HomeMy WebLinkAbout0155 SEVENTH AVENUE (HYANNIS) - Health 155 Seventh Avenue
Hyannis
A= 245-050
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TOWN OF B.ARNSTABLE LZ
L ATION ���., /" "/' �- SEWAGE # �
VILLAGE 1
ASSESSOR'S MAP � LOT
INSTALLER'S NAME 6z PHONE NO.
SEPTIC TANK CAPACITY Ono ',,a d-d A-1
�tvw
LEACHING FACILITY:(type) ° FG v5 ca2S (size)
NO. OF BEDROOMS PRIVATE WELL OIL PUBLIC WATER
BUILDER OR OWNER fy\r -f\MJs w 2
.DATE PERMIT ISSUED:
DATE .C011$LIANCE ISSUED:
VARIANCE GRANTED: Yes No i-"
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cA a rr
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b� THE COMMONWEALTH OF MASSACHUSETTS
.BOARD OF HEALTH
..........................................
�� �► Appliratiun for Disposal Works Tonstrur#iun Errant
Application is hereby made.for a Permit to Construct ( ) or Repair ('--�an Individual` Sewage Disposal
S at: 5b 5 S�o L.o
. .... ..._ ____'-----......._........... ::' --............._...._...
.... ..........w.... - !ti! ?_ ....._ d ............._.._......
Location-Address or Lot No.
..........rn !.:___.... :.\.S�: --..................................... --.....----•------------�' } ?ti:2........................................._........
c--� Owne Address
W .._._.. ...._...4C.! :e. 5.---•..............................:. .............. . ?' .� !-? .5�. --......_...
Installer Address
Type of Building Size Lot............................Sq. feet
............................Ex Garbage Expansion Attic Grinder
U Dwelling—No. of Bedrooms............... p ( ) g ( )
P4 Other—Type T e of Building No. of persons............................ Showers — Cafeteria
fir yP g ------------------••---•-•-- P ( ) ( )
a' Other fixtures .------•---•----•-------•----------•-------....:...................:...•-.........-•---------------•--•-------•-•------•-•••-•-•••-•------------.._...
Q _
Design Flow......-.J._.�.......................gallons per person per day. Total dai17 flow....... gal
WW �� ... Ions.
Od Septic Tank—Liquid*capacityZ0.720.gallons Length... .......... Width...5......... Diameter................. Depth................
Disposal Trench—No..-../............. Widthli?.......... Total Length._e3k.a.!....... Total leaching area-..._...._.........sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
-------------------•---......------------
•-----------
•........................................................................................
0 Description of Soil..-•-------=----•...........................•---------------••--•---------•-•-••-----------------•----------.._...........---............------••--••-•-................
W .......•------------------- -•-------•-----------._.....-------------------------•-•••----....... ...............---
UNature of Repairs or Alterations-Answer when applicable.... .`ram 1__...._............. .. ..........T
...................... �. ..... U..t�-- Tf.�✓� flaw ! ......... ........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b
-acen issued by the boar iea
Signed........ . ............••. .-----
r Date
Application Approved By............. -� ...................................
Date
Application Disapproved for the following reasons:...........................................................................................................---
----•--••------------------------•------......_.....-------------•--............--------...----------.............---........----...------......--------•-•---.........-•---•--••----•••-.............__
Q Date
PermitNo......'1••7 -.. .f ................ ... Issued................ ..--•-----.....--.........._..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF....... '�A v V...!�.66. .....................................
Appliration for Disposal Works Tontrurtion Vrrmit
Application is hereby made for a Permit to Construct or Repair (`')an Individual Sewage Disposal
System at: -556
.........: .--.... :`.. :� ............................. ....................�41l wW VL
Location-Address or Lot No.
............. ........................S `.P.:.......--...........................-.......
........
Ow ��• Address
......-•................. ........... . --............----
Installer f t �'� '"�� Address'` =
q� Type of Building "'� Size Lot. Sq. feet
Dwelling—No. of Bedrooms.......�............................................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ...........................: No. of persons-:" � ......_._...._ Showers ( ) — Cafeteria ( )
==
D ................................
WW Other fixtures .............................................................. .:'-........_ ....
C� Septic Tank—Liquid capacity� gallo ser day: Total daily flow....... ....................gallons„
�..7 D Design ... ....gal
os, per person Length..•............ Width.. .�_._... Diameter................ Depth:..............
Disposal Trench—No.._../............. Width.?W......_._._ Total Length.. .a 1....... Total leaching area...................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet..................... Total leaching area_................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit................:`. Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground.water........................
x -•...--•........-- ........................ .........................................................
