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Home My WebLink About0015 PRINCESS PINE ROAD - Health 15 Printyotss Pine load H w. N. Y_annis '.3 P' P,. 269. 088 i 4 f i e i f' i 1 4 r L 6 J TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE "pS ASSESSOR'S MAP&PARCEL Q0 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ,04i �� k Y 2, (size) 2 NO.OF BEDROOMS 3 OWNER Jap%rr AkAa a 11sAre AgxrPm,-S er*k lyos,,- PERMIT DATE: COMPLIANCE DATE: ' Separation Distance Between the:` Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY c f -23i• a. y C; v iG` 17.5 w TOWN OF BARNSTABLE LOCATION r me z SS „vy SEWAGE # ling _ 7 �y. oQ' N; LAGS_ ASSESSOR'S"MAP & LOT INSTALLER'S NAME&PHONE NO. Co 6ag-775-35h3 SEPTIC TANK CAPACITY I CA .� LEACHING FACILITY: (type) Q !JQQ C—aAtt.xQ7 ,,JKsize) 02 7 X 13 X NO.OF BEDROOMS BUILDER OR OWNER Lit, are PERMITDATE: 1016 1 hazz COMPLIANCE DATE: Separation Distance Between the: E Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility eet Private Water Supply Well and Leaching Facility (If any wells exist �! on site or within 200 feet of leaching facility) W/A Feet i Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by y I4:0 . PronccsS P„ne� TOWN OF BARNSTABLE LOCATION 15 rincess SEWAGE # 9QQg 7 VILLAGE 1 f fir/cI»lt S - ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. __ �Ylr�c,�11 �7r�Ps�/►•.c i,�+ C� SOSaT7S-3 SEPTIC TANK CAPACITY I50c7 GRL47ti/ "LEACHING FACILITY: (type) 6440ii (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) o" Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) �J' _ Feet Furnished by 3 i- P�� r� �� I a c i"tiC.2S5 dries _ '` Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address y,. MARK VOGEL Owner Owner's Name information is required for every HYANNIS V MA 02601 5/11/2020 page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms Sys' AK FIO on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return Company Name key. 350 Main Company � Company Address W Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 SI-14423 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the•inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority- 4. ❑ Fails _5/29/2020 pector s Slgna 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 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 form should be sent to the system owner and copies sent to ' the buyer, if applicable, and the approving authority. Please note: 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is HYANNIS _MA 02601 5/11/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: f SYSTEM IS IN WORKING CONDITION f 2) 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ` ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is reequiredquired for every HYANNIS MA 02601 5/11/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3)' Further Evaluation is Required by the Board of Health: r' - ❑ 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is requred HYANNIS MA 02601 5/11/2020 i for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. E] ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two,weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts E Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v� 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: i Number of current residents: 2 Does residence have a garbage grinder.? ❑ Yes ® No Does residence have a water treatment unit? ❑'Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): '19- 141 GPD '18-34 GPD Detail: Sump`pump? ❑ Yes ® No Last dateof occupancy: CURRENT Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is HYANNIS MA 02601 5/11/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes E No If yes, volume pumped:. gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage.odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: 10'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD `J Property Address MARK VOGEL Owner Owner's Name information is HYANNIS MA 02601 5/11/2020 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"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 GALLON 2,1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 1„ 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 How were dimensions determined? ESTIMATED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 12" BELOW GRADE t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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): / Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name Information is required for every HYANNIS MA 02601 5/11/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert EVEN 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.): DISTRIBUTION BOX LEVEL AND WATERTIGHT t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. City/Town State Zip Code Date of inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: z Type: ❑ leaching pits number: ® leaching chambers number: 2-500 GALDRYWELLS ❑ leaching galleries number: El leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts @ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-500 GALLON DRYWELLS, 12.8'X27', FOUND DRY DURING INSPECTION WITH NO EVIDENT STAINING. COVERS ARE 42" BELOW GRADE a 12. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids — Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owners Name information is HYANNIS MA 02601 5/11/2020 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately s Q of Owe . yt i x � . .fi i r e. #•' t as-_., rJ :az 'key„ y "-r'`YE�7�•� ...5 tswm.doc•rev.7=2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is required for every HYANNIS MA 02601 5/11/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: +11' 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: PRIOR INSPECTION ON FILE AT BOH ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: ASBUILT CARD ON FILE SHOWS MAXIMUM ADJUSTED GROUNDWATER TO THE BOTTOM OF LEACHING FACILITY AT 75' r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 l p I me a uYnciai In5pecuon rorm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 PRINCESS PINE RD Property Address MARK VOGEL Owner Owner's Name information is HYANNIS MA '02601 5/11/2020 required for every -- - page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: • A. Inspector Information:,Complete all fields in this section. ® B. Certification: Signed &Dated and 1, 2, 3, or checked , ® C. Inspection Summary: o`j compi ted as Epp ial r2te 4(Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included F t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ti f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments g Gil M 15 Princess Pine Road property Address J A M