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0060 QUAIL LANE - Health
60 QUAIL LANE Hyannis A = 288 - 218 If e J ; 041 P nx Commonwealth of Mass.achusetts Y r Subsurface Sewage Disposal System Form Not for Voluntary Assessments o- 60 QUbil Ln Property Address - Kathleen'Vivona Owner —____..._.. ..........,..._ ---.�____.. .. _.................... _ Owner's Name information is anniS ort Ma 02647 10/9/2013 required for every -� _ _..__._.. _._..._-_ _. S _....... ...:. m ..._.__ _. ....... ...... page. . CitylTown State Zip Code: Date of Inspection Inspection.results:must be submitted on thi%for . Inspection forms may hot fae'aIN d In s. way. Please see completeness checklist at the.end of the form. important:When filling out formsGlen� ' �CEf � a to . on the computer;. use only the tab key to move your InSpectClr: cursor-do not Sean M Jones I �I-;L. . . ... useahe return --• - _ _ ......... ....__ ._ -..._ .__.__.___. _ Name of Inspector Capewide Enterprises_ ,_. _ __._ _. .............. ._. _ Company Name 183 Commercial St. Mashpee Ma 02649 ty -._.__. _ ........---- --. P ... Ci (Town State Zip Code 508-477--8877 S14522 - Telephone Number License Number ., B.Zerfification I certify that l have personally inspected the sewage disposal system atthis address an0that'the information reported.below is true; accurate and complete;as of the time of the inspection The inspection has performed based on m,y-training and experience in the proper function antl maintenance of on.site sewage disposal systems. I'ai¢t.a CEP approved systa?ra%inspector pu�syant 10150 Section 9 34U.:o# Title.6(U CAR 15.OQE}�. The.system: ®Passes ❑ Conditionally Passes ❑ :Fails ❑ Bleeds Further Evaluation by the Local Approving Authority �~- - 10/9I20'13 Inspector's Signature Date The system inspector shall submit a copy of-this inspection reportto the Appfoving Authority (Board of Wealth or DEP) within 30 days of completing this inspection: If the system is a>shafed;system' or has.a design.flow of 10,000 gpd or greater,;the inspector-and the system owner`shall submitthe report to the appropriate regional offiice of the,DEP. The original should be;;sent to ttie system'owner and:copies;sent to the buyer, if applicable,:and the approving authority. * **'this report only describes c€h(litioias at the timd i f inspection and uhder th"e cptnditions oif rise: at that time.This inspection dales not address heir the systernwill.pe:s�orrri in the€�iture aande�: ,. the same or different conditions of use. eDAI-V 13 t5ins•3113 Title 5 Official Inspection Form:S ur# Sexage Disposal.System-.Page 1 of 1"r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M10 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is H annis ort Ma 02647 10/9/2013 required for every y p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete al,l of Section D A) 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: The dwelling located at 60 Quail Ln Hyannisport is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a precast leach pit. The system was fou d to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section Kneed to be replaced or repaired. The system, upon completion of the replacement or repair,las 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): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disp I sal System•Page 2 of.17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every Hy p annis ort Ma 02647 10/9/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): I 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(l)(b)that the system is not functioning in a manner which will protect public health, safety.and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M SV6`' 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is p required for every y H annis ort Ma 02647 10/9/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". - Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 60 Quail Ln M Property Address Kathleen Vivona Owner Owner's Name information is required for every Hy p annis ort Ma 02647 10/9/2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT duei to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground)water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private 