HomeMy WebLinkAbout0869 PITCHER'S WAY - Health (2) 190 BETH LANE, HYANNIS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 Beth LaneI��
7M
Property Address 2
Gerald Fowler p��� J�
Owner Owner's Name
information is Hyannis MA 02601 August 15, 2008
required for Y g
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
t
Important:When filling"out A. General Information
forms on the `w
computer,use
1. Inspector: I
only the tab key .,
to more your David D. Cou hanowr t
cursor-do not Name of Inspector
use the return �.
key. Eco-Tech Environmental ~=
Company Name ,
43 Triangle Circle
Company Address -a rTi
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection:The inspection
was performed based on my training and,experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
August 15, 2008
Inspector's Signature Date-
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5-3001.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
.a .
,
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is Hyannis MA 02601 August 15, 2008
required for y g
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
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) cr 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
t5-3001.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 Beth Lane
G„M
Property Address
Gerald Fowler
Owner Owner's Name
information is August 15, 2008 Hyannis MA 02601 Au
required for Y g
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont,):
El distribution box is leveled or replaced
ND Explain:
❑ The system required pumping,more than 4 times a year due to broken or obstructed pipe(s)..The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced -
❑' obstruction is removed
ND Explain:
C) Further Evaluation is'Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the,system'is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
15-3001.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9c� 190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is 9
required for Y H annis MA 02601 August 15, 2008
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z 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.
t5-3001.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is required for Hyannis MA 02601 August 15, 2008
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.).
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ° ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis.[This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd
10,000gpd.'
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large.systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑, the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
15-3001.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is Hyannis MA 02601 August 15 2008
required for Y 9
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
SAS also
evaluated ® ❑ Were all system components, excluding the SAS, located on site?
Outlet only
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5-3001.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments
190 Beth Lane
7M
Property Address
Gerald Fowler
Owner Owner's Name
information is August 15, 2008 Hyannis MA 02601 Au
required for H Y g
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 - Number of bedrooms (actual)`. 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 296 gpd(30 mo)
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: undeterminedDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft.,, etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? `❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/user Date
Other(describe):
t5-3001.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is Hyannis MA 02601 August 15, 2008
required for y g
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Age: 10+years. Certificate of Comphance issued 10130197(Board of Health permit#97-612)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
15-3001.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
190 Beth Lane
7M
Property Address
Gerald Fowler
Owner Owner's Name
information is August 15, 2008 Hyannis MA 02601 Au
required for H Y g
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
2
Depth below grade: feet
Material of construction:
❑ cast iron MAO PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leakage or backup into dwelling was observed.
Septic Tank (locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: - years
-Is age confirmed by a Certificate of Compliance? (attach`a'copy'of certificates' ❑ Yes ❑ No
Dimensions:
8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth:
8 in
Distance from top of sludge to bottom of outlet tee or baffle 26 in
Scum thickness 0 in
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? As built card
t5-3001.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
<c�M 190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is Hyannis MA 02601 August 15, 2008
required for y g
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed. Inlet cover is;ender deck and not accessible for inspection.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:' Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
t5-3001.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is August 15, 2008 Hyannis MA 02601 Au required for H y q
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank,(cont.)
Dimensions:
Capacity
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
. Depth of liquid level above outlet invert
At outlet invert
Comments (note:if box.is level and distribution to outlets equal,,ariv evidence,of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump:
Pump Chamber(locate on site plali):
Pumps'in working order: ❑ Yes ❑.No
Alarms in working order: ❑ Yes ❑ No
t5-3001.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is Hyannis MA 02601 August 15, 2008
required for y g
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 1
❑ 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.):
Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching gallery stone and no standing effluent or effluent contact staining was observed in the stone
or overlying soils.
t5-3001.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is August 15, 2008 Hyannis MA 02601 Au
required for H Y g
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: K
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5-3001.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is 9
required for Y H annis MA 02601 August 15, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
LOCATIONS
LEACHING
GALLERY A B
1 27 FL 19 FL
2 27.5 FL 55 FL
t
D-B0X 2 SEPTIC
TANK o
A B
EXISTING
DWELLING
# 19
W
Z
J
W
H
3I
B E T H LANE NOT TO SCALE
t5-3001.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systerr•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 190 Beth Lane
Property Address
Gerald Fowler
Owner Owner's Name
information is August 15, 2008 Hyannis MA 02601 Au
required for H Y g
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cost.)
