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HomeMy WebLinkAbout0081 QUAKER ROAD - Health ' 81- 83 Quaker Road .Hyannis P �; A = 310 312 Date: TOWN OF BARNSTABLE OXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: (I�Ii�1iL` G(T BUSINESS LOCATION: X-D INVENTORY MAILING ADDRES 1✓'f'1S 441;x— 0 Z-Ca,/ TOTAL AMOUNT: TELEPHONE NUMBER: Df_ ,;70 '422 116 &A-L CONTACT PERSON: `'o , /9 rotes EMERGENCY CONTACT TELEPHONE NUMBER: SO?— 2F0 MSDS ON SITE? TYPE OF BUSINESS: °`�'�Ni 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 materials 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) Misc. 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 Misc. petroleum products: grease, Photochemicals (Developer', lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) O aulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt & roofing tar PCB's L5_6Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels �-� Paint'&varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor&furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash j WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Date: TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: l' A1 C L� N N �Z 1�IC`.E5 BUSINESS LOCATION: q J (�W.0 R r N N( S INVENTORY MAILING ADDRESS. 49 , 4ft rS- A -O G01 TOTALAMOUNT- TELEPHONE NUMBER: g g6 6?y o')- CONTACT PERSON: - PrW QEI24 -GiPr EMERGENCY CONTACT TELEPHONE NUMBER: Gb s oZg O -3S$ o MSDS ON SITE? TYPE OF BUSINESS: CLEF N � NG 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 materials 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) Misc. 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 Misc. petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Misc. 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 (inc. carbon tetrachloride) NEW USED Any other products with "poison" labels Paint &varnish removers, deglossers (including chloroform, formaldehyde, Misc. Flammables hydrochloric acid, other acids) Floor& furniture strippers Other products not listed which you feel Metal polishes may be toxic or hazardous (please list): Laundry soil & stain removers a, %aQzn c Lopio x d c-A m U (including bleach) u Uj I Dc—X Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash de , 0� WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS f Jo'` i �: ,: ;� >> !i 's ..�._9.._.r..--.�� .:��-.--....e._..z�.� �1 . d n ®G � � ..�� _ .�� �� a � � i i � a _ f t i i ��.s...�.�-. .. __ .__..f.�°t .. . 5 C "S � 1 _, � _ j ` .. -� ;; _r 1 sue' � --_�- � . . � C �� c N -� _ fi. � f i; f Y _ Fu) (� 1. i i a I ._ j t i i - { i F I t 7 3 / t f { f f� _ 1 f R t f { �F 1 � t 9 � Z i Y i 1 1 - 7i—O e f � f Y TO i E S i f i qq r q - mra TOWN O,F,Bn�ARNSTABLE SEWAGE #, LY 7l3 VILLA1 o +ASSESSOR'S MAP& LOT INSTALLER'S &,.HONE NO. SEPTIC 'TANK CAPACITY LEACHING FACILITY: (type) 144JJ-- (size)NO.OF BEDROOMS s BUILDER OR OWNER Ul PERMIT DATE: eI �:— COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility -Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands'exist within 300 feet of leaching facility) Feet Furnished by w � I Cl) t� No. Fee Aw THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Mfi6pooal *p5tem Cow6truction Vermtt Application for a Permit to Construct( )Repair(/pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Addressor Lot No.g 1—E3 �Jaw2� Owner's Name,Address and Tel.No. 14C NNLS � Assessor's Map/Parcel 31 �� _T0 v IL�` ex, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �o�-��l�d\De A5 as 6 p?,,eGp Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures`i Design Flow q() gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 4�CovVCI ;r� K1"L— Description of Soil O� Nature of Repairs or Alterations(Answer when applicable) -T PP-k` fit r l_ 1 O cSY (1 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 lace the system in operation until a Certifi- cate of Compliance has been issu ar G� \ Signed Date 7 -d�I Application Approved Date ,`" 2. Application Disapproved for the following reasons Permit No. Date Issued �,7� t 1 r+r r No. Fee 'i..t/ 3 ITHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Mi!6poml *pe;tem Construction Permit