HomeMy WebLinkAbout0037 SEAGATE LANE - Health 37 Seaga-fie-Lane
Hyannis
A= 249 - 146
1
i
TOWN OF BARNSTABLE �
NATION �j1f:�� TE Li9/UE �SEWAGE# l � ID
LAGEJ/11�s . ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. �� �i� ® �7
SEPTIC TANK CAPACITY E X i S<<!u ci /Dz)<S 3,41
LEACHING FACILITY:(type)C������ �� 3o5'O (size) 3(.s-q r 12.2/� 2�
NO.OF BEDROOMS.
OWNER ! 12.
PERMIT DATE: 3�S�D 7 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility P r Xt7 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) N Feet
FURNISHED BY Ir�Q�CU
a
Q
0
W
• r
TOWN OF BARNSTABLE
y`.
01ON 37 ca& — SEWAGE #
AGE ASSE/S/1SOR'S MAP & LOT 9
TaTCT A r r n � �r A�ter- a r1Lrlli�l�AT/l �� 1
q Q''wri xxv axry
SEPTIC TANK CAPACrN
LEACIENG FACILITY: (type) (size)
NO.OF BEDROOMS � eyo
BUELDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between@th�e
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
No,2007? Fee_lan —
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZppYicotion for �Digonl 6p5tem Con.5truction Permit
Application for a Permit to Construct(( ) Repair( ) Upgrade( Abandon( ) ❑ Complete System El Individual Components
Location Address or Lot No. 3-7SeAgrAJe k 0 Owner's Name,Address,and Tel.No.
fus a,,i & rLC�
Assessor's Map/Parcel /�
Installer's Name,Address,alld&&zANCO Designer's N e,Address and Tel.No.
350 Main Street lass n—er C^j MSS 3 /A 6
W. Yar
Type of Building:
Dwelling No.of Bedrooms Ll Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures 2
Design Flow(min.required) yyU gpd Design flow provided y 1 3 gpd
Plan Date / / Number of sheets Revision Date
Title
Size of Septic Tank T� S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 6 '4
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 Environment ode and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of e th. —7
Signed CC �CGGC L Date as
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued
No Fee
`x THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIpplication for Migboal *patent Cowaruction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. 3-7 Se,,_-( I ,4 4 e /�� Owner's l� Name,Address,Iand Tel.No.
Assessor's Map/Parcel L ��
Installer's Name,Address,and Tel.No. Designer's N me,Address and Tel.No.
38s. 3' a 6
Type of Building: v � I, _
_._ t � a i
Dwelling No.of Bedrooms ( -c w y Lot Size sq.ft. Garbage Grinder ( ) 1
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) f'yy90 gpd Design flow provided gpd
Plan Date /�1 12 ` Number'of sheets j Revision Date Aj)A
Title j%6c - -14 s i
Size of Se tic Tank
p /J�� Type of S`A.S'.
Description of Soil �,��" QL`]
r
f
Nature of Repairs or Alterations(Answer when applicable)--"
Datl last inspected:
Agreement: a
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in f 3•
accordance with the provisions of Title 5 of the Environment Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of .e th.
F Signed C!! t{ C L Date
Application Approved by Date
Application Disapproved by: Date _
for the following reasons
Permit No. -96 J046X Date Issued y`
— ————————————————————— ——--- ------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( Upgraded (x)
Abandoned( ),by �t!�
a at ��' has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. c dated
Installer Designer
#bedrooms T Approved design flow gpd
The issuarice of this permit shall jrotAe cons rued as a guarantee that the system will function as designed. k;.
Inspector
No Fee /VQ
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
Digpogat:*pgtent Con5truction 'Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( )
System located at 32c V
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: Co struction must be completed within three years of the date of this p i
Date Approved by.