Site Exam:
❑ Check Slope
❑ Surface water '
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water: 20+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked; date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database -explain:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 20 feet above the
groundwater table.
t5-3001.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town ®f Barnstable
Regulatory Services
lA"SPABLE, , Thomas F. Geiler, Director
y MASS. �+
Public Health Division
plfp Mp'+;s
Thomas McKean,Director
200 Main Street,' Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor.does
this Division agree with,any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does. not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit
If you should have any`questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
TOWN OF BARNSTABLE
1 OCK-ION- ' G r 1 �,r :���b SEWAGE.# �'`/6/
VILLAGE_ ASSESSOR'S MAP & LOT - �.
INSTALL,ER''S NAME&PHONE NO.
SEPTIC-TANK CAPACITY ,46 -6�
LEACHING FACU ITY:'(type)' _S-/',/P-J .7 ti r 3 (size) 16
f
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE nDATE:/ -1;-' '7- `7
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
,A\ on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leactun acility) Feet
Furnished by
i'
A�
rd
L
f
No. - `� , Fee $5 0. 0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: k-/
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for Mie;paar bpgtem Construction 3permit
Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. 1 9 0 Beth Lane Owner's Name,Address and Tel.No. 7 7 5—31 2 7
Assessor'sMap/Parcel Hyannis, MA Jerry Fowler
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm E Robinson Sr Septic Service
PO Box 1089, Centerville, MA 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( no
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil gravel
Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting
of D-Box and three H-20 stonepacked infiltrators .
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 by th' oar of Health. c�
Signed 1/a l �.�cL Date Z6
Application Approved by Date
Application Disapproved fort folio di g reasons
Permit No. Date Issued
Fee $50.00.
-THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
- Zipprication for ;Diopoml *potem Construction Permit
Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1-0 0 Beth Lane Owner's Name,Address and Tel.No. 7 7 5—31 2 7
Assessor'sMap/Parcel Hyannis, MA Jerry Fowler
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
Wm E Robinson Sr Septic Service
PO Box 1089,. Centerville, MA 02632
tType of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( no)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil gravel
z
Nature,of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting
` of D-Box and three H-20 stonepacked infiltrators.
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-
icate of Compliance has been issue by t�ys oar of Health. q
Signed l 1 _ Date 7—
Application Approved by r°{Date
Application Disapproved fort followi reasons
Permit No. 7 Date Issued ,
,.,
THE COMMONWEALTH OF MASSACHUSETTS
Fowler BARNSTABLE, MASSACHUSETTS
Certificate of Compliance--
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( XN Upgraded( )
Abandoned( )by
at 190 Beth Lane Hyannis has been constructed in'laccordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - dated
Installer WM E Robinson Sr Sept Sry Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date f 7 !r -r:6 4'I Inspector
1 �
( ?.. -----------
No. Fee $50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Fowler lwizpoot bpotem Congtruction Permit
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( )
System located at 190 Beth Lane
Hyannis, MA
Installer Wm E Robinson Sr Septic Sry
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 thisipermit.
Date: /0 - 1-1 - 9,7 Approved by e
tl
NOTICE: This Form Is To Be Used For the Repair Of Failed
.Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
.I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated AQ 2-- q �7 , concerning the
property located at 190 Beth Lane, Hyannis, MA, meets all of the
following criteria:
y
* ZD e are no wetlands within 100 feet of the proposed leaching facility.
* he are no private wells within 150 feet of the proposed septic system.
* re is no increase in flow and/or change in use proposed.
* dare are no variances requested or needed.
* If the proposed leaching facility will be located with MO feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.'