Application for a Permit to Construct( )Repair(/Upgrade( )Ablandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.g —63 JAB- Owner's Name,Address and Tel.No. ht ANTIS — o on-/, 0, l Assessor's Map/ParcelZId -73 1� Ly V7 1 Installer's Name,Address,and Tel.No. ! Designer's Name,Address and Tel.No. Type of Building: t Dwelling No.of Bedrooms 't Lot Size sq. ft. Garbage Grinder( ) Other Type of Building Q-�4)�e-f4 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow L1 0 gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank 1560 Type of S.A.S. Description of Soil _ V� Nature of Repairs or Alterations(Answer when applicable) N S`t f�l` `^\- D iQ Sepik l C_--VA t`VL t Date last inspected: , Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site.sewage disposal system in accordance with the provisions of-Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by rh;c R ar ealth. Signed Date 4? 4-� Application Approved v Date , Application Disapproved for the following reasons Permit No. 7 ," Date Issued THE COMMONWEALTH OF MASSACHUSETTS T` BARNSTABLE, MASSACHUSETTS �. Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(vo,) Abandoned( )by at ajN,IS has been constru ted idaccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. i dated � ~ Installer Designer "� p The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date �'i `Z GI" 1 Inspector —��---------`------------------- No. Fee "lAes THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Ziopooal *p$tem Con$truction Permit Permission is hereby granted to Construct( )Repair( (.Xpgrade(' )Abandon( ) System located at " .?, (Q vo- .- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of t ' it. Date: 1`' Approved b NOTICE: This Form is to be tlsctl for the Rcpair of Failed Septic Systems Only CERTIFICA110N Or SKETCH ANC APPLICATION FOIL A DISPOSAL'. 1VOIZ10 CONS]AUC ION I'EItI191*1' (NVI'I'IIOU'F .DESIGNED I'LAN hereby certify that the application for disposals works construction permit signed by me dated � , concerning the located at — 3 �`" meets all of the property following criteria: • There are no wetlands within 300 feet of the proposed septic sy stem • There are no private wells within 1 So feet of the proposed septic system The observed groundwater lable is 14 feet or greater below the bottom of the leaching facility • There is no Increase in(low and/or change in use proposed • There are no variances requested or needed. SIGNE�: k DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER IAtlach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submiltcdl. _ -� -- �cC� �3 _ ^+ i TOWN OF BARNSTABLE e -C LOCATION I-93 SEWAGE # VILLAGE, f /�l�' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC.TANK CAPACITY LEACHING FACILITY: (type) /7 (size) I k.2 NO. OF BEDROOMS •i BUILDER `OR OWNER—i-- t �® CROPA "rO PERMITDATE: COMPLIANCE DATE: /0 ,4Q 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 iFurnished by BW 09 ®m r a1 I , TOWN OF BARNSTABLE �� v LOCATION 51 -93 � Q;, SEWAGE # VILLAGE �Y 1/S�" ASSESSOR'S MAP &LOT12LO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3-1350 CA49V size) 3 NO.OF BEDROOMS BUILDER OR OWNER ALA-0 C✓I /PA(�D'rO PERMITDATE: ,�f> ��® COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r t: 61) 4z a� No. FEE COMMONWEALTH OF MASSAC14USETTS Board of Health, 9�/L.it/,STM , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(X Abandon( ) - ❑Complete System )kIndividual Components Location kJ E3 j4 d .4ytt� Owner's Name Map/Parcel# fte J® r -�J 2 Address Rt Lot# Lu Telephone# Installer's Name uJ� B.7 Designer's Name t'f1lt.��R !N Address 7,j /t� AddressS. Telephone# Z Qom/ -- / 14-W�7 O Telephone# Z(p Type of Building sJ`ciO! �— !/v%le Y Lot Size 1--:� X—r sq.ft. Dwelling-No.of Bedrooms 2� `� aN1r� S Garbage grinder ( ) Other-Type of Building / r►�79 No.of persons Showers ( ),Cafeteria ( ) Other Fixtures - ! Design Flow (min.required) t1 gpd Calculated design flow 4 4c) Design flow provided ,-;L gpd Plan: Date laA4167-� Number of sheets 2 Revision Date WIA Title lnr.Sec/ G Sv Ski+ //,ae�lI�3 GjvrcLCc✓ /mac[ �z yGb✓1vt fS _ /14 Description of S $oil( ) Q In 1t/��' l S' , `=2.