I '
f
FROM FAX NO. May. 01 2007 01:50PM P2
Town of Barnstable
Regulatory Services
>: Thomas F.Geiler,Director
NAM . Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 509-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: s- 'O I Sewage Permit# 06o1 0 k:' Assessor's Map\Parcel 2�91 �fo
Designer: WS 946k. E/U&J RgJN(X Installer: A 0/\JC0
Address: P-0, 60,X 110 Address: 3'50 MAID 5 r
E, JdeNNl1 mh 674q ) Imo. HAR- OV114� MA 61473
On A CANCO was issued a permit to install a
date (installer)
septic system at 37 5 EA&AT:F LANF , H I ANN)S based on a design drawn by
(address) '
FA SS )Z1%'t rL eA/C-Ah6FrLJ N(7' dated.�1-7'D 7
/ (designer)
V 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 Re lations. Plan revision or
�.
certified as-built by designer to follow.
d� tHOF
111011AB1
Z
(Instal er's Signature)
(Design ' Signaffim) (AIM Designer' Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEAI.TII DIVISION CERTIFICATE OF
C MPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-B li �Xp ARE
MCKIYED JJY=RARNSTARLf,PL L1C HEA LTH DIVISION TUANK YOU
Q:Ifealth/SeptidDesi9w Certification Fotm 3-26-04.doc
Commonwealth of Massachusetts
— Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
VON
37 Seagate Ln. < �
Property Address
Bearse
Owner information is Owner's Name
required for Hyannis 1/
MA 02601 10/26/18 !
every page. Cltylrown State Zip Code Date of Inspection
to
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.
A. Inspector Information SI -(3qS
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Ci__r own State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. El Fails
- I
I
10/26/18
Inspectors ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
t
Please note:This report only describes conditions at the time of inspection and under the f
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.
` t
t5 rtsp.doc rev.7P26/2018 Titles Official Inspection Form:Subsurface Sewage Disposal System•Page r of is
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes: .
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y,N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
r
:Si6V.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N
❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment: }
- I �
t5insP.doe•rev.7/26/2018 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 3 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more1rom a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
� I
a
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
1 t5Ensp.rtoc•rev.7f2612018 f Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. Cltylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply. ;
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.El i
® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
I
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doq.rev.7/2812018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
-_ P Title 5 O ici�ae Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. City/rown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
r;i%p.poc•rev.7/262018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection (Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. City/Town State Zip Code
Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail r
" 4
1
i
Sump pump?
❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc rev.7/26f2018 inspection forth:Subsurface Sewage
� �._.a Title 5 Official Ins g Disposal System•Page 7 of 18
1
Commonwealth of Massachusetts
IVTitle 5 Official Inspection FormSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: No recent pumping per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp,Qog-rev.72612018 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 18
Commonwealth of Massachusetts
- -- Title 5 Official Inspectio
n Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components; date installed(if known)and source of information:
Septic tank per age of home, new d-box and SAS 2007 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 24"
feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: >10'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
tainsp.go:rev.7/26/2018 We 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Own er Bearse
information is owners Name
required for Hyannis MA 02601 10/26/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 18
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years —
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
Sludge depth: 3„
Distance from top of sludge to bottom of outlet tee or baffle >12
Scum thickness Trace-1/2"
Distance from top of scum to top of outlet tee or baffle-
Distance from bottom of scum to bottom of outlet tee or baffle >2
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Pumping suggested every 3yrs to prolong the life of the system
t5insp,0od•rev.712612018 Title 5 Official Ins
pection Form:Subsurface Sewage Disposal System•Page 10 of 18
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Own-,
Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
El 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: i
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
` ❑concrete ❑ metal
❑fiberglass ❑ polyethylene El other(explain.):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
15insp.doc` ,7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 or 18 I
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert oil
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.):
H-10 D-box appears to be structurally sound cover raised to 18"of grade
t.l5insp.doc`v.7/2612018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r
37 Seagate Ln.
Property Address
Owner Bearse
information is Owners Name
required for Hyannis MA 02601 10/26/18
every page. Cityrrown State Zip Code Date of inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ElNo*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 4
leaching galleries number:
1
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.do6-rev.7282018. Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 13 of 18
by
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
- 37 Seagate Ln.
