
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No. t Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Pk,JBLW,— HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplitation for 3 po.,gal *pgtem CongtrUction j3Crmtt
Application for a Permit to Construct( ) Repair( ) Upgrade(,Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No.13 51 �i h e 4S te44—/�/ Owner's Name,A dress,and Tel.No.
Assessor's Map/parcel ww DD��pp— 0 ( ( S',4�y1
Installer's Name,Address,and�1�e&B CANCO Designer's Name,Address and Tel.No.
350 Main StreetW. Yarmouth
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures //,/
Design Flow(min. red) yob gpd Design flow provided '7'7�0� . gpd
Z;Z6
Plan Date / Number of sheets f Revision Date /U/A
Title /f2 t��!✓,aS-C
Size of Septic Tank Fx-i� /O O O Type of S.A.S.
Description of Soil
er-
Nature of Repairs or Alterations(Answer when applicable) �C r 1'�,I^
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 Certificate of
Compliance has been issued by this Board of Heal
Signed x x Date 6
Application Approved by Date
Application Disapproved by: Date
for ollowing reasons
a
Permit No. Date Issued b
2 ' No. low �r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC,HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplicotion for Bigogal �&pgtem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No:/3.C�14'¢c f l`o�) " t , Owner's Name,A dress,and Tel.No.
Assessor's Map/parcel CC Q J-4
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided �T��c , gpd
Plan Date / c7 /6 ' Number of sheets Y:/ Revision Date
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Title
;
Size of Septic Tank F,r a rS %``:�Cf /O U U Type of S'.A.S.
Description of Soil-,-
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Nature of Repairs or Alterations(Answer when applicable) C T i,
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 Certificate of
Compliance has been issued by this Board of Heal
Signed J L Date
Application Approved by Date �>
Application Disapproved by: Date
for ollow�inglreasons
Permit No. Date Issued (77>
—— — ——__———————..
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded
Abandoned( by y
at /7ic.'h C rJ 0 f 1/'1/J/ S has been constructed in accordance /
with the provisions of Title 5 and the for Disposal System Construction Permit No. 306) jj /-7 dated /! 2
Installer .A Designer
#bedrooms f Approved design flow L4 4,(�> gpd
The issuance of this permit hall /ot be construed as a guarantee that the sy em will t1 ctio es ned.
Date 0111 Inspec
———No. 2WV 0/7 IN 2/= '"41 Fee �DC�
THE COMMONWEALTH OF MASSACHUSETTS p/C
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
ligo5al i§pgtem Cow5truction Permit
Permission is hereby granted to Const t ( ) Repair ( ) Upgrade ( -)---Abandon ( )
System located at C��/� �� V
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.
Date Approved by
&-19 1200M .
ED
( 0OV4-)
-�N of�Ssgcy
o� DARREN G�
M
. ,,. MEYER N
No. 114®
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Town of Barnstable
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Regulatory Services
Thomas F. Geiler,Director
MAtPublic Health Division
Thomas McKean,Director
:-::- 200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
t
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Date: ��J Sewage Permit# c)666- 0(7 Assessor's Map\Parcel
Designer: Installer
A& B CA
Address: h�I,�J7� ��1 Address: 350 Main"Street`-.
W. Yarmouth.,`-MA;:02673
On <;) A AJCU was issued a permit to install a
dat ) (installer)
I
septic system at a based on a design drawn by
(address)
dated V 1` og - 0 6
(designer)
KI certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & L t ations. Plan revision or
certified as-built by designer to follow. of MAS
DARREN
U., YE N
(Installer's Signature) No `l a
\ SANITAR�P� 'D�.
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form.!.164doc
a
_.Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, � "� ' ►� " t ,hereby certify that the engineered plan signed by me
dated 0 ' 0 D '06.1 ,concerning the property located at
L3 J P jrq�e�_5 Way meets all of the
following criteria:
• Two soil evaluations excavated for detailed examination(no hand augering) and two
percolation tests shall be conducted.
• This failed system is connected to a residential dwelling only. There are no commercial or
business uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch.
• There 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 63 D +adjustment for high G.W.
DIFFERENCE BETWEEN A and B �'rt. t�` *n4,N 21,0
SIGNED : VVl DATE:
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptic\percexemp.doc
TOWN OF BARNSTABLE
LOCATION SEWAGE # 9Q
VILLAGE /7't/u.ve,t; ASSESSOR'S MAP & LOT —L1
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)tfe C ��- r 'y� - (sue) /000 r
NO. OF BEDROOMS S PRIVATE WELL /OR PUBLIC�WAT
BUILDER OR OWNER PAr
DATE PERMIT ISSUED: 10
DATE COUPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No.-��..`.-`..`1 ME........�.?..........._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
�4
Appliratiuu for Disposal Works Toustrurtiun Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair (K) an Individual Sewage Disposal
System at:
..--••.3 ..---Q-!�� ............ .......... ---------------------------------------------•.
