HomeMy WebLinkAbout0082 SAINT JOSEPH STREET - Health 82 Saint Joseph's Street:
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St
Property Address
Cheryl Grimes
Owner owners Name
information is required for every Hyannis MA 02601 7-27-13
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.
Img out forms
When n A. General Information
on l the computer,
use only the tab 1. Inspector: y�`�P� gss9cti�i
key to move your
cursor-do not James D. Searsb ; J A M E S :m
use the return Name of Inspector
key. *.•
Capewide Enterprise LLC o '
: �
,®y Company Name -9, 1V T `• G��.`
153 Commercial St.
Company Address
raw
Mashpee MA 02649
City/rown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ F i1
= -=►
El Needs Further Evaluation by the Local Approving Authority
P-Ij��- 7-27-13
pedors Signature Date j0
The system inspector shall submit a copy of this inspection report to the Approving A1itthorityr--(%oard
of Health or DEP)within 30 days of completing this inspection. If the system is a shay sysf4im 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.
Ohl
t5ins•W13 riue 5 offidal r:Sb.,urtaw Sewage Disposal system•Page 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
't 82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is
required for every Hyannis MA 02601 7-27-13
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-3/13 Title 5 official Inspection form:Suburface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due,
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pop,')of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ z Liquid depth in mmwpW is less than 6"below invert or available volume is less
than%day flow .4 F%litiG
t5ins-3113 Title 5 Offidel Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes If the well water analysis,performed at a DEP certified
laboratory,for fecal coliforn 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.]
❑ ED The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3M 3 Title 5 Official Inspection Form:Subsw1boe Sewage Disposal System•Page 5 or 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in h r® ❑ y a 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 NIA)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
330
t5ins-3113 TiUs 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. Cityrrown state Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal.tank D Box and five infiltrator's
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes (D No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: PRESENT
Date
CommerciaWndustrial 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-&13 Title 5 Official tnspedion Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner owners Name
requ required
is Hyannis MA 02601 7-27-13
required for every
page. QWTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
4-6-12 Capewide
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/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 I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Oftiel Inspection Form:SubsuAace Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form•Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. Dityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
Tank 1982 permit 729/D Box and leaching 2005 permit#2005-384
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3'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.):
Pi in is 4" PVC SCH 40
Septic Tank(locate on site plan):
Depth below grade: 23"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. Precast
Sludge depth:
t5ins•3113 Title 5 a Offi al Inspeaion 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
�t 82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. Cityffown State Zip Code Date of inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Plan-TapeSludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank at working level. Tank and covers at 23"below grade.in and out baffles. No sign of
leakage or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3M 3 Title 5 MW Inspection Forth:SubsuRace Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yY 82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner owner's Name
requiredifo is Hyannis MA 02601 7-27-13
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Flame
information is required for every Hyannis MA 02601 7-27-13
-
page. City/Town 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 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-4' below grade w/cover at 32". Box is clean and solid w/one line out. No sign of
over loading or solid cant'over.
PumpChamber locate on site plan):
( P )
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3M 3 Title 5 Df oal Inspection Form:Subsurface Sewage Disposal system-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'f 82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5
❑ leaching galleries number:
® leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is five infiltrators. Camera out from box and ck. box. No sign of over
loading or solid carry over. No sign of holding water in leaching.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No ,
t5ins-3/13 Title 5 Oftel bispection Forth:Subsurface Sewage Disposal System-Pape 13 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Prhry(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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 or 17
• Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°t 82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is Hyannis MA 02601 7-27-13
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
' A E,4 A
e
13 —/ A
/2 A
A -3 = 3G
13-3 - 3 '7
t5ins-3/13 We 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
on Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope
❑ Surface water
Check cellar
❑ Shallow wells
N°
Estimated depth tofhigh ground water. 1 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: 8-4-05
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:
T.H. on design plan 84-05. No G.W. at 12'+ lot high..
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Offidal bspection Form:Subsurtace Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
82 St. Joseph's St.
Property Address
Cheryl Grimes
Owner Owner's Name
information is required for every Hyannis MA 02601 7-27-13
page. Citylrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
's
IDC.T`ION ^ J' 'S S 57r SEWAGE# �
f
VkLLAGE --�-'� A E SOR'S &LOT 01'f(-0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY `STD/
LEACHING FACILITY: (type) . �� Z'v.�lr (size)
NO.OF BEDROOMS
BUILDER OR OWNER oe i'►"-G
r,.
PERMITDATE: 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
b '
,.� Cr)UJ
y
S
7C% , (�
6 ,
No. Fee Ald r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS.
01pplication for Ziopoof *pztem Conelruction Permit
Application for a Permit to Construct( . )Repair( )Upgrade }Abandon( ) ❑Complete System /Undividual Components
Location Address or Lot No.� wnerame,Address;and Tel.lyoi 5
Assessor's Map/Parcel C �-
2 /
Installer's Ni Addressd Tel.No. C—C,��Q_�1--1�Q 1 esigner's�T7 A drS an T 1.No. 56`�!%L 5 rw,6 0I 'Q f 0 & la
o-tj � l UZJ/ 3 l
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 71t�� gallons per day. Calculated daily flow 3 � gallons.
Plan Date Number of sheets r Revision Date
Title
Size of Septic Tank V13D " Type of S.A.S.
Description of Soil U
0
Nature of Repairs or Alterations(Answer when applicable)
i
Q / C( e ✓ �i/Y�
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 b this oard of H 1 47
Signed Date 0
Application Approved by Dates -d.SA
Application Disapproved for the following reasons
Permit No. Dd — Date Issued �'�U�
No. :_ v` - Fee
THE-COMMONWEALTH.OF MASSACHUSETTS Entered in computer
Yes
PUBLIC HEALTH DIVISIO W-TOWN OF BARNSTABLES MASSACHUSETTS
- Appkication for 30i.5pool 6p.5tem congtruction permit
-_----' ' }`Application fora Permit to Construct( , )Repair'( )Upgrade)Abandon(. ) 1 Complete System /Undividual Components
Location Address or Lot No 5�- wner's Name,Address and Tel.N .
Assessor's Map/Parcel �, 6tnn�5 " 'ems ' 5
2 _
Installer's Name,Address,and Tel.No. C_ �7_�� Designer's ame Address.and Tel.No. } /
6 r vs�n- (� S{1�,1G-� �6 �r - b
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
F Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �?7b ( `hi,n gallons per day. Calculated daily flow 3 gallons.
Plan Date `�D Number of sheets Revision Date
Title /
Size of Septic Tank 1[ (iltlt! ;u ��n Type of S.A.S: ('t-)o ive-
Description of Soil lJ ' h
Nature of Repairs or Alterations(Answer when applicable)
r . vt.C'f /ZQ (,c —6tj CA C 1v P ✓" Cc�r�...
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system f"
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$y this Poard of He lth 7ny��,
Signed V Date C�V
Application Approved by Date��t
Application Disapproved for the following reasons f `r
Permit No. r'7Dd 1�_-- 3�y Date Issued ? —ar_
h
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance a pdou.- c
v THIS IS TO CERTlYY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded o)
Abandoned( )by kU br � E N
at , Cyr 2 has been constructed in accordance
with the provisi P f Title 5 nd the for Disposal System Construction Permit No. u 5/ dated
Installer t J Designer
The issuance of this permit shall not be construed as a guarantee that the syst m wihfu c io�n�a\s designed.
