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HomeMy WebLinkAbout0018 QUAKER ROAD - Health 18 Quaker Road lyarinis' A= 310-000-002 I t Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r _ 18 Quaker Road Property Address Ron Bourgeous , Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 F 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. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information CS l's 3 on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S114324 - --- Telephone Number License Number t f B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 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 Dan Hawkins Y Digilally signed by Dan Hawkins %'Date:2021.04.2208:20:26-04•00' 4-16-2021 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 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts »:- _- p h= Title 5 Official Inspection Form - J Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is required for every Hyannis Ma 02601 4-16-2021 page. City/Town 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: ■❑ 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: The system was in working order at the time of inspection. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is required for every Hyannis Ma 02601 4-16-2021 page. City/Town 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. i ❑ 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 3) 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. 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: l5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts - -_=r Title 5 Official Inspection Form �- - s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y 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.00c•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ O Static liquid level in the distribution box above outlet invert due to an,overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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. ❑ El 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 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. I ❑ El 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. 'i l 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 ❑ El Area 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.726/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts .................................. - Title 5 Official Inspection Form j- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y page. City/Town 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 El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? E ❑ 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? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? ❑ ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ 0 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 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.726r2018 Tifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts v Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 7 7 Number of bedrooms(design): Number of bedrooms(actual): 772/GPD DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 9 Number of current residents: 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 0 No Seasonaluse? ❑ Yes No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2020- 140,624gallons 2019- 201,960gallons Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA 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: Owner- last pumped 3/21 Was system pumped as part of the inspection? ❑ Yes X No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.726I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts d rp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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: New SAS added to existing leaching in 2019 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑cast iron ■❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.728f M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of^8 Commonwealth of Massachusetts Title 5 Official Inspection Form f" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 21 Depth below grade: feet Material of construction: ■❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 2 Dimensions: 000gallons 311 Sludge depth: 3511 Distance from top of sludge to bottom of outlet tee or baffle On Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �6 r Title 5 Official Inspection Form .J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c � 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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: NA Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 cf 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is required for every Hyannis Ma 02601 4-16-2021 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): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c ; 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is required for every Hyannis Ma 02601 4-16-2021 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.): NA * 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: Type: ❑ leaching pits number: (6)500 gallon chambers 0 leaching chambers number: ❑ leaching galleries number: ❑ 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 j- ....... Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road v Property Address Ron Bourgeous Owner Owner's Name information is H annis Ma 02601 4-16-2021 required for every y page. City/Town 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.): The SAS was in working order at the time of inspection. Leaching had 2" of standing water when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): i5insp.doc-rev.726/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts R9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Offical Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �/� 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y 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 TEX COMMONWEALTH 0F'r4ASSACFICJSET 5 F 'PUBLIC=>3EALTH DLVSIQTx-�tA1ZNSTABL'E,.MASSACHUBk 7 TS �topoo,ALOPetem Consttuuxan berm{t bPennisaion se hereby�gtantad to Construct(-:,) ,.R.opair C✓f„§ UPgrxte( ) a Abandon( ) System located ate G`i.>, "l+t r� 71;,�. 5 'and tw destinbed itt the atwve Apr 7loaxlon for Thsgosal gystem Constnxctton Ye ;it. The appl7cant racog,126d wslltat d •Title 5 aqd:the 1o71owiiig.loca7 prouisions or special oondahons '� FIY wifh m �t7ovidad Construction m be c,vmgjoted within three year;o€the date ofthis pa It fl/1 s 7}ate : e n. „ ApProvedfhy �, : TOWX QF BARNSiY BLE .vLOCA' fAN fj'$'.:t'�;.32�t•C.�� Qs� SEWAC3E#_201�1 �C?'2a I.,�� r i `INSTALLER S NA HONE � 'LEAClt`644I'FACILITY e cr x�s (tYP) s t 1 - � 4 PER M[T tJATE / 1 c t o CC)WLIANC.E.DATE j ►+l 1 el ep:Saratio n 1)iatanee Betwcert the : Y e :Iviewmum Adjusted fiiotmdwater.Table to th m6 Bdtto of"aclung Faolljty Feet a s 1)rlvate 1Vater Supply VobL land Leac7ing Fac71 ty(If ata}y watts oxrsC vn a' sttb or.viithln 200 Feet of lesah ng fhciltry) a WeiIarid Sind Leaching Foc3lity(It any watlnnds eitlst wlt}dlt" Fo6t `�'` � a {360 foot flcacblirg facility); : i { i,'URA1IS)1}'3b y Y a , A Ciz '!Q a z { u , x R CA RY k A 1 g r Y g,. r "'k } t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y page. City/Town 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: No GW @ 126" feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record 1/13/2019 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Ron Bourgeous Owner Owner's Name information is Hyannis Ma 02601 4-16-2021 required for every y 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 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 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 t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATION $ Quo W_, - Rg SEWAGE# ZOIq - 02q VILLAGE Jg4cxo fN% S ASSESSOR'S MAP&PARCEL;S10 9-OZ INSTALLER'S NAME&PHONE NO. B Q 9 X Ca y oA i n gx 14')*)- 01,53 SEPTIC TANK CAPACITY 2D00 qa.0 LEACHING FACILITY:(type)* SO_ Oq X) Llc G) (size) 13 X 59 X 2- NO.OF BEDROOMS OWNER ROnalot Bog.2i-q co',S PERMIT DATE: 0-lS^19 COMPLIANCE DATE: 9- 9 - 19 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 Al-3°�� 131 Az,36 62 ' REAR _ A 133.se ,q B. N S4'L " 8� sq 3 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftPliLation for RisposAY 6pstent Construction Permit z Application for a Permit to Construct( ) Repair(✓j Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. I g Qua KL l' Rod qa nn i S Owner's Name,Address,and Tel.No.Po„ 4(30ur9 co i S Assessor's Map/Parcel 31 O-00 O Q-,)_ 1 S Q)c,_JZc r RAC d y 0.^^'J S Installer's Name,Address,and Tel.No.,B i-0 CAC X%Jc 1 o e\ Designer's Name,Address,and Tel.No,,�vr_ F j0.kc.rALJ Iq -rcaScrry to- Foresi da.lc y917- pZ,53 ?.o•,Sox 331 -q.ty _99q- 11LG Type of Building: Dwelling No.of Bedrooms 77 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 72770 gpd Design flow provided `7 2 gpd Plan Date ► Number of sheets Revision Date -1 • 1 Q Title Size of Septic Tank ZOOO Type of S.A.S. ,5'00 dc3.) L�L Description of Soil Nature of Repairs or Alterations(Answer when applicable) 20 BOX- 500 QQ1 L) C �L> Rate 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. , Si Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued No. CJ ..i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS applitatiou 1pir,oposal *pstrm Congtruttiou Permit Application for a Permit to Construct( ) Repair(,�Upgrade( ) _ "(� ) ❑ p y ❑ p t�ban�om Complete System Individual Components Location Address or Lot No. jg Q,.3.Kt p- 19a( (5wnett s Name,Address,and Tel.No.�on burg Assessor's Map/Parcel ,0_ o Q Installer's Name,Address,and Tel.No.$g EXCa Uo�-�i o ADesigner's Name,Address,and Tel.No Iq ?c-AScrmi to. Forc51 do.lc L49'7• pG.53 Qo..00x 331 �larLj,c�, 1`ty -99`�- IOLG Type of Building: Dwelling No.of Bedrooms r7 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 7W n gpd Design flow provided !I 'Z gpd Plan Date -R- Number of sheets Revision Date ! . � Title Size of Septic Tank -7 nC)C? Type of S.A.S. L Description of Soil Nature of Repairs or Alterations(Answer when applicable) 7_t7X - ;� ��� ►o_ /l Date last inspected: greement: 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. Si a Date r Application Approved by Date Application Disapproved by -- Date for the following reasons Permit No.