Property Address
Own.. Bearse
information is Owners Name
required for Hyannis MA 02601 10/26/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System(SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
The infiltrators were video inspected and there is no signs of hydraulic failure, the effluent level is
approximately 12" below the invert at this time top of chambers is about T below grade
12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doo•rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
t5inse,d4o•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
AsBuilt
Page 1 of 1
TOWN OF BARNSTABLE
LOCATION 31 -611&¢I?E 114AC SEWAGE# (b ity-b (D
VILLAGE--A J �.ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO. �fp ! /Q/(�p �7 r•'� go0
SEPTIC TANK CAPACITY
'LEACHING FACILITY 3orj'0 (size) 3�•� �Z ZIAZ•
N0:•OF BEDROOMS
OWNER IJ�•12{ '
PERMIT DATE: COMPLIANCE DATE:.
Separation Distance Betweenthe: -�
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) F
FURNISHED BY
,2E9R at^ //ov C-
t
htt ://iss 12/intranet/ ro data/ rebuilt.as x?ma ar=249146&se =2
P q P P P P PP q— 10/26/201$
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. CltylTotun State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water. >12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 2007 NGW 144"
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
4'seperation per 2007 compliance
❑ Checked with local excavators, installers, (attach documentation)
® Accessed USGS database-explain:
TOPO mapping, Site is 54'msl and nearby surface water is 24'msl
You must describe how you established the high ground water elevation: t
See above
I
;
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
i
t5insp.doe-rev.702612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
a. �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
37 Seagate Ln.
Property Address
Owner Bearse
information is Owner's Name
required for Hyannis MA 02601 10/26/18
every page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1,2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
1
i
)
' r
9
r
• _ l
n t
A
t5insp.cloc_'yv.7l26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 i
V
February 25, 2007
To Whom it May Concern:
When we bought our house at 37 Seagate Lane, Hyannis, MA,we were told that the original owners
added the fourth,bedroom in the mid-1970's.
a
Yours Truly,
Susan T. Burke
nPri
PUBLIC
A]" - MAR 2 c37
\ ju
4 C ;1 ----------------
PPPP�1�lIQll\\\�
S
I
UNITED STATES POSTAL SERVICE �iet �s 1ti
` r... ..
I! �:`. �J+'3PS
Permit No.G-10
• Sender: Please print your name, address, and ZIP Iw 'box•
I
I i
PUBLIC HEALTH DIVISION
TOWN OF.BARNSTABLE
I 200 MAIN STREET
HYANNIS, MASSACHUSSETS 02601
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
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. Date 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
I
Ms Susan-Burke
17 Seagate Lane I
,Hyannis, MA 02601 3. Service Type
❑Certified Mail ❑Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from service label) 7005 1160 0000 0191 .2632
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
qa . �
ru
M G Gv rIM1
LLLL:,1L'�1
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0 3 DH.I.
Postage $ ,p Certified FeeoM Return Receipt Fee �� ))/�Q (Endorsement Required) •AM Restricted Delivery Fee
(Endorsement Required) sPs
rq /
Total Postage&Fees rs •Ip
u1
� Sent To
O
fSheet Apt = ------------------------------
orPOBoxNo.
City State,? 4
Certified Mail Provides:
A mailing receipt asanaa)aooaaunr ooeeufiodsa
e
o A unique identifier for your mailpiece
o A record of delivery kept by the Postal Service for two years-
Important Reminders:
o Certified Mail may ONLY be combined with First-Class Maile or Priority Maile.
o Certified Mail is not available for any class of international mail.
o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
n For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage'to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
o If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
Internet access to delivery information is not available on mail
addressed to APOs and FPOs.
Town of Barnstable
°F IME
Regulatory Services
Thomas F. Geiler, Director
r r
IARNSTABLF,
MASS.9� Public Health Division
ATFp.��.A
Thomas McKean,Director
200 Main Street,.Hyannis,.MA 02601.
Office:. 508-862-4644 Fax: 508-790-6304.
January 10 2007
Ms Susan Burke.
