HomeMy WebLinkAbout0158 SEVENTH AVENUE (HYANNIS) - Health Seventh-Avenue
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TOWN OF BARNSTABLE 7
LOCATION !� 1/ '49 SEWAGE# 90 0 —31
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHQNE NO. A 11 (� TIC
PR e.V
SEPTIC TANK CAPACITY 1-50- 0f XCD,DC,
LEACHING FACILITY:(type) , (SOD er2u W-10CkAWV5 (size) .9%.;,X ;f
NO.OF BEDROOMS
OWNER Qic VoO Agca0 w-e/
PERMIT DATE:,. ibJ�c7�� COMPLIANCE DATE: / J�
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Jr � � 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
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TOWN OF BARNSTABLE, -
LOCATION SEWAGE# 82oIs- 3 'M
VILLAGE IV, rt//7 ASSESSOR'S MAP&PARCEL S-0 70
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INSTALLER'S NAME&PHONE NO. / lam-l/S/ck
SEPTIC TANK CAPACITY /moo GA-/. ('ice 10.)
LEACHING FACILITY: (type) (S6 �1z — A, (size)
NO.OF BEDROOMS
OWNER ��C�� A.Cc LltsZ
PERMIT DATE: COMPLIANCE DATE: U (k
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlarids exist within
300 feet of leaching facility) Feet
FURNISHED BY --� S�! �/ / °✓l O�//} (S/. C)A
77A. i"n Tb Ek(i I`I;If Fes ,. 01 -J-4
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a �1
� �'b,2C�J �CICA�n o.•`l
yod` a
No. tr�4 .,��y`� Fee
�= THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ftpYication for Disposal 6pstem Construction Vertu
Application for a Permit to Construct( ) Repair(/) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 136 5evavf'k.kvv_ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel yts 0 70 �h
Installer's Name,Address,and Tel.No. Designer'i Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms \ Lot Size /'��CX�O sq.ft. Garbage Grinder( )
Other Type of Building 't CAS 1 a 0,4 Ft.� No.of Persons Showers( ) Cafeteria( )
Other Fixtures
+ Design Flow(min.required) I, `)p gpd Design flow provided 3 3 y r,S- gpd
Plan Date /0 AaC,lilco-Q Number of sheets Revision Date
Title
Size of Septic Tank cyjaii-s DIpg loco crag-p.L Type of S.A.S. jCJ5r0Ckd%M ¢4 ')Q
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) kr�E��� c* tae z JMA rzyam6r on o_sno 4ed 6r,�
q—try &nan as C,s.6VOW') o"J O[A
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 1/ 07/902D
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. ,2a Qt4 ��?j Date Issued M.( ,Z
0 „(+n*n►r.^hf`+�an.,r..T•s°#:'�'..�-.•-,;.,+'1ja.,r,..y.,,.y.sfF ��.Nv�,�.,���`FF.�.,du 'c� .'c. �. r....� k,.r.-.e�.+:�•ni::�- �x..��,"�k.•.,�..•�d"s,. ""w ;' '°�ti;
1Vo `fib --?��-l� r Fee
THE COMMONWEALTH OF,MASSACHUSETTS Entered in computer: Yes
=PUBLIC HEALTH DIVISION TOWN',,'OF BARNSTABLE, MASSACHUSETTS
f plication for Disposal bpste-m Construction 3pPrmit
' Application for a Permit to Construct( ) Repair(Upgrade,( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 15'6 s'eVwd-k Ape f l#W:1 Owner's Name,Address,and Tel.No.
f 4+ a
Assessor's Map/Parcel yJf d 7 't'm O l. Ar, 514
Installer's Name,Address,and Tel.No. Designer's`Name,Address,and Tel.No.