�Q Date Issued 1 -------------------------------------------------------------------------------------------------------------------------- ------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by (-�.o A�, —V C , .�;s, At�{R� r ( J has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoW 4 " dated Installer ^mot^A,,-,x, Designer_ 113 P�r! 4 , #bedrooms '"� Approved design flow_ 2 gpd The issuance of this permit shall not be construed as a guarantee that the system will fun 'o ig ed. Date ) )7 /- Inspector, i ---------------------------------------- -------------------------------------------------- v d Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(vol Upgrade( ) Abandon( ) System located at. J R and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions.or special conditions. Provided:Construction must be c mpleted within three years of the date of this pe irtfi t. ^ Date 1 Approved by P � Town of Barnstable r a f 7 7 Department of Inspectional Services r NAM Public Health Division Date ZI q 1619. 200 Main Sheet,Hyannis MA 02601 Office: 509862-46" Date Scheduled � Time Fee Pd. Soil Suitability Assessment for age Disposal Performed By:. Witnessed By: 4,41 I8` LOCATION&GENERAL INFORMATION Location Address QV (i_ „ ,/J Owner's Name Address Z / l o!dn4 3 .Assessor's Map/Parcel: �l�/n�Z Engineer P Z A" 's Name 7 !A Engineer's Emai• NEW CONSTRUCTION REPAIR Telephone# Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Are It Drinking Water Well ft Drainage Way It Property Use ft Other It SKETCH:(Stint name,dimensions of lot,exact locations of tst holes&pen tests,loeatewetlands in proximity to holes) Parent material(geologic) `'U—'" v v'"''" '' Depth to Bedrock 'V Depth to Gmandwater.Standing Water in Hole: k & Weeping from Pit Fax _ Fstinmted Seasonal High Groundwater 4: DETERMINATION FOR SEASONAL:HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole. in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in Groundwater Adjustment R Index Well 0 ReadingD>ate: index Well level Adj.factor Adj.Groundwater level PERCOLATION TEST Date 11819 M. 94— Observation Hole# � Time at 9" ' Depth of Pcm Time at r Start Pre-soak Time® J V Time(9"f") End Pre-soak Rate MinAnch G Site Suitability Assessment: Site Passed V11, Sile Failed: Additional.Testing Needed(YAK Original: Public Health Division Observation Hole Data To Be Completed on Back ***If percolation test is to be conducted within.1001 of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:WppGcadon ForneAPERCFORM 20I&doc DEEP OBSERVATION HOLE LOG Hole# Depth From Sol Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenev.%Gravel) low'?I, L-S DEEP OBSERVATION HOLE LOG- Hole# Depth from Soil Horizon Soil Texture Sol Color Soil Other Surface(in.) (USDA) (Munscll) Mottling (Saucume,Storm,Boulder. Consistenev.%Gravel Al Ili- C-5. ` DEEP OBSERVATION HOLE LOG Hole# Depth from Sol Horizon Sol Texture Sol Color Soil other Surface(in.) (USDA) (Murreli) Mottling (Structure,Stones,Boulder. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from. Sol Horizon Soil Texture Soil Color Soil Other Surface(im) (USDA) (MunseIO Mottling (Structure,Stones,Boulder. Consistency.%Gravel) Hood Insurance Rate Maw Above 500 year flood boundary No-4 Yes r Within500yearboundary No_ ..Yes Within 100 year flood boundary No'*— Yes F Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring rvio material exist.in allareas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurrin pervious material? Certification r y I certify that on 1 I, Q7i(date)I have passed the soil evaluator examination approved by the Department of Environmental Prot 'on d that the above analysis was performed by me co sistent with the required training, expertise and experience scnbed in 310 MR .Old: 9 ' Signature. Date QAApplication FormsWEkCIFORM 2016.doc I S y �IZ, ' (� nil r— Town of Barnstable ��oF1H l°wti Regulatory Services Thomas F. Geiler, Director B"NSrescs. _ Public Health Division' Thomas McKean, Director AlfD MAC 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 ' ° Fax: 508-790-6304 Date: "Ta211,, 19 Sewage Permit# �1�� � Assessor's Map/Parcel p 11- OZ Installer & Designer Certification Form Designer: Installer: •. EX� o.�i o►s I; �0.V � fl V Address: -?O BQX 331 Address: _►y �T"ca►5er��a L� Narw;Clk Sr-csic odr_ On —To.q IS. 19 Bi i3 6Ycm0,aAj0A was issued a permit to.install a (date— (installer); septic system at 1$ QyoXl2ei- R�-_L based on a lm desi drawn by � (address) y� F1o��cr u dated 11R (designer) _ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distrilution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. " r changes I certify that.the septic:system referenced.above;:was installed with major i.e. greater than 10' lateral relocation.of the SAS or any vertical relocation of any:component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer:to follow. Stripout (if required) was inspected and the soils were found satisfactory. 