Location-Address or Lot No.
c`
Sv W �
---. ............ . ^-----—•----_ ---••.__•-•-•--••- ----.---------•-------------•--•-••-----•-------------••-------......_...................__...._
Owner Address /
iU 27 e I�iILI/I(
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............................... .....Expansion Attic ( ) Garbage Grinder ( )
U,
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ---------------------------••••• -
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---_---------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
1
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
LL, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.:--__--_,_.--__.•._----
r4 --------------------------------------------------------------------------------------------•-------........................................................
O Description of Soil......0 �-----•- ------------------2 -_ . f"" e.Src.-ksJ --p���
x
w
U Nature of Repairs or Alterations—Answer when applicable...RA ram__----_. ....... t tsrivc4__•C SSSi?�tlS
N� �nysm•y�` �(.....`-'�------�'-`=�°�'fi '== r ��n aT c: .�,cr�_• `�.� ...,j_ ? . IT��...
Agreement: t
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has ee issued by the board of health.
Signed :. ..... ... ...... .................------------ ------C Q. 2 3 .-0.--
Dace
Application Approved By ---- - --- ------ - - ------------ - ............................
Date �
Application Disapproved for the following rear' s- ------------ ....................................................---................................................
---------------------- .--------------------...---------------...............-----------------------------.--------- .................................
J Date
PermitNo. --- 0............ .. ............... Issued .......------------------..--------------------------....----......
..----'--.......--'- --'-- Date
Fps.. 30.
No..- •-- — i ...... ._......_
THE COMMONWEALTH OF MASSACHUSETTS
° 11% - BOARD -OF HEALTH
TOWN OF BARNSTABLE
`h C Apphrativil'dux Tiipniu1 Works Tonstrurtion 11prutit
Application is hereby made for a Permit to Construct ( ) or Repair (X5 an Individual Sewage Disposal
System it:
Location-Address I or Lot No.
--Owner•-1�-----•--------------•--- ••Address-- --.........._..._
W 1A to-ILF Le � 'a'tU1 c �1 c ..... �...._.. �?5® ? T /
a -----... ............. ---- ? _... .... .. ...............................................
�}
'� Installer L,i � Address
Type of Building ( .�. r .' Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.._`..... ...............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............ No. of persons............................ Showers — Cafeteria
Other.fixtures .----•----'----='-....--------------------------------....----•-----•----------------------------------------•--------------......------••------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid:capacity............gallons Length.......;�...... Width-:.............. Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length_;%................ Total leaching area....................sq. ft.
W Seepage Pit No...................:. Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ")• %\ Dosing tank ( ) - f.
aPercolation Test Results Performed bY........................•,................................................. Date................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
LTt Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.....................................
O 1 Description of Soil--- = .......sv ................ �y C' _ n.J """ 'S`'" Vie, -�g
x .........-•-•-
vl =^ ...........................................................11,
UNature of Repairs or Alterations—Answer when applicable...QJ r±� _____' !^ �V �l
tr t
-------- -
I.090 C-0,0-tv Q`� �I
.....................................................••••....... 1------------o-------- ------•-••-................•---•---------------•---.
'Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
• om
Application Approved BY �r .0 /. .L �. i -------------------------- Date
Application Disapproved for the following reason ,
..........
....... ' ` ..................-----------------...-------......,........-----------------------------
.......................... A 7C+.. / J ,--.--.....................:.................................-............-................................... ........-...--..Date--.......-----.-.-
Permit No. y--------- ----- -- // //...1 ---------------
Date
Date
4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH.
TOWN OF BARNSTABLE ' -� ..
C�er#i t��t#E of C�nm Xtttn�ej73r�- 6t --#7` Lh
THIS IS TO CERTIFY, That-the Individual Sewage Disposal System constructed or Repair`ed'( ) .
by ......: {-(C- 4 C_%wSV (5-......:...
----------------------------------------------------------- ---------- -------------------------------------------------- -J .
Installer ,,t 4- , -... ...---
at .........5.............P l`ZC .... . ,t�Y..... +A1 - 111 _ ...� -... = ... r.l t..�
has been installed in accordance with the provisions of TITLE 5 of The State Envirot mental Code-as d se cribed in
the application for Disposal Works Construction Permit No.....lb.....r" ...... dated ... t �-�....,
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS`A GUARANTEE THATJTHE
SYSTEM WILL FUNCTION SATISFACTORY.t ~" ��� • � -�f��l.—�2��'/�r ��. �..j
DATE. ......... ... 1�...��.......................... Inspector ....-----;. --.------....-----......v..................t .-C_.. ------
v
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�r1 TOWN OF BARNSTABLE 3
No....qh_..' ..(8 FEE........................