� t 15rc.w a 08e0oo-7/Sr N �,�C'P/,n✓ Gc ,IBC
Type of Building:
Dwelling No.of Bedrooms \\ Lot Size 12;000 sq.ft. Garbage Grinder.( )
Other Type of Building -t ftk l V tVv 1{tti 1 No.of Persons Showers( ) Cafeteria( )
xzti Other Fixtures
Design Flow(min:required) '°}O gpd Design flow provided )I Al,S' gpd
Plan Date 10h cl000-Q Number of sheets Revision Date '
Title
Size of Septic Tank CXt.gtirv� o1 p � D.0 Type of S.A.S. SGC c�>��NC Vli,ntiCpFC 14 y b
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) '' yc,�j c-, ,Sp,,,) 't7J`yio rkaAA69f rwc) 'O . wo ae.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed /" -----� Date
Application Approved by ® A Date f
Application Disapproved`by a . Date
for the following reasons r_
Permit No. 71g3 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate,of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired(�)__�Upgraded
( )
_. Abandoned( )by ')_ 17 (w o T t 3 C N
at / C.,�.,P-AA A.Je- N v,.0et a C% 'e :A d has been constructed in accordance
with the provisions of Title 5 and the for Disposal"System Construction Permit No: 6 dated
Installer -.,L /=pphi Designer
#bedrooms "7, '� °Approved design1low, ' '(' 4 r ' gpd
The issuance of this permit shall not be construed as a guarantee that the system will furiction,as designed. /
Date 1 &I ZU Inspector
No. ✓ ?l _ •--._ - - _ - Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION BARNSTABLE MASSACHUSETTS
p
Permission is hereby granted to Construct (�1►�� �OttgtrUCtIOII>�Errnit YJ -
Y ~ ,Upgrade( ) Abandon( ^)
System located at / '1 1)OVI-A A o e. 41%1 1WAl f$
I
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. :.. . r
Provided:Construction must be completed within three years of the date of this permit.
Date l-lJ IqI Approved by
I
aFWEE r�
Town of Barnstable
�oT Regulatory Services
Richard V.Scali,Interim Director 'I,
snxxsznaM
"�; �0�at
Public Health Diirision
°rEa,Notm Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fay: 508-790-6304
Installer&Designer Certification Form
Date: II II Sewage Permit# 2- -3L ' Assessor's Map\Pareel `Z-kS—T'7G
Pc �- 'f''1 C.
Designer: �=Y�c ,`,,ee�.'n� t v cs 1a1, Installer: �,j 1ti L
Address: )Z. wi Address:
1::jr,P,s,-d4 Le. M! 6 z6qq C�.t�•�w,t� 022�,�i�
On W 1�A (—.a, was issued a permit to install a
(d te} (installer)
septic system at_j 5 c5 ��- /Avt gla�ed on a design drawn by
(address)
.eer'i Nc✓LLs.Jk( dated
(designer)
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. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
g o Strip out(if required)was inspected and tIre soils
were found satisfactory.
I certify that the system referenced above was constructed in with the terms
of the 1\A approval letters (if applicable) y'A
nstaller's Signature) cl%I%L
gyp.351'09
O
(Designer's Signature) (Affix Designe ere)
PLEASE RETURINT TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:'.Septiv-Designer Certification Fonn Rev 8-14-13.doe
Engineers note:This certification is limited to an as-built inspection of system components as installed prior to backfill.The
engineer did not supervise construction of the system.The installer assumes responsibility for all materials,workmanship,backfilling
to specified grades with proper compaction and setting risersfcovers as shown on the design plan.
No. 015 ._3 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZippliCation for 33ispo8al 6pstem Construction pertn t
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 5 Av+e. Owner' Name,Address,and Tel.No.
g-ke
sw
VN9�
Assessor's Map/Parcel -0 y 430 Atli CC e;,,�
Installer's Name,Address,and Tel.No. �aq Designer's Name,Address,and Tel.No.
3cvcp. MR,catt;�r
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(40
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date W A Number of sheets Revision Date
Title
Size of Septic Tank /S'O0 6otf/C14 Type of S.A.S.
Description of Soil
Nature of Re airs or Alterations(Answer when applicable) f3 ✓ 6 sr S 7►C ✓ C
/ems, vJ /a✓1 T!� f' �� Ove C S i� l a0 '� �•
lip
V -r AeC,�«►
Date last inspected: , 02 5
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued b this Board Health.
Si ned o Date 0 CW/ 6
Application Approved by a 1 Date
Application Disapproved by Date
for the following reasons
Permit 140 Date Issued
r"' w
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
application for 30isplasal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. 5 u �`, P V�. Owner's Name,Address,and Tel.No.
. / .
� '1�'1r1�S I'.kk �"1 G.CCM1 Sir' O �S��
Assessor'sMap/Parcel t2p n/ 400 V J W % ( e- l'
idr Installer's Name,Address,and Tel.No. Ssd�° Designer's Name,Address,and Tel:No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(;f/0
Other Type of Building No.of Persons Showers( ) Cafeteria( )
- r
Other Fixtures
Design'Flow(min.required) gpd Design flow provided gpd i
Plan Date /l/(�� Number of sheets Revision Date
Title
Size of Septic Tank / TO 0 G r N l�u� Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answ/er when applicable) 5 I f� /:i p o 6i,4 S� r)T r T/44 4 xh-")
I�ISl�p�v / Iv✓1. l�u�— 7 /�Id- �rrl1oat t° Yls%�n�(tsI tlG�— /— , i)T�%�,j T��'�( � T(�'!' r
6r- R �P V 'l'nsneC 0 4rt `.