eS Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Adam Riker cursor-do not use the return Name of Inspector key. R.L.C. Company Name PO Box 726 Company Address South Yarmouth MA 02664 Cityrrown State Zip Code 5087766460 Telephone Number License Number B. Certification { I certify that 1 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 tgyS'ection 15.340of Title 5(310 CM 16.000).The system: =M ® 'Passes ❑ Conditionally Passes ❑ Fail ` C0 ❑ Needs Further Evaluation by the Local Approving Authority 1/17/2007 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. title five inspection report•08/06 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 Princess Pine Road Property Address J r�►16 s /Va��+ah E s�o► 7/v�-�c Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 every page. Cityrrown 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 need pumping B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed title five inspection report•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 f I t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 Princess Pine Road Property Address Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 every page. Cityrrown 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: ❑ 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. title five inspection report•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Princess Pine Road Property Address Ja..es Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 every page. Cityrrown 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ` ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. I ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. title five inspection report-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 wM 15 Princess Pine Road Property Address 47ar%er 4ja, fS•Ln�e rj,�c�tt Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 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. ❑ Z 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. title five inspection report•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 'l 15 Princess Pine Road Property Address Jt,..a s Nei�a•.s.��c• Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 _ every page. Citylrown 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] title five inspection report•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 15 Princess Pine Road Property Address ./arse r AhefQft C-CA& 7 A Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 _ 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 Number of current residents: 7 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: current 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): title five inspection report-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Princess Pine Road Property Address f JGrwta 0,4w'. fs/Wc. >/wS Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: needs 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: installed on 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No title five inspection report•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Princess Pine Road Property Address �4PUS /y��r� LP1�+►� �� Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: >.01feet 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.): Septic Tank(locate on site plan): Depth below grade: .6 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: 5'8"w-8'6"L-5'8"H Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 15" Distance from top of scum to top of outlet tee or baffle lot 3" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? cloth and stick tide five inspection report•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 M "I 15 Princess Pine Road Property Address Owner J`rs4 a &r/l�1 Ice�k TI VS Owner's Name information is required for Hyannis MA D2601 01/16/2007 - y every page. Cityrrown 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.): septic tank needs pumping appears to have excessive soilds 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): title five inspection report•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 wM >r 15 Princess Pine Road Property Address Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 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 >1/4" 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No M title five inspection report•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M " 15 Princess Pine Road Property Address Owner Owner's Name information is required for Hyannis MA 02601 01/16/2007 every page. Citylrown 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: 2 ❑ 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.): water level 10" below top of drywell title five inspection report-08/06 Title 5 Official Inspection Forth: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 w "t 15 Princess Pine Road Property Address Owner oz l�6 Oak r�vr-cs. Owner's Name information is required for Hyannis MA 02601 01/16/2007 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: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): title five inspection report•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy< 15 Princess Pine Road Property Address -- Owner s�•+• .f /(foi� ��y+► ?JIJ�'y�c Owner's Name information is required for Hyannis MA 02601 01/16/2007 every page. Cityfrown 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 buildi I If 3 3a A•s • �y� 0 � 0 C- C+ � � �` . II 1 i G /7. s B • y ; 1�. G . s- title five inspection report-08/06 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 15 Princess Pine Road Property Address _ Owner o4nt,r 71,!-4W-1 4,r" '1'�I441- Owner's Name information is required for Hyannis MA 02601 01/16/2007 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 ground water: n/a 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: 10/03/2002 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: located area well readings You must describe how you established the high ground water elevation: plan of file i I s I� title five inspection report-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for_Voluntary Assessments 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is Hyannis >/ MA 02601 09/01/2013 required for every - y 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. Important:When A. General Information filling out forms on the computer, use only the tab 1 . Inspector: (� key to move your ��••� �{ °�„ 1 • cursor-do not Adam Riker use the return ° l key. Name of Inspector R.L.C. �V Company Name PO Box 726 Company Address ,- South Yarmouth MA 02664 J Cltyrrown State Zip Code 5087766460 S14590 Telephone Number License Number B. Certification I certify that I have personally,inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.i am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ 09/01/2013 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board t •",' 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. file•08/06 Title 5 Official Inspection Forrurftfac.ewage Disposal System•Page 1 of 15 S f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments x ..