'water supply well. ❑ ® Any portion of a cesspool or privy is less than 1'00 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Displosal System-Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is p required for every y H annis ort Ma 02647 10/9/2013 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Quail Ln M Property Address Kathleen Vivona Owner Owner's Name information is required for every Hy p annis ort Ma 02647 10/9/2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2012 — 15,900 cu. Ft. ; 2013—40,500 cu. Ft. Sump pump? ❑ Yes ® No Last date of occupancy: vacant 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface'Sewage Disposal System Form - Not for Voluntary Assessments GSM 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every HY P annis ort Ma 02647 10/9/2013 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): 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: 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): i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every Hy p annis ort Ma 02647 10/9/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: original system 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every HY p annis ort Ma 02647 10/9/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 3" Scum thickness 31' Distance from top of scum to top of outlet tee or baffle 61' Distance from bottom of scum to bottom of outlet tee or baffle 101, How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every HY p annis ort Ma 02647 10/9/2013 _ 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.): 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 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every Hy p annis ort Ma 02647 10/9/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0,1 Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every Hy p annis ort Ma 02647 10/9/2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number'. 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leach pit was found to be dry at the time of inspection with a stain line 1'from the iinlet invert. 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every Hy p annis ort Ma 02647 10/9/2013 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts pp Tit I e 5 ,0 ff ic Owl Inspection Form I :::. i' - Subsurface Sewage Disposal System Form Not for Voluntary Assessments. 60 Quail Ln ............ ......... ........ ......... .. ............. .... Property Address Kathleen Vivona Owner --- - Owners Name _ information is H :annisport a 02647 10921fegirad for . ....... __�..3 .....state Zip Cpage City/Town ode Date:of nspection• _._. System. Infor af! n (cant) 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 bta lding. Check one of the boxes beI' hand-sketch in the area below ❑::dravuing attached separately �F . ... . .. ....- .... .. . ..... b r 25 `I. A. Z 4 Z7` _ A'3 39 3 ` 3Z A-4- qq t5ins.3113 Title 5 Official Inspection Porn:Subsurface.5ewag9.Disposal,System•Page,15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is required for every Hy p annis ort Ma 02647 10/9/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water.elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators; installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dispcsal System•Page 16 of 17 Commonwealth of Massachusetts Title -5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 60 Quail Ln Property Address Kathleen Vivona Owner Owner's Name information is p required for every y H annis ort Ma 02647 10/9/2013 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:,Subsurface Sewage Disposal System•Page 17 of 17 L _- f Town of Bllrnstable r# Department of Regulatory Services �Ae� • Public Health Division Date0110 MAM a'679-A`�� ;� 200 Main Street,Hyannis MA 026 Y Date Scheduled Time':, Fee Prl, --� Soil Suitabilio Assessment for Sewa Lisp®sal Performed By: NIGhAp�� P(ti{Yl r,k.l. ET CS Witnessed By: rry ` LOCATION& GEN1ERAL INFORMATION Location Address Owner's Name Le1tuS Address 9 R00GZ P_a X-f W °k -: (nT P Assessor's Map/Parcel: 1�q 7,;Z/693 Engineer's Name 4�e�v��� E4-j � Is es (—LC NEW CONSTRUCTION X REPAIR Telephone# 2�—4 Z 2 Z 77TG Ev!rj trlee�tn� Land Use