Date 1 R l 5 Inspector(
No.-v a ` Fee MC
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
�Digomf *pgtem Construction Permit
Permission is hereby granted to Construct( )Repair( )U grade Abandon( )
System located at R D- 54- 3-0 S p ..t
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 this pe it.� (�
Date:_,__X—ty- C/ Y Approved by
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
hereby certify that the engineered plan signed b me
� Y
dated concerning the property located at
meets all of the
\�
following criteria:
• This failed system is connected to a residential dwelling only. There.are.no commercial or
business.uses,associated with the.dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or.may conduct deep
test holes and percolation tests.at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) Na.
B) G.W. Elevation Q Q +adjustment for high G.W.2-4= cXoc. q
DIFFERENCE EN A and B.
SIGNED : DATE:
NOTICE
Based upon the above information; a repair permit will be issued for bedrooms
maximum.. No additional bedrooms:are authorized in the future without engineered septic system
plans.
-14
gASepae\percexemp.dac
Town of Barnstable
F °FT"E rq�, Regulatory Services
�• Thomas F. Geiler,Director
BARNSfAB14
1639. ,0$ Public Health Division
Thomas McKean,Director
.200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: I c
Designer: Shay Environmental Services, Inc. Installer: .
Address: P.O. Box 627 Address:East Falmouth,Falmouth, MA 02536
On OS Sly-C_ was issued a permit to install a
(date)' (installer)
septic system at C�� :�i6k . based on a design drawn by
(address) ���
Shay Environmental Services, Inc. dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
�y1N of*so
CARMEN ',
( nst er's Si na ure) E.
SHAY
No. '1181
�FcisTe
NIT R\
esigner's Signatur (Affix De i tamp Here)
PLEASE RETURN TO ARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
COMMONWEALTH OF MASSACHUSETTS
gal
EXECUTIVE:OFFICE OF-ENVIRONMENTAL AFFAIRS
_:.;
DEPARTMENT OF ENVIRONMENTAL PROTECTION
� f
I $ ® I
TITLE 5 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION RECEIVED. ,
Property Address: 82 St.. Johns-"Street JUL 2. 9 Z003
Hyannis, MA
Owner's Name: Scott G orcje TOWN OF BARNSTABLE
Owner's Address: HEALTH DEPT. -
Date of Inspection: I:—S 6-3 -
Name of inspector:(please print) Wi 1 1 i am R_ . Robi nson Sr. :MAP
a-
Company Name: . William E. Robinson Septic Service
Mailing Address P O_-Box 1089 PARCEL '-
Centerville, 'MA` '
Telephone Number: (5 0 81 7 7 5-8 7 7 6 LOT
CERTIFICATION STATEMENT
1 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 1 am-a.DEP
approved system inspector,pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Cl Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: (,i:, d j �.� Date: ?>s 0 3
0
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 bas 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Address:
Property �---
Owner.
Date of inspection `� CO.)
Inspection Summary•.
Check.A,B,C,D or E/ALWAYS complete..all of Section D
A. Syst Passes:
1 have not found any information which indicates of that an;aof ced e failure
ailur criteted ria
described in 310 CMR
15.303 or in 310 CMR 15.304 exist Any failure criteria n
I _
Comments:
B. stem.Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaire .The system,upon completion of the replacement or repair,as approved by the.Board of Health,will pass.
Answer es,no or not determined(Y,N,ND)in the for the following statements.if"not determined"please
explain.
Th septic tank is metal and over 20 years old`or the septic tank(whether metal or not)is structurally
unsound, xhibits substantial infiltration or exfiltration or tank failure-is imminent System will pass inspection if the
existing is replaced with a complying septic tank as approved by the 13oard of Health.
•A metal eptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND expl
bservation of sewage backup or break out or high static water level in the distribution box due wbroken or
obstru pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approv of Board of Health): are replaced
broken pipe(s) p .
obstruction is removed
distribution box is leveled or replaced
ND expla'
The ystem required pumping more than 4 tires a year due to broken or obstructed pipes).The system will
pass inspect on if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is ramorod
. R
ND explain: �_
Page 3 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A : .
CERTIFICATION(continued)
Property Address: 82 St. Johns Street
Hyannis., MA
Owner: grc)t-t Ganrae
Date of Inspection: 2-S-0 3
C F rther Evaluation is Required by the Board of Health.
nditions exist which require further evaluation by the Board of Health in order to determine if the system"-
is failing protect h'
health..safe
ty e or the environment.
P
1. Sys em will pass unless Board of Health determines in-accordance with310 CM11,1:5.303(1)(b).that the
syst is not functioning in a manner which will protect public health,safety and the environment.
esspool or privy is within 50 feet.of a surface water
_ sspooI or,privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System ill fail unless the,Board of Health(and Public Water Supplier,if any)determines.that the
system is:fu coning in a manner that protects the public health,safety and environment:
The systernhiis a septic tank and soil absorption system(SAS)and the SAS.is within 100 feet of a
surface m Ater 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.
- Th .system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a
privat water Supply Well**.
Method used to determine distance
'• s system passes if the well water analysis,performed at DEP certified laboratory,for coliform
"< ..bacte 'a and volatile organic compounds indicates that the well is free from pollution from that facility and,
the pre ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure riteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL SYSTEM,INSPECTION.FO
PART A
CERTIFICATION(continued)
Property Address: a2 s Tnhnr street
Owner:
Date of inspection:
D. S tem Failure Criteria applicable to all systems:.
You m t indicate"yes"or"no"to each of the following for all inspections:
Yes No
ackup of sewage into facility or system come of the u ound or surface waters deue to an overloaded or
ischarge or ponding of effluent to theaurfac gT.
ogged SAS or cesspool: .
_ S tic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or':
ce spool
_ Liq id depth in cesspool is less than below invert.or avai1.lable volume►s lessthan'/:day flow
Req ired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s):Number
of ti es pumped .
Any ortion of the,SAS,cesspool or privy is below high groundwater elevation.
Any p rtion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water upply.
'Any p rtion of a cesspool or privy is within a Zone 1 of a.public well.
Any,p" ion of a cesspool or privy is within 50.feet of a private water supply well.
Any po ion of a cesspool or privy is less than 100 feetbut greafer than 50 feet from a private water'
supply ell with no acceptable water quality analysis.(This.system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria.and volatile organic compounds
onia
indica es that the well is free from pollution from that facility ti that nothe cother fae of ilure criteria
nitrog n and nitrate nitrogen.is equal to.or less than 5 ppm,provided
are tr' gered.A copy of the analysis must be attached to this form.]
(YesMo) he system fails.I have determined that one or more of the above failure criteria exist as
descr ed in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Heal to determine what will be necessary to correct the failure.