��` S , Z� �8d 4 /�` .ao+e��Gr Soil Evaluator Form No. Name of Soil Evaluator-LG'Al- in/`4 Date of Evaluation Ibl i-7 02-- DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above des ribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to to plfce th tem' ation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 0 Inspections S—O/ �II "a,.\ .. ""'-.• t.`�.^+�..,,�+.a�+ �,�-A'��.'w. ., ` ., i�-��+v,.^.s:i�ti.r^JCS+.+n-,.t^,w,d,^c.-.,.:...:. ,;y,<. ., r. # -'i:.i-� UU .� elf $ No. ..--?4 r FEE �v I i k p. Board of Health, 9,'41ZW3rA1l- MA. i , APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgraded Abandon( ) - ❑Complete System Altidividual Components i p p , Location &/ 6 3 OUQ�e.- ) - v A4t' Owner's Name �✓�� 6 RIQ-�o f Map/Parcel# 3/D pr I 3 '�, Address IF/ Qu k,141 v Kale S /� 0 Lot# C V Telephone# Installer's Name ✓ • H dAftJGir� 'O✓1 Designer's Name r �nit✓��a im7,4f S / Address ' a Address 23 ✓ HD�la•-Ul/W '" f d,k r 1 P Telephone# �Z d��S OZ� yj Telephone# If ZCI Y Type of Building /c.Cl/dqif ✓GtdI �vi%le!C Lot Size /r�o Q �� sq.ft. j Dwelling-No.of Bedrooms 2" j2�/6 M 0/V/7-S - /4 r3o;:O/2E10/1-t S l Garbage grinder ( ) ' Other-Type of Building /N/A No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow min.required) 44 d Calculated design flow .44y Design flow rovided /-� S d t;yy g ( q ) gP g g P -�gP i Plan: Date w /OIl v I!2 Number of sheets 2 Revision Date K Title ad .4,oL .ASv.sJt�r Vgo✓q✓�P wig 6va�✓ . {�yA•?�`�3 . } Description of Soils Q-/ /�A r s / z 4��r G.5 to"—,To ` C/r .S4ne/�Crr4i°�� Fo 'rr " F p ' ( ) 4 - � �� 4 /'�9 �Z:.S�a� G Soil Evaluator Form No. Name of Soil Evaluator Y[k0, Date of Evaluation /0/1 71 6Z"_ DESCRIPTION OF REPAIRS OR ALTERATIONS l r �If The undersigned agrees to install the above des•ribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and ` further agrees to t to place th tem': adon until a Certificate of Compliance has been issued by'the Board of Health. ,::.Signed Date - Inspections� � .. E _�- 1/ J ` l i v No \`Lj//[/�/ FEE J lJ COMMONWEALTH OF MASSAC14USETTS Board of Health, &,-QJ rA,6 l I% MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersign- d hereby ce(rtifyy�that the Sewage Disposal System; Constructed ( ),Repaired t)�Upgraded ( ),Abandoned O at I ,�� '(LWf-.1 i � � U �, . �4 has been installed in accordance with the provisions of 310 CMR V5.00 (Title 5) and the approved design plans/as-built plans relating to application No.�� � dated Approved Design Flow �! (gpd) r Installer i� Designer: Inspector: 1 !i fib Gl e ll�X�'1 Cd.9`,�f Al: !V l-:3 !fi The issuance of this permit shall not be construed as a guarantee that the sys�te/m will function as designed. FEE�► � COMMONWFALT14 ®F MASSACHUSETTS Board of Health, f3AV211-1s1 01&tDISPOSAL SYSTEM CONSTRUCTION PERMIT MA. I Permission is hereby granted to; Construct( ) e air( Upgrade Abandon( ) an individual sewage disposal system _ V at / �1(i A as described in the application for Disposal 4stem Construction Permit No. ' ,dated Provided: Construction shall be completed within rei- years of the date�f tM�� : All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health / � v � f � THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA i� nh TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma �J d Parcel Permit# Hialth Division —1 U 2 r -,5 Date Issued Conservation Division ?� � � <4 Q� Fee ✓ r Tax Collector / / n J— 4-v rj S Treasurer rrl SEPTIC SYSTEM MUST BE —T INSTALLED IN COMPLIANCE Planning Dept. WITH TITLE 5 Date Definitive Plan Approved by Planning Board ENVIRONMENTAL CODE AND TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address Ly o W K_elz K_ Village U l .