SCOTk.fQmi(X Jkel( terve Slopes(go) �` Z Surface Stones j 66-273-0 37 7 vockn} tat (eztsl rh5 Distances from: Open Water Body — ft Possible Wet Area ft Drinking Water Well ___:_ft Drainage Way — ft Property Line 7 i0 ft Other ft SIMTCFI:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) see.. ak�,6�ecl �1Q.n e.t.a :p. w� .. t= � rn Parent material(geologic) � �SY, Depth to Bedrock, ^ Depth to Groundwater. Standing Water in Hole: _ Weeping from Plt F!tce t , Estimated Seasonal High Groundwater DE'I'ERAIIlVATION FOR SI+ASONALMIGH WATER TABLE Method Used: DtfeC'l 00Ser0atfan Depth Observed standing in obs.hole: i 2 In. Depth to soil mottles: Depth to weeping from side of obs,hole: _111, Groundwater Adjustment _ fr. Index Well# Reading Date: Ldex\'fell level Adj.factor�® Adj.Groundwater Level I EI RCOLATION TEST Data la-b l3 Time Observation Hole# Tinto at 9" Depth of Pere +I y 4 y©'r�8 rl Time at 6" Start Pre-soak Time @ 9-Y5 PH 5'd 8 PH Time(9"-6") End Pre-soak �! 55-Q M Rate Miil./luch Z L 2. Site Suitability Assessment: Site Passed 7�f S Site Failed: Additional Tesdng Needed(YIN) N Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\S EPTICIPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# t +Z Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. • onsigtency,46 oravel) Dry ' r�>t �s /l� Yr3/2, _31 G 1 IS,• 2 5 '-4 `. 5 io°l 5 ��� lase. DEEP OBSERVATION HOLE LOG Hole# 3 + Depth from Soil Horizon Soil Texture Soil Color Soil ,Other Surface(in.) ',a (USDA) (Munsell) Mottling- (Structure,Stones,Boulders. Consistency,% ravel /UYrJ14 y0 l26 G N S 2..5 DEEP OBSERVATION HOLE LOG hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other ' Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,9n Gravel) r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, Consistency. a Flood Insurance Date Map: Above 500 year.flood boundary No_ Yes Within 500 year boundary No'� Yes Within 100 year flood boundary No:✓ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on 16,27-1 1`� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise de er ence described in)10 CNM 15.017. Signature ` Date QASEPT'IC\PERCPORM.DOC No. q0 2— / Bo Fee ( I / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l.J PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppliCAtion for �Dfigp al *p$tem Cotv5trUCtion Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No.k QvA ,(_,ij Owner's Name,Address,and Tel.No. HYA001 S J d t-!U ()1 W.U126 v1 S a Assessor's Map/parcel z S 3lo l �`CbQ���5To" Cr -R)a(S 0-1 L&4 Installer's Name,Address,and Tel.No. 502-471-9 8 71 Designer's Name,Address and Tel.No. d AVr�DE eVREX- �s� � l A 150 r S P&7r- Type of Building: qq�� DwellingNo.of Bedrooms /"A Lot Size 3 3 k 01'1 =' sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures y� Design Flow(min.required) A)n-- gpd Design flow provided A � gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) f2>1:P64(i1E 6OTLAET 78E� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date D " 16 - ao l3 Application Approved by Date Application Disapproved Date for the following reasons Permit No. 001-5— Date Issued /6 16 ;.Vi No. 20(F2L(0 2. ' / Fee (� . 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Tigpogal &- pgtem Congtruction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ('Individual Components Location Address or Lot No. 100 Q VA(`4,4 Owner's Name,Address,and Tel.No. �O 14 U O'RO uRk Assessor's Map/Parcel a a �������` ' "" 7(oy 5`fb'Qp/lam 5TLCrS / � �'U�tS D LCC a So T7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �AaF.3c�D6 G~R�'.P•QCS�'$ C-(.rC. �y /A [So �4t, SZ 94NE& ` Type of Building: A) Pc No.of Bedrooms /" Lot Size „ S 336 Q� sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) • Other Fixtures t � Design Flow(min.required) N19- gpd Design flow provided A)I gpd Plan Date Number of sheets Revision Date ��- Title - r' Size of Septic Tank Type of S.A.S. ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) R21E 44( O(TtLAFT 'T"Ez;r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date —I a � �t`7 - a01, N - •--Application,Approved by _a Date 4 / .•Application Disapproved Date for the'following reasons Permit No. �(?j- y02211 Date Issued o 16 ?