E. Large Systems
To be considered a rge system the system must serve.a facility with a design now of 10,000 gpd to 15,000
gpd•
You must indicate ei er"yes"or"no"to each of the following:
(The following criteri apply to large systems in addition to the criteria above)
yes no .
the system is ithin 400 feet of a surface drinking water supply
the system is ithin 200 feet of a tributary.to a surface drinking water supply
the system is ocated in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or a mapped
Zone 11 of a ublic water supply well
or answered
If you have answered" es"to any question in Section E the system is cons tdered a significant;yst con idered a
"yes"in Section D abov the large system has failed.The t1wn�or he system in accordance with 310 CMR
ction E or failed under Section D upgrade significant threat under f the Department.
regional office o P
should contact the appropriate
g
15.304.The sys
tem own r shou PP
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEVYAGE DI SPOSAI SYSTEM INSPECTION FORM
CHECKLIST
Property Address: 82- St. Johns Street
Hyannis, MA _
Owner: Scott George
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
— Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in*the previous two week period,?;
— Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) .
V _ Was the facility or dwelling inspected for signs of sewage backup?
_ 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:
Yes no
— xisting information.For example,a plan at the Board of Health.
t/ — 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(3)(b))
5
Y
Page 6 of 1
k
OFFICIAL,INSPECTION FORM .:NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C=.
SYSTEM INFORMATION
82 St. Johns Street
Property Address: _
H=aririi G, MA
Owner:
Date of Inspection:_' -®3
FLOW CONDITIONS
RESIDEN...TFAL
Number of bedrooms(design):. Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x R o bedrooms):17`/D 'J�� Y
Number of current residents: Al A4
Does residence have a garbage fit' der(yes or no):
Is laundry on a separate sewage system(yes or no):,6v0 [if yes separate inspection required)
Laundry system inspected(yes or no): d
Seasonal use:(yes or no): A. 0
Water meter readings,if available(last 2 years usage(gpd)): r;, 4-1 0-0 3"`=1 1 9`;31 0 gals.
Sump pump(yes or no):-�?i°
Last date of occupancy:
COMMER IAL/INDUSTRIAL
Type of esta lishment:
Design flow aced on 310 CMR 15.203): ftpd'
Basis of desi flow(seats/persons/sqft,etc.):
Grease trap resent(yes or no):_
Industrial w ste holding tank present(yes or no):_
Non-sani waste discharged to the Title 5 system(yes or no):
Water met r readings,if available:
Last date f occupancy/user
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): A,
if yes,volume pumped:_gallons--How was quantity pumped determined? d6'crcv
Reason for pumping: _r 41 s b- L-v rJ✓k. 2C.
TYP OF SYSTEM
_Scptic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date in called(if known)and source of information:
6 0/ 7
Were sewage odors detected when arriving at the site(yes or no): di
6
c Page 7 of 11
OFFICIAL INSPECTION FORM-: NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)..... ..
Property Address: 82 St. Johns Street
Hyannis, MA
Owner: Scott George
Date of Inspection: r "0 3
BUILDI qG SEWER(locate on site plan)
Depth be ow grade:
Material of construction: cast von 40 PVC_other(explain):
Distanc from private water supply well or suction line:
Comm is(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: locate on site Ian
—( plan)
Depth below grade: ) t
Material of construction: concrete—metal_fiberglass—polyethylene
other(explain)
If tank is metal list age:y_ Is age confirmed by a Certificate of Compliance(yes or no):_.(attach a copy of
certificate) F j
Dimensions:
Sludge depth: C)
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: i
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: o L tyti3 '
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.): v
GREASE T —(locate on site plan)
Depth below gra e:_
Material of cons ction:—concrete_metal_fiberglass—polyethylene_other.=
(explain):
Dimensions:
Scum thickness:
Distance from toF of scum to top of outlet tee or baffle:
Distance from bo om of scum to bottom of outlet tee or baffle:
Date of last pum ing:
Comments(on p mping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outl t invert,evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM'
PART C
SYSTEM-INFORMATION(continued)..
PropertyAddress• 82 St. Johns Street
Owner: --ge
Date of Inspection: 7f e e 3
TIGHT or WING TANK: (tank must be pumped at time of inspection)(locate oasite plan)
Depth below 9 adc: - g _ y y
Material of co struction: concrete. fiberglass _p of eth lene other(expla�n):
metal
--------------
Dimensnofalann
Capaciallons
Design allons/day
Alarm no):
Alarm lAlarm in working order(yes or no):
Date o
Comm of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (tt present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: O q y m, evidence of .,
Comments(note if box is level and distribution to outlets equal,an evidence of solids carry over,any
leakage into or out of box,etc.):
PUbIP CHA BER: (locate on site plan)
Pumps in wo king order(yes or no):
Alarms in w rking order(yes or no):
Comments ote condition of pump chamber,condition of pumps and appurtenances,etc.):
---------------
Page 9 of I l
OFFICIAL INSPECTION.FORM-
NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 St. Johns Street
Hyannis, MA
Owner: Scott George
Date of inspection: !2 !=o o
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
ching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system .Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
CESSPOOLS: (cesspool 71111
pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet Yen:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of constructio
Indication of ground ter inflow(yes or no):
Comments(note co dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locat on site plan)
Materials of cons ction:
Dimensions:
Depth of solids-
Comments(no a condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
i
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNZ'A RY ASSESS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 St. Johns_ Street
Hyannis,
Owner: Scott George
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
g
U �
�1
10
Page l l of 11 '
OFFICIAL INSPECTION FORM-NOT FOR VO
LUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 82 St- Johns Street
Hyannis, MA
Owner. Scott George
Date of Inspection: —S"a
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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:
J-
You must describe how you established the high ground water elevation:
O l+b !xS q p
I1
I
°
i
TOWN OF BARNSTABLE
BOARD OF HEALTH
ii ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
Date 1 Time: In Out
Owner- ► � L 11� CS Tenant
Addressq0 0A(-'9PN5 RD Address �2 S �J 05 N S�l-
W. -TI5BLAP- . C�1A 4)(4non) tS , ma
Compliance Remarks or
Regulation# Yes NO Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply
5. Hot Water Facilities V O V 10/1)S O a
6. Heating Facilities IVila — 5E(
al
7. Lighting and Electrical Facilities
8. Ventilation tz
9. Installation and Maintenance of Facilities
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural /
Elements v
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal ) g
XP
17. Temporary Housing
18. Driveway Width Z (3P.,',5 F,Z
19. Number of Tenants Observed 1
PART II
37. Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allow ax)
Number of Persons Allowed (max).
.l
Person(s) Interviewed / 601 Inspector
If Public Building such as Store or Hotel/Motel specify here
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid.
USPS.
Permit No.GG10
• Sender::Please printyour name,address, and ZIP+4.inthis box.
i
I
Town of Barnstable
Health Division
200 Main Street
Hyannis,MA. 02601 I
a
SENDER: COMPLETE THIS SECTION" COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A ignature
item 4 if Restricted Delivery is desired. ❑Agent I
■ Print your name and address on the reverse X ❑Addressee
so that we can retu?n the card to you. B. Re ' by(Prints ame) C. Date of Delivery
e Attach this card to the back of the maiipiece, A✓,
or on the front if space permits.
1. Article Addressed to: D. Is delivery address di#e nt from item 1? ❑Yes
C If YES,enter delivery,ad W `below ❑No
\���
SE
P 5 2007�
C\7,'s) � , 3. Service Type
0 Certifiedail \O EV ess Mail
❑Registered El Retum Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2..Article Number I �pp3 1680 3004 5458 5323 '�
Mc(71ansferfrom see l abel)
PS Form 3811;February 2004 Domestic Return Receipt 102595-02-M-1540
c�
°pIHF r°wti Town of Barnstable
P °s Regulatory Services Department
+ BARNS-TABLE, '
MASS.