9 4 DAVID �1 D. staller's Sign t ) LAHERTY, JR. No. 1211 4 T (Designer' :Signatu ) (Affix Desig p Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\office formsWesignercertification form.doc TOWN OF BARNSTABLE Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: P/f W,IJ1Q,7-1 If BUSINESS LOCATION: /jr- d.1/,4 Ke-/z. - 2.Q INVENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: S0E-3E2 /.6p / (-ILL p L105, CONTACT PERSON: I'� G II I���nS EMERGENCY CONTACT TELEPHONE NUMBER: ij,F•��, -���,� Mi9 SITE? TYPE OF BUSINESS: /Q2/4/r INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation.gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) &aulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, A� Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash zed" WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's ignat Staff's Initials Commonwealth of Massachusetts Title 5 Official Inspection Form 's Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments '< .18 Quaker Road Property Address Our Child LLC Owner Owners Name information is required for every Hyannis MA 02601 0923/13 page. CityrFown 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 foram. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your 616 ,`cursor-do not Michael Kellett V --t key the return Name of Inspector , , 215 Y � Aardvark Environmental Inspections -j Company Name = �' PO Box 896 Company Address ' Q===� rem East Dennis MA 0?;641 Cityfrown State ZiPi Code -1 508-385-7608 SI 3742 Telephone Number License Number = i 4.u"1 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 0923/13 Inspe s Signatute 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. 1 u/15/, , t5ins•11l10 Till.5 Official lnspedion Form: ubsurrace Sewage Disposal system•Page 1 of 17 --- --.. _ AD - \I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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: 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. 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•11/10 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts iTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 page. City/Town state Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cunt.): ❑ 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): n ❑ 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): 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 mannerwhich 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 OUTS-11/10 Trite 5 Official inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 tI Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 page. Citylrown state Zip Code Date of Inspection B. Certification (cunt.) 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 El ® or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'e 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 09/23/13 page. Citylrown state Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® 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. An portion of a cesspool or is within❑ ® y p a Zone 1 of a public well. Po Pm+Y ❑ ® 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. his p PPS+ P q �Y Y LT 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. r Yes No t ❑ ❑ 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage spe ubsurfac Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 09)23/13 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"non 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): 7 Number of bedrooms(actual): 7 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 770 t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 09/23/13 page. Cityfrown state Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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)):. Detail: 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: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I j . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 09/23/13 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) 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,K any) ❑ Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 page. Cityfrown state Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed (if known)and source of information: 08/08/83 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.7 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.): Septic Tank(locate on site plan): Depth below grade: 2.2 feet Material of constriction: ® 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: 1,500 gal w Sludge depth: 4 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 page, Citylrown 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 28" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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 t51ns•11/10 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 '< 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 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.): 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-11/10 Title 5 Official Inspection Form:Subsurrace Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): The box was level and tight with no sign of carryover. 