37.Seagate Lane
Hyannis,.MA 02601
ORDER TO COMPLY-WITH STATE ENVIRONMENTAL-CODE;-Title 5
The septic.system owned by you located-at 37 Seagate Lane;Hyannis, -MA was last
inspected November 24th 2006 by Mark Polselli a certified septic-inspector for the.State.
of Massachusetts. .
The inspection of your septic system showed that your system"Fails"under the
guidelines.of 1995.TITLE 5 (310 CMR 15.00)due.to the.following: - -
System is in hydraulic failure
You have 2 years from the date of the system failure to bring the system into.compliance.
If there are any.questions about this reminder,-please.feel free to.contact the Barnstable_ _w
Health Department..
w BARNSTABLE HE TH DEPARTMENT
Thomas.A..McKean,.R.S., C.H.O.
I Agent of the Board of Health
` COMMONWEALTH OF MksSACHUSETTS
j EXECUTIVE OFFICE OF E-TNgRO\'vIE--,\7T4A-L AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
C ,
f
oyM 5`w
C� q9
TITLE 5
OFFICI.AL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
�J CERTIFICATION
Property Address: / �C�Gt y ttit-
NN/ OoZ LO/
Owner's Name: ALr�.L
Owner's Address: ,3�} e q
Date of Inspection: 02// p T
Name of Inspector.: (pl se print) )ak-17 /D
Company Name /I/!i/o — TEG.� j �� _..,•,
5 ";3 Ga
Mailing Address: ,do
Telephone Number:(,Ep- ) 7�`jS—��"V[ -= c—)
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infor nation rep ned,i
below is true, accurate and complete as of the time of the inspection. The inspection was performed ased on snr,-
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP r-
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system M
Passes
C�12ffierr
Passes
' Evaluation by the Local Approving Authority
Fails
Inspector's Signature: c� /�F�'� iG, Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of i 0.000
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 a pro- ir.?
authority. / / n
Notes and Comments Se ��✓ 0 �� �G �✓ o<o�'►
W �
'***This report only describes conditions at the time of conditions inspection and under the
P ditlons 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 611512000
page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLLNVTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: SG�a Lam/
h Gi yl N
Owner:
Date of Inspection: "
Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D
A,.� System Passes:
have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 C_VIR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
/v One or more system components as described in the"Conditional Pass'section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the.Board of Health; will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it.is structurally sound;not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due.to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
\TD explain:
T41. E T"cnarr;n„
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT
PART A
�CERTIFICATION(continued)
Property Address:
Owner: U
Date of Inspection: o
C.�Fu�rther Evaluation is Required by the Board of Health:
/V Conditions exist which require fiuther 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 CINIR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety, and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public �k arer 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 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,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form_
3. Other:
T;tlo S
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI
PART A
CERTIFICATION(continued) .
Property Address: y e-
�'/f�
/� 1
Owner: 0.>k
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes >Dis�hap
of sewage into facility or system component due to overloaded or clogged SAS or cesspool
rge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
,.=gged SAS or cesspool
—/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
Lesspool y�
iquid depth in cesspool is less than 6"below invert or available volume is less than ',2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
✓(of times pumped
— y portion of the SAS cesspool or ivy is below high ground
water
elevation.
An portion of cesspool or privy is wit— y p p p y within 100 feet of a surface water supply or tributary to a surface
— Pp
1--�Vater supply.
_j_,Anyportion of a cesspool or privy is within a Zone 1 of a public well.
wry portion of a cesspool or privy is within 50 feet of a private water supply ;ell.
:?"-Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Nvater
supply well 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
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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
Q (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMT R 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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Xye
e system is within 400 feet of a surface drinking water supply
e system is within 200 feet of a tributary to a surface drinking water supply
e system is located in a nitrogen sensitive area(Interim wellhead Protection Area—nVPA) or a maned
Zo II of a public water supply well
If you have answer "yes"to any question in Section E the system is considered a significant threat. or ans«-ered
"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 v irh 310`01R
15.304. The system owner should contact the appropriate regional office of the Department.
Titles C incnortinn L'nrm �!1[/711l1h Q
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the follovo'ina.'