0 Description of Soil...........................................................,........---...............--•---<--------•-•---........:----•----...---•---------••-----•----••------------•
W •-•--•-•-•----------------------------•••-----------•-•-----------------------------................--------•----------------•------•.._..------------•---•-..........-•-•-----.._._.....__......._...
' . U Nature of Repairs or Alterations-Answer when applicable_.... ..........
9y�s1 ..... �� cv�� l�t�.:. �,� r S�.�rs----- l / 2 �fiG.K .........
,....... �. ......._....
Agreement:
The 'undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board o -l—i"ad h. s
L�.Sign
Date
----------
Application Approved B c �
PP PP Y.............U....�-:.�._. _.e.�n:r:.—.—:--�......---._.._..._........_........ ........................................
.._._.., •---•---- .............
Dart .
Application Disapproved for the following reasons:--<--------------------------•---------------..........------...-------------------••-......._......------
................... ........•--.•----^....-•----...------........................................-------...........----•-------............................................ . -----------•.
Date
PermitNo...... ................._.... Issued.-------------- ....--•---•-- ............._
Da
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4� � �
OF....... T��-................ �...............................
Trrtif utttr of Tomplittnrr
THIS IS TO CERTIXY,That the Individual Sewage Disposal System constructed ( ) or Repaired ()�
by.....:...... � ................:2�...r --- --------.......----•----•-------•-----•-----.----•--------------------------...--.----..--.--.------.---------.----•-
Installer
-------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for. Disposal Works Construction Permit ::........... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 1\
DATE........................'. ' �-O— 5"� -- Inspector t ��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Disposal Worker TunotrWi an jrrmit
Permission is hereby granted.............�....__:_.....�-� _.�3 I..�c._ _ ._....
to Construct () or Repair ( G)—an Individual Sewage Disposal System
at No.: - •- �T /� u r /�__ �.........`�... -•--•-.._............................
...... ............ ---------•••----.L2.-----..._..------...... .
Street _
as shown on the application for Disposal Works Construction Permit Nof 7..j!L Dated......................
(7 Board of Health
DATE..----------•----•-•---------------•----•-.................................•.
Commonwealth of Massachusetts
_ Title 5 Official Inspec ion Form
Subsurface Sewage Disposal System Form = Not for Voluntary Assessments
155 7th Ave:^M
Property Address:
Sonja Pliner
Owner Owner's Name
information is .
required for eve.ry.. Hyannis Port .'-MA 02647 8/1.0712
page. -City/Town State Zip Code Date of Inspection - -
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
_. Important:When:filling out forms A. General Information
on the computer;
use only the tab -
1. Inspector:
Key to move your
cursor-do not. Ricky Wright
use the return
key. Name'of Inspector
B & B Excavation;Inc.
r� Company Name
14 Teaberry Lane ...
Company Address
renori
Forestdale 02644.
. . MA: .
City/Town State Zip Code
508-477-0653 S 14595
" Telephone Number License.Number )
1 5
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 properfunction and maintenance of on site
sewage disposal systems. I am a.DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15:000). The system:
...
®. Passes, El Conditional) Passes
y ❑ Fails: ; ' .
El.,Needs Further Evaluation by the Local Approving Authority
8/10/12 a .. _..
Inspector's Signature . Date
t.�.
The:system inspector shall submit:a copy of this inspection report to the Approving Authority(Board
of Health or.DEP)within 30 days of completing this inspection. If the system is a shared system or
` has a design flow of 10,000 gpd or greater, the inspector and the.system owner shall submit the..
report to the appropriate regional office of the DEP. The original should be sent to the system owner
. ..:and copies,sent to the buyer, if applicable, and the:approving authority
***.This report only describes conditions at the time.of inspection and under the conditions of use'
at that time-This inspection does.not address how.the'system will perform in the future under .
` thesame or different:conditions:of use.,:
2
t5ins•11/10::: N L Title 5 Official ins onrrm�iu4bsurface Sewage Disposal System.•.Page 1 of 17
t r ....} I
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form -Not for Voluntary Assessments
155 7tn Ave.
Property Address
Sonja Pliner ;
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)'
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: *".
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
,,
Comments: ,t
" «
• z
13) System Conditionally Passes:
❑ Onenor'more system components as described in the "Conditional Pass section need.to be 4 " -
t replaced or repaired.The system, upon completion ofthe 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,"note :;
w determined,"please explain. k ,
} 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
C : Compliance indicating that the tank is less than"20 years old is available.