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.): Soil Absorption System(SAS) (locate on site plan,excavation not required): If SAS not located,explain why: t5ins•11/10 Title 6 Official inspection Form:Subsurface Sewage Disposal System•'Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection spect on Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 page. Citylrown state Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc): This system has two 6'x6'precast pit surrounded by a foot of stone.The pits had about 20"between the inlet invert and the liquid.There was no staining above the liquid. 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•11/10 Title 50frrcist Inspection Form:Subsurface Smage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 09/23/13 page. Cityfrown state Zip Code Date of Inspection D. System Information (cunt:) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condifion 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 09/23/13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 rear 30 28 41 32 54 44 34 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurrace Sewage Disposal System Form-Not for Voluntary Assessments 't 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 09/23/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 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(abutfing 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: USGS maps show anelevation of over 20.0 feet Before filing this Inspection Report,please see Report Completeness Checklist on next page. t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 18 Quaker Road Property Address Our Child LLC Owner Owner's Name information is required for every Hyannis MA 02601 0923/13 page. Cityfrown 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-11/10 Titre 5Olficiatlnspection Form:Subsurface Sewage Disposal System Page 17 of 17 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 23 d Time: In Out Owner E s 1 N Oysa, Tenant L o t>c4 ► w, in YZ-oC>I- "C et..S.T , Address Address S V/a krr- t rL.10 %.( t S r'l/� C32 G e Compliance Remarks or Regulation# YeVr NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities S W 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities -00"-1 N ® 'oro 10. Curtailment of Service 11. Space and Use 12. Exits f Do rL- � 1-4- -c0 4� 13. Installation and Maintenance of Structural A ' w I-nn Elements N q- mo r- Dcc, 0 y L 0 tr., r- 14. Insects and Rodents �" �"a-c�-�' �► "'`"' �N C'&'L i 15. Garbage and Rubbish Storage and Disposal In c�.L<— v 16. Sewage Disposal 17. Temporary Housing // 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; E Removal of Occupants; Demolition Number of Bedrooms f� // Number of Vehicles Allowed (max) Number of Persons Allowed (max) co Person(s) Interviewed �T� Yr�r�2e� �� Inspector �•S . If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date Owner � V� Tenant Address Address Complionce Remarks or Regulation# Yes No Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities f_ 4F 6. Heating Facilities v/ (O Y 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal e j� 16. Sewage Disposal 17. Temporary Housing i PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Person(s) Interviewed Inspector I If Public Building such as Store or Hotel/Motel specify here 1-0 TOWN OF BARNSTABLE � � Z 9 BOARD OF HEALTH 1 V74- j ARTICLE I1:MINIMUM STANDARDS FOR HUMAN HABITATION ''4", Date ,�j Owner '�-'aze l�� /� � �� �� Tenant Address G Address Compliance Remarks or Regulation# Yes No Recom ndations 2. Kitchen Facilities W 3. Bathroom Facilities ' 4. Water Supply 12" �I 5. Hot Water Foci lities /z 6. Heating Facilities aAO--5' 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal -j 17. Temporary Housing PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Persons Interviewe / Ins ect4� � ) P -71 If Public Building such as Store or Hotel/Motel specify here HOBBS$WARREN,INC. TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date I /0 Owner Ojv,-VK Tenant Address Address Compliance Remarks or Regulation# Yes o Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities .10, 10. Curtailment of Service :tj V 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural / Elements V 14. Insects.and RodentsA 15. Garbage and Rubbish Storage and Disposal ✓ Macm 16. Sewage Disposal 17. Temporary Housing PART 11 37. Placarding of Condemned Dwelling; N Removal of Occupants; Demolition FF Person(s) IntervieWeO-I��� Inspector Le If Public Building such as Store or Hotel/Motel specify here HOBBS&WARREN.INC. z g ac 3 W _ C C CX / J 44 +> y 1 W4g S W (Y 3E W W t Z N V O @ = 3 N Z J - cc cc N C ` G � 1-� V 1 W .j a _ �s o 0 Y r Chi y h% �Ja GN 5 o'� No........