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map)
SIGNED: DATE ��"o`er ✓
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
G _
1
TOWN OF BARNSTABLE ''
LOCATION-0 O 113,i� ff I4 SEWAGE # '3
VILLAGE ASSESSOR'S MAP& LOT 13 7
INSTALLER'S NAME&PHONE NO. a
SEPTIC TANK CAPACITY 46 ,6�
LEACHING FACILITY: (type) 3-/4R� -7ti rs (size)/n� s
NO.OF BEDROOMS 3
BUILDER OR OWNER o w Ice
PERMIT DATE: '�"�" '� COMPLIANCE DATE:./ '7
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 leaachin acility) Feet
Furnished by ►rC� --
1
I
V
to i. U
hl/
4 �
LOCATION SEVACE PEOC31T ao.
ey,o
HILLAq-E
1 M S T A LLE'R'S NAME & ADDRESS
, JO
HN A. AALTO RA All GE SEQ4
150 ,Walnut Street
West Barn
0 UILDER OR OCJpER /
DATE PEItMIT ISSUED
DATE COMPLIAMCE ISSUED l2_�� _ oap ..
on � N
r
.• 1
Fmm..
No. 1.+ :. 3�...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .OF HEALTH
p !/A/...............o F.......... ` 11� L,, ------------------------
Allpfiratio n for Uhipatial Workii Tomatrurtion rantit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
............J_9P......., ....?...---- -------------------- ------------------------- -..... � _....----------------------..............
cati dd ess � , o� No.
..........�,P v, _..., °. ------------------ ...................................... .---�=....�' .......- -'-'-------•-------
W X ® J.w' Owner - /�/��� ddress A�
Installer Address //``
Type of Building Size Lot...!w!_- _ Sq. feet
U Dwelling—No. of Bedrooms-___.___.--•3 _..._ _.___Expansion Attic Aa Garbage Grinder (6)
p•, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fi
W Design Flow................ ... .__.gallons per person per day. Total dai� flow..............3�0._ gal Ioa
ns.
WSeptic Tank—Liquid capacity..lo0'®.gallons Length................ Width__-4......... Diameter---------------- Depth..._:4•:___----
x Disposal Trench—N Width Width_..._.............._ Total Length.................... Total leaching area--____-_-___________sq. ft.
Seepage Pit No----------J---------- Diameter...1.0%....... Depth below inlet.....�s.1.._.... Total leaching area.2_9'S ..sq. ft.
Z Other Distribution box (X) Dosing tank ( ) p
olation Test Results
a PercTest Pit No. 12' -gam_--....minutes pedr nch Depth of T®Pit------J_d-�-__�t__.__ Depth to ground at�4.N_P1.4 F"
+ , tl �.
(.� Test Pit No. 2......._ ......minutes per inch Depth of Test Pit-------- ......... Depth to ground water..____.___.__________.
a - _ - } . ....-----
----•--•......... ........ ....
DescriH ion of Soil - - -�` n,c e'�.. .�1-12
cx.> --- .........I.e�... •- - -a�^'°- ---..= a4 v- A-------------------------------•---------------------------------------------
W ------------------------------------------------------------- ---•-•--•---•---....-••-•••-----••------------------------------------•-----••-••--•--------•--••--------------•--------•--•-•------••--
UNature of Repairs or Alterations—Answer when applicable-------------_--_-.--_---.-.-__-_-..-___---.__---__--:-_---__-__--.-____-___-_-___--_________-_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'TT E, y g g p y
5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been.issued by the board h. lth.
igne ........... V Li u
Date
Application Approved By...... ----•-.---. ----•••.... .. ! /l ...•.
Date
Application Disapproved for the following reasons:-------•...----•----------------------------------------------------------------------•••. ...---•--------•---
---•-•-•-••--••-----------------•----•-=••---•-•••--••-•------------•-•------------------------------- -----------------------------------------------------------------------------------------
02
Permit No..................................... Issue(------
.Date
r Date
No..... ... Flcs....................."•.
THE COMMONWEALTH OF MASSACHUSETTS
r�.
BOAR® OF HEALTH
.. ...1�f..................OF................. 1.�(�..3�j � ........
Appliration for Dhgpoii al Workii Tomitrurtion Vautit
Application is hereby made for a Permit to Construct (>6 or Repair ( ) an Individual Sewage Disposal
System at:
_.... ...._.
ocati Add ess .
No.dot- J
-- --•--••--•••••••-------•-••---••--•...---•..............•.._...-•--..............................
Owner Address
Installer Address
f .Sq. feet.;
Q Type of Building Size Lot____:�___________...