Yes No
✓>Pumping information was provided by the owner,occupant,or Board of Health
- c _ Were any of the system components pumped out in the previous two weeks?
L, Has the system received normal flows in the previous two week period•?
i
/`'—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\;A)
v — Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out
v — 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.
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)]
i
Paae 6 of 11
OFFICIAL INSPECTION FORT I—NOT FOR VOLUNTARY ASSESS- IENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 22
Owner
Date of Inspection: 0 t
FLOW CONDITIONS /
RESIDENTIAL � c 0 ✓�)
Number of bedrooms(design): 3 Number of bedrooms(actual): T, ��
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x of bedrooms): �f
Number of current residents: 9
Does residence have a garbage grinder(yes or no): /l/�D w �
Is laundry on a separate sewage system(yes or no): [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no):_
Water meter readings, if available(last 2 years usage(gpd#
Sump pump(yes or no):_
Last date of occupancy:
C O 1N LEI E RC IAL/IND US TRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holdinQ tank present ent(yes or no
) _
h on-sanita ryW3Ste discharged to the Title 5
t
system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspecti (yes or no): /f-;,P±
If yes,volume pumped: gallons--How was.quantity pumped determined?
Reason for pumping:
TI'P SI'STEM F
_ eptic 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,"te b:
obtained from system owner)
Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components, date installed(if kn'wn)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
Trtlo �Tncrartinn Fnr... �11 G/'1/lnn (.
r
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS1iENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1I
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: // A(,
BtiILDING SEWER(locate on site plan) � � � �C ��V7 OH
Depth below grade:
_Materials of construction:_ a�-cyst iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.)`.
SEPTIC TANK:_<Ioc�ateqon- site plan)
Depth below grade: /—
Material of construction:�conerete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age`_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 25-Ix
Sludge depth: oZ a 9 ,f
Distance from top f sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee of baffle:
Distance from bottom of scum to bottom of owlet teeyor baffle:_2—
How were dimensions determined: j-,2,^o h e
Comments.(on pumping recommendations;inlet and outlet tee or baffle condition.structural integnty,liquid levels
as related to outlet jvert, evidence of leakage,etc.):
h o 2e 54 o lc-1 Ce r 74, 7C
Gi G
GREASE TRAP: (locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal fiberglass_polyethvlene_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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, strucfaral integrity, liquid le eels
as related to outlet invert, evidence of leakage,etc.):.
T;rlo G T cr Art;�n L r �11 c/-innn 7
Page 8 of 11
OFFICIAL INSPECTION FORIVI—NOT FOR VOLUNTARY ASSESS-NTENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI
PART C
SYSTEM INFORMATION(continued)
Property Address: 29 Se.-, ACE
PiI ro
Owner: �w✓�C�
Date of Inspection: / 6
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_��olyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:&-"'(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into of out of box.etc.):
PUMP CHAMBER:A?�(Iocate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber;condition of pumps and appurtenances, etc.):
T;tlo G Tnena�tinr� F�rrr �/t f/7l1M
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR`I
PART C
SYSTEM INFORMATION(continued)
Property Address: �/ �G�e,;%
`7 ann fir,
Owner:
Date of Inspection: ///�L
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type /` 1� T�
leaching 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 ofponding,damp soil, condition of vegetation,
etc.): !✓� _/ _ C / -f /
/ H G l✓1 `t '� �1Oli�r� ' J O i 7)) �4 v�i C r1 c� S;4l A4 e eL
O✓1 Tm O T /a n A c' /Cy. '
CESSPOOLS:A/ (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 or no):
Comments (note condition of soil, sins.of hydraulic failure,level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of veaexaron etc.):
T;tlo : T»cnart;nn ,�„ 411 G/7Mn 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS -IENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: VG' �- j-
hRnr��f,
Owner
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.
a �
3
/q/-��
43
--��
d2TO
r;*io c Tncr arr;nn .,,,, ��i v�nnn 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSNNIENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
n
Property Address:
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water OZ 0 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:
Obsj�d site(abutting property/observation hole thin 150 feet of SAS)
Checked with local Board of Health-explain: �g�4 ter'
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must de ibe h iv you established gr�d watqr elevalion: /
y
Title C Tncnnrtinn T:nrm �iT cionnn 11
Iled
6e
9-e d,-o o V
U
l
Namj- ,A: F�s...�.:....`............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OE WEALTHOF........pliration for ioVooal orkii T.unotrurtion rrnnt
ppcaons hereby made for a Permit to Construct . or Repair ( ) an Individual Sewage Disposal
System at: !