& r�............. t i it.. `J THE COMMONWEALTH OF MASSACHL.3ETT BOAR® OF HEALTH ..-ily-C.............0F..P.. .J._�.. .Z—f�--- ................................. VV1tratiun. for Bi ipasal Workg Tuntitrur#iun Errant pp ication is hereby made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal System at• b 7- 6 ----........ ....................... oLtLocation-Addess o. _ Ow r Address aAn.�.... �.... . ......... � Installe...r Address Type of Building Size Lotg. � ��.___.._..Sq. feet c� ,..-, •Dwelling—_No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aa, Other-Type of Building ______________-__:____--- No. of persons----------------------------- Showers ( ) — Cafeteria ( ) Q' 1 g, Other fixt res d ---------------------------- W Design Flow........ ............................gallons per person per day. Total dail flow-___-_-7 Via......................._gallons. WSeptic Tank—Liquid capacity-AM-0gallons Length-/ '�- /�- Width.6a__: ------ Diameter................ p ' ;V x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. P Seepage Pit, No.:..�. .__.. Diameter:/.Pt..5_..... Depth below inlet..... ........... Total leaching area.:_. .K..> .It z Other Distri ,ution box (k) --Dosing tank ( ) aPercolation est Results . Performed by.--. Q.CN_... "._ .( ...,!l11 Date_._./.'1 4� ........ a Test PiV`E, �'__A.....minutes per inch Depth of Test Pit... ...... Depth to ground water ........ . Test PitNNo. 2..................minutes per inch Depth of Test Pit.................... Depth to ground water.. DUr7/7`E/c£� O Description of Soil............}j5.4�.__. 'L .._ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W V 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 iITI U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by th 7 oard of health. Signed . '--------•-••-----...... ................................ Date Application Approved By---••-•--�_� ,,,. /-'_ ......... -•...lam, ` I------- Date Application�ap.rovedffofollowing reasons:-------------------------------------------------------•--------------------•--•------------------•••....----- qyL .............................. ....••••• = •--.........-••--•--•.......-•-•--•.....•.••. jffPermit No._�.--•--'.. ----------------------- Issued................/ [....... .�4......... ate No....:_ w� .I:.l6ag A Fim 57.0.._.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /:f{ ! ........ OF.-elf', .,e�TIz: C1:.-r............... ................ Appftration for Disposal Votks Tonotrurtion Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: Location Address or Lot No. 7 "..------•----•............................. ;.......-•---- = ---_._---•---- ------- Owner Address ►W-a ----•---•-•..........................•----^--•----••----•--......------.....--••-••-•--•--------- .................................... ................................................ Installer PQ Address Q Type of Building " Size Lot, .?f_ ll d.........Sq. feet`f U Expansion Attic "' Garbage Grinder., Dwelling—No. of Bedrooms______ _________________________ p ( ) g ( ) pa4 Other—Type of Building ____________________________ No. of persons------------- Showers ( ) — Cafeteria ( ) Other fixtures _.__._.:'.._._... ------------ `= ---•--•••--•----- .,.. W Design Flow____..s__�_________________............gallons per person per day. Total daily flow----_.,7T ...........................gallons. WSeptic Tank—Liquid capac>t)900_.6_gallons Lengthy. //`. Widthfo.__lsr_._.._ Diameter_______________ Depth.y__�__- fx Disposal Trench—No_____________________ Width____f.�._._.___ Total Length_.______.___________ Total leaching area-.._.._-________._._sq. ft..- Seepage Pit No...1j_4_4...... Diameter./Ot._6 _,._ Depth below inlet....4........._. Total leaching area_=�l.S�.s�t ;%�P Z Other Distribution box (X) Dosing tank.( ) 64 '-' Percolation Test Results Performed by..10.W...... 4...,/'!U�__ Date___,/&!./4r.ne!y.._...__. a Test Pit No. 1.S__, ______minutes per inch Depth of Test Pit_141/_l/`'__�<Depth to ground wateW!P!__�A�.` f= Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.e_0.V&.__7E9,C b a ---•-------------------------•-•-•...---...------•-•--•------.......--------........----------------------------•-•----•----_-•--------------•----•------ O Description of Soil..........._s='f : ................. U •-•--------•-----------•--------------•-•--•---........------•----------------------...••-•-----------•---•-------------•-••----••••----...----••--------------------•-•-•-•--------•--•---...__._...- W •----------------------------------------•-•----------------------•---------•---------...----••--••---••---------------------•------•------•••----•---------------------•-------•------•---------•----- UNature of Repairs or Alterations—Answer when applicable............................................................................................... l Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT a 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed----- % � Date Application Approved By......... z.,r�... ................................ .�-•2:� ------- Date Application Isap roved f o following reasons: ; ----•--------------------•--•-----------------------------------_____-________------ .:....--�'1->- (� ........ .....t=o,�10 .............................•---=----••---_._._...._.....__._....--=:--------•-------------•--------•--- .......................... s Date . �.. Permit No..r�.z::y.'"--�------- ........................ IssuecL...------------�-`�---- •--••--- r ate THE COMMONWEALTH OF MASSACHUSETTS ~`'•� BOARD OF HEALTH OF..... + t t Trrtifirab of Toutplioure THIS IS TO CERTIFY, That the Individual Sewage Disposal. System constructed ) or Repaired ( ) by -------------------------------------------- Installer 7_ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in -the application for Disposal Works Construction Permit- 4_9-_____-_____ dated_.-------------------_........................... THE ISSUANCE IL THIS CERTIFICATE $HALL NOT BE CONSTRUE AS G. ARANTEE THAT THE ' SYSTEM WILL FUN ION ATISFACTORY. DATE............................ --- ------------------------- Inspector......:... = ._... THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH ;l .............................OF._..-.-...-----.........-----------...-----------------......_.........._........._.. S• No... !_ �P I� FEE..... 0.:........... Mapooal Works Tolonotr ion amit Permission is hereby granted.....................................................................................------------------•--------- .......................... '! to Construct ( ) or Repair ( ) an Individual Sewage Disposal System 4 'g atNo.....l 7-------4---•------jCQ ll/`'� ' ........ •, f�!-`, ��?l.l. ................................ ..........................tree. as shown on the application for Disposal Works Construction Permit No�K'' � Dated. __ � 5_._.__._:_:_........ Yi/'•"' s -Board of Health DATE ......... ---------- F&I". 1255 -A. M. SULKIN, INC., BOSTON� e� ,,,�„_ •��}�Jy��� ,. r TOP OF FOUNDATION COVERS TO BE WATERTIGHT AND SEPTIC SYSTEM PROFILE BROUGHT TO WITHIN 6"OF FINAL GRADE Flaherty Environmental Services EL. 60.0' EL. 58.0' (not to'scale) INSP. PORT W I 3" OF GRADE CLEAN SAND P.O. Box 331 2" of 8"to 2' DOUBLE WASHED EL. 58.0' Harwich, MA 02645 - 4" CAST IRON or EQUIVALENT PEAS�ON�OR GEOTEXTILE 774.994. 166 MIN. PITCH 1/4" PER FOOT FILTER FABRIC 4"SCHEDULE 40 PVC PIPE 4" SCHEDULE 40 PVC PIPE VENT IF REQUIRED FLOW LINE (8iat2'tobelevel) a'. 28' 1% e., SS.61 ;.:.'•: L.EXIST. L 14„ -------4'► ® . 0°ccoc°oc EL.EXIS I°°°°°o°o°o° ° ®� rr , o°o°o°o°c EL.55.6' +0°00000 0 0 00°o LuJ( oo000oo°°c 0 0 0 0 0 0 0 00 0 EL 55.15' + o 0 0 0 0 0 0 o 00 o c EL.55,32' ( ° 0°°°0°000°0° o°°°o°0°c 2.0' GAS BAFFLE EL.55.13' o°o°0°000°°°0°0° l`-J'� [ � Q• 0°0°o°00c— ;�',..a. �O�OOoO°2O ODO�OO •A' •� L°O°O°O°O° - I o 0 0 0 0 0 0 e• a °o°o°o°o° EL.53.13' ° '+ 6"CRUSHED STONE ORH-20D-BOX) SOIL ABSORPTION SYSTEM .g .'' ' ` °' MECHANICALLY COMPACTED (6) 500 GALLON H-ZO CHAMBERS " 2000 GALLON H-20 SEPTIC TANK 5.65' (DATUM: ASSUMED) (EXISTING) all 1„ WITH 4' STONE AROUND IN A 4 to 1� DOUBLE WASHED STONE 12,83'X 59.0'X 2'CONFIGURATION / BOTTOM OF TEST HOLE EL. 47,5' EL. 47,5' CUSGS ADJUSTMENT: N/A LOCATIONMAP 58 GROUNDWATER ELEV: N/A N TH Q0 QO \ ` �W DRIVEWAY Rt.28 s P (�J \ puaker Road v GARAGE LOT 6 LOCUS 0,5 ACRESi MAP 310 LOT 9-002 35 7' Nrs .w EXISTING N OFAf4 'R BR D ID q y 58 DWELLING EXIST. S.T. �'� GJ' O TH—l+a '.; 21.8' " LP J >'' o•�',' N 2 TH-2 EXIST. LP'S S /STER O 56 �/� is NITAR)PN 3 /1 BENCHMARK: r; DATE;•1/6/2019 REVISED:111312019 OTOP OF FNDN (6BRTO7BR) , EL. 60.0' :,:• SITE AND SEWAGE PLAN FOR �rlcoS } '�° B & B EXCAVATION, INC./ RONALD BOURGEOIS . 4 t 1.2 U 18 - QUAKER ROAD i t HYANNIS MA SCALE : 1 " = 30' REF.•LCP 21173-D PAGE 1 OF2 ............ .. ............. ....................... .......... ........... ... .................. .............................................................. ......... ........................ ............. ............ ....... .......................................................................... ......... ............. .................................................................................................................................... ........................................................................ .......... .............................. ....... .......................................................................................... GENERAL NOTES DESIGN CAL CULA TIONS S YS TEM DETAIL Flaherty Environmental Services P. 0. Box 331 1. ALL PRECAST COMPONENTS TO BE H-10 Harwich, MA 02645 RATED UNLESS OTHERWISE SPECIFIED. NUMBER OFACTUAL BEDROOMS 7 774.994.1166 DISTRIBUTION BOX(ES)AND A)VY COMPONENTS WITH ANY ANTICIPATED GARBAGE DISPOSAL UNIT NO VEHICULAR TRAFFIC TO BE H-20 RATED. 2. THE DESIGN OF THIS SYSTEM DOES NOT TOTAL ESTIMATED FLOW ALLOW FOR THE USE OF GARBAGE (110 GALIBRIDAYX 7BR) 770 GAL./DAY GRINDER. REQUIRED SEPTIC TANK CAPACITY 1540 GAL. 3. MUNICIPAL WATER IS AVAILABLE. 