HomeMy WebLinkAbout0041 PONTIAC STREET - Health 41 Pontiac Street (aka 19 Pontiac)
Hyannis.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper'Cape Septic Services ^�
Company Name
29 Atwater Dr _
Company Address r
E. Falmouth MA 025361
City/Town State : Zip Code` -
0 1-508-495-0905 S13971 qo
Telephone Number License Number r :=
cn
B. Certification ,
I certify that I have personally inspected the sewage disposal system at this address and that the
1'. 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
7-3-08
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
f, t . jj ..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.
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts -
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08 .
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:
System is new and in good condition.
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"n t
determined,"please explain.
❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts ,
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services -
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.): ,
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of.Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t ❑ 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.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
R
Commonwealth of Massachusetts -
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08
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
0 ® 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
El than 1/ 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
El ® tributary to a surface water supply.
t5insp•03/08 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
41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is x
required for Hyannis MA 02601 7-2-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont):
Yes No
❑ ® Any portion of a cesspool or privy.is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
t •}„ 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
❑ 0 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 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Pontiac St (Aka 19 Pontiac St) ,
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis ` MA 02601 7-2-08
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?
[E ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
®• E ❑ 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(arid 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.
® . .E] 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)]
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 41 Pontiac St (Aka 19 Pontiac St) -
Property Address
Premiere Asset Services
Owner Owner's Name
information is {"
required for Hyannis MA 02601 7-2-08
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220
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 years usage (gpd)):'
Sump pump? ❑ Yes ® No
Last date of occupancy: 6-08
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: '
Design flow(based on 310 CMR 15.203)- Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? = ❑ Yes ❑ No
Industrial waste holding tank present? ° ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water'meter.readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp-03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments
41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: N/A,
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons =
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
Maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the 1/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
2006
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is Hyannis MA 02601 7-2-08
required for y •
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan): `
Depth below grade: 16!
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Good condition.
A,1 Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gal
Sludge depth: 6,.
26„
Distance from top of sludge to bottom of outlet tee or baffle
2"
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
12"
How were dimensions determined? Tape
t5insp-03/08 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
41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08
every page. CitylTown 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.):
Tank in good condition with baffles in place. x `
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):
t5insp-03108 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 41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is Hyannis MA 02601 7-2-08
required for y •k
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑' Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition.
Pump Chamber(locate on site plan):
Pumps in working order: A ❑ Yes ❑ No
Alarms in working order: ❑ Yes . ❑ No
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c�M 41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: Infiltrators
❑ leaching galleries number:
❑ leaching trenches number,-length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level.of ponding, damp soil, condition of
vegetation, etc.):
Leach field with infiltrators in good condition with no sign of back up.
4 6
t5insp-03/08 - 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
41 Pontiac St (Aka 19 Pontiac St) `
Property Address
Premiere Asset Services
Owner Owner's Name
information is Hyannis required for H y MA 02601 7-2-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools(cesspool must be pumped as part of inspection) (locate on site,plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (riots condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 ,
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08
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.
m" o:
4;!`5
; 5' - - I
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Pontiac St (Aka 19 Pontiac St)
Property Address
Premiere Asset Services
Owner Owner's Name
information is required for Hyannis MA 02601 7-2-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (Cont.)
Site Exam:
❑ Check Slope �.._
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10,
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 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:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 10'.
t5insp•03/08 Tate 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Regulatory Services
BARNSTABLE, : Thomas F. Geiler, Director
v MASS.
39.
�ArFa ra Public Health Division
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.
Q:ISEPTIODisclaimer Private Septic(nspections.DOC
��� D 1 TOWN OF BARNST ABLE
P n!rQC �! anUrdCzocMTON. A I P SEWAGE
C-AG ASSESSMS .L0%2a 1-07a
INSTALLER'S NAME&PHONE NO.
SEpC7 c "TAN.K CAPACITY PACI:T"Y :� .�., ��1V
�
L / a�6Y S.
- (size) 37 X/G X .,
1�.A(:l�#INt".c 17A�It..@T'Y': (type)�_.� ,-_NO,0PBEDROOMS
BUILDER OR OWNED.
S�;psarration�istaara�;Bct�ur�ra tie:
Maximum AdjustedGroundwrater able to the Bottom of 14ZLchEns.pa ility
Pr vate Water Supply Well and LcacWng Paacility (If any ells exist
on site.or witlaiit 200 feet of leaching facility)
Edge of Wedand and Leaching r-acility(if any wetlands exist
within 300 feet 'leac:lun'.Cali 1 ,� «Feet
Furia shed b 7
y
of
0
Q
A q a
TOWN OF BARNSTABLE
LOCATION / A, / I q JR0PJ r CSEWAGE # 7;2'00 -OQJ
c
VILLAGE iA-dybly] ESSOR'S MAP & LOT 07
INSTALLER'S NAME&PHONE N0.