.........� ...... .......
. ..A d dr ............ .............^ �' `6 .�'�`.....r,A Ld d t e
o
P ............................
s o ................................
Owner
..... ....................................... ........... .......
Intalrsle Address ..Q Type of Buildii Size Lot............................Sq. feet
U
Dwelling o. of Bedrooms............ .............................Expansion Attic ( ) Garbage Grinder ( )
P., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures .................
W Design Flo2Ldh—
....................:... ... . Ions per person per day. Total daily flow....... � .gallons.
.. ..
WSeptic TanLiquid capacity __._ allons Length................ Width................ Diameter................ Depth.___.___..._._ _
Disposal T o......._....I........ Wid h............. .. tal Len h.....___.___._.._.._ Total leachin area..._.__. . . s . ft 6Seepage Pit No._ __-_.__-_-- Diameter. �.�epth below Length
.................... Total leaching arsq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.....................al__..__.......____._....__......._..
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit----
---------- :.. Depth to ground water---________---.-________
t�
--------O Description of Soil................. _..._._. ._......�0_
x
U .--•---------•----•••--•---•----•--••----------•---------•-•-------•---•--•-••...............•--------•-•---•------•--•-••-....•••---•---•----•----••-------••._...•••---•...............-•-•----•••-----
W
,T,
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 provisionsrof 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 is ed by the board
of h 1th
{ Sign ......... -•-- ------------•. .
Application
'Approved B
Date
Application Disapproved for the following reasons------------- ............... ----- ......_..._... •--•-----------•-•--•-•--•--••-•-------•-•--•------_--••••
..................................................---------------------------------------------------------•-•.......................... -- . ------........................................
Date Permit No......................................................... t Issued.. ......... ....
6 Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
App irzalil"att for Dispinal orkii Touf rurtion Prrutit
Application is hereby made for a Permit to Construct "or Repair ( ) an Individual) Sewage Disposal
System at, fir .+ £-"//�/"� ! C r�L /
.......... „ *�,.•"� .....�..s .�,,:' ,. f: ,, ..... ,1�•f^°: ...fc' rxfss',rF^"+ ee+iz ............... .:: ..4 ...............
! h Addr s L or I.qt So: ,
..... �, fj+/ �.ss.•�e� ."^aw-ew.w-w.e-v..w.....a..e /a .d,N� �w was dst /...............................
Owner o6 ddr ss
Y
....` ......,. ................... ...w_�,d1 ,_. , r r�" r! ................................_.._...-•--•--
i `"� Tns:alIei Address
.....
d Type,of Build* Size Lot....:._.__w_________________Sq. feet
U Dwelling of Bedrooms....... _ ..................:__._Expansion Attic ( . ) Garbage Grinder ( )
p-, Other—Type _of Building ______________yp � ___._.._•_.__. No. of persons____________________________ Showers ( ) — Cafeteria ( )
a' Other fixtures ..............
W Design Flow__________________________ ~" llons per person per day. Total daily flow------- a � gallons.
WSeptic Tank Liquid capacl�� ' allons Length________________ Width____....._....__ Diameter....____.__...._ Depth................
x Disposal Trench—No ..........:..__... Width .. tal Length.................... Total leaching area sq. ft.
Seepage Pit No ___________ Diameter._�,!� th below inlet;......:_._...:._._ Total leaching area_.� q. ft.
Z Other Distributiofi box ( ) Dosing tank ( ) �-
�" Percolation Test Results Performed by--------------- -- -- ... ,..... ........ Date....
Test Pit No. I................minutes per inch Depth of Test Pit_................. Depth to ground water-------------------;_"..