-V i` S Owner �l l ►� C C Q�t'A (✓RTo Address r ft= )LC,> , Telephone `' 0 V 6 Z— 6 3 C1 Z Permit Request r1T(yZA G-1�, k9/ / T)'C :5 �'JO � 0/0 Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new 6 s e Valuation Zoning District Flood Plain Groundwater Overlay Construction Type w'ao of Size U 3 S Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. elling Type: Single Family ❑ Two Family ( Multi-Family (#units) of Existing Structure Historic House: ❑Yes , S No On Old King's Highway: ❑Yes $�No ent Type: V Full ❑Crawl ❑Walkout ❑Other \nt Finished Area (sq.ft.) Basement Unfinished Area(sq.ft) �of Baths: Full: existing new Half: existing new Bedrooms: existing new Count(not including baths): existing new First Floor Room Count 'Fuel: A Gas ❑Oil ❑ Electric ❑Other Yes ❑No Fireplaces: Existing New Existing wood/coal stove: :❑'Yes ❑ No. ❑existing ❑new.. size Pool: ❑existing ❑new size Barn:❑existing ❑new size existing ❑new size Shed:❑existing ❑ new size Other: als Authorization ❑ Appeal# Recorded❑ "MN o If yes, site plan review# Proposed Use BUILDER INFORMATION 5 _Holt Q 'N Telephone Number .less License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ..Y� THE SOUTHERN MA. ' y TELEPHONE CO. EASEMENT .__ ----------------------- NEW ENGLEND TELEPHONE & TELEGRAPH CO. EASEMENT — S88 45'00"E 165.59' NEW ENGLEND TELEPHONE & TELEGRAPH CO. EASEMENT THE SOUTHERN MA. _—— TELEPHONE CO_ EASEMENT ---------- _ ----------- IN O _ O ------ti------ - --_- ,J -- - - QO 49¢O O y .. Plan • ZONE. "RB" This MORTGAGE INSPECTION Bank lUseoOnly FLOOD ZONE.- "C" THE DISTANCES AND MEASUREMENTS DN THIS PLAN SHOULD BE VERIFIED BY AN INSTRUMENT SURVEY. WN: _H 9NLV45---_-------_ REGISTRY OWNER: JEFFREY A_ LYON & JEIVIVIFER S_-_—K -- D REF: _=149-061------ BUYER: -P-AULQ- YANDEaEL4-CQRPBLATQ----------- E: 912V00_____-- -_ PLAN REF: _Z1173=F_ ___SCALE:1"= 30___FT. REBY CERTIFY TO -CL(AS'E MANEATTAN_MQEIL�A-GE— 'Of YANKEE SURVEY RPORATION _THAT THE BUILDING �N ON THIS PLAN IS LOCATED ON THE GROUND AS PAUL CONSULTANTS AND THAT ITS POSITION DOES _ CONFORM A. 40B (SUITE 1) E ZONING LAW SETBACK REQUIREMENTS OF THE a ME�MITHI OF _—_BARNSTABLE—_—_---------AND THAT M . 3de N INDUSTRY ROAD Q MARSTONS MILLS,- MA. 02648 ES_ NOT _ LIE WITHIN THE SPECIAL FLOOD HAZARD ` -`G15I�c��9 TEL: 428-0055 AS SHOWN ON THE H.U.D. MAP DATED 8Z19.�85 _ �vy�, tA�� nit -Panel 250001-0005-C% FAX 420-5553 _—__-- THIS PLAN NOT MADE FROM -AN INSTRUMENT SURVEY ,29582 LM A• MERITHEW PLS NOT.TO BE USED FOR FENCES BUILDING PERMITS ETC.. . i I RECEIVED AP P 2 2 2000 COMMONWEALTH OF MASACHUSETTS TOWN OF BARNSTABLE EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS HEALTH DEPT. DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary, ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM P PART A CERTIFICATION Property Address: 81 &83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Address of Owner: BOX 64 HYANNISPORT MA.02647 Date of Inspection: 9/11100 Name of Inspector: JOHN GRACI { I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O'BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT " certify that I have personally inspected the sewage disposal system at this address-an that the information reported below is true,accurate and complete as of the time of inspection.jhe inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes6y�f s _ Conditionally Passes - _ Needs Further Evaluation By the Local Approving Authority"' S E P 2 2 200Q f Fails 1 — c t 1v0wN0FBAPNSTA8U HEALTH DEFT. Inspector's Signature: /mita Date:9119100 The System Inspector shall suopy of this inspection report to the Approving Authority<(Board-of Health or DEP)within thirty(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 Department of Environmental Protection.The original should'be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. j NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M,. inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." i THE SYSTEM PASSES TITLE V IN'SPECTION.RECOMMEND PUMPING THE SYSTEM EVERY ONE TO TWO YEARS FOR PROPER MAINTENANCE.RECOMMEND NOT DRIVING OVER-THE SYSTEM IS H10 Is revised 9/2/98 Paoe 1 of 11 S . i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 81 & 83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9111100 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. 