Date lases � G t inspected: �,1., 1 5
Agreement: -
The undersigned agrees to ensure the construction and maintenance of the afore described on site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued bpy this Board o•,Health.
Si ned a e Date 0 C, �i b
Application Approved by 04 IDate
[.
Application Disapproved by Date `
for the following reasons ; a
Permit No. i Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(tl< Upgraded( )
Abandoned( )by S /1 G Ir?C ,r1 �n n S 1
at /.S8 S e u N Iry r. l,j 1 r' has been con ed in acco e
with the provisions of Title 5 and the for Disposal System Construction Permit N . ed r
Installer )T-UU, G.Cc ,5 c� Designer_ f
#bedrooms 3 Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system wi_ ction as designed.
Date ! ' t Inspecto
-----No.----.------ -- ----- ----------------------------------------------------------------------------Fee-------------------
�*
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem (Construction Permit
Permission is hereby granted to Construct( ) Repair(V11 Upgrade( ) Abandon( )
System located at S e V C/)Ip u r•
1AJ n -k 1.0 a r`7
5s t,Z-� -T-A K(A 9 MT x
and as described in the above Application for Disposal Sys eyr I Construction Permit. The applicant recognized his/her duty to comply with
��
Title 5 and the following local provisions or special conditions.
Provided:C s uc'on ust be completed within three years of the date of this permit.
Date Approved by
ti
Town of Barnstable
+ lARN9TAHM "
Regulatory Services Department
rfD MA'S A
Public Health Division
200 Main Street, Hyannis MA 02601.
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 7/6/15
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet'of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching pit or cesspool with high liquid level, <12"below inlet (per Town Code
§360-9.1)
OTHER
c,j2jj 000 I rnf 01/Gn �
Repair deadline: G dav/
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
• THE
Town of Barnstable Barnstable
MANSTABM
Regulatory Services Department `s j
OfA°``A Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7014 1200 0001 0358 4954
August 4, 2015
Peter F. &Mary J. Molander �,
%Molander Family Trust I
8 Woodcrest Drive
North Andover, MA 01846 �jI,c
ORDER TO COMPLY WITH ATE ENVIRONMENTAL CODE,TITLE 5
The septic syst 1=cated at 8 Seve th Ave,Hyannis, MA was last inspected on
7/8/2015 by ichael DiBuono, a ce If
septic inspector for the State of
Massachuse s.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Cesspool has collapsed
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PE .0 R OF THE B HEALTH /
As
• Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Conditionally Passes Ltr\I58 Seventh Ave Hy.Aug2015.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
158 7tn ave im
Property Address9'7
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is
required for every hyannis MA 02601 7/8/2015
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 Trevor Kellett
use the return Name of Inspector
key.
TK Septic Inspections
Company Name
38 Vacation Lane
Company Address
P-A West Yarmouth MA 02673
City/Town State Zip Code
508-579-5502 S113744
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:.
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/15/15
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does-not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a 158 7'''ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page. City/Town 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:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system.Components as described in the"Conditional Pass' section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes', "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally.sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
® Y ❑ N ❑ ND(Explain below).-
the Cesspool has collapsed and needs to be replaced with a Title V septic Tank
t5ins•3/13 - Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t e,
158 7 h ave
Property Address
MOLANDER, PETER F&MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page: City/Town State Zip Code Date of Inspection
S. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break but or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below).
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required-pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
:i Title 5 Official Inspection. Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
158 7 h ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every" y
h annis MA 02601 7/8/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (coat.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•.3/13 Title 5 Offidal 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
t
w 158 7 h ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis _ MA 02601 7/8/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water qualify 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.]
a ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or.a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes' in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, ` 158 7 h ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page.. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in 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
® El information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 158 Ph ave
Property Address
MOLANDER, PETER F&MARY J TRS
Owner Owner's Name
information is h annis MA 02601 7/8/2015
required for every y
page. City/Town State Zip'Code Date of Inspection
D. System Information
Description:
Cess pool into an infiltrator
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ns:3/6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
158 7 h ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ innovative/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):
Cesspool into infiltrator
t5ins•3/13 Title 6 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
158 7"'ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page" City/Town State Zip Code Date of Inspection
D: System Information (coat.)