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
--
O Description of Soil -: r I ------ ----------------------------------
U -=-•-----------------................................... ..................................... ............................ ...............................................................
..........------=------------------..............................................................................--•-------------------------------------------------....................................
U Nature of Repairs or Alterations—Answer when applicable...__.........................................•..:..___._...__.........__.__.___._..._......._..
.......--_w--------------------•---•-•----•------------••• ---------- ----- -------------•-•-•-------
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 board of health.
f/
j ir3 Date
Application Approved B "�` "-
- .. ----' at,
.e;4
Application Disapproved for the following reasons----------------------------- ........._........------.....--•-------------...-••.........__...........
-w--------------------------•-----------------------------------------•-------•---------w-----"-----"-........................................................................------••----•-••-----••-
6 Date
Permlt No. --------•----• •-••----••--..........••....._.. Issued
Date,•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF) HEALTH
f ,
...........OF........
IS IS TO CERTIFY hat the Individual Sewage Disposal System constructed ( or Repaired ( )
',Mir,
-�
has been installed in,accordaiaee witla''the,prop isions of Article h of The Stately} e as described in the
application for Disposal Works Comtruction Permit No_______ ___ --------- dated. _ _ .✓; ,_�_ __, �^
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA tANTE6 THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 0-e;
DATE..... Tns ector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,
........../....t!�Z� . ...........OF......
F.o ._... ✓ FEE.........................
19ispoa#1 Workn T ,itrurfintt ramit
Permission s. eby granted : )� '' ..._.
i --••-
to Constru ( or Repair ( )-an I lcidua! wage Disposal s em
at No...., _. y, . •-•_....
.� ^ - i ....
r
� ... St
rt
as shown on the application for DiCpcisal Works Constl uc lion P � No... :__._. Dated:__xj ,..yt•-••-•-.
r ''� I f y�,t �, "
Board o Ilcaltl-��`
DATE _... --
FORM I? 5 08IRS W REN, INC_ PUSL]SHERS
N KEY: .
EXISTING CONTOUR: - - - SEPTIC SYSTEM DESIGN SEPTIC SYSTEM SECTION
PROPOSED CONTOUR: -................_
LOCUS 4 EXISTING SPOT ELEVATION: 25.5 2" PEASTONE
FLOW ESTIMATE: COVERS WITHIN 12" OF
PROPOSED SPOT ELEVATION: 25.5 FINISED GRADE " "
TEST HOLE:
4 BEDROOMS AT 110 GAL DAY = 440 GAL DAY IOO,92 3/4 -1 1/2
4f (ONE INSPECTION COVER WASHED STONE
UTILITY POLE: -U- TOP OF FOUNDATION TO BE WITHIN 6"OF GRADE)
FENCE LINE: - - SEPTIC TANK: 3' MAX.
r" y � COVER INSPECTION PORT
�Q HYDRANT: 440 GAL/DAY x 2 DAYS = 880 GAL (1' MIN)
RETAINING WALL: 97 26 ELEV.= 96.5
USE 1000 GALLON SEPTIC TANK (EXISTING) 98.53
7s 97.5 i ELEV. rT
t t" ELEV.. (EXISTING)
PINE ST z ELEV.
LEACHING AREA: (EXISTING) (EXISTING) 97.17 97A o 0 94.0
ELEV.
USE 4 INFILTRATOR CHAMBERS(MODEL 3050)WITH 10W GAL ELEV. D-BOX E4 ELEV.