�'` 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is required for every y H annis MA 02601 . 09/01/2013 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: On inspection of septic system there were no indications of failure observed. B) System Conditionally Passes: ❑ One or more system cornponents,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.bytheyBoard.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: k ❑ Observation of Sewage backup or break out or high static water level in the distributior box due to broken or obstructed,pipe(s) or due to a broken,settled or uneven distribution box. System will; NMITWI pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed file•woe.' 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 : 15 Princess Pi ne ine Road Property Address Maureen Norton Owner Owner's Name - information is Hyannis .MA, "' 02601 09/01/2013 required for every 4:A r F page. City/Town " State Zip Code, K Date of Inspection. # . B. Certification (cont.) > B) SystemConditionally Passes (cont.). ❑ - ' distribution boz is leveled_or replaced ND Explain: .Tay r - . - r !' - - • f ❑.. The s stem re uired pumping more than 4 times a year due to brokeri or-obstructed pipe(s). The system will pass inspectin_if(with approval:of the.Board of Health). -_ El broken pipes) are replaced ❑ obstruction is removed t ND Explain: C)' Further Evaluation is Requiredaby the.Board of Health: . ❑ Conditions exit which require further evaluation by the Board of Health in order to defermme,if the system is failing to protect public health,safety or the:environment, ' -1. System will pass unless iBoard�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 44 Cesspool'or privy is within 50 feet of a bordenng vegetated wetland or,a salt marsh 1 ISystem 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 aseptic tic tank and soil absorptionps stem SAS °'and th- Y py ( ) e 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. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. file•08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M y� 15 Princess Pine Road ti Property Address Maureen Norton . Owner Owner's Name information is required for every Hyannis - MA 02601 2, 09/01/2013 page. Cltyrrown State' Zip Code Date of Inspection B. Certification (cont.) . C) Further Evaluation is Required by the Board of Health (cunt.): ❑ 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: W 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 El ® ' _ 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 El ® a or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ® Required pumping more than 4 times in the last year NOTdue 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. file•0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is required for every Hyannis MA '02601 09/01/2013 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." ❑ ® fi Any portion of'a cesspool or privy is within 50 feet of a private water supply well. El ® 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 w 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.] Ej ® The,system isa cesspool serving.a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails.I have determined that one ormore 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 4 Area IWPA)or a mapped Zone II of a public water supply well If you have answered ayes"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 P 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. file.•08/06 Trtle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 15 I_ ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is required for every Hyannis MA 02601 09/01/2013 a e. Cityrrown State Zip Code Date of Inspection P9 P p C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No E ❑ ® 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) 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(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)] file,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:' _ 15 Princess Pine Road - Property Address Maureen Norton Owner Owner's Name > information is required for every Hyannis `MA 02601 09/01/2013 page. Cityfrown 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: 110 330- = ( p gpd x#of bedroomsj: . Number of current residents: Does residence have a garbage grinder? ❑ Ye's ® No Is laundry on a separate sewage system? [if yes separate inspection required] ,F ❑ Yes ® No Laundry system inspected? - El Yes, ❑ .No Seasonal use? °❑ Yes ® No Water meter readings, if-available-'Past ast 2 ears.tasa a /a `S� 9 � Y g (gPd))� Sump pump? ® Yes ❑,:No Last date of occupancy: current Date Commercial/Industrial Flow Conditions. Type of Establishment:.; Design flow(based on'310 CMR 15203): ' Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): t 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): file-08/06 .. r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 1^- Commonwealth of Massachusetts Lr a Title 5 Official Inspection FormP Subsurface Sewage Disposal System:Form:-'Not for Voluntary Assessments.; 15 Princess Pine Road } Property Address Maureen Norton Owner Owner's Name information is required for every Hyannis MA :�02601 z 09/01/2013 page. Cityrrown State - Zip Code Date of Inspection i D. System Information (cunt.) - A Genera llnformation f Pumping Records: Source of information homeowner. Was system pumped as part of the inspection? - ` ❑ Yes ® Non If yes,volume pumped .,gallons. How was quantity pumped determined? • Reason for pumping:" bi annual pumping recommended Tyne of System: ® Septic tank;distributiori box,soil absorptionsystem ;. Single cesspool, Y ❑ overflow cesspool `. = 0 Privy. 0 - Shared system:(yes or-no) (if yes, attach previous inspection records, iYany) Innovative/Altemative technology.Attach a copy of the current operation and'_ f maintenance contract(to be obtained from system owner) .a Tight tank.