SEPTIC TANK CAPACITY r
LEACHING FACILITY: (type) G�-- (size) "
NO.,OF BEDROOMS
BUILDER OR OWNER
gY'6e-
PERMITDATE: COMPLIANCE DATES 3 D
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) t "Feet.
4
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) 'Feet
Furnished by
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No.. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppYication for �Digoga[ gppgtem Comaruction Vermtt
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) f;�komplete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel ofLq
Installer's Nuag,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms C Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �3 3 gpd Design flow provided 3 ��� gpd
Plan Date )L `6 Number of sheets Revision Date
Title O--c—1`e—
Size of Septic Tank ,�i S "CV Type of S.A.S. s m v l_
Description of Soil V ,_A S �,�� o yn—K- I S
Nature of Repairs or Alterations(Answer when applicable) t.-
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 Boa4of Health.
Sig Date y Q
Application Approved by Date
Application Disapproved by: _ Date
for the following reasons
Permit No. Date Issued
fl,
No. `� 3 Fee
THE C�O.MMONWEALTH OF MASSACHUSETTS Entered in computer: .
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for migpogal *pgt m Con.5truct ou permit
Application for a Permit to Construct(.) Repair( ) Upgrade( ) Abandon( ) ;�I%Qomplete System ❑Individual Components
Location Address or Lot No. D � ft`le' Owner's Name,Address,and Tel.No.
CAA w(.`t� �1 c
Assessor's Map/Parcel
41nstaller's e,Address,and Tel.No. Designer's Name,Address and Tel.No.
{
b . _ sA-wy
Type of Building:
#Dwelling No.of Bedrooms (P11 Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �J v gpd Design flow provided 3 gpd
Plan Date Number of sheets Revision Date
Title 4 U l-1`e.
Size of Septic Tank SG1b Type of S.A.S. r-ket �—
Description of Soil _ccaC Q U 1g-- 011
Nature of Repairs or Alterations(Answer when applicable) f�
Date last inspected:
f-
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 Boa. of Health.
Sig end e y'7 Date //�/'�
Application Approved by Via` _ ' (/ Date /
4" Application Disapproved by: _ v ( / �•-. Date
for the following reasons
j
t Permit No. oMaly Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERT a the On-site Sewa e Disposal System Constructed ( ) Repaired ( ) Upgraded (p7r
Abandoned( )by i d z-'A S �� r
at A l Ow ✓ A V �u`k-°/has been construct d'n a •ordance
with the provis' Title 5 an the for Disposal System Construction ermit No. dated ��
Installer dS Designer
#bedrooms I ' Approved deign flTv d gpd
The issuance of this permit shall not be construed as a guarantee that the system will functjon�as desined.
Date Inspector
t
——————— ———————————————— — --------------
No. Fee.—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
1=igpogaf *pgtem Construction Permit
Permission is hereby granted to Construct ( ) Repair ( ) . U grade ( 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.
11 Provided: Construc on st be,,completed within three years of the date of th' er}}f�it.
Date ( Approved by p(:�
r
Town of Barnstable
p tHE Tp�
do Regulatory Sqrvicel,;
Thomas F. Geiler,Director
* BAMSTABLE,
9� MAM. Public Health Division
Argo►�►`�°r Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date:
Designer: Shay Environmental Services, Inc. Installer: _ C��'SL�� Q tc JCS,
Address: P.O. Box 627 Address: -Nq,c� ,
East Falmouth, MA 02536
On / o(.0 C was issued a permit to install a
( ate) (installer)
septic system at �Z �p� =+GC . , �;S based on a design drawn by
(address)
Shay Environmental Services, Inc. dated 3 1z�0
(designer)
I 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 & Local Regulations. Plan revision or
certified as-built by designer to follow.
H OF MASS,
CARMEN �`47
c`3 : E
ler's Signature) SHAY N
No. 1181
0
. �FGISTER� •
SANITAR\Pa
(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
f
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
� c
hereby certify that the engineered plan signed by me
dated 3 1m, concerning the property located at
n'ti G.c 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.