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 o the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. n1a The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n1a Sewage backup o'r,breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced n1a The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed .I revised 9/2198 Paoe 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 81 & 83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9/11/00 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I! NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has at:iseptic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,uriless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance n1a (approximation not valid). 3) OTHER n!a revised 9/2/98 Paoe 3 of 11 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) l Property Address: 81 & 83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9/11100 I D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than'4 times in the last year NOT due to clogged or obstructed pipe(s). Number of time pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No F � X the system is within 400 feet'of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further information. i . i revised 9/2/98 Paoe 4 of 11 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 81 & 83 QUAKER RD HYANNIS, MA 02601 Name of Owner: JEFF LYONS Date of Inspection: 9/11/00 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: ,3 Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. , X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information, For example, Plan at B4O,H, {tx , X _ Determined in the field(if any:of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. is revised 9/2/98 Paae 5 of 11 f k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 81 & 83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9/11/00 J FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):n/a Total DESIGN flow: 440 gpd Number of current residents: 3 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): NO Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL ?,c Type of establishment: n/a r Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a .t Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no): NO Water meter readings.if available: n/a Last date of occupancy: n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons 1 Reason for pumping:n/a TYPE OF SYSTEM X 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a 5 APPROXIMATE AGE of all components,date installed(if known)and source of information: 1997 Sewage odors detected when arriving at the site: (yes of no): NO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM revised 9/2/98 Paoe 6 of 11 I PART C SYSTEM INFORMATION(continued) Property Address: 81 &83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9/11/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 10" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: nla Diameter: n/a Comments: (condition of joints,venting,evidence of leakage,etc.) TOWN WATER f" SEPTIC TANK: X (locate on site plan) Depth below grade: 3" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: nla If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1500G L 10'6"H 5'7"W 5'8"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 2" 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: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY ONE TO TWO YEARS. r e. GREASE TRAP: (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: nla Dimensions:nla Scum thickness: nla Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) nla revised 9/2/98 Paoe 7 of 11 • i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 & 83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9/11100 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:NIA Alarm in working order: NO Date of previous pumping: n/a i Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a a } DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal,evidence,of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) 1 Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a iA II ;a revised 9/2/98 Paoe 8 of 11 h SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 & 83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9/11100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits, number: (n/a)n/a leaching chambers,number: (6)INFULTRATORS leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: nla Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) n/a PRIVY: .(locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2/98 "" Paoe 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 8.83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9111100 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 6 q I C h k AA �I► s. revised 9/2/98 Paoe 10 of 11 v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 &83 QUAKER RD HYANNIS, MA 02601 Name of Owner JEFF LYONS Date of Inspection: 9/11/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+FEET .r revised 9/2/98 ''° Pape 11 of 11 COMMONWEALTH OF MASSACHUSETTS ExECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL ONE WINTER STREET, BOSTON MA 02108 (617) 4b 0 lr WFLI.IAAi F.WELDv�� R� q9� TRUDY cow Governor 19 Secretary ARGEO PAUL CELLUCCI `�\v 2 1Pg�E Lt.Governor J t� HOAgNpE S Com11.missioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F PART A CERTIFICATION Property Address:—P cl3 vex V.¢.�_ k Address of Owner. P Date of Inspection: �.sT�G6'� �— (If different) r. �'1. ot.. Name of Inspector: e.� Company Name, Address and Telephone Number. CERTIFICATION STATEMENT�!`� ���'ti�_VA p. � t a.�r�,�� v�{�yC� 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 inspection_ The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes .� Conditionally Passes t\eeds..Funher Evaluation By the Local Approving AuthorityFails Inspector's Sign��at...re c �� Date: vi The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: 1 have not found any information which indicates that the syst violates any of the failure criteria as defined in 310 CNIR 15.303. Any failure criteria not evaluated are indicated below, B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or epaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, fh, or ND)_ Describe is of determination in all instances. if"not determined", explain why not The septic tank is metal, cracked, struaurall unsound, shows substantial infiltration or exfiltration, or tank failure is imminent- The system will pass inspection f the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. {revised 1:/03/95) 1 'I _ { r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address;— Owner: �;'�l.VCis Date of Ins e¢tion. Bj SYSTF1+i,CONDITIONALLY PASSES (continued) x Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed -� pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): J� broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cj FURTHER EVALUATION 15 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for cohform bacteria and volatile organic compounds indicates that the we!I is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPM- 3) OTHER (revised 11/03/95' 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:Y-i ok Owner: '->A Date of Ins�ection: / D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as'defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. .'� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 i I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: �� Date of nT'spection: Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. PAs built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: L - Owner: 1/ /L� 44 Date of I�ctio`n� L ' Ct L ` © SlZ6l`7 FLOW CONDITIONS RESIDENTIAL: Design flow: 440 gallons Number of bedrooms: Oq Number of current residents:Jr • Garbage grinder (yes or no):_V Laundry connected to system (yes or no): � Seasonal use (yes or no): t-'16 Water meter readings, if available:_ (30 U$� Last date of occupancy:_V_zV--JK— COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: tU�JLS C UV %P f to o1 System pumped as part of inspection: (yes or no)_ If yes, volume pumped: ¢allons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system _ Single cesspool `gbow {�g Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) Y.b (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:i ! 