39
i639• Public Health Division
��
ArEO MAC A 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
August 22, 2007
Steven Barboza
10 Seaboard Lane
Hyannis, MA 02601
Dear Steven,
I am writing in regards to the new rental inspection that was conducted by
Timothy O'Connell, Health Inspector, on February 22, 2007. I spoke with the owner of
the property on July 19, 2007 and she stated all violations have been corrected. The
phone number provided on the application is no longer a working number. Please contact
me at your earliest convenience to schedule a re-inspection, and issue the Certificate of
Registration for the property.
Thank you in advance for your cooperation.
Respectfully,
Caitie Barrett
Rental Program Coordinator
Health Division
#508-862-4072
CERTIFIED MAIL# 7003 1680 0004 5458 5323
L
Town of Barnstable
Regulatory Services Department
+ RAMSTABL&
9 m i6gq39. Public Health Division
Qj �0
200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
July 19, 2007
Steven Barboza
10 Seaboard Lane
Hyannis, MA 02601
Dear Steven,
I am writing in regards to the rental inspection that was performed on February
22, 2007 by Timothy O'Connell. At the inspection,he observed some violations of the
State Sanitary Code, as well as the Town of Barnstable Code. I spoke with the owner of
the property on Thursday, July 19, 2007 and she stated all violations have been corrected.
I am writing to schedule a re-inspection of the property to ensure all violations were
taken care of. Please contact me at your earliest convenience so we can schedule this re-
inspection, and issue the Certificate of Registration for the property.
Thank you in advance for your cooperation.
Respectfully,
Caitie Barrett
Rental Program Coordinator
Health Division
#508-862-4072
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UNITED STATE TA4VW?I -Em. Ri f Y2-
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•Sender. Please print your name, address, and ZIP+4 in this box•
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Q Town of Barnstable
EOM. Health Division
200 Main Street
Hyannis,MA 02601
i'rr.:...r:�.rr. r►,:..,. r.r..rrr,..,►i...,.�r; rr..,rr.;.,r.t;r
COMPLETE •
■ Complete items,1,2,and 3.Also complete ikfiature
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the,card to you. B. Received by(Printed Name) C.,.pate of Delivery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes
If YES,enter delivery address below: ❑No
•� . (��ax to3
3. Service Type
�' Tt�7��c OZ s7S Keertified Mail ❑Express Mail
❑Registered QJ Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number r�
(Transfer from service labeo 7 O O 6 0 810 0066 3 5 2 4 8 6 2 2
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
Certified Mail#7006 0810 0000 3524 8622
4�ttt�ro�� Town of Barnstable
NAP 0
Regulatory Services
+ UARNSTABLE;
9 MASS. g Thomas F. Geiler, Director
1639.
ArfbMAta Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
February 28, 2007
Cheryl Betts Grimes
P.O. Box 103
West Tisbury, MA 02575
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 82 St. Joseph Street, Hyannis, was inspected
on February 22, 2007 by Timothy O'Connell & Meredith Morgan, Health Inspectors for
the Town of Barnstable. This inspection was conducted on the basis of the rental
registration in accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.351 —Owner's Installation and Maintenance Responsibilities.Kitchen
light with taped junctions for wire splicing.
105 CMR 410.482—Smoke Detectors. No smoke detector in basement.
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements.
Rotting and cracking deck boards on front deck; large black stain which looks like mold
and is a sign of chronic dampness; signs of chronic dampness in garage ceiling which
may be from leaking roof, stair tread in need of repair on cellar steps.
105 CMR 410.503 - Protective Railings and Walls. Guardrails on front deck only 27"
inches high when 36" is required; no balusters on guardrail on back deck; loose boards
on back deck.
QAOrder letters\Housing violations\Rental ordinance\82 St.Joseph Street.doc
The following violations of the Town of Barnstable Code were observed:
170-7—Posting of Owner's Information. Owner\Property Manager's name, address
and telephone number were not posted inside the dwelling.*
*Note: Once all the other violations have been corrected, you will be issued a certificate
of registration for the rental property. The certificate of registration will have all the
necessary information to satisfy the requirements of § 170-7 of the Town of Barnstable
Code.
You are directed to correct the violations listed above within twenty-four (30) hours
of your receipt of this notice by obtaining appropriate building permits and
repairing both decks (back and front) by repairing or replacing rotten and loose
boards; by making all guardrails at least 36" in height; by installing balusters on all
guardrails on decks; by installing smoke detector in basement. You are ordered to
correct the violations listed above within thirty (30) days of your receipt of this
notice by repairing or replacing stair tread leading into basement; by curtailing all
sources of chronic dampness; and by repairing wiring on kitchen light.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF T BOARD OF HEALTH
o a . McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc: Steve Barboza, Tenant
Cc: Timothy O'Connell &Meredith Morgan, Health Inspectors
QAOrder letters\Housing violations\Rental ordinance\82 St.Joseph Street,doc
Certified Mail#0000 0000 0000 0000 0000
Town Of Barnstable
x I 'dSTel$L& s
Regulatory Services
�$ �9: Thomas F. Geiler, Director
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
date
name
t®�
a dress—TtIA
city,state, ip
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY
CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. -
The property owned by you located at g� was inspected
on J— /)-)-/ 67 b To N P (Address)
y ! l , Health Inspector for the Town
(date) (Inspector's name
of Barnstable,
(Reason for inspection)
The following violation(s) of the State Sanitary Code were observed:
State code violation number-violation escri t'on
105 CMR 410.56o
it
105 CMR 410. v� - M"— fi rkvl DZIL/ \ -
Q:\Order letters\Housin.-violations\Rental ordinance\template.doe
M
105 CMR 410. 3S( eVj
The following violation(s) of the Town of Barnstable Code were observed:
Town code violation number-violation description
7
§170- - &jJ4L 4— T
§170-_-
You are directed to correct the violations listed above within ( ) •
'
of your receipt of this notice by 6& t (written#) (#) PAn4wt,
?�` 3Co _ y
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of $100.00 per violation. Each days failure to
comply with an order shall constitute a separate viol ion,
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Cc:
(Name,tenant,owner,Fire Dept.,Building Dept....)
Cc: -(L
(Health inspector's name)
(Generic codes located at QAOrder letters\Housing violations\Rental Ordinance\GENERIC CODES.DOC)
QAOrder letters\Housing violations\Rental ordinance\template.doc
FORM 30 ���� HOBBS 8 WARREN
,M THE COMMONWEALTH OF MASSACHUSETTS
• BOARD aHALTH
CIT /TOW qq t
DEPARTMENT � ry
'c,� ADDRESS O� wL
L
TELEPHONE
Address _ Occupant V .
Floor Al Apartment No. No.of Occupants
No. of Habitable Rooms —3 No.Sleeping Rooms___.-
No.dwelling or rooming units— N Stories.---
Name and address of owner _ -
Remarks Reg. Vio.