4. ALL CONSTRUCTION TO CONFORM WITH SIZE OF SEPTIC TANK 2000 GAL. (EXISTING) 310 CMR 15.000 AND ALL OTHER 59.0' APPLICABLE LOCAL, STATE AND FEDERAL SOIL CLASSIFICATION CODES AND REGULATIONS. 5. INSTALLERICONTRACTOR TO REVIEW& DESIGN PERCOLATION RATE <2 MIN.ANCH VERIFY ALL ELEVATIONS AND DETAILS 0 0 0 0 0 0 12.83' AND REPORT ANY DISCREPANCIES TO EFFLUENT LOADING RATE 0.74 GALADAYIFT2 DESIGNER PRIOR TO CONSTRUCTION OR ASSUME ALL RESPONSIBILITY. LEACHING AREA (59.0' 6. INSTALLER/CONTRACTOR IS (2)x 59.O'x 12.83'+ f2.837(2) =75 287SF 7 SF RESPONSIBLE FOR MAINTAINING SAFE 1044 SF x 0.74 =772 GPD WORK AREA, VERIFYING ALL UTILITIES AND NOTIFYING "DIG SAFE" USE(6)500 GALLON H-20 CHAMBERS WITH 4'STONE (1-888-344-7233) 72 HOURS PRIOR TO INA 12.83'X59-O'CONFIGURATION ASDIAGRAMMED CONSTRUCTION. 7. ANY CHANGES TO OR DEVIATIONS FROM RESERVE LEACHING CAPACITY NIA GPD THIS PLAN MUST BE APPROVED IN WRITING BY FLAHERTY ENVIRONMENTAL SERVICES AND LOCAL BOARD OF HEALTH. 8. FINISH COVER OVER COMPONENTS IS NOT TO EXCEED 3'PER 310 CMR 15.000 (NTS) UNLESS SHOWN PER PLAN 9. ALL ABANDONED SEPTIC SYSTEM COMPONENTS TO BE PUMPED DRY AND SOIL EVALUATION FILLED WITH CLEAN SAND OR REMOVED TESTHOLE#1 PW 15877 OF TESTHOLE#2 PWI5877 AND REPLACED WITH CLEAN SAND. Evaluator. David D.Flaherty Jr.,RS,REHS Evaluator- David D.Flaherty Jr.,RS,REHS 1 O.ALL COMPONENTS TO BE PROVIDED SE#2755 SE#2755 DA BOH Witness: Don Desmarais,RS BOH Witness., Don Desmarais,RS WITH WATERTIGHT ACCESS PORTS Date: Januaiy 8,2019 Date: January 8,2019 F E . WITHIN 6"OF FINISH GRADE. 11.ALL SEPTIC TANKS, DISTRIBUTION TH-1 ELEV.58.0' TH-2 ELEV.58.0' BOXES AND PIPING TO BE INSTALLED /STEVL WA TER TIGHT. 0--6- A LS 10YR 312 0--6- A LS 10YR 312 'INITARI 12.NO KNOWN WETLANDS OR WELLS WITHIN 100 FEET OF PROPOSED 6--28- B LS IOYR516 6--28- B LS 10YR 516 LEACHING. 13.THIS IS NOT A CERTIFIED PLOT PLAN AND UNDER NO CIRCUMSTANCES IS THIS PLAN TO BE USED FOR ZONING OR 28"-68' C1 MCS 2.5Y616 (41-) Perc 28'-66" C1 MCS 2.5Y616 7 certify that on November 12,2002,l have passed the examination approved by the Department of SITE AND SEWAGE PLAN BUILDING PURPOSES. Environmental Protection and that the above analysis has been performed by me consistent with the FOR 14.LOT IS SHOWN AS ASSESSOR'S MAP 310 required training,expertise,and experience described LOT 9-02. B & 8 EXCAVATZON, INC./In 3 10 CMR 15.018(2). 15,LOCUS PROPERTY IS NOT LOCATED RONALD BOURGEOIS WITHIN ANAQUIFER PROTECTION 68'-126" C FMS 2.5Y 616 1 68'-126" C FMS 2.5Y 616 18 QUAKER ROAD DISTRICT(ZONE II). G.W.ELEV.NIA G.W.ELEV NIA HYANNZS, 14A BOTTOM TH-1 ELEV. 47.5' BOTTOM TH-2 ELEV. 47.51 PAGE 20F2 ...................................................-............-............................................... ........................................................................................................................................................ ....... .. ... .... .. .... . ......... .... ...... ...... ... ............. ....... ....... ............................................. ............................ ............................................. ....................................................................................................................................... so' GELLA 4 ----- —- -- - - - - - -- -- -— -Zoviu CoA 4 -_-_- - -. - P3 - q 4 , - - — - Q s_� ti O T'E- EXT&ti./D HL. L. /9 PPL/Ci9 BL E --.----- ex15-f'rl5 car-ovrnd P'-of'/le H0�2Iz. Sc �9LE : / "' _ /©� SL- C 7- 1 oAJ - V � ,� � v�^ C �9LE : / '" = �0' MA/VHOLE. CaVERS 7-0 r.-l/T/-! A./ ProPosed c�rovnd Profs le SCHED. 40 P. V. C. o,2 - FLOW E a U,�9L 7-0 SEPT'i C Cr7->i rn i r-n urn /" Per food-) 2 o f �B - Y2 washed S-fo rl e TANK•-r -,tea,�, .s--t �::,^4 wa— x D/577 BOX ° -_ o 6'dia. e �PT/C . ° r 6" Svrnp dashed me o ° ° •,� a e EE SO.00 QtJ c ° �.-- GfiG. .� TP1�K sto rJA1L hJ POLE �tt�fi _-_ ° e L I-- F9 C!-4 F;l T' 47.9 `� -o- --- POLE Lo-r rr - _ t-1OUSE DFa T c io <51si4_._ �7'�E-5 ,' f3Y: J��� �.. JJ� �.__�s1L 47.4 Qr W x 1/r �n o r Ti*1 E ,`?�k' ►«� 3 4 disPo3r tJ G . . A$P .-fdf EAL ss 9 9 f El L-c_ PE P L.L.P Ztt-73 8 (v PT 'G 7-,,9/V 17 _— X /. S = I ►55 rU ry D LS 2g U S LOO . 4 8 v 9 - E. C.'-/ p/T. SLJB501L 43.5 Z4" Z:) .1r2 49-3 Q� ti L. C.P. Zt173 F 1.�.9S. r=. 94. LOT 07-7-0Nl LOT USE. LE lqC!-/ r- 7-5 38.5 e4 ZZ, 400 + t4ED14�M {lnO .OD 5 A► D 33.5 144 � / C c-A�?; ;r- Y 7-/IjQ7- THE BU/LD AjG -, 0,4J Tf-/E- G�-�oUti/D yS / Tom` ��7' r� -� A- S r-/ o cti.v v nj - -,L// s P L A3 AJ D o E- S o,c : .�T G? J A L/E-2 2� tap ► 1�A�!f.l 5 ( t3 AQ r.� S A B L E CO/VFOA'M L. G. P. Z I ; 7 3 C7 TNE- Town.J OF _�AKr_,��.�.AB►,� __ _ . __ ._ . 21 G O A Q i2 A i2 E t J 5 T k LJ R :4 ,. Rem '�' �•a � 1 • , j� J / AIJ +, \�eT� � 0. 00 _ e x !.S-t-j n c� e e �I o n 8L 1> C. SETf3 ,E: — % 14? /"7 U T1000 'E- U/A2 e AJ7-S '. �r o n-f /S t i nfF c o n f o u f-S /-9 r->)nD 2 0 ✓E D —° .—o—o— ,__.__. r-„-c�x,�,,•mod con-t-our-s Ez�►B.n.�S��BL E _ --- -- , �-7 F/S�. # P.J. ,