Approximate age of all components, date installed (if known)and source of information:
7-8-74 per boh
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2"1
feet
Material of construction:
®cast iron ❑Q PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade:
� feet
Material of construction:
concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Mrs 3/13 - - Title 5 Offidal Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
158 Ph ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner owner's Name
information is required for every hy annis MA 02601 7/8/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins r 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f `
Commonwealth of Massachusetts
F _
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w. 158 7"'ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
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:
El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain).
Dimensions:
Capacity: gallons
Design Flow.
gallons per day
Alarm.present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑. No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5iris•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 158 7th ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
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
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.):
no d box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order,system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
,u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
158 71h ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
E leaching pits number:
® leaching chambers number: 1
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation; etc.).-
There is one infiltrator at this property
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration 1
Depth—top of liquid to inlet invert NA
Depth of solids layer NA
Depth of scum layer NA
Dimensions of cesspool NA
Materials of construction drywell blocks
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Offidal Inspection Form:Subwrrioe Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
158 7 h ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hY annis MA 02601 7/8/2015
.
page. City/Town State Zip Code, Date of Inspection
D. System Information (cont.)
Comments(note condition of soil,signs of hydraulic failure, level of ndin , condition of vegetation,
Y Po 9 9
etc.):
Could not get accurate measurements since cesspool is collapsing
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding;condition of vegetation,
etc.)-.
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
158 7 h ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below.
® hand-sketch in the area below
❑ drawing attached separately
A
back of house
B
C
1
2
A1)38.3
B1)16.6
B2)20.7
C2)24.3
t5ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 158 7"'ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page. City/Town State Zip Code Date of Inspection I,
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 1 feeett
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from_system design plans on record'
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS Maps show GW at 10 feet
the bottom of the leaching is at 6 feet
I augered to 8 feet and found no water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
=. 158 7t''ave
Property Address
MOLANDER, PETER F& MARY J TRS
Owner Owner's Name
information is required for every hy annis MA 02601 7/8/2015
page. City/Town State Zip Code Date of Inspection
-E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
Z Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
No.......1c-3-v..... Fxs. .......
COMMONWEALTH
THEF
BOARD C HEALTH TS
..... .... ...d..
Appliration -for :43isposal Works C omitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at: '
�.�s. ............ ................................._..._-_-__../ ' .. .....____........._.._.._ .......__..__..__......_._.........__•___
L ca' n-Address ........................ Lot No:
!/ n r "` Address
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
0.' Other fixtures ----------------••--
-------------------------------------------------------------------------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter................ Depth.-..------------
x Disposal Trench—No- --------------------- Width-------------------- Total Length.................... Total leaching area--------_-----------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.--_-.-_-.--___.-sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date............. ..........................
al Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
fz, Test Pit No. 2................minutes per inch Depth of Test Pit.--------.-._...... Depth to ground water......................
P4 ------------------------------------------
Description of Soil s `._..-•--•...-•-•--------- ------------------------------------------
U ------------------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------
W -------------------------------------------------------------------------------------------------------------------------------------------------•--•----•••---...................--•••-------------
U Nature of Repairs or Alterations nswen appli le.-.-_.... . .. ......................... . ------------------
- :--------------------
------------ ..
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 n is ued by�the board of he th.
St � . .. c '
Date
Application Approved B �' '- ...................... --------------
PP PP Y----- - ---- ------
Application Disapproved for the following reasons____________ ___________________________
----•.......................................... Date.....-•----•--
--•................................•--------•------------------•-•--•--•••-•--------.....-----••---------•••--•......---•-••----•--•.....--..---
j� 0 j7/ Date
Permit No. Issued..r[/� . --------------•------•-----------
Date
No........ .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
OF.._ ... ...................................................
Appliration -for :41-4poiial Worko TotwtrurtioA',,Vrrnfi1
Application is hereby made for a Permit to Construct or Repai (r 4) an Individual'Sewage Disposal
a .Address
Sys
.. ................. .....................................................
V A r �-__ ........................
or Lot No.
0�
---------------------
...... ---------- .. ............. ........... ................................ ..................................................................................................
Address
r
... ................................... ----- ...... ---- ------------------------------------------,',,'------- ------- ------
Installer Address
Type of Building Size Lot.............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
PL4 Other—Type of Building ---------------------------- No. of persons---------------------------- Showers' Cafeteria
Cafeteria ( )
PL4 Other fixtures —.......................7,7 .................................. -------------- ....................
-----------------------------------
Design Flow____________________________ _.gallons er pet-son perday. Total,,daily flow------------------------ ------------------gallons.