YARD Out Bld s.: Fences: (v- 1 ,,,,,
Garbage and Rubbish i s
Containers: /
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches: ' 10_ S0 i
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows: 45o (f) v '7 ✓�
Roof L-f(0-50 39
Gutters, Drains:
Walls: ' ✓✓
Foundation:
Chimney:
BASEMENT Gen.Sanitation: �J
Dampness: ��^- 71
Stairs:
Li htin : A
STRUCTURE INT. Hall,Stairway: 01
Obst'n.: (0 -
Hall, Floor,Wall,Ceiling:
Hall Lighting: 10- 13 S
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen. Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2 lD
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect..-
Stacks,Flues,V , t , afeties:
Kitchen Facilities n
\Stove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY "
INSPECTOR TITLE
A.M.
DATE TIME s
A.M.
THE NEXT SCHEDULED REINSPECTION
P.M.
tf re`y"56w :,rrl-:.+, sS7-a ,3`fi .t%`'^;f' Qeh +vi �'rrd+ t -•. yy..aia�hs ':t?+rslr�fiFar � f�w �. G,.f7r*�tS.ri"�".; r�++rr:►r;�
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410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises, shali be deemed conditions which may endanger or
impair the heaith, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
.prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 10 R 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105.CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A) and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner
to remedy said condition within the time so ordered by the Board of Health.
THE FOLLOWING
IS/ARE THE BEST
IMAGES. FROM POOR
QUALITY ORIGINALS)
IM ^ �
DATA
r :
OF BARNSTABLE .
LOCATION SEWAr-P id -,
VILLA
INSTE -
SEPTI
LEACI
__1 „ a)
NO.OIZu
PERMI :
Separat
Maxims Feet
Private ►,
on Si-. - -
Edge of .. .. - 1
within 300 feet of leaching facility) Feet
Furnished by
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isN
Ilk
Gee `
ell
37
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THE COMMONWEALTH 'OF MASSACHUSETTS
BARD ® HEALTH
4 . ... .. -----------------_
. .._ ..... ---OF...-.....
Avvitration -far billpl ial Works Tatt,itrurtion Vanift
Application is hereby made for a Per ' to Construct ( or Repair ( ) an Individual Sewage Disposal
Syst at
Location• dress Lot
--
Owner Add ess
--------••---- . . . •. ------. ..................
staller Address
Q Type Buildin �� Size Lot----------------------------Sq. feet
U Dwelling No. of B'e rooms.,_____��__________________________________Expansion Attic ( ) Garbage Grinder ( )
per, Other—Type of Building ._-_�_---�-___:_.._. No. of persons___________________________ Showers ( ) — Cafeteria ( )
Otherfixtures --- -----'--------------•----•--•---------•---------------•--•--------•-------------------------- =
W Design Flow- ---------------Sllons per person per day. Total daily flow._.________.__._.___.______.....__..._.._.._gallons.
P4 Septic Tank Liquid capacity/ _ _ allons Length________________ Width---------------- Diameter..........------ Depth___...___......
x Disposal T nch—)OX
...�_.._�,.._.____ Width--- _ r,Aal e ___-_- T al leaching area____________________sq. ft.
Seepage Pit No_____ ___'_._. Diameter _ ._'__ e ml .._.____ otal leachin area.__..______.___.sc. it.
---
z Other Distribution ( �) t��"` Dosing tank ( ) � �� �0/3//?3 -�
a Percolation Test Results erformed by----------- -------------- ----------------------------------------------- Date--•-----.----------------------•------..
Test Pit No. 1.........._./.---minutes per inch( Depth of "Pest Pit-------------------- Depth to ground water------------------------
*1utes Test Pit No. 2......... niin1utes per inch Depth of Test Pit.................... Depth to ground water--..-.-..__-_--.---_..__
� I ;
O -
Description of SoiL__________ ___ _____ _______________ �`
----- - -- ---------------------------------------------------------------------------------------------
xf ------ ------ --------------------------------------------•-------------------------------------------------------------------------------------------
W ------------- --------------
V Nature of Repairs`r Alterations—Answer,`when applicable..-------------- -------------------------- ------------------------- ........-----------------
--------------------------------------------- ----------------------------'•---•-----------------------------------------------•--•-•--------------------••--•------------------------------------....
Agreement:
The undersigned agrees to install the'aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XIlof the State Sanita ode— T e undersign d further agrees not to place the system in
operation until a Certificate'of Compliance ha b n issued the boar health.
1 igned-- ------ - ---•- . .•-•------ -------- •------------------•- •----------- ---•-••---••--
Date
Application Approved By........ . . ......... ............. Hate - ...
n
Application Disapproved jo'r-_the following rea+ons:------�i---------------------------------------------------------------------------------------------------------
' - -- .......................� ---yeli.,..........•---------------------------.......................................................
Date
Permit No.- �', . -Z -- Issued....................................................
&r` _ �"�, `� Date --.
H �
i
No... ...... ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH z
_..----- -------OF......... ...r...`..%?�(. -. :� ............... ..................
j
Appliratioo -for Ii-4posttl Works Towitrortioo Vantit
Application is hereby made for a Permit to Construct ( L or Repair ( ) an Individual Sewage Disposal
System at:
_ Location-!Address / A" `Lot No. �
"— Owner / Address
W
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
Dwelling-"—No. of Bedrooms---------------- -----------
-----Expansion Attic ( ) Garbage Grinder ( )
pal Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- --
W Design Flow__ _________________, ......gallons per person per day. Total daily flow___.______..__..r"I U__-_ �' ..__.gallons.
WSeptic Tank Liquid capacity--!_ gallons Length---------------- Width................ Diameter---------------- Depth..--------_---
Disposal Trench—No_ ___________ _____ Width•..-_-.-_-_-__:'-_.---Total Length_._-_____-__f----- Total leaching area--------------------sq. ft.
3 Seepage Pit No---------4--------- Diameter/%___�_,/ ';Depth lb'e�pw nl ----+=.rTotal leaching area------------------ ft.
z Other Distribution box ( ) Dosing tank ( ) e� . /'/C r'` " / ' f a ,' 7_ - /'"- it
aPercolation Test Results Performed by.......................................................................... Date----.----------.-----.-----.-----.------
,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water---._-____----.-__---.
C14 Test Pit No. 2......_---------minutes per inch Depth of Test Pit.................... Depth to ground water-_.-..-----..--_---..__.
-------------------------------------- ------------------ •----------------------•-----------------------------------------------------------------
D Description of Soil----------------------------------------------= ----_' - -_/.
x ,y . •-•---r. --••------•-----•- -----------------------------------------------------------------------
V -------------------------------------------------------------- -------------------•-----••-•----....--------•-•----•-•--••------•-------•----------------------•-----•----••------........--------
W
-
------------------------------------------------------------------- .......... --••-••--•---•------------•-••-------------------•--------•---- ------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...--...........................................................................................
------------------------------------------------------------------------------------------------------------------------------------------ -------------------------------------------------- ------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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, of health.
d ttll t i � �.'� ' I �C r 1A
Signed. - '----------- ---- �........................................................... --------------------•-.-------
A Application Approved B �� /'-/-____�_ _..._`.1'��'`�`�__G Date
PP PP Y --------------- -------------------------- ------------------- -------------------
Date_----•-----•-•
Application Disapproved for the following reasons:_____________________________________________/_____
----------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued........................................................
f$ Date
CV 0 0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF- HEALTH
/h..........OF......... .... -ti�L/t•�ii�''7G�/
. ............