Disposal Works Tonutrudivit "prruti#
Permission is hereby granted_....�.S!4L?......--..-`-0,\5�....__..C-`v - S w 1
. -•- • .............................................................•......-•-••----
to Construct ( ) or Repair (lc))an Individual Sewage Disposal System
at No............. "t P f•C c,t,2,R L�t f `t •----�`rN"ts t
........................ -•---.....--• ....... .....................................................................................
Street
as shown on the application for Disposal Works Construction Permit No. . ............0� Dated.........................
_............................ .-..; -......
_
Board o Health
DATE. i . / /,�
..................... -----------------------------------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
o _
d n NOTES:
ASSESSORS MAP : C HOLE LOGS
y � TEST
�� o Cape Cod
� � , I) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
Melody PARCEL:
THIS PLAN 995 MASSACHUSETTS TITLE V '& TOWN OF
Tent SO I L EVALUATOR: �D,I'Aw .,( F5 >v ,
o — � BOARD OF HEALTH REGULATIONS.
FLOOD ZONE : � �a2�� .�-
WITNESS f� - 't3
9
ION OF UTILITIES
�. REFERENCE: � ` P _(}•U�' DATE: UPr� ��S 2 C.� 2) THE INSTALLER SHALL VERIFY THE LOCATION ,
�i � 1 -1 --}--
5 q M' SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
PERCOLATION R E �- N
u�� � 0�ja c�t�s s7 i �t INSTALLATION:
o �N 9
s i INSTALLATION
".3 r - = 4i ' TH-2 .Ia 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INS L
i po L O f- L NG `. TH ! L 0 E(.�a
5 t _� ___ w � ONLY, AND . SHALL . .NOT ` BE USED FOR PROPERTY LINE
Loffm 3 DETERMINATION.
10`((� (v
sPn� 6d
_ ` 5 { SCHEDULE 40 1/8 "/ FOOT. UNLESS
U► 4) ALL PIPING TO BE 4 S @ E
ao E
LDP
S SPECIFIED OTHERWISE). ! � IoyrZ /a
•�� Z� � 5 .:THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
LOCATION MAP(wr.,5) CpP�RS GARBAGE DISPOSAL.
� CO
BOXES WHEN INSTALLED
)
� G 6 SEPTIC TANKS AND .DISTRIBUTION ( )
SftTI _ I? )
34. MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
2 Sy A BASE OF 6"OF CRUSHED STONE.
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122
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1
No w of a No 6 65 fl 1
a 11-NOW N:PPJ VATS ,vac t,5-_ w ,�, !So_6 F.PP- P.-_ h
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tea o �� SEPTIC SYSTEM DESIGN
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OF � W ST 1 MATE FLO E D 6'a W N D!G
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r✓o r
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1xP1-T
C 00 4 GAL/DAY 2A _6_F { - - -4 BEDROOMS ATSAL/DAY/BEDR M ��'�'OUl
SEPTIC -TANK
GALIDAY x 2 DAYS GALw _ !! 5�AN REPc.At,� w l Soo a er1 �� L TA�iL0_ USE ( Q��J+I} GALLON SEPTtC T K / � � �of n�aSSo ,--FjYit-END, O�A�f� ek dNI7E2517.�aaSOIL ABSORPTION SYSTEM
` , I l T02 30;a,UN1 W Z � c. 0. 1140
i -� _:.�. + 1-1- __ lZa XZ.! �a c?�1 S ail GSIDE AREA:('(3 -Z+02.16�Z1X 2. x 017(4 �E�j D �E-N� BOTTOM AREA: -3, x. i z,.I"(, ti 0,?y - 30
g►tSE � �O
a` fui� FN®N -
LIJUI Top .°Fo. o" 442' � GP
AO
SEPT I .0 SYSTEM SECTION
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SEPT I C TANK
32
o �tve�Ik55
96-3 f-- ___. 34 L X I Z.l6 w -----------�.�•
L16A—C !�J_ CRass EG7t Q�1
(o --�, $o7pm o� 577-}fl L
C) 4 /'
mMa r IST 0 {t
57
Z t 2� SITE AND SEWAGE PLAN
O o J
S � Q -�1� l tJaSke�J
U o � Sf�te LOCAT I ON : I35 T S w
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PREPARED FOR : CT'R.f�nl n�9'vJ
48 3t� 48
(WASh-e4
12.tlo
SINe. SCALE: Zo
DARREN M. MEYER, R.S.
P.O. BOX 981
DATE: O/-d -Q
EAST SANDWICH, MA 02537
h
W DATE HEALTH AGENT Ph: 508) 362-2922
W