Dwelling—No.' of,Bedrooms.............D----------_--------------Expansion Attic 01!5 Garbage Grinder
aOther—Type of Building ___________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ••-•••••••--•-•-•------••---•-•••-•-•-••----••--•--•--•••--•--•--•••-••--••-•-----•--•....--••----
W Design Flow____________________:.*.,._. "; _._gallons per person per day. Total daisy flow......_..._...... ................gallons.
WSeptic Tank—Liquid capacity___ _gallons Length......0�'__------ Width__.$--------- Diameter................ Depth.... .......
x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area............__._____sq. ft.
Seepage Pit No-----------I--------- Diameter._..L3' ..... Depth below inlet_____ ___________ Total leaching area.2L6'.�.__sq. ft.
ZOther Distribution box (X) Dosing tank
Percolation Test'Results Performed by.... Z.4_.. 'f _ Date....� _ � _ ��_..
a
4 Test Pit No. 1_�wr:_ �:____minutes per inch Depth of Test Pit_.... _�_..__. Depth to ground water•._._. _``�l l
h, Test Pit No. 2..........=......minutes per inch Depth of Test Pit__________________ Depth to ground water-------------.I..........
9 _--• -----------••--• -
O @ a e r r, r -
Descr�Ion of Soil C' 2-•• 9 `��± a! ; �_,. �' .&1� g 6_.
;t-•------•- ---11 ---- ------ ---- ----. --
L -,� ... ----•--•-
------- ----- ------------
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 TITL of the State Sanitary Code— The undersigned further agrees not to place_the system in
operation until a Certificate of Compliance has been is ed by the bo"id of /
T
Signe = �! .` tl . ®
Date
Application Approved BY f f
-- ------
Date
Application Disapproved for the following reasons: ------------ -"
Date
PermitNo...........:............................................... Issued.............................------------------_-•---
Date
4
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
Trtifiraft of Tompti anrr
T. ISI� TO CC IF ' at the Individual Sewage Disposal System constructed ( or Repaired ( )
Y .;Zb t - • --- _--•-
Installer
at............. �--x-- f---- r... ..
been installed in accordance with the ro lsions of TI` j f State Sanitar Code as descri ed in the ,
application for Disposal Works Construction Permit No.__ .__._ ___. _ _________ da.tedy..._ `' '*.. �
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL�pUNCT1ON SATISFACTORY.
DATE ! °L- Inspector...-
------------
--THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
d. ........OF.... ._.dam..... ..................................... .
No........... . .I° FEE.......................
4 i Vu l or D III nr#ion umit
Permission,isrhereby granted... - -•••••_... --- -------'--••-• ---•••-•••..........................................................
to Construct ( ') or e ( 'e Individu, DS S . 'a e posal System
--
- Street
as shown on the application for Disposal Works Construction P t Nol_ Dated••--f-!'--�.•op— d_.__•____.... ,
--•-�[ r of f Health
DATE. := == ==1 U
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TYPICAL SYSTEM PROFILE
AREA PLAN FINISH GRADE=,MQQ
FDN TOP NOT TO SCALE
-2,00 FINISH
I It= 7
SCALE : FINISH GRADE OVER TANK= s/.06,
GRADE OVER �P T
'q�4"'Trw,
LOT 10 BETH "S LANE
0
it 4 00
I. ,TE'ES
PV6,OR , 71
151
.84 , off
BSMT
f R
L GA D I REINFORCE ST. BOX
cONCRET
r-8 -INSTALLED
TO:BE , ON
A
LEVEL'STABLE BASE_
0'. 0.
T
P AN K ,' �
i'BE -A
N STALLED, ON
E V E L::-
STABLE BASE
2 1/8
J/2 WASHED PEASTONE ALL,�
a R CK'S; M 0 RTAR COURSES'AS
".::IAROUND FREE OFIRONS FI N ES
AN -DUST,.IN.
D
RADE ,
R EQUIRED TO�BR ING'COVE R TO
/_0 7-49��-4 �G
PLACE
L E A, H I RIT
c
MANHOLE COVER 8i i/2 WASH ED CRUSHED',
24 to I
OF, EVEL
FR
_LL A RO
STONE A UNDTREE BASE JO,,, BE
AME�; -SEE D ETA I L
P L AC E:
RONS ��FINES AND -DU
S T.]N
0
FOR FIN"
SEE SYST P FILE
PERCOLATION
N UAJA�
"-M I N.