`Attach a.copy of the DEP.approval. x a Other(describe): ar Approximate age of,all components, date installed (if known)and source of:information: _ installed on 2602 " • r 1: Were sewage odors detected whenuarrivingat the site? ❑ Yes ®, No file•oa= Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 8 of 15 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z•°" 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is Hyannis MA 02601 09/01/2013 required for every H y _ page. City/Town State Zip Code Date of Inspection. D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 1 - feet Material of construction: - T ❑ cast iron ®40 PVC ❑other(explain): Distanc6 from,private water supply well or suction liner feet Comments(on condition of joints,venting, evidence of leakage, etc.): Dry no leaks Septic Tank(locate on site plan): Depth below grade 8 feet Material of construction-.- concrete ❑ metal -ry f ❑fiberglass -' polyethylene 0 other(explain) r. 1f tank is metaF,'list age: years Is age confirmed by,a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ 'No Dimensions "5'8"w-8'6"L-5'8"H 4n Sludge depth: Distance amfro top of sludge to bottom of outlet tee or baffle 30 lot Scum thickness . .Distance from top of scum to top of outlet tee or baffle fill - Distance from bottom of scum to bottom of outlet tee or baffle 1411 How were dimensions determined? cloth and stick file•'08/06 Title 5 Official Ins on Form:Subsurface Sewage Disposal P� 9 SysOem•Page 9 of 15 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Princess Pine Road - Property Address Maureen Norton Owner Owner's Name information is Hyannis MA 02601 09/01/2013 required for every y 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.): . septic tank needs pumping appears to have excessive soilds Grease Trap (locater on site plan): r 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. r s: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,' liquid levels as related to outlet invert,eevidence of leakage, etc Tight.or Holding Tank(tank must be pumped_at time of-inspection) (locate on site plan): 4s Depth below grade: Material of construction: ❑ concrete. ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 'file•08/06 Title 5 Official Insp ection 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 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is required for every Hyannis MA 02601 09/01/2013 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' >1/4" 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.):. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No file•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form { Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' "r 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is required for every Hyannis MA, 02601 00/01/2013 page. Cityrrown 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: s = Type: leaching.pits number:' - ❑ leaching chambers ,° J number:. ® leaching galleries ,= number: ❑ leaching trenches number, length: ❑,. leaching fields ., �> ; number, dimensions: ❑ overflow cesspool:: , =s -number: ❑ innovative/altemative system M Type/name of technology: Comments(note,condition of soil,`signs of hydraulic failure, level of ponding,damp soil, condition of .vegetation;etc.): water level W'below top of dywell file•OS/OB 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 15 Princess Pine Road Property Address Maureen'Norton r, Owner Owner's Name information is Hyannis 'MA 02601. 09/01/2013 required for every y page. CitylTown State Zip Code Date of inspection "k �M 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 r Depth of solids layer Depth of scum layer ti. Dimensions of cesspool Materials of construction Indication of groundwater inflow E Yes ❑ No Comments(note condition of.soil, signs of hydraulic failure;level of ponding,condition of vegetation, etc.): *: f 'Privy (locate on site plan), F Materials of construction: ` y Dimensions .:e Depth of solids Comments(note condition;ofsoil, signs of hydraulic failure;level of ponding, condition of vegetation, *:. etc.): E= file•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 l Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form, Not for Voluntary Assessments �y 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is required for every Hyannis MA 02601 09/01/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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. �4 — Sg3yo _ 0a - P . • file-08/06" 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., , y�< 15 Princess Pine Road Property Address Maureen Norton Owner Owner's Name information is required for every Hyannis MA 02601 09/01/2013 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: i ® Check Slope ® Surface water - ® Check cellar, ® Shallow wells Estimated depth to ground water: n/a 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: 10/03/2002 Date El 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 USES database-explain: located area well readings 3 4 You must describe how you,established the high ground water,elevation: plan of file file•0&06 Title 5 Official Ins pedon Form:Subsurface Sewage Disposal System-Page 15 of 15 Ni- �`-� ��(.> Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Diopool *pgtem Conotruction permit Application for a Permit to Construct(fie)Repair(,,e,)Upgrade(' )Abandon( ) -N Complete System ❑Individual Components Location Ad Vs or Lot No. p Owner's Name,Address and Tel.No. I� r c.ss 'ptn Q ` 0 l�r_,�*� HND DfiRY6N1X' 15QJvVs MMS InKlieri Name,Address,and Tel.No. Designer's Name,Address and Tel.No. I'Ng1Gwr G>,J5faLkG'1'01 co 5G �'N�ir:F_E�z,Od� -+ OV5 c rrrr=5 o - r IOU 3 A , t gc)3 o 3a iMn, 55 Type of Bu ding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 6. 1:. ,Z _ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow / 3 3 30 gallons per day. Calculated daily flow a13'gallons. Plan Date nz/al D ) Number of sheets o2 Revision Date Title Size of Septic Tank 1 GAC W Type of S.A.S. -tA, i3�25� Description of Soil Nature of Repairs or Alterations(Answer when applicable) + Le",jg Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the.Adre=c)'es"�f besltP �j �is�osal system �-a in accordance with the provisions of Title 5 of the Environmental Code and not:to,placc lie t�f91�►t e e t i na:Certi i cate of Compliance has beejT n'sued by this Board o ealth. WAS INSTgI -n To Fp) Sign d Date Application Approved by Date Application Disapproved for the following rea 61 Permit No. Date Issued 41- Fee--- VYe . Entered in com uteriTHE COMMONWEALTH OF MASSACHUSETTS PPUBLIC HEALTH DIVI.ION--TOWN OF BARNSTABLE, MASSACHUSETTS ricatiott for Miopogal pgterrt 'Con5tructton f ermit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) Comolete System El Individual Components Location Add ss or Lot No. Owner's Name,Address and Tel.No. ' I S e.s5 'Pl n e `� M,-r ti AND S�fiRYL a �F 51�r=rvs As so ' Ma Jr � /y 1 5' 'Y fC 1 n1G}3 P I IJ l IZ Inst ler'l Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /'NK)G►if (�nl5rfc2ltC5,�J L� 5C r5 + I. ' A ( yes'- 35�3 0 g7 3�l 0265S JType of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 5. V. SL . No.of Persons Showers( ) Cafeteria(, ) Y" Other Fixtures t ,f Design Flow x 3 = 3 gallons per day. .Calculated daily flow `�20� 137 5—gallonsy- Plan Date 12,l1 Number of sheets Revision Date e Title Size of Septic Tank 160,-:> GAf_A&.J Type of S.A.S �. 