SEPTIC TANK
4' OF STONE ALL AROUND (36.4' x 12.2' x 2' DEEP) (EXISTING) (6" OF STONE UNDER) e 36.4' - �
TEE SIZES: (TO BE CONFIRMED)
LOCATION MAP SIDE AREA: (36.4' + 12.2')x 2 x 2 = 194 SF (0.74) = 144 GAL/DAY INLET:6" UP, 13" DOWN 96.0 4 INFILTRATOR CHAMBERS(MODEL 3050)
LOT 4 (10.152 SF) OUTLET: 6" UP, 14" DOWN GAS BAFFLE WITH 4' OF STONE ALL AROUND
ASSESSORS MAP: 249 PARCEL: 146 BOTTOM AREA: 36.4' x 12.2' = 444 SF (0.74) = 329 GAL/DAY AT OUTLET TEE ELEV. (36.4' x 12.2' x 2' DEEP)
PLAN BOOK: 194, PAGE: 153 CAPACITY = 473 GAL/DAY
FLOOD ZONE: C
TH-1 99.0 TH-2 99.0
TEST HOLE LOGS LO/A HORIZONOAMY SAND ELEV. LOAMY SAND ELEV.
BATH BED 8„ IOYR 3/1 98 3 7„ lOYR 3/1 98.4
BED ROOM ENGINEER: THOMAS McLELLAN,P.E. B HORIZON B HORIZON
ROOM WITNESS: DON DESMARIAS,R.S. LOAMY SAND LOAMY SAND
BED 30„ 10YR 5/6 96.5 30" IOYR 5/6 96.5
ROOM DATE: 1-12-07
PERCOLATION RATE: < 2 MIN/IN C HORIZON C HORIZON
Znd FLOOR MEDIUM SAND MEDIUM SAND
WITH GRAVEL WITH GRAVEL
2.5Y 6/6 2.5Y 6/6
144" 1 87.0 132" 88.0
NO GROUND WATER ENCOUNTERED
KITCHEN�ATH BED
ROOM NOTES
DIN LIVING 1. VERTICAL DATUM: ASSUMED
GARAGE ROOM ROOM
2. MUNICAPAL WATER IS AVAILABLE.
3. SCHEDULE 40-4" PVC PIPE TO BE USED THROUGHOUT SEPTIC SYSTEM.
1st FLOOR
4. ALL PRECAST UNITS SUBJECT TO TRAFFIC LOADS TO CONFORM WITH AASHTO H-20 LOADING SPECIFICATIONS.
- 5. PIPE PITCH = 1/4" PER FOOT(UNLESS NOTED OTHERWISE).
G_FLOOR PLAN
EXIST�N
6. FIRST 2' OF PIPE OUT OF D-BOX TO BE SET LEVEL.
----1 7. THE SEPTIC SYSTEM HAS NOT BEEN DESIGNED TO ACCOMODATE THE USE OF A GARBAGE DISPOSAL.
FENCE .�
8. ALL CONSTRUCTION DETAILS ARE TO BE IN CONFORMANCE WITH THE STATE OF MASS. ENVIRONMENTAL
CODE(TITLE FIVE)AND LOCAL HEALTH REGULATIONS.
EXISTING 9. Z LEACH PIT9. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION.
�
(SEE NOTE 11) \ 10. GROUND COVER OVER ALL SEPTIC SYSTEM COMPONENTS NOT TO EXCEED 3'.
lEXISTING
OQO GALLON // W 11. EXISTING LEACH PIT IS TO BE PUMPED AND FILLED WITH SAND OR REMOVED.
SEPTIC TANK 12. FIELD SURVEY PROVIDED BY THE HOOD SURVEY GROUP, MASHPEE, MA.
LP EXISTING
EXISTING
4 BEDROOM
BENCHMARK AT DWELLINGS 92
CORNER OF CONC. STEP ` top fnd._
ELEVATION = 100.0
ST
g
} GARAGE PAVED DRIVE
K \ 99.2 98.1 �►
\ M
0
'~ �. . . . x TH-2
. .'
98.5 p
MIN
TH-1 G
HE FENCE \
`� rn
AMIN
SITE FLAN
94.00'
99
98.0
LOCATION:
37 SEAGATE LANE, HYANNIS, MA
OF PIASJ. PREPARED FOR.
MCCLEL
ctVIc.
SUSAN BURKE
9No.36471
F 4 P SCALE: 1" = 20' DATE: 1-17-07
BASS RIVER ENGINEERING
~ THOMAS McL LAN, P.E. P.O.BOX 1163, EAST DENNIS,MA 02641
508-385-3426
JOB#M6-63