-0, --------------,__ ---- F THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site SewageYDisposal System Constructed ( ) Repaired ( Upgraded ( ) ' Abandoned( )by IdAPIEWID6 ej,>TE34MIZ� f at (o0 a VA u- L.Aoe ky k,�)0 g t>c t has been constructed in accordance with the provisions of Title 5 and the fcr-Disposal,System Construction-ermit No. "703- 4"- _ dated 6 ( � Installer CAaQytD� E � AQ1�£ LCDesi Designer r17 3 . 14 #bedrooms /Vh ;x_` Approved design flow /l/i'4 gpd The issuance of his p rmit shall not be construed as a guarantee that the system will func i as desi ed. Date �o I"?// Inspector �! 7 No. Zo 3 q O FeeAs /W w THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 1=i5poga[ ,*pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair (�) Upgrade ( ) Abandon ( ) ,System located at LAor— 14yAL)05?o?--T— and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. e Provided: Construction must be completed within three years of the date of this Date Z O I t& z7—1-3 Approved by 1' �T L -C&.T 1 ;E PERMIT M 0. �.S U Q��� '�• Q �.�-- - �GC 'fir����4 T .-VILLAGE ------------ ---._ . -_1I�1 ST..L1 L-ER�5_IJ�,tJIE_�_AD.DRE_S.S LD .R_5Q- _A E UI_ ME_ D_D-R SS 13 E � -- - �1► � i ►� a , ` 4 \ � � � l � '1 i .---- THE COMMONWEALTH OF MASSACHUSETTS ROAD® HEA TH .. .-- _.OF........:............................ _. ............. -- .................. AVV ira iou -for UhiVvii l Worku Tong#rurtion Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ; 111 - ---------------- ............4..jle�—---------------------......................... L ; o t' Addre o L t o. caner 1 J Address .......W1 ...................................................... Installer 'Address Q Type of Building Size Lot...., f ..j/.�.._._Sq. feet U Dwelling'VNo. of Bedrooms..--_----.&-_ __________ __ ________Expansion Attic ( ) Garbage Grinder {--�- P4 Other—Type of Building ----8414 a.._.-.____ No. of persons...._ ................. ewers (-,� — Cafeteria (y— �' Other fixtures -------%? ,Wt l �.��t_.......__f�'� ) W Design Flow.................................. per person per day. Total daily flow-----------��-_______--.-.-----.-gallons. x Disposal Trench i tNo capacity/At- dtl1ns -, Lent 0below yl Length Width____--- Total leaching area.--�epth................ W Septicqg` g P j � g g� -------- ------sq. ft. Seepage Pit No..__--:_-/_____-___ Diameter.. .....t1....��`'P3e inlet_.,, ........... Total leaching area------------------sq. ft. Z Other Distribution box (✓) Dosing tank ( ) Ah v /04 Ah — to — l,S---ZS' aPercolation Test Results Performed by--------------------------------------•-----------------•---------------- Date.......................... -----------.. Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-..____....._..___. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------- -------------------------------------------------------------------••--------------.----- . ---------------------------- --------....----•-----•••---- -------- 0 Description of Soil------------ ----3�. -------- x `,i -' 4 s i j �-. _ _ i____�__ _i__-_I-----. ------ W UNature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------.----------------- - . Agreement: The undersigned agrees to, install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee Wb boadoalth. Signed... . C:_ 9�►►�4.4%�_yn_ � e Application Approved By----------------------- Date Application Disapproved for the following reasons-------------------•-•-•------...-----•------•------------------------•-•----------------....--------•-----_..... --------------------------------------------------------------------------------•--•------•--....-----•-----------•-------------•---------•-----------------------------------...------•--•-•--- Q ^ ^ 6� _ 7 J-,,Date PermitNo......................................................... Issued...................... ................................. Date Flea../4. ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ? .. -- .OF.......... ...... Applirtttion -for Uttipmat Workii Towitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --------•---•` ugh Ia .�...Y-----• ±.. "/- --------------------•--.._..----------- Lofa,rti�n-Address ,/ or�L/ot No. ----------1'/-- /30';[_f G /a S'.!