3 n l I ) �_ vac Owner: ` f Date o Inspection: o s/2 6l5 SEPTIC TANK._ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ' integrity, evidence of leakage, etc.) GREASE TRAP:37 (locate on site plan) Depth below grade:- Material of construction: _concrete _metal _FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: "� OL Owner: ----��-- Date of --I— Date pection: TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: i Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:4 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:—ki'O (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of InIt tion:LA— ` �t o SOIL ABSORPTION SYSTEM (SA ):_45 (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of pondirtZ, co itio of vegetation,etc.) mac, , _ CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: V- 3N Depth of solids layer: Zq Depth of scum layer: root Dimensions of cesspool: Materials of construction: �n�_�rc� Indication of groundwater: inflow (cesspool must be pumped as part of inspection) On Comments: note cQndition o soil, signs of hydraulic failure, level of pond'n , condi • n 4f vegetatio , etc.) r c 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.) (revised 11/03/95) $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: -::I Lk-.)�L(•G ��'_ Date of Inspection: o -5-/26'!q SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' t LA g 20 DEPTH TO GROUNDWATER Depth to groundwater: '�G�j feet i �- method of determination or approximation: Y (revise? 1!/03/95) 9 PAR Real Estate? System - General Property Inquiry Help Parcel Id: 310 312- - Account No: 228685 Parent: Location.' -81 QUAKER RD HYANNIS Neighborhood: 63AD Fire Dist., HY Devel Lot: 36 Lot Size: . 35 Acres Current Own: WRIGHT, JOHN M TRS State Class: 104 P 0 BOX 579 �� '-Is - No. Bldgs: I Area: 1536 Year Added: W CHATHAM MA 2669 Deed Date'. Reference: C8180,M) January Ist: WRIGHT, JOHN M TRS Deed MMDD: 0000 Deed Ref: C81809 Comments: Values: Land: 20400 Buildings' 66500 Extra Features: 1400 Road System". 81 Index: 13:37 ( QUAKER ROAD ) Frntg: 114 Index' ) Frntg: Control Info." Last Auto Upd-' 050695 Status." C Last TACS Update: 080392 Land Reviewed By: Date." 0000 Bldgs Reviewed By: ML Date." 08::-:.7 Ta.x Title." Account". Tat-:en' Account Status: Hold Status: Cancel F'ress XMT for more data Next screen PAR Action Owners Name Road Index Road Name Parcel Number :310 313 I TOWN OF BARNSTABLE LOCATION: SZ C� :.... � SEWAGE # b VILLAGE. . ASSESSOR'S MAP& LOT ,jt6 -_,JjT INSTALLER'S PLE&PHONE N0. SEPTIC TANK CAPACITY C) LEACHING FACILITY: (type) ` (size) L U NO. OF BEDROOMS BUILDER 6R OWNER W.n j PERMUDA;I)✓'_ eI -2 - 7 COMPLIANCE DATE: - Separation;Distance Between the: Maximum`Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or.within 200 feet of leaching facility) Feet 'Edge of Wetland and Leaching Facility(If any wetlands exist within 300'feet of-leaching facility) Feet Furnished by . / F.l r O^SdqS { _ ' LEGEND goy Locus S 12'32'000W 80.00 x 98.9 _ I 9g PROPOSED CONTOUR ROUTE 28 LLAN 21173"F r1pe PROPOSED SPOT GRADE Etd LOT 36 1 EXISTING CONTOUR 10 MAP 310 , f I RCEL 312 W 110 EXISTING SPOT GRADE N 3 o Q�a CO '� ro 15,697fS.F, / 0 36 (J TEST. PIT. a Q D W EXISTING WATER SERVICE I k E�ar�d e Potton r Ave /� u� z L T 34 ro OH W-- EXISTING OVERHEAD WIRES � T 33 38 —� 1 UU I ro -- G EXISTING GAS SERVICE z r LOCUS MAP N.T.S. TP OI z ° EL98,9 if 1. ', � ram' m Z �I 1 I Ln x D d GENERAL NOTES: O m99,1 d tJ1 1. ALL'CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. of D BDX 1I m _ 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE L_ J m o o z LOCAL RULES AND REGULATIONS. Itft I I-•-13,2 m sp I 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 1 f I n -1 Q, D Z TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE I I f i o m N DESIGN ENGINEER. j j N j D z m 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING z FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN x N m D m _> I -i ENGINEER BEFORE CONSTRUCTION CONTINUES. Q j 99'6 _, 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 03 _m I 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF � ff - corrcre po tfo s THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 98 9 0 HEALTH- FOR PROPER INSPECTIONS DURING CONSTRUCTION. EXIST SEPTIC TANK x99.0 99.3x x rnx 7. WATER SUPPLY PROVIDED BY TOWN WATER. TOP DF TANK EL 96,78 �94% 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. INV.