<, E Y_-, ❑ N. ❑ ND (Explain below):
r 4
- - } F,S
o
t5ins-11/10,- ` ,y' " Title 5-0ffcial Inspection Form:Subsurface Sewage Disposal System;Page 2 of 17
A"x' +
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 155 7th Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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):
r `
❑ 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 FIND (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:
'y❑ -Cesspool or privy is within 50 feet of a surface water g`
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
155 7th Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647, 8/10/12
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 ,
w, �' ® Static liquid level in the distribution box above outlet invert due town overloaded
or clogged SAS or cesspool
El 1z Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y2 day flow
t5ins•11/10- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 155 7th Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is
required for every Hyannis Port MA 02647 8/10/12
page. CityfFown 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.
❑ 0 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 2000gpd-
10,000gpd.
0 ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 0
f
Commonwealth of Massachusetts
_ W Title 5 Official Inspection :Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°~ 155 7th Ave:'M !
Property Address..
Sonja Pliner
Owner
Owner's Name •'' '
information ie Hyannis Port MA 02647 8/1.0/12
required for every.. y
Cltyrrown State Zip Code,' ° ` • Date of Inspection
page.
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
❑ Z 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 Arid 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 breakout? r
®' El,. 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,
wo 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.): 2 Number of bedrooms (actual)-. 3
DESIGN flow based on 310 CMR 15.203.(for example: 11.0 gpd x#of bedrooms):
220
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r
°M 155 7th Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes Z No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
'Laundry system"inspected? •❑ Yes Z No
Seasonal use?.. : ❑ Yes ® No
Water meter readings, if available last 2 ears usage n/a
9 ( Y 9 (gPd))�
Detail:
. Sump pump?, ❑ Yes R. No
Last date of occupancy: 2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203)- Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes 'El 'No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 155 7th Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
page. Cityrrown State Zip Code Date of.Inspection
D. System Information (cont.)
Last date of occupancy/use: ry Date
Other(describe below):
General Information
a
Pumping Records:
Source of information: a
}
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons Y
How was quantity pumped determined?
Reason for pumping:
Type of System: t �.
® Septic tank, distribution box, soil absorption system
❑ . Single cesspool
❑ Overflow cesspool
El 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
El Tight tank. Attach a copy of the DEP approval.
El Other(describe): ,
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 155 7t'Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)'
Approximate age of all components, date installed (if known)and source of information:
1987
Were sewage odors detected when arriving at the site? _ ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3.5
feet
"Material of construction:
❑,cast iron ® 40 PVC ❑ other(explain): -
Distance from private water supply well or suction line: >20feet,
Comments (on condition of joints, venting, evidence of leakage, etc.):
Aftime of inspection building sewer appeared to be in working order no sign of leakage or blockage.
Septic Tank(locate on site plan):
_
Depth below 2.5 grade: feet -
Material of construction:
®;concrete ° i ❑ metal ❑fiberglass ❑ polyethylene ' ❑other(explain)
If tank is metal, list age:
years f. .
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate), ❑'Yes ® No
Dimensions: 1000 gal
Sludge depth: no sludge
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17
k. �.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 155 7th Ave.
0.
Property Address
Sonja Pliner
Owner Owner's Name
information is Hyannis Port MA 02647 8/10/12
required for every H y -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle no sludge
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance,from bottom of scum to bottom of outlet tee or baffle no scum '
How were dimensions determined? scour stick
Comments (on pumping recommendations, inlet and outlet tee-or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound ,no sign of back-up.
Grease Trap (locate on site plan): t
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 155 7th Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is Hyannis Port MA 02647 8/10/12
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete. ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
. gallons ..
Design Flow: gallons per day i
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.):
f
` *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface sewage Disposal System.,Page 11 of,17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 155 7th Ave.
Property Address ;
Sonja Pliner r
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
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-
Y
r
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.):
At time of inspection d-box appears to be structurally sound no sign of deteration,or leakage.
t
Pump Chamber(locate on site plan):
Pumpsain working order: ❑ Yes ❑ No
Alarms in working order: Y ❑ Yes ❑ .No.'
Comments (note conditionof pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate-on site plan, excavation not required): `
~ If SAS noflocated, explain why: ,.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
155 7"Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® , leaching galleries number: 2-flow diffusers
❑' 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.):
At time of inspection leaching was dry and appears to be in good condition.No.sign of hydraulic
failure.
s
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
• Number and configuration
DDepth—top of liquid to inlet invert
-Depth of solids layer
Depth of scum layer • R
Dimensions of cesspool
a Materials of construction
Indication of groundwater inflow ❑ Yes [:] 'No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 155 7th Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every y H annis Port MA 02647 8/10/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: t
Dimensions
Depth-of solids r
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,-
etc.):
..•F ` ,- „ ; - ' .,. o�� . , , �'• ram..
t
r•
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of'17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
,M 155 7tn Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647. 8/10/12
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
o101 ..