�tY _.Ird!�...�lr? .�'� t"�-----� ( _______ ____ -------- ---- E wner j Address . Installer Address Q Type of Building Size ------Sq. feet U Dwelling VNo. of Bedrooms_----__-._ ___-Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---Cs4 .°._�'____------- No. of persons-------f2................. Showers (2) — Cafeteria ( ) p' Other fixtures _.._._,j-- W Design Flow-------J.�?...........................gallons per person per day. Total daily flow---------- ----------------------.gallons. 1:4 Septic Tank—Liquid capacity------0----gallons Length................ Width---------....... Diameter___--__.-.._____ Depth--------------- xDisposal Trench—No_ ____________________ Width___.___________._ .. Two I Length-.-----__--___-____ Total leaching area--------------------sq. ft. Seepage Pit No---_---------------- Diameter.._._....__._.�� Vth below inlet.................... Total leaching area___----.-_-_______sq. ft. z Other Distribution box ( ) Dosing tank ( ) Ah, lo!_ JOz Percolation Test Results Performed by-------- ---•--•---•----------------••••••...........----•----•-•-••-•---- Date--------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.._._--------.--____..._ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.--_-____-_-•___-•-• Depth to ground water--.---_-_______---_--._. P4 ----------------------�-----_•--------------�---�----r-----y--r•�1:' r DDescription of Soil--------- ------------------- ------V .. -- _ , W ---------------------I---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable..---------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ue by the board ofAiealth. Signed.. .. -- .: _orgy �� ..�L . . ._ / Da£e ApplicationApproved By-------------------------------------------------------------------------------------------------- ........................-----------•---- Date Application Disapproved for the following reasons:-------•--•---------------------------•-•-------........--------•-•---...---------•••............-•.....•----_.. --...•-•-•-------•--•--•--•-•---•------------•---•--------------------------•---•-------------•--------------------_.._...•-•--•----•------------...-- ........................................... Date Permit No......................................................... 2 ,d 7 J� Issued. ---- -- - --- --- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Jl-y/1:;.............OF......... �.0rf� „-4.................... 0.1rrtifirtttr of 0,11mpliatta f THIS O ER",IFY, That the Individual Sewage Disposal System constructed (�"or Repaired ( ) Installer �/ ,. / has been installed in accordance with the provisions of Article I of TKe State anitary Code as described in the application for Disposal Works Construction Permit No._____r_�. ..................... dated..... .':_�_1_-_.7_.,�_-............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. y DATE ---•---•----------------------------------------------------------•-•-•_.. Inspector..../......:...X......................... =....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 0iF HEAL� of �t,�/'�............ -. �, ....:'... No....a_07t...... . T FEE... .. lfzr Tomitrurtion rrrmit Permission is hereby granted-----•--• ••••-••-----....._...--•--•••-•••--•---•-----------------••••--•----••.....-•---•......----•-•-••-=...--•--- to Construe('or Repa�r)( ) an Ludivid,dal Sewage DI oral System at Street as shown on the application for Disposal Works Construction Pernu No._______.'.._...... Dated.7'_��.............................. .PP P � tj �i��/ / Cl Board of- ealth DATE.... ....................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 'I,xg � `4 fN t) r - .. p �� o fS1'�`N� 60� oe � R ' ttED PLOT PL -AN S �O.e7T lof.q S.S. .01C Art ON: �. ► L DATE 7/8�75 k ff E E'E -R C-N C` It: ASE/N .Lo'T zS �9S S;Hoct/� LY, t 5 D' AT. E [ iffR -13Y CE_"R, TIFY� THAT ' THE S.UI__L'DING' REG l AN :D SURVEYOR_ ' SFFOW"Ia: HGS:' -PLAN I- S- LOC AT,ED;: 0 N rtHE' G -ROUND AS 5 WOWN HEREON AND 'Cfi IT G�o. S CpNFORM`. TO THE flFMgs� _BONIN G BY -L:AWtS Of._ TWE T0W-N OF o� qcy ,� • �,/SAB G : H E N C O N S T R U C.T:E D ctQ�cEy T B L E 5 ULL`R V:E Y C 0 PiL S U T A f� T S. IV.0 ti s7 4 WE S T .`FAR. O tJ T N tut ASS S �� _ -" - - r .