13x;Z5D Description of Soil Nature of Repairs or Alterations(Answer when applicable) )�j,4,J _?Zac IT IQ 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*visions of Title 5 of the Environmental Code and riot toplace the system in operation until a Certifi- cate of Compliance has�been issued by this Board of-Health. Sign Date 7w � Application Approved by I%11 / �: Date Application Disapproved for the following reasons V v Permit No. Date Issued ll THE COMMONWEALTH OF MASSACHUSETTS , x: w F BARN STABLE, ST BLE MASSACHUSETTS Certificate of Compliance THIS IS;TO CERTIFY,that the On-site ewage Disposal System Constructed( fit)Repaired( 'X)Upgraded( ) Abandoned( )by trA'�T e�r4r,,.L��,,-► at 1 0 v r r,,n, 1 _ has ben constructed in accordance IX with the provisions of Title 5 and the for Disposal System Construction Permit No. '" ated �_n2' Installer C4 Designer f►k�Z_ c� /f - - ,,.a -r 145�,c,J." The issuance of this e t shall not e construe as a guarantee that the s 's em will function,Ps desi, ne'di 1 P b d e g Y� 1 �r- Date 1r/ Inspector -- _ -- ,��(i�--s---------------------------- � No. Fee l - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS tg ogaf *p!6teru Cory.5tructton Vermtt Permission is hereby granted to Construct(Y)Repair(_c)Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ��ff t Provided:Construction thust be completed-within three years of the date of this pe':" !� ° Date: 1!1 /�� e/' Cis A roved b � � ._ I �� PP Y t J I TOWN OF BARNSTABLE LOCATION_� �r in r �VIA- "IQ SEWAGE # _ 447 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. e,,., (—p ,Qc 17t s s1►3 SEPTIC TANK.CAPACITY LEACHING FACILITY: (type) � �(7a(_�1 . "]��_, ,(size) �7 x 13'�c ' NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE:Z)� v ov Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility —0—_- - eet Private Water Supply Well and Leaching Facility (If any wells exist / on site or within 200 feet of leaching facility) X/A Feet Edge of Wetland and Leaching Facility (If any wetlands exist � within 300 feet of leaching facility) `3• II Feet Furnished by 43.0 Jq-S' bit,0 6 .a> A 13 -1 :t_yz 26. 0 ' '�'1� :, 1 i ' - PESCE ENGINEERING AND ASSOCIATES P.O. Box 321 Osterville, MA 02655 Phone/Fax 508-428-3730 November 3, 2002 Ms. Donna Miorandi, R.S. Town of Barnstable Board of Health 367 Main Street Hyannis, MA 02601 As-Built Subject: -B it t Inspection for the Septic System Repair at 15 Princess Pine Road, Centerville, Septic Installation Permit# 2002-447 Dear Donna, I am writing to confirm for the record, that I have conducted construction inspections of the new septic system installed at the property located 15 Princess Pine Road, Centerville, owned by Keith and Darlynne Selens. I inspected the site on 29 & 30 October 2002 and found that all workmanship and construction has been completed satisfactorily, and in accordance with the approved design plans, dated 21 December 2001. Thank you for your help on this project, and as always, please call if you have any questions. Sincerely, Cp � L /Edw L. esce, P.E. cc: Mr. & Mrs. Selens Doc;381. 57 ' 10— 2---2002 1 @ a 5b BARNSTABLE LAND COURT REMTRY DEED RESTRICTION WHEREAS, 5-eAnsof J,5 Pr c MA (owner's name) (address) is the owner of 1 ®v,�►c�5P, located ath} a�� (address) MA (hereinafter referred to as ) and being shown on a plan entitled "Subdivision of Land in MA, Property of lc , Selen , et al, hodan-e selens duly recorded in Barnstable County Registry of Deeds in Plan Book , Page bo • yqq x-)6 L-0_ - �3 — aa,Yjs' WHEREAS,Le L16 5-elenS as the owner of said lot has agreed with the Town of (owner's name) Barnstable Board of Health to a restriction as to the number of bedrooms which can be included at this property as a pre-condition to obtaining a building permit for this property; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to authorizing the issuance of a building permit for the construction of a single family home on this lot is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE,Me 14 50enSdoes hereby place the following restriction on (owner's name) his above-referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: may have ,c�o�nstructed upon this property a house containing no (address) more than ,/Y1V''Cr (?) bedrooms. 2. kp jjkA eIPj3S agrees that this shall be permanent deed restriction (owner's name) dylit till affecting located on )�r-Qr,IncesS PLI-& , MA, and being shown T= Raged--�-----, . For title of :k f t'n� see the following deed: (owner's name) CT V A Itul Executed as a sealed instrument this day of. C A Q m, Q_; S;.r6i�Alr-R- TT(date) deedr i f { Witness hand and seal this ,; Clay of ,200,2- COMMONWEALTH OF MASSACHUSETTS SS. DATE Thenpersonally appeared the above named r 1 and acknowledged the foregoing instrument to be free act and deed before me. Notary Public My Commission expires: /,q - d 6 BARNSM REGIS A TRUE < 1 d® Es M BARNSTABLE REGISTRY OF DOS '4� F IMME rGy,� DATE: • sattxszns FEE: y MASS. ... o i639. ♦0 REC. BY JAN I own of Barnstable SCHED. DATE: TOWN i• Board of Health HEAr_i�, 367 Main Street,Hyannis MA 02601 Office: 508-8624644 Susan G.Rask,R.S.FAX: 508-790 6304 Sumner Kaufman,M.S.P.H. Ralph A.Murphy,M.D. VARIANCE REQUEST FORM LOCATION Property Address: JPR540 C, _ eAD Assessor's Map apd Parcel Number: Size of Lot: 0 2Q . Wetlands Within 300 Ft. Yes Business Name: N�o/ Subdivision Name: ^� j APPLICANT'S NAME: h 9 Phone '/ J Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON Name: k �N ' ' N �v Name: s Address: ' �la � ��. Address: Phone: Phone: �1 a d VARIANCE FROM REGULATION(List_ (May attach if more space needed) `st Reg.) REASON FOR VARIANCE 'ir pinn NATURE F WORK: House Addition House Renovation ❑ Repair of Failed Septic System o Checklist(to be completed by office staff-person receiving variance request application) Four(4)copies of the completed variance request form Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) Signed letter stating that the property owner authorized you to represent him/her for this request Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variance requests only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/leasee only],outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems .[only if no expansion to the ilding proposed]) Variance request submi d at least 15 days prior to meeting date BARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Ralph A.Murphy,M.D. Q:/WP/VARIREQ a U s� � qx l IA S � S TZ, o� 6 �i 1 AT- (l) 0 c c� b ' 1 1 RESCE ENGINEERING AND ASSOCIATES P.O.,Box 321 Osterville; MA 02655 Voice/FAX (508) 428-3730 February 15, 2002 Mr. Thomas A. McKean, R.S., C.H.O. Director, Town of Barnstable Health Department Barnstable Town Hall 367 Main Street Hyannis, MA 02601 SUBJECT: Notification of Abutters, 15 Princess Pine Road, C�iille Dear Tom, As you know, at the last public hearing held by the Board on January 23, 2002, 1 informed the Board that the abutters had not been notified as required for consideration of the variances that have been requested for this project. Since that time, the abutters have been properly notified via certified mail. For the project record, please find attached the following: • The "green card" certified mail receipts List of Abutters • Copy of Sample notification letter Thank you again for your help with this project, and please call if you have any questions. Sincerely, Edward L. Pesce, P.E. cc: Mr. Ketih Selens Attachments TOWN OF BARNSTABLE BOARD OF HEALTH REQUEST FOR VARIANCES Applicants: Keith and Darlynne Selens Project Location: 15 Princess Pine Road List of Abutters Assessor's Map#269 Parcel #87 Kevin D. Ratliff & Debra Poirier, 20 Princess Pine Rd., Hyannis, MA 02601 Parcel #89 Daniel Cunningham, 25 Princess Pine Rd., Hyannis, MA 02601 Parcel #92 Stacey A. Andrews, 28 Ferndale Rd., Hyannis, MA 02601 Parcel #93 Rosalind Edwards, 383 Pitchers Way, Hyannis, MA 02601 Parcel #139 Melissa Lima, 18 Ferndale Rd., Hyannis, MA 02601 Parcel #140 Town of Barnstable (MUN), 367 Main St., Hyannis, MA 02601 Parcel #141 James D. and Anne Lombardi, 367 Pitchers Way, Hyannis, MA 02601 I PESCE ENGINEERING AND ASSOCIATES P.0 Box 321 Osterville, MA 02655 508-428-3730 January 28, 2002 TO: The Abutters of 15 Princess Pine Road, Assessor's Map # 269, Lot# 88 SUBJECT: Notification of a Request for Variances for the Repair of an Existing Septic System TO WHOM IT MAY CONCERN, In accordance with State Law; 310 CMR 15.00, Title 5,.and the Town of Barnstable Health Regulations, you are hereby notified that a request for variance(s) has been filed with the Barnstable Board of Health by the owners of Lot # 88 as described above, regarding the subject house remodeling. Additional details follow: APPLICANTS: Keith and Darlynne Selens ADDRESS: 15 Princess Pine Road, Hyannis, MA PROJECT LOCATION: a. Same as above b. Assessor's Map # 269, Lot# 88 PROJECT DESCRIPTION: Application for. an existing failed septic system to be repaired. The existing septic system will be repaired to Title 5 standards. APPLICANTS' AGENT: Edward L. Pesce, P.E., Pesce Engineering and Associates; Osterville, MA PUBLIC HEARING: Tuesday Evening, February 19, 2002, 7:00 PM at the Barnstable Town Hall Plans for this project and application describing the proposed activity are on file with the Board of Health. Sincerely, E ward L. Pesce, P.E. i� Town of. Barnstable f Board o Health 200 Main Street,Hyannis.MA 02601 Office:.508-862-4644 Susan G.Rask,R.S. FAX: .508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. February 22, 2002 Mr. Edward Pesce, P.E., R.L.S. P.O. Box 321 Osterville, MA RE: 15 Princess Pine Road, Hyannis, Assessor's Map 269, parcel 88 Dear Mr. Pesce, You are granted variances, on behalf of your clients, Keith and Darlynne Selens, to construct an onsite sewage disposal system at 15 Princess Pine Road, Hyannis. The variances granted are as follows: 310 CMR 1.5.211: The septic tank will be located three and one-half (3.5) feet away from the westerly property line, in lieu of the ten (10) feet minimum setback required. 310 CMR 15.211: The soil absorption system will be located four point two (4.2) feet away from the northerly property line, in lieu of the ten (1'0)feet minimum setback required. 310 CMR 15.211: The soil absorption .system will be located five. and one-half (5.5) feet away from the westerly property line, in lieu of the ten (10) feet minimum setback required. PART VIII SECT 1.00: The soil absorption system will be located 83 feet away from a bordering vegetated wetland, in lieu of the 100 feet minimum setback required. PART VIII SECT. 1.00: The septic tank will be located only 76 feet away from the wetland, in lieu of the 100 feet minimum separation distance required.. Pesce8. J6 The variances are granted with the following conditions: 1 No more than three 3 bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and .similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (2) The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to three (3) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. (3) The septic system shall be installed in strict accordance with the engineered plans dated December 21, 2001. (4) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the submitted plans dated December 21, 2001. These variances are granted because physical constraints at the site severely restrict the location of a soil absorption system due to the fact that wetlands adjoin the property. The proposed new septic system is designed to meet the maximum feasible compliance standards contained within the State Environmental Code, Title V. Sincerely yours, Susan G..Rask, R.S. Chairperson Cc:.Keth and Darlynne Selens. Pesce8 fvfrj 15 Princess Pine Road Jk`` ISvepair, Hyannis,MA.02601 To, . January 2, 2002 Re: Proposed Septi Request for Variances To Whom it May Concern, As owners of the property located at 15 Princess Pine Road,Hyannis, we wish to state that Mr. Edward L, Pesce,P.E. is authorized to represent us in all matters pertaining to a Request for Variances with the Barnstable Board of Health, for the proposed septic system repair on our property. Sincerely, Ke'th Selens Darlynne Selens PESCE ENGINEERING AND ASSOCIATES P.0 Box 321 Osterville, MA 02655 508-428-3730 January 28, 2002 TO: The Abutters of 15 Princess Pine Road, Assessor's Map # 269, Lot# 88 SUBJECT: Notification of a Request for Variances for the Repair of an Existing Septic System TO WHOM IT MAY CONCERN, In accordance with State Law; 310 CMR 15.00, Title 5, and the Town of Barnstable Health Regulations, you are hereby notified that a request for variance(s) has been filed with the Barnstable Board of Health by the owners of Lot # 88 as described above, regarding the subject house remodeling. Additional details follow: APPLICANTS: Keith and Darlynne Selens ADDRESS: 15 Princess Pine Road, Hyannis, MA PROJECT`LOCATION: a. .Same as above b. Assessor's Map# 269, Lot# 88 PROJECT DESCRIPTION: Application for an existing failed septic system to be repaired. The existing septic system will be repaired to Title 5 standards. APPLICANTS' AGENT: Edward L. Pesce, P.E., Pesce Engineering and Associates, Osterville, MA PUBLIC HEARING: Tuesday Evening, February 19, 2002, 7:00 PM at the Barnstable Town Hall Plans for this project and application describing the proposed activity are on file with the Board of Health. Sincerely, - E ward L'.