Cr
9a= .23 -
A� = -2(o
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15'of 17'
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments
155 71h Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar t
® Shallow wells
Estimated depth to high ground water: >8
feet
Please indicate all methods used to determine the high ground water elevation-
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date - r
® Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: •`
0 Checked with local excavators, installers-(attacli docurrientation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation: `
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 155 7th Ave.
Property Address
Sonja Pliner
Owner Owner's Name
information is required for every Hyannis Port MA 02647 8/10/12
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
•
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:Page 17 of 17
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' ZONING DISTRICT: RB DISTRICT
N
N
N MIN. LOT SIZE 43,560 SQ. FT. '
MIN. LOT FRONTAGE 20' g a h R
MIN. LOT WIDTH 100' rpigvil
MIN. FRONT SETBACK 20'
MIN. SIDE SETBACK 10' r st
MIN. REAR SETBACK 10'
L cus can
LOCUS IS WITHIN FEMA FLOOD ZONE B & A10 (EL. 11)
AS SHOWN ON COMMUNITY PANEL #250001 0008 D Q
DATED JULY 2, 1992
(ELEVATIONS BASED ON NGVD) Nantucket
TIDAL CREEK (MHW) IS 194' TO PROPOSED DECK Sound
(EXIST. PATIO IS 193')
WETLAND FLAGGED BY
HAMLYN CONSULTING LOCUS MAP
EXIST. 3 BEDROOM SEPTIC SYSTEM TO SCALE 1"=2000'f
REMAIN
(NO INCREASE IN BEDROOMS PROPOSED) ASSESSORS MAP `245 PARCEL 50
SITE IS LOCATED WITHIN AP OVERLAY DISTRICT
I
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O 00 W
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W
w m ¢J x11.18 11.29
PROP. WORK LIMIT LINE OI W 10 10.72
EXISTING OF STAKED SILT FENCE a ZO �, 9.03 0
POST & RAIL N 157.00' .0
FENCE \ HEDGE x 8.07 � �; 2 ,,0
bo
9.69 I
HEDG
E I 8.78 OAKS
4 17 x x 5.7 r� `I�/
9.51
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00
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-.- 3
0.0' x71 48. 5O
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x 5. 1 LG. 0 L EXISTING HOUSE ; 8.93 x .10
'o �T P FNDN. EL. 9.9 8.81 8 6
o F.F. 11.1' C
XJP. I �'EXIST. ST \ \ x 9.08
I w O ZS 2 8.60 8.668.90
�.
Z IN
x 5.50 \ 8.86
1 LAWN 15.5' !: LAWN \8.51 eV2
15.0' \ 6182
xk8.4#2 .3. cs \ G
HEDGE
5.20 N EXIST. SAS 8 8, k .46 6 8 93
.a 6 c
2
.
TO PROP D CK 3 7. 8 RE-BUILD EXIST. CHIMNEY �89
6 I io HEDGE
8.92
• .55
#1
EXIST. PATIO WITH PROPOSED DECK WITHIN BENCHMARK: C. BASIN
HEDGE SURROUND EXIST. PATIO FOOTPRINT AT EL 8.9' NGVD
(TO BE REMOVED) PROPOSED STEPS
f PROP. 5'
WIDE BUFFER
PROP. NATIVE PLANTINGS, IN
CONSULTATION WITH CONSERVATION
AGENT - SIZE & SPACING T.B.D.
DEPENDING ON TYPE OF PLANT. (REFER
TO CAPE COD COOPERATIVE EXTENSION SITE PLAN
SERVICE [IN BARNSTABLE] PUBLICATION:
"TREES AND SHRUBS FOR COASTAL
ENVIRONMENTS") SHOWING PROPOSED DECK
IN PLACE OF PATIO
AT
155 SEVENTH AVENUE
OF W. HYANNISPORT
�e:fj��,SN ow Ass ;� Sqo
DANIEL PREPARED FOR
LAIJIELA. A. ERIN EPKER
off 508-362-4541 �0 OJALA OJALA
fax 508 362-9880 CIVIL No.409 0
JANUARY 7, 2013
down cape engineering, inc. ��� �rsTER�C �`� eUR ss� Scale:1"= 20'
Cl VIL ENGINEERS k --J
V LAND SURVEYORS vFMENE
s39 Main Street - YARMOUTHPORT, MASS. DATE DANIEL A. OJALA, PE', PLS 0 10 20 30 40 50 FEET