................................
..................:..
r �Il
THIS IS TOI CERTIFY,jhatf.t e'Individual Sewage Disposal System constructed ( ) or Repaired ( )
by._...... - =-- ----- ---------------------------------•-------------------------------- ------------•---------•---
- ------
1 Inst filer
has been installed in accordance withtthe provisions of .Article'-XI of The State Sanitary Code as described in the
g^ z. t ' oN * ' ` "�-------- dated .. `.
application for Disposal Works�Cgnstructlon,:Permit No .............� �' �!��-�_�___�,�._._.:
THE ISSUANCE OF THIS 10ERTIFl8ATE SHAD NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM Wl L. FUNCTION ATISFAGTOR.
DATE. //✓� %---------------------------- Inspector---- --------- ----- Z�-----------------..-.--•--•--•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF/HEALTH
......................................... ................._.- ...........................................................No.-----�-=------`----- FEE----="C-------•-••---
,Dis:Vo,itt1 Work,,- Tooitrortion Prrmit
Permission is hereby granted-----------------------'......................................................................................................................
to Construct!( or-Repair ( ) an Andividual Sewage Disposal System,-
/�, ----
atNo.-----�•------•-----------•-•-•---•---•-••---,,;:r---,•---•--------------------------y-...-•--•------Street`-----------...-----•--•--/------•--•--%•--------��------•-••-•--•------
as shown on the application for Disposal Works Construction Permit/No.-----•.-e�---------- Dated_-& �__.::.__ r�`------
f /fr- vf/j--- 1
Board of Healtl
DATE...............................................................................
/f
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
-
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292-55001 00R, �,✓Y�vf
'y
W ILLIAM F.WELD f I``�ii� TRUDY COaE
Govemor « ' "Secretan
ARGEO PAUL CELLUCCI `
DA;VID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ±E �, r Commissioner
PART A
CERTIFICATION
82 St Johng Street Samuel Kaidf.man
Property Address: Hyannis, MA Address of Owner: 20 Dyer Avenue
Date of Inspection: 8-5-9 8 (If different) Milton, MA 02186
Name of Inspector: Wm E Robinson Sr
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Serv; rP
Mailing Address: PO Box 1 089, nter r; 1 1 o r MA 02632
Telephone Number 5 0 8 7 7 r_R 7 7 F
CERTIFICATION STATEMENT
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-si7P,
a disposal systems. The system:
s
_ Conditionally Passes
Needs Further Evalu on By the Local Approving Authority
_ Fails
Inspector's Signature: 14/�) Date:
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:
/yJ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ 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 conforming septic tank
.as approved.by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World
o d Wid
e Web: h a/www.ma netatate.ma. -
nP 9 us/dep
J Printed on RecyGed Paper
Z -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 82 St John' s Street, Hyannis
Owner: Kaufman
Date of Inspection: 8-5-9 8
`BJ SYSTEM CONDITIONALLY PASSES (continued)
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). Describe observations:
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 FUR T ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
onditions exist which require further,evaluation by the Board of-Health in order to determine if the system is failing to protect the
p lic health, safety and the environment.
1) SYS BEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
W RICH 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) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
T SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
EN RONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well.
The system has a septic 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, unless 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 (approximation not valid).
3) OT
(revised 04/25/97) Page 2 of 10
5�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 82 St John' s Street, Hyannis
Owner: Kaufman
Date of Inspection: 8_5—9 8
D] SYSTEM FAILS:
You must indicate eir,er "Yes" or "No" as to each of the following:
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.
Yes o
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 112 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] LAR E SYSTEM FAILS:
You ust indicate either "Yes" or "No" as 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
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 ow er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requir ents of 3.14 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 82 St Johns St, Hyannis
Owner: Kaufman
Date of Inspection: 8—5—9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or 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.
As 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:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 82 St Johns St, Hyannis
Owner: Kaufman
Date of Inspection: 8-5-9 8
FLOW CONDITIONS
RESIDENTIAL:
Design flow:-'C"_g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):.,,�—' V
Laundry connected to system (yes or no) l*3
Seasonal use (yes or no):Ito D
Water meter readings, if available (last two (2) year_usage (gpd): 5/9 6 - 5/9 7 - 7, 600 Cu f t 57, 000g
Sump Pump (yes or no):L0 5/97 - 5/98 - 5, 500 Cu ft 41 ,250g
Last date of occupancy: $•S-9�
COMM RCIAUINDUSTRIAL•
Type of tablishment:
Design flo :_gallons/day
Grease tra present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanita waste discharged to the Title 5 system: (yes or no)_
Water met f
readings, if available:
Last date f occupancy:
OTHER: ( escribe)
Last date occupancy:
GENERAL INFORMATION
PUMPING RECORDS a9fd source of information:
System pyAl3ecl as part of inspection: (yes or no),Lg,�,-5
If yes, volume pumped: Ions
Reason for pumping: d
TYPE O�,SYSTEM
_ V 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. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
o
Sewage odors detected when arriving at the site: (yes or no)�i C)
(revised 04/125/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 82 St John' s Street, Hyannis
Owner: Kaufman
Date of Inspection: 8-5-9 8
BUILD
NG SEWER:
(Locate on site plan)
Depth low grade:
Material of construction: _cast iron _40 PVC_other (explain)
Distance from private water supply well or suction line
Diamete
Comme ts: Sndition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on.bite plan)
� 3
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: `� a--
Sludge depth: CP °t
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness:_ t
Distance from top of scum to top of outlet tee or baffle: ° I
Distance from bottom of scum to bottom of outlet tee or affle: IV
How dimensions were determined: -Zi -<
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, epthpiquid 'level in re ion to outlet invert, structural
integrity evidence f lea etc.) �6 Jd�' /� S e
GREASE P:
(locate on to plan)
Depth belo grade:
Material of onstruction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions
Scum thic ess:
Distance om top of scum to.top of outlet tee or baffle:
Distanc from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping: 4
Comments.
(recommen ation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, a idence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 82 St Johns Street, Hyannis
Owner: Kaufman
Date of Inspection: 8_5_g 8
TIGH OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth low grade:
Materi of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dim sions:
Capa ty: gallons
Design flow: gallons/day
Alarm evel: Alarm in working order_Yes; _ No
Date o previous pumping:
Comm nts:
(condi on of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: l�
(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 CH MBER:_
(locate on 'te plan)
Pumps in w rking order: (Yes or No)
Alarms in rking order (Yes or No)
Comments:
(note con tion of pump chamber, condition of pumps and appurtenances, etc.)