• 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 deep
test holes and percolation 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). . O 6
B) G.W.Elevation •f 5 +adjustment for high G.W. __ 1_5-4. 5 O
DUTEERENCE BETWEEN A and B • �d
0
2&�
SIGNI D : DATE: O o
NOTICE
LBaseduponhe above information, a repair permit will be issued for bedrooms
o additional bedrooms are authorized in the future without engineered septic system
M► � ��
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gASepdc\percexemp.doc
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*NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. r-�
[hu
-10' min. from VENT PIPE (O Least 24 ind,es tall 1S'ECTION A A j ' \Existing Foundation ose to septic tank Schedule 40 PVC w/Charcoal Odor FNter
TOP OF FOUNDATION ELEV. 100.00 Assumed tonk covers must t» o-Box cover must he PROFILE VIEW OF ADDITION TO LEACSING SYSTEM �'�'oRTT LEAST�. 12' CONCRETE COVER r+Y,��kw�, ab
(Assumed) within 6 in. of finished grade within 6 in. of finished grade E1v eMIN '2 t
' _ 2
Ands over Sepik Tank-tt9.00 (cods over D-Box- 9650 I l over SAS- tisoo a 3- 7()Su:
; -•.••s, °�, r s V-L
KNOCK3" of 1 8" 1 r Washed Peost
3/4' to 1 1/2 ' Washed Crushed Stone •�\: �
s
S � 0.02 12' fIET
3 HOLE Box 0 3' Morknwn Cover INSTALLED AND 70 CMS 6'OF GRADE
r
Top OF System-Eiev. -93 00 _ %
10• NEW S-0.01 a "Greater . f � 41 f►NAhe Ri4j,;°f
EXIST. tm� $ to 1,500 GAL p S< o.OI' , tss•
FROM EXIST. FWNDATIIN rn uii SEPTIC TANK 15• Per foot O"EffeetI Depth 1.75' '°►<v �__ k►gf
I H-10 ee..... °' C-4 s PLAN SECTION CROSS-SECTION ` r; o�urr CONCRETE FULL FOUMOA p j tl d rn 5 Units 2 6.25' = 30' AlS�une
Suemtae r
e 0.83 (10 inches) o
SYSTEM PROFILE j 6�a�/4ed ��- ',• o 4 3 31.25' 31
3 HOLE H-10 DISTRIBUTION BOX .� 0 M
C > O O Ol i 190a " Rd
Not to Scale c I• 37.25 NOT TO SCALE zoos _ ga fij
'0 3.5' I 3.5' N Effective Length r �d!tk+rE 'pZaoaMrertEo `°`''
-c c4-�
3' 'o SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES
6 in.of 3/4-1 1/2' p 10'
compacted stone a Effective Width INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE m 1. Contractor is responsible for Digsafe notification, Verification of Utilities
i (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes.
W Bottom of Tact Hula 1 EfeOW Bo NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" 2. The septic tank onl, distribution box shall be set
Groundewtar Observed NOW OBSERVED /EFFECTIVE HEIGHT IS t0" level on 6" of 3/4'-1 1/2" stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
P E R C 0 LATI 0 N TEST
EST 4. This system is subject to inspection during installation
by Carmen E. Shay - Environmental Services, Inc.
Date of Percolation Test: MARCH 10, 2006 5. The contractor shall install this system in accordance
Test Performed By. CARMEN E. SHAY, R.S., C.S.E.
with Title V of the Massachusetts state code, the approved plan Results Witnessed By. WAIVER (Per Barnstable B.O.H.) and Local Regulations.
EXCAVATOR: Shay Env. Svcs. ' �� 6. If, during installation the contractor encounters any
Percolation Rate: Less Than 2 MPI ® 40" soil conditions or site conditions that are different
I from those shown on the soil log or in our design
I I installation must halt & immediate notification be
Test Hole Test H�1(e made to Carmen E. Shay - Environmental Services, Inc.
No. 1 No 10000' 1 7. No vehicle or heavy machinery shall drive over the
DEPTH SOILS ET DEPTH .
ELEV. I septic system unless noted as H-20 septic components.
0 98.00 98 1 i I 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
Sandy Loam 7dyy Lo t i �9. All Distribution Lines shall be 4 diameter Schedule 40 NSF PVC pipes.
i TEST HOLE #1 I 10. All solid piping, tees & fittings shall be 4" diameter P P
10 YR 3/2 R /2 Mr I I P P 9• 9
0"-9" Ae 97.25 O"-9" As 2.75 ELEV.= 98.00 I
I Schedule 40 NSF PVC pipes with water tight joints.
Sandy Sand - 11. Municipal Water is Connected to ALL OF The Residence and Abutting
Loam Loam
,` ` ► Properties Within 150 Feet.