(DUT) EL. 95.4f m m I 9. SEPTIC SYSTEM COMPONENTS SHALL BE INSTALLED AS DESCRIBED EXISTING DUPLEX z z IN 310 CMR 15.000 SUBPART C. 2-2 BEDROOM UNITS 10. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED TO � I A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. BENCHMARK (#81/83) D 1 11. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE TOP CONCRETE PA EL:100.00(Assume T,O,F.=100,68+ THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING � CONSTRUCTION. 12. PROPERTY LINES SHOWN HAVE BEEN COMPILED FROM EXISTNG PLANS I AND DEEDS OF RECORD `AND ARE APPROXIMATE ONLY. THEY DO NOT q I REPRESENT AN ACTUAL ON THE GROUND PROPERTY LINE SURVEY. � i G� z 0 F l 4 �9C P TER T. i { 1 MCIVILE NF ROPOSED SEPTIC SYSTEM UPGRADE G� No. 35109 R�cis�E��o1 83 QUAKER ROAD, HYANNIS, MA N 13 10 20 EO 114.21 FSSIONAt E� red for: Paulo Cropalato, 81 Quaker Road, Hyannis, MA e SCALE DRAWN JOB. NO. by://�� ]� tpj,al� ringWorks 1 "=20' P.T.M. 114-02 QUAKER ROILL low Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 10/19/02 P.T.M. 1 Of 2 e 4d NOTE: TO PREVENT BREAKOUT, THE PROPOSED r. F.G. EL: 99.3t FINISH GRADE SHALL NOT BE < EL:95.43 r ­TGP_OF SLAB `` FOR A DISTANCE OF 15' AROUND THE EL:100.68# PERIMETER OF THE S.A.S. EXISTING F.G. EL: 99.7#(EXISTING) F.G. EL: 99.2#(EXISTING) � MAINTAIN 2% MIN SLOPE OVER S.A.S. N -B❑X TD ISTALL RISER OVER D 3_ INSTALL RISER OVER CHAMBER/S INSTALL RISERS OVER INLET & OUTLET �500 GALLON LEACHING CHAMBERS IN SERIES SHOWN ❑N PLAN AND SET C❑VER/S TO WITHIN 6" OF FINISH GRADE WITHIN 6' OF FINISH GRADE WITH 4' STONE ALL SIDES WITHIN 6' OF FINISH GRADE L =18' L =22'(MAX) J. 4" SCH 40 PVC 4" SCH 40 PVC 2' LAYER OF 1/8' TO 1/2' ®® �® DOUBLE WASHED STONE e 10' jL44' @ S= 1% (MIN.) 6' @ S= 1% (MIN,) ®®�®®®® (EASTON REQUIREMENT) EXISTING ,�' EXISTING Z' EFF. DEPTH, ®®®®®0� d 1500 GALLON INV. ELEV.=95.22 INV. ELEV.=95.15 3/4'-1 1/2' SEPTIC TANK 4' S'8 4. DOUBLE WASHED EXISTING STONE FFECTIVE WIDTH = 13,2' INSTALL INLET -& OUTLET TEES INV. ELEV.=94.93 -GAS BAFFLE TO _BE-INSTALLED ON INV.EL: .95.4# OUTLET TEE AS MANUFACTURED BY TUF-TITE, ZABEL, OR EQUAL TOP CONC. ELEV.=95.7 —BREAKOUT ELEV.=95.43 D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE moo® ON A MECHANICALLY COMPACTED SIX INCH CRUSHED ! INV. ELEV.=94.93 ®®�� STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). . ®®®®�®'a�aa BOTTOM ELEV.=92.93 4, 3 x 8,5' = 25.5' 4' 5' KIN, ABOVE BOTTOM OF EFFECTIVE LENGTH = 33,5' SEPTIC SYSTEM PROFILE , T.P. EXCAVATI❑N OR G.W. LEACHING SYSTEM SECTION NO G,W. ENCOUNTERED N.T.S. -BOTTOM OF TP EL: 86.9 (3) 5" DWOUTLETS �e\1� �F M4 f fy�y DESIGN CRITERIA � PETER T� ', s McENTEE NUMBER OF BEDROOMS: 4 BEDROOMS CIVIL iss• ' j- .I `- r e' No. 35I0� 6' SOIL LOG SOIL TYPE: CLASS I DESIGN PERCOLATION RATE: 2 MIN JIN. $S/pNAL \ H-10 LOADING 2' j-- -I DATE: OCTOBER 17, 2002 DAILY FLOW: 440 G.P.D. p�BCX SOIL'EVALUATOR: PETER T. MCENTEE P.E. DESIGN FLOW: 440 G.P.D \ `��0'L' INSPECTOR: NOT REQ'D 0` "T$ Q GARBAGE GRINDER: NO I I to LEACHING AREA REQUIRED: (440) = 594.6 S.F. I I M Elev. TP— 1 Depth 74 l s8.s A o" a i LOAMY SAND tOYR 3/3 EXISTING SEPTIC TANK: 1500 GALLON CAPACITY a„ ®®®® 0 ®®®® 98.4 F ®®®®®®®®®®® 33" B LOAMY SAND ®®®®®Ea®®®®® 10YR 5/8 USE 3-500 GALLON LEACHING CHAMBERS fN SERIES N ®ram®®®®®®®® ---- 96.6 28„ C1 SIDEWALL AREA: 2(13.2' + 335) X 2 = 186.8 S.F. toe" M-C SAND 13.2' x 33.5' = 442.2 S.F. 2.5Y 5/6 BOTTOM AREA: >20%GRAVEL TOTAL AREA: 629.0 S.F. 4" KNOCKOUT "ti 20" DW COVER HIV p�� �'l- �9- 1 92 2 C2 80 DESIGN FLOW PROVIDED: 0.74(629.0) = 465.5 G.P.D. 4" KNOCKOUT O�4" KNOCKOUT 62" "'..'.....'.,.`.""'..... .».�........ 2.5 6/4 PROPOSED SEPTIC SYSTEM UPGRADE concrete ;7� 1.1 i 10%GRAVEL 4" KNOCKOUT 1 81 83 QUAKER ROAD HYANNIS, MA BAa(..'F" Llf'* .�'uill.a�r�'ar'V1..9 869 144" Prepared for: Paulo Cropolato, 81 Quaker Road, Hyannis, MA 500 GALLON CAPACITY, H-10 LOADING NO G.W. ENCOUNTERED Engineering by: SCALE DRAWN JOB. N0. CHAMBERS PERC RATE: <2 MIN/IN. "C" HORIZONS NTS P.T.M. 114-02 S.A.S. LAYOUT I Engineering Works rLT.s. Ki.s 23 Deer Hollow Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. I (508) 477-5313 10/19/02 P.T.M. 2 of 2