.42
(revised 04/25/97) ��, Page 7 of 10 "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 82 St Johns Street Hyannis
Owner: Kaufman
Date of Inspection: 8—5—9 8
SOIL ABSORPTION SYSTEM (SAS):
(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:
Alternative system:
Name of Technology:
Comments:
(note condition of il, signs of hydraulic failure, level of pond g, con tion_ofyege ition etc.) J
Al
7 74
^1
CESSPOOLS: _ U
(locate on site plan) �, L
b
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 (cesspool must be pumped as part of inspection)
Comm en
(note condi 'on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on site Ian)
Materials of co struction: Dimensions:
Depth of solid
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(zevimed 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 82 St John' s St, Hyannis
Owner: Kaufman
Date of Inspection: 8-5-9 8
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Ps��)t�
/3a C
i)vl
' � 1
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 82 St Johns St, Hyannis
Owner: Kaufman
Date of Inspection: 8_5_9 8
Depth to Groundwater d
Z�L Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
(revised 04/25/97) Page 20 of 10
i,
No. Fee $5 0 .0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplication for Ziopo$AY *p$tem Con!aruction Permit
Application for a Permit to Construct( )Repair(x4 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 82 St Johns St Owner's Name,Address and Tel.No. 61 7—6 9 6—9 41 4
Assessor'sMap/Pazcel F annis Sam Kaufman 20 Dyer Ave
—� Milton MA 02186
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
- W E Robinson Septic Service
PO Box 1089, Centerville 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(no)
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic System consisting--
- of 1500g tank, D-box, and two concrete precast leach chambers.
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
Ais oazd of Health.
Signed i Date -
Application Approved by Date
v
Application Disapproved for the following reasons
Permit No. Date Issued 7 2�'
1 k -
No. Fee 50.00
THE COMMONWEALTHEntered in computer:
OF MASSACHUSETTS
1 Yes
PUBLIC HEALTH"DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
_ " Yicatiott for Migonl *paem Cow6tructiott Permit
Application for a Permit to Construct( )Repair(X Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
�; Location Address or Lot No. 82 St Johns St Owner's Name,Address and Tel.No. 61 7-6 9 6-9 414
'-Assessor's Map/Parcel H annis Sam Kaufman 20 Dyer Ave
Z Milton MA 02186
Installer's Name,Address,and Tel.No. 7 7 5_8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service
Box 1089, Centerville 02632
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder(no)
Other Type of Building No.of Persons Showers( ) Cafeteria( )'
- '✓ Other Fixtures
Design Flow gallons per day. Calculated daily flow =' gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic System consi st-i
ng-
- of 150na tank D bnx and t2m concrete precast leach cha_mhers$
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 this -oard of Health.
Signed.- ` Date �-.` " 9
Application Approved by Date
Application Disapproved for the following reasons
a.
5t�w
Permit No. 1� Date Issued_ 7- 7 8- 5YOr
-- --------.--.--.—.—.--_-------
" THE COMMONWEALTH OF MASSACHUSETTS
-BA^RNSTABLE MASSACHUSETTS
Kaufman
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (XX)Upgraded( )
Abandoned( )by
at _ 82 St Hohns St, Hyannis �T ,,hags been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.-� dated 7- Z - .
Installer W E Robinson Septic Service Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date_ 5' 1 .1 �l Inspector
No. "L
Fee$50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Kaufman Mwigpogal *pgtem Cott!tructiott Permit
Permission is hereby granted to Construct,(%' ).Repair(X:�Upgrade( )Abandon( )
System located at 82 St Johns Street
Hyannis, MA
Tnataller. W F Robinson Septic Ser$Rce
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 this permit.
Date: - �� Approved by ,
NOTICE: This Fore Is To Be Used For the Repair Of Failed �
Septic-Systems 0-1 -lv. I�
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISP®SAT, WORKS CONSTRT TC'TION PER1! IT (WI'THOtT"T
ENGINEERED PLANS)
4
i, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated 219 Y_ 9. _, concerning the
property located at 82 St Johns-Street, Hyannis, meets all of the
following criteria-
* There are no wetlands within 100 feet of the-proposed leaching facility.
* Thcrc arc no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands- the bottom of the
proposed leaching ucility will not be located less than fourteen(14)feet above the maximum adjusicd
groundwater table elevation.
Please complete the following:
A)Top of Ground-Elevation(according to-the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map) Z S
SIGNED: - DATE 2`" l
LICENSED SEPTIC SYSTEM INSTALLER IN THE'TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesscs a certified plot plan,
this elan should be submitted).
v
c
J
\ I
Y
A
r
i
r
ti
TOWN OF BARNSTABLE �+
LOCATION "L 5� h kr-J S Sfi2 —'�" SEWAGE # /p O "'SAPS
VILLAGE t4Vk 1rJTJ t S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. WM. F'Plob�_,vScctl� 560 lc —1175-8?7
SEPTIC TANK CAPACITY i S'a-o 5�—
LEACHING FACILITY: (type) 10(r C4,4MrZR5 (size)
NO. OF BEDROOMS c�—
BUILDER OR OWNER
PERMTTDATE: 7;�a��Pfc� COMPLIANCE DATE:T�f JS'�
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
;NOTE- ALL PIPES ARE TO BE 4" SCHEDULE 4Q P.V.C. - J
-10' min. from :S SECTION A A All 011 PPES FMW T rt<4.
Existing Foundation �house to septic tank _ PROFILE VIEW OF ADDITION TO LEACHING SYSTEM �F°0 T��sT82 FT. 12- CONCREW ooYErt #) �`�i_4
D BOX cover must be
TOP OF FOUNDATION $ ELEV. 100.00 (Assumed) Septic Conk covers must be within 6 in. of finished grade
a 9m SAS 99 00 - t- .- 3- S'OUTLET b.a„•. s 2 Nv H h / i�Fit°^,C Dx yxr f
6 In. of finLhed de sae & �
Grade over Septic Tank 99.0o Rode over D-Sox WOO over 3' Of 1/8 1/2 Washed Peost / KNoacou S E. / 1 '�'*" '�•j„
A\ 3/4' to 1 1/2 - Washed Crushed Stone :r ,P f agrts+ _
INLET
S - 0.02 3 HOLE H-10 4•N%c(CAPPED)NNSPECDON PORT`TO BE r f GuaET 01,
ST. BOX 3 Naxkmsn Cover Tap OF System-El �90.30 NNSTALLM AND To BE MRON 6'OF GRADE ! '
10 EXIST. S=0.o1 or Greater :. - ee Q issNNBi
ExTsr.PIPE - $ 1,000 GAL 10. S� 0.01•p� faot a 10"EHectNv.Depth - 1s 4" - SCH. 40 T 1.rs'
FROM EXIST. FOUNDATION w SEPTIC TANK r -
03 to
1s PLAN SECTION CROSS-SECTION ,
> D H-10 �o
CaNCREW rut-fOIANGA o u > °' 0.83' (10 inches) 5 Units E 625' 30' ,u"sltna
6 ll .3/4--1 1 - a � "M' � 3, 3L25' 31
3 HOLE H-10 DISTRIBUTION BOX # � M.+4N•^ ""
SYSTEM PROFILEcompacted stone o N7@m ccr,rosm.�rk` "`
A 37.25 �oeNt
cc c ° ° I rn NOT TO SCALE LMnAvt1T � .ava bt
Not to Scale - - ° > > 4' I 4' n Effective Length 4' %tw trty3e«gfytiroo7 i
° 3' o SOIL ABSORPTION SYSTEM (SAS) GENERAL -NOTES
b in.of 3/4'-1 1/2"' p 11' °
compacted none Q Effective ' ' INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE m 1. Contractor is responsible for Digsafe notification, Verification of Utilities
p - (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes.
w NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" 2. The septic tank and distribution box shall be set
level on 6 of 3/4"-1 1/2 stone.