+Pence;'P E �' COMPLETEi-ENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY COMPLETE THIS SECTION ON DELIVERY • ■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Dat of Ilivery ■ Complete items 1,2,and 3.Also complete A. R eived by(Please Print Clearly) B. Date of Delivery , item 4 if Restricted Delivery is desired. „. if 0 Print your name and address on the reverse - ■ Printitem 4ouRname and addreed ss on the reverse C. Si nature y so that we can return the card to you. _ C. Sign re ❑Agent so that we can return the card to you. ■ Attach this card to the back of the mailpiece, X ❑Addressee ■ Attach this card to the back of the mailpiece, X ❑Agent or on the front if space permits. Addressee or on the front if space permits. D. Is delivery address different from item 1? ❑Yes D. I delivery address different from item 1 Yes I. Article Addressed to: If YES,enter delivery address below: ❑ No 1. Article Addressed to: ry I YES,enter delivery address below: ❑No Kgvpj kprt�45�F �/� �y��,y ` 3. Service Type i F��6t! Wa L� 3. Service Type �® PPK �5 i r� Certified Mail ❑ Express Mail /V�/� sP� ( ❑Certified Mail ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ��y�fn N d S/ " ' ' tt� /} 9 P ❑Registered ❑Return Receipt for Merchandise / e60� ❑Insured Mail ❑C.O.D. ❑Insured Mail ❑C.O.D. (��OG� 4. Restricted Delivery?(Extra Fee) ❑Yes 4. Restricted Delivery?(Extra Fee) ❑Yes ?. Article Num r(Copy from service label) — yy�� -• /j�/�j Q') ) • 2. Article Number(cop) 7001 1140 0003 5339 519 0 Ce IS Form 3811,July 1999 Domestic Return Receipt 102595-99-M-1789 PS Form 3811,July 1999 Domestic Return Receipt 102595-99-M-1789 + --� • M _ SENDER: COMPLETE • COMPLETE •N COMPLETE THIS SECTIONON ' ■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. f livery ■ Complete items 1,2,`and 3:Also complete A. Received by(Please Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse C.Signature ■ Print your naFne C. Sign u and address on the reverse so that we can return the card to you. ❑Agent so that we can return the card to you. ■ Attach this card to the back of the mailpiece, X ❑addressee ■ Attach this card to the back of the mailpiece, X Agent or on the front if space permits. or on the front if space permits. .-•^ ❑Addressee D. Is delivery add different from Rem 17 ❑Yes Is d livery a'dress different from Rem 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No 1. Article Addressed to: If YES,enter delivery address below: ❑No e°`CCA��' 7qYti n-e L,®vn loao^o c ejrSQy 3. Service Type 3. Service Type 1�y4 h rt I;S f /r W ®o 60 ❑Certified Mail ❑Express Mail a Q ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise Ik/Gf 5( �V r ®� ❑Insured Mail ❑C.O.D. ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Articl'' `^•'^^^••F..,..,"^"ra lahell 2. Arti, 7001 1140 0003 5339 5206 7001 1140 0003 5339 . 515.2 . t !I i. 102595-99-M-1789 {PS Form 3811;,July 1999 ;Domestic Return Receipt PS Form'3811,July 19.99 Domestic Return Receipt 102595-99-M-1789 + f 'COMPLETE SECTIONON DELIVERY` vti' ■ Complete,items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. ,f} ' ■ Print your name"and address on the reverse gn ure so thatwe can return the card to you. C. Agent ■ Attach this'card to the back of the mailpiece, ss or on the front if space permits. Is delivery address different fro�itl? ❑Yes `} 1. Article Addressed to: ❑ No �-If ,enter delivery address below: Da niY I Cu itF1 t Vy h 0� ds' e cl Wvq s.� aG�Ts.®� f U 3. Servi T pe � . 6. ii ie Mail ❑ Express Mail Slt 1$e� ered ❑ Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 'Pit 4. Restricted Delivery?(Extra Fee) ❑Yes W, 2. Article Numb � . tt ,l 73�1 1140 p0�3 5339 5169 PS Form'3811,July 1999 Domestic Return Receipt 102595-99-M-1789 y 4 } p, UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid LISPS Arl Permit No.G-10 �! ° Sender: Please print your name, address, and ZIP+4 in this box ° PESCE'ENGINEERING&ASSOCIA'TE`• P.O.Box 321 OsterVINe,MA 02655 a ySyia.,a Ti IIIlIiIIIIIlIIlitillli11llllllillllllllllllllllllll114IIliIIII SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION-ON DELIVERY SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Dat of D livery ■ Complete items 1,2,and 3.Also complete A. Re eived by(Please Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. item 4 if Restricted Delivery is desired. ■ Print your-name and address on the reverse ■ Print your name and address on the reverse so that we can return the card to you. C.Signature so that we can return the card to you. C. Sign re ■ Attach this card to the back of the mailpiece, X ❑Agent ■ Attach this card to the back of the mailpiece, X ❑Agent or on the front if space permits. ❑Addressee or on the front if space permits. Addressee D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: D. I delivery address different from item 1 Yes 1. Article Addressed to: If YES,enter delivery address below: ❑No I YES,enter delivery address below: ❑No �d pp� af:5:55 {�_,�y.➢, 3. Service Type 3. Service Type t+�/ e�"" 'Certified Mail ❑Express Mail `- 'y6.j4VI(,S /� .OXd t ❑Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Registered ❑Return Receipt for Merchandise 99 f0 N iV�� Xl6n ❑Insured Mail ❑C.O.D. i ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 4. Restricted Delivery?(Extra Fee) ❑Yes L Article Num r(Copy from service label) •2. Article Number(Copy, 7 0 01 1140 0003 5339 519 0 'S Form 3811,July 1999 Domestic Return 102595-99-M-17e9 Receipt PS Form 3811,July 1999 Domestic Return Receipt 102595-ss-M- os ' n — -- + iENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY 110" ■ Complete-itemS-1,2,and3.Also complete A. Received.by(Please Print Clearly)" B'. Date of Delive Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. t f D livery item 4 if Restricted Delivery is desired. item 4 if Restricted Delivery is desired. ■ Print your nafrid and address on the reverse Print your name and address on the reverse C. Signature C. Sign u �� so that we can return the card to you. � so that we can return the card to you. ,l/r'v _"' ❑Agent ■ Attach this card to the back of the mailpiece, X Agent ■ Attach this cardto the back of the mailpiece, X C ❑Addressee or on the front if space permits. ❑Addressee or on the front if space permits. Is livery a dress different from item 1? ❑Yes D. Is delivery add different from item 1? ❑Yes d 1. Article Addressed to: If YES,enter delivery address below: ❑No 1. Article Addressed to: If YES,enter delivery address below: ❑No 07'e RKf\ h&le 44, 3G 7 ��-}eaeus r^ra� aI,,� 3. Service Type J A^^ 3. Service Type 17�61 K Vl t S AAA- O a6®) ❑Certified Mail ❑Express Mail /yc�VN Yl S /°o• 00 601 ❑Certified Mail ❑Express Mail ( ❑ ❑Registered ❑Return Receipt for Merchandise Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 4. Restricted Delivery?