10 YR 5/t1 10 YR 5/6 r `
9"- 40"1 Be 94.67 9"- 40 8, 94.67 .4'1• e r f THE PROPERTY LINES ARE APPROXIMATE AND
Medium/Coarse Medium/Coarse „ -.��-- COMPILED FROM THE SURVEY PLAN GENERATED BY
d and Gra Sind and Gra I Failed - !� CHARLES SAVARY OF HYANNIS, MA
ENTITLED "SUBDIVISION PLAN OF LAND IN HYANNS, MA,
2-5 Y 7/4 2s Y 7/4 Cesspool _ ' r` DATED MARCH 18, 1968 AND PLAN BOOK 225 PAGE 109
40"- 132 C, ao"- 132 C, '�' TEST HOLE #2 EXIST. �� W AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
. .
98_-�`. `� ELEV.= 98.00 DRIVEWAY IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
THE SEPTIC SYSTEM INSTALLATION.
89
�- EXISTING CESSPOOLS TO BE PUMPED OUT AND
\\ D-Box 0 REMOVED TO FACILITATE THE INSTALLATION OF THE NEW SAS
Fai d 4' % 1 t-- NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
Cesspool FROM THE EXISTING CESSPOOLS TO BE DISPOSED
IOF AS PER BOARD OF HEALTH SPECIFICATIONS.
- - Pert #1 p THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
Depthto Perc: 42" to 60" PROJECT BENCH MARK O ' I j 1 0
Perc Rate= 2 MPI TOP OF FOUNDATION 01 `t v
Groundwater Not Observed 4.5'--�- _ o ASSESSORS MAP 269 PARCEL 072
No observed ESHWT ELEV. = 100.00 (Assumed) NEW 150p GALrlicipa °t {' ;
ADJUSTED H2O Elev. = None SEPTIC TAN�C i LEGEND
EXISTING 1 6 00 104X1 DENOTES PROPOSED
3-24 DIAM.ACCESS MAMtOlES zHAOUREOU�f I SPOT GRADE
DENOTES EXISTING
46
SPOT GRADE
i F
PL PROPERTY LINE
NKLEar
l \ Otl 7 ; I
96P PROPOSED CONTOUR
THE ACCESS COVERS FOR THE SEPTIC TANK,
A DISTRIBUTION BOX AND LEACHING COMPONENT �T.,,r. �� SHALL BE RAISED TO WITHIN 6" ofAolcse #4> -- ----97 EXISTING CONTOUR
`•'s .•.:�:� ' a :�; FINISHED GRADE. 16,250 Square Feet
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EQUALS I DEEP TEST HOLE &
PLAN VIEW ON ALL OUTLET TEE ENDS
PERCOLATION TEST LOCATION
3-24'RIM MAKE OOVERS
6 FOOT STOCKADE FENCE
7k F ::; EXISTING I
min.clearance
tNLE7 e'minTlz•min.kdee to outlet s.iiie, '"E' �� GARAGE
ftr
�j ua,a i.rei OUTLET
` to•rah I rt
b9 so ado. uoidd depth CB D.H.
FND
OF PROPOSED SEPTIC SYSTEM UPGRADE
'r-O'min. PLOT PLAN
� 1a-o• s•'�' CB D.H. PREPARED FOR
CROSS SECTION END-SECTION FND 11 0'00' M R. MARTIN E. H 0 X I E
TYPICAL (H-10 LOADING) 1500 GALLON SEPTIC TANK AT
NOT TO SCALE #41 PONTIAC STREET A. K.A. 19
Bedroom Bath Kitchen Design Calculations H YA N N I S, MA
/Dining
��N�=f�,q c PREPARED BY:
Number of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Gal./Day Min. per Title V) CA RMEN
Garbage Grinder: No ( V) Bedroo oCw F2P. -i m E Sl l Y
Leaching Capacity Proposed: 330 Gal./Day Minimum Min. Per Title Living Room
Septic Tank - 2 x 330 Gol./Day = 660 USE NEW 1,500 GAL Septic Tank. a
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch Mud ENVIRONMENTAL SERVICES, INC.
m
Room
Bottom Area: 0.74 gal/sq. ft. x 372.5 sq. ft. = 275.65 gallons
' }Sidewall Area: 0.74 gal./sq. ft. x 78.72 sq. ft. = 58.25 gallons 0 20 40 50 P.O. BOX 627
�F�;S; gam EAST FALMOUTH, MA 02536
Providing: = 333.90 gallons
BE HOUSE FLOOR SCHEMATIC SANITAR��\a TEL/FAX : 508-539-7966
Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCAL
DS. NO STONE UNDER. 1"=20' DRAWN BY: CES DATE: MARCH 14, 2006
TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE „- ,
ON THE EN SCALE. 1 =20
PROJECT SD875 FILENAME:# SD875PP.DWG SHEET 1 OF 1