8 PERC R A'T' E
4'
SEE
t :' C� 'D _ SPOHR�
PROFILE'
�,�R INV. ELEV
4
SYS EM � TAKEN BY :
LIN-El
OPEN N S,_
41 0 � I'll il 11 � I 'BY:
WITNE
moo, SSED
'I G W/4-1/6
INLET T
":ZPA f
�8i-1 -3/4 DATE .
011","OUTER Dlk
JEST..PIT-GN EL V.
I N S I D E DIA
7 D
Ole
40 'T T,
0
o A
— 0 AREA'
.
0,
u 0
0 0
/Q L& 6
7:
', ',E F FE_CTIV E '�D I A ,DOWN
�,SECTION
P T:
C Hl N b .1 N
6 OF':, BEDROOM
SC A LE: -A :
DESIGN i?:DAT,
YS
NOTE: DO.NOT v E P N tm
7VO DISPOSAL
EST. TOTA GALS'.
H14G 0 1 E S.
Vsc WAI c
L DA FLY�E FF'LU
' G-A
TANK. 000 '
I CONC.�TO BE, 4 0 00'P.S. _�'8 .DAYS-.
pz;oe;f�v C0A1C_0-4eA4S 74)
M
�'6 'W
2. N W x 6,' A - , W
z
-GENE ALI,
E U I WE M EN TS -NOTES
E AVAILABLE ' 0
2 AN6�4�,,�sECTI ON �.,AR�
R
.. GREATER DEPTH"IR
BE�INSTAI tED' I N
1 LL��SYSTEM_CO
ACCORDANCE. WITH IT''
T LES OF,THES-TATE'sANITARY CODE
'0
�-'E XC
R LOWER S�tj DATED JULY-11977 ANY -L CAL R UL E S I CABLE.
L
'AY 0"-THIS�PLAN ,MUST BE PPR D; IN
E ALL'LOA
REQUIREDTOREMOV M AND,�,;C C0 N TA I'N I N 6: -tH
2: ANY ANGET A
MATERIAL .:BENEATH�PIT_ PLACE EXCAVATED MATE
RIAL
OHR,!�
WR IT I N G,,,,,.t]3 Y M R'�;,tHARLE
'OWN �'B U'ERS � ] L El
Y
TH CLEA�4�,,t�L,AY""O.kE;E ,,,.GRAVEL�;�,',MECHANiCALL
'3. .WHEN 'CONSTRUCTION 'IS PR16RTO- BACKFILLING
Ad
COMPACT AN'
FOR,I NSPECTION.
G I D 0"0
4
ED
N OT I�Y,-T H �`EN NEE
SIDE, F S-
�AREA`--
GAL G A L s
16L 6 7_pil IMZ�'
1 I ON �ELEV.�M UST.BE CHECK MW H 8N ETED.
L� GALS .,
BOTTOM ARE S 'F A
M
TOTAL4AREA,
'tHEtEELEVS THOUT WRITTEN'
5 UST N6t�k
VALB .-SPOHR
GALS
'tH4RLESib
0 Y
ECT' ON REQD 'fE LEG E�N D, _W I N EXCAVATED.
6. FO
�EXISTGROUN D E LE V.
+ 50
V'7
NDERLIN
a . m :''N
50.0' FJN I S Ff. G Rb UN` D' ;��IL E
U
D E,�_CR i p
1 L E_:V.-�
47 50' 'PIPE R E'V,,. bkT E,,
Al
44),r to
I 'S R
E
0 S EWA G
JEST M,':
PIT l6cATI
St0Tl'C ,:-TANK
-A -,K
AREA,+,� ±,_'L--�.N.
o,oq T N"",80,
HE
4 C,c
NOTE. r
;e?Al' -TI
-4 :BIT.,r
GHTJOINTS ,
b E S I G' Ni D.,SPOH'R: DA,TE
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FI
P,..R��,Vy I N 0 N 0
PROPER
TY,'L)N't
I E:'A-S�8;SCA
D R WN"
M.1 N -01 STANCE
ODE
MAP SEC P.CL,, v_ yA1
LOT . IHOUSE
ci E C kl�'D:, C 0, S . �