(Extra Fee) ❑Yes yy , 2. ArtiCl-•�.."•....in,...,,s....,ooniinw label) 2. Arti 7o01 1140 13003 5339 5206 ' 7001 1140 0003 5339 ,5152 PS Form.3811,July 1999 Domestic Return Receipt to25s5-ss-M-nes PS Form 3811„July 1999 Domestic Return Receipt - to25ss-ss-M-nes j ' PESCEENGI�••J��EyE�I�bbN��G/I��&��ASSOCIATI ? , OstGMNG,MA 02656 10, r 7001 1140 0003,, 5339 5176 REP` Vol44 Ikt, E` IL I S t _ .�. j. Z � i_ _ -=.'tl .issssla :sJ�a �ifs�ls. +�.rasss�(sstl ;.s ,s'ftl,.is��a3�ls1. SENDER: • •N COMPLETE THIS SECTIONON DELIVERY 1i ■ Complete items 1,2,and 3.Also complete A. Received by(P/ease Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. ■-Print your name and address on the reverse Ott so that we can return the card to you. C. Signature ■ Attach this card to the back of the mailpiece, X ❑Agent or on the front if space permits. ❑Addressee Jo D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: If YES,enter delivery address below: ❑ No 3T 3 . P1 rle,rs wo 3. Service Type �[�e%v ''II ❑Certified Mail ❑ Express Mail s ' 7 n U� ( /' Y 1 y 0,;t6.o/ ❑ Registered ❑ Return Receipt for Merchandise , ❑ Insured Mail ❑C.O.D. ` 4. Restricted Delivery?(Extra Fee) ❑Yes. 2. Article Number(s 7001 1140. 0003 5339 - 5176 PS'Form 3811,JUIy 1,999{( y(f{{y Domestic Return Rece,p1 102595-99-M-1789 ri a(id5 ti!:i iYti tiFtt l; kf.Y 1 1 lit it YA IS P' VARIANCES REQ UESTED.- 1) SEPTIC TANK 3.5' FROM SIDELINE ROUTE' 28 (10' REQUIRED 310 CMR 15.211) y 2) LEACHING AREA 4:2' FROM FRONT LOT LINE AND 5.5' FROM SIDELINE (10' REQUIRED 310 CMR 15.211) LOCUS I?OAD PRINCESSSE -�, 3) LEACHING AREA 831 FROM WETLAND a PINE ROAD p �S7 — (100' REQUIRED PER BARN. PART Vlll, SEC.1. 00) � pf?l�CE � 17 - 100• 00 „ TOWN WATER LINE �r 6.17'50 LOCUS MAP ip ASSESSORS MAP- PR . OPOSED 5.5 \ - WATER LINE 4' PLAN REF 22825P 2 LAND SURVEYED BY: RELOCATION \.::;1 O 15o W/POLYETNYLE'NE o \:: \ Qd / ZONING. „RB„ SHEATH PIPING -- -:.- o-BOX VEL `'�' YANKEE SURVEY EXISTING CESSPOOLS I I o t- GRA VEwAY cfl 90 FLOOD ZONE.• "C" (To BE PUMPED & FILLED r DRI / o ` CONSULTANTS WITH SAND OR REMOVED) COMM. � � I _ _ _ f / . � 1, LOT 25000PA � (SUITE 0005 C INDUSTRY- - - 100 1 _ _ _-34.2 ____- ' / 88 — '9'2 MARSTONS MILLS, MA. 02648 ________ DATED. 8119185 GAS LINE TO REMAIN N 17 4 = ,5- �'j, I TEL 428-0055 ABOVE SEPTIC SYSTEM N HSE #1 FAX 420-5553 3.5' - o =-_ 34 2 - / / PROPOSED SEPTIC SYSTEM REPAIR BENCHMARK 0 0, J DECK 15 PRINCESS PINE ROAD TOP OF FND �pROP SED / OFELEV. = 100. 0' , 1500 CAL / IPAW, HYANNIS, MASS. A. 0 SEPT TANK APPLICANTS.- / 240. s KEITH AND DARL YNNE SELENS LOT l l / i p� 15 PRINCESS PINE ROAD 94 0 / LOT 93 /AREA =7 12,281fS/� ��E� '85 PE-SCE ENGINEERING & ASSOCIA TES \ ��`tH of ,� ^ P. O. 80X 321 o� ti ., OSTER VIL L E, MA. 02655 �0 0� , ,ail,:. E PESCEWARDL �'',' 10 PH. (508)428-3730 �E I 5.00 CIVIL H 0s / i No.32001 B A�,f �► ERA SCALE. 1 "=20 DA TE.• 12 21 01 76*3920 N LOT 98 1 REV.• I REV.• JOB NO. 5284 4 SHEE T 1 OF 2 719P OF fVUNDATION Y , EL =100.0(ASSUMED) F-- 10' MIN t, 2"LA YER OF 4' SCHEE6'40 P. V.C. f;. 1/8"-1/2" EL= 98.6' MIN. P/7rH 1/6 PER FT. i 314" 7V 1-1 2" WASHED STONE WASHED NE EL= 98.4' 4" CAST IRON PIPE EL.= 97 8' / / / ♦ ♦ / / / (OR EQUAL) MIN/NUM INVERT INVERT P/7t^H 1/4 PER FT EL.=95.5' ��L EL =95.1 CLEAN SAND FILL 9" 4 D/A SCH fDR 2' MIN FLOW LINE ♦0 PW P/PE EXIST/NC 1 10" INVERT N/N. 14" `F 0 0 o O O p O om o O 0 O om o 00 EL.=_97.B'-- IN " 24" o °' O O r1 dlo °o O O CPO °O Qy INVERT INVERT o o o B o 0 0 00 o� m o�00 93.1' k DISTRIBUTION 4.° 8.5, 2.o' 4.o BOX (T ) 27 0' PROPOSED 1,500 GAL. 2-500 GAL. DRY WELLS SEPTIC TANK (H-10) 1 BOTTOM OF TEST HOLE ELEV. = 87.9'_ j PROFILE OF SEWAGE DISPOSAL SYSTEM NOT TO SCALE S R VATION HOLE I ELEV.= 98.9_ TE Z__ MIN./ INCH A T _0 INCHES PERCOLATIONRA' EL= 98 9 EPTH HORIZ i TEXTURE COLOR MO TT. OTHER 314" TO 1-112" 2" LJ YER OF EL= 9715 0-21" 7VPSOIL & FILL ' WASHED S71�NE 1/8" — 1/2 WASHED S71�NE EL= 96.82 21"-25' A f.OAMY SAND EL= 95.l5 25"-45 B LOAMY SAND 10Y6/8 2OXCRA VE EL= 87 9 45"-132 C MEDIUM SAND 2.5Y7/6 PER GENERAL NOTES 4'-� 4.8' ' 4' NO GROUNDWATER ENCOUNTERED PERC TEST PERFORMED 9 67" DEPTH I2.B'DRY WELL 1) ALL WORKMANSHIP AND MA TERIALS SHALL CONFORM TO D.E.P. j, TITLE 5 AND THE TOWN OF BAR_NSTA_B_LE___ RULES AND BARNSTABLE PERC TEST # P10,690 END VIEW REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. 2) ONE COVER ON SEPTIC TANK SHALL BE BRO UCHT TO WITHIN 6- OF FINISHED GRADE, OTHERS WITHIN 12" DATE OF S 0 I L r TEST 1010512001 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITNESSED BY:' DA VID STANTON - B. O.H. WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN SOIL TEST DONE BY EDWARD PESCE, P E. DESIGN CALCULATIONS. 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10 FT OF DRIVES OR PARKING AREAS. 4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL NUMBER OF BEDROOMS . . . . . . . . 3 BE MORTERED IN PLACE. CARBACE DISPOSAL . . . . . . . . . NO 5 NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH s 71�TAL ESCALATED FLOW 330 _CA LIDAY ) ( _119 _CAL/BR/DAY x _3_ BR) I DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO USE 1500 CAL SEPTIC TANK 1500 CAL OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VA TION CONTRACTOR INSTALL- 2- 500 CAL DRY WELLS ( WITH 4' CRUSHED STONE) IS TO CALL TIC- SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS SOIL CLASSIFICATION . . . . . . . . 1 PRIOR TO COMMENCING WORK ON SITE. ' DESIGN PERCOLATION RATE . . . . . < 5 MIN/IN. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS EFFLUENT LOADING RATE . . . . . . . 74 CAL/DAY/S.F. SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. 1 7VTAL LEACHING CAPACITY 373.55 GAL/DAY i 8) PARCEL IS IN FLOOD ZONE___C_" __ S/DEWALL• (27' f 12.e) X 2' X 2 SIDES)( 74)=117 B! CAL/DAY 9) LOT IS SHOWN ON ASSESSORS MAP _269 AS PARCEL _ B8 . BO77VM.- (27' X 12.B)(74)=255.74 GAL/DAY 10) NO WATER SUPPLY WELL EXISTS WITHIN 150' OF SAS 52844 SHEET 2 OF 2 JOB NUMBER——_____—