Tabs_ Groundwater - Test Hole 1 Elev.= 88.00 (Adj. Per CAPE'COD COMMISSION ELEV. 90.40) 3. Backfill should be clean sand or gravel with no
v PROJECT ADJ. Groundwater = ELEV. 90.40 stones over 3" in size.
4, This system is subject to inspection during installation
P E R C 0 LAT I O N TEST by Carmen E. Shay Environmental Services, Inc.
5. The contractor shall install this system in accordance
with Title V of the Massachusetts state code, the approved plan
Date of Percolation Test: AUGUST 4, 2005 and Local Regulations.
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. 6. If, during installation the contractor encounters any
Results Witnessed By. WAIVER (per Barnstable B.O.H.) soil conditions or site conditions that are different
►J el .J rJ �J l Z, l EXCAVATOR: Shay Env. Svcs, from those shown on the soil log or in our design
Percolation Rate: Less Than 2 MPI ® 36' installation must halt do immediate notification be
(40 FOOT 'RIGHT OF WAY) ! �� l mode to Carmen E. -Shay - Environmental Services, Inc.
Test Hole Test Hole
O NO. 1 No. 2 ' 7. No vehicle or heavy machinery shall drive over the
O �- septic,system unless noted as H-20 septic components.
I_DEPTH ;SOILS Ell DEPTH SOILS_ ELEV. S. Install Tuf-Tate gas baffles or equals on all outlet tee ends.
--------------- -------------------------------.--___ 0 99.50 � 0 99.50 9• All Distribution Lines shall be 4' diameter Schedule 40 NSF PVC pipes.
Sandy Loam Sandy Loom
10. All solid piping, tees do fittings shall be 4' diameter
I 10 YR 3/2• 10 YR 3/2 Schedule 40 NSF PVC pipes with water tight joints.
� 0"-9' A, 98.75 0'-9" As 98 75 11. Municipal Water is Connected to ALL OF The Residence and Abutting
9z 68.42' - - ,� = Sandy Properties Within 150 Feet.
_ 9 10 YR 5/6 IG YR 5/6 ARE APPROXIMATE AND
`---- ___ 00 ,��� THE PROPERTY LINES
--------- L ���, COMPILED FROM THE SURVEY PLAN GENERATED BY
-- ��� 9-- 20- Be, 97.83 9"- 24' Be 97.001 _
94�`1' - 63 / Sand-Modium I SandMod I ENTITLED B"F"FOUNDATION OLOCATION SPLAN OF LOT38 ST. JOSEPH'S ST.,
1 CENTERVILLE, MA" DATED DATED MAY 1976 .
2b Y 7/4 25 Y 7/4 1 r r
9g, � i �\ 20'= 144 �' AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
\ / / \ C, 24'- 144
IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
THE SEPTIC SYSTEM INSTALLATION.
\ ' I EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE
�\ ----- ------- \\\ \ NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
FROM THE EXISTING LEACH PIT TO BE ,DISPOSED
\ OF AS PER BOARD OF HEALTH SPECIFICATIONS.
6 1-
THERE ARE NO WETLANDS ARE PRESENT WITHIN 2 0'- F THE
- 0 0 E
\ DECK O / \ Perc1
EXISTING i ���\ \ Depth at Perc: ,36" to 54" ASSESSORS MAP 291 PARCEL 041 -
LOT 39 \\ / / �\ � Perc. Rates 2 MPI
\ 2 BEDROOM
�� /� ���\ �-92 MIW29/ZONE C - INDEX = '7.5 for 7/05 j
\\\ SOUSE �� k`` SAC ADJUSTMENT = 2.4 FEET LEGEND
��� ,rOO OBSERVED H2O Elev. 138" or 11.5' below Grade
\\\\\ #82 104X 1 DENOTES PROPOSED
TEST HOLES SPOT GRADE
ELEV.= 99.50\\ �\ O�
EXIST. 1000 GAL. EXIST. o DENOTES EXISTING
X 104.46 SPOT GRADE
SEPTIC TANK / O� GARAGE '• --__ S ��I \���`.� ��}J
t0 / DECK 1 �� PL PROPERTY LINE
�00- _, • ``' LOT #38 �� �� � t 6P PROPOSED CONTOUR
3 18,000 Square Feet +/- \�\ \�
/94 - - -- --97 EXISTING CONTOUR
D-Box_ _ \
�-
-
_ ----------- DEEP TEST HOLE &
PERCOLATION TEST LOCATION
>1 5' EST HOLE #2 6 FOOT STOCKADE FENCE
ELEV.= 99.50 Leach Pit 273.32' \��� -
-
2-19" UAW ACCESS MANHOLES �� ♦\
.. ty.y P LOT P LAN
I PROJECT BENCH MARK
OF PROPOSED SEPTIC SYSTEM UPGRADE
NNVt.ET THE ACCESS COVERS FOR THE SEP,ttz TANK, TOP OF FOUNDATION
_ I aslseeultaa BOX AND tFna�+c COMPONENT ELEV. = 100.00 (Assumed) PREPARED FOR
, SET DEEPER THAN B NNCHEs BELOW FRMSFNED
- r QRAOE SHALL BE RAISED TO WIM 6'OF 0 20 40 50 M S. C H E RYL B ETTS
t FINISHED GRADE Pi AT rr rs -•g;i-.,F--r-•+--.-•es- r- �" ..INSTALL TUF-TnE CAS BAFFUM OR EQUALS ' _ y
-
•-°. y
STEEL REINFORCED PRECAST CONCRETE `
#82 ST. JOSEPH S STREET
PLAN VIEW ,
SCALE: 1 =20
3-24•,�ABI E H YA N N I S, MA
y 4• -: >; Design Calculations
NY"W.Tif min• iNet to wwt Na' Number of Bedrooms: 2 Equivalent to 220 Gal. Da 330 Gal. Da Min M PREPARED BY:min. rJaarv+os
_ . per Title V) /�/� u/� v
MET 10•ei,. UpN�Tivsi ,* ou1tET � Garbage Grander. No R N yGN CA�1IL �� E. �1111 l
- � Leaching Capacity Proposed: 330 Gol./Day Minimum (Min. Per Title V) m •
w E• ,4'-0'W.M. s' _r Septic Tank - 2 x 330 Gal./Day 660 USE EXIST_ 1,000 GAL tic Tank. v RPICIsS. INC.
�115�. eP �P ENVIRONMENTAL SE
o o.ers. tivoNd , SOIL ABSORPTION AREA: Using percolation rate of <2'min./inch 1
f Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. _ 273.8 gallons ,Q O P.O. BOX 627
Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons EAST FALMOUTH, MA 02536
Proving: 331.80 gallons a
: ,..
Tr-o'
4 -tNr TEL/FAX 508-539-7966
CROSS` SECTION END-SECTION Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS,' HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, ,
SCALE. 1 =20 DRAWN BY: CES DATE: AUGUST 3, 2005
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE
TYPICAL 1000 GALLON SEPTIC TANK ON THE ENDS. NO STONE UNDER. PROJECT#SD783 FILENAME: SD783PP.DWG SHEET 1 OF 1
QT TO SCALE -
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