I ameter P4 Septic Tank capacity --------gallons 'L ngth..........;'.�..... Width_. 7.. ...... Dk ................ Depth----------------
Disposal Trench—No_----------- Width____ -_______ __ Total Length. ....... .____:�,,.-,TOAIIeachinZ area.._......_ .. ------sq. f t.
Seepage Pit No_____________________ Diameter__.__. .,........ Depth l3eloWirtlet............... ... Total leaching are.u. .... ..........scl. f t.
9
Other Distribution box in ",tank
Percolation Test Results Performed by----------- ....... ....... .............................. Date__________________________---____-.---.
Test Pit No. 1................minutes per inch Depth of Test Pit......:.__:_....... Depth to ground water..-----------------------
(14 Test,,Pit No. 2................rninutesper inch ' Depth-of Test Pit-________- --------- Depth to ground water...-_-__-_-_-._____
...... ... ..........
........................... ..).,. .................................................................
-------S, -----------------------------------------------------------------
----------------- .... ..
0 Description of Soil..............................................
4-f-111eq. . ............
..... ..........
U ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------............................................................................. -----------------------------------------------------
U Nature of Repairs or Alterations,—
;Ans �eppli ble.
A4 ----------- ------ ---------------------
----------------------------------------------------- ...........
. ...... ............ -------------------------
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 en sued'Ei4the board of Whth.
Date
Application Approved BY---- -----------------------------��1111 ....................Date--------------
Application Disapproved for the following reasons ........................ .......................... ......................................................
............................... .............................................................................................
-----------------A........................................
Date-,
Permit No...................................
.................. Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTIS.,,,,.
BOARD OF, HEALTH
.0 ............ ...... ........................
Tutifirate I Tompliaurr
THI TV, C,*R T I hat the I vidual Sq§Xge DispoZi System constructed or Repaired'
b, .. .... .... ... .... ..... ................................... .....................
Ins 11
at-. ............ ...... .........
---------- .......... . ...... .. ..
-----------------------
has been installed in accordance with the provisions of . rt e XI If e State Sanitary CQde as described in the
r-Disposal Works Construction Permit No application for- !,.y-------------------- dated......Y .... ..y................
THE ISSUANCE .OF THIS,-iCERTIFICATE SHALL NOT BE CONSTRUED AS A GIJA ANTES THAT THE
SYSTEM'WILL U TO
N' SATISFACTORY.
E............... Inspector ...... ........
DATE -------
-----------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH•-
.... ................. C39—
..........r...... ........OF_..........
N3 6 FEE...2.1............
0........................
Permission is hereby grante .. ..... . ..... .
-- ---- ----------------------- --------------------------.......
to Const Vet or Repair an g D sp ystem
44ividual Sewa
r at
............... . .................... .... . ......... ........ - -- -----------
.. .......
7
reet X
7 as shown on the a Dated____ ---- --------- -----..........
application for Disposal Works Construction P"it D
;t.eK,
i_svpree
-7 7/-
w.
..4.'_44, .....................
Board of Health
DATE--------. / ...........-------------------- ------. -
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS'
y
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UNITED STATES 9STA S RVICE First-Class Mail
&�:�-�'�+ :::
M _ Postage&Fees-Paid
�rv4r.:i•:'EY', '.; .:' USPS
Permit No.G-10 l
• Sender: Please print your name, address, and ZIP+4®in this box*
I
Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA 02601
nt}i•^!•.i2 i::ii:!ii l} i!!i!}•iii }i111 ijii e}i}:!ii i !iifilli
i. I is •t!i:.:F:::
i
SENDER: COMPLETE.THIS SECTION COMPLETE,THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Sign ure
item 4 if Restricted Delivery is desired. X ' ❑Agent
■ Print your name and address on the reverse / ❑Addressee
so that we can return the card to you. "B�Received by- . 'nted Name) C. Date of Delivery
■ Attach this card to the back of the mailpiece,
N or on the front if space permits.
D. Is delivery address �ifferent from item 1? ❑Yes
I 1. Article Addressed to: If YES,enter'delive address below: ❑No
I
Peter F. & Mary J. Molander `� w
% Mol'ander Family Trust
8 w00dCreSt Dr1Ve 3. Servi6d*pe
I ❑Certified Mail® ❑Priority Mail Express'"
North Andover, MA O l 846 ❑Registered ❑Return Receipt for Merchandise
I ❑Insured Mail ❑Collect on Delivery
4. Restricted Delivery?(Extra Fee) ❑Yes J
2.. Article Number Jillr;70:y4 !1,2od1 OOO'- 0358 4954 (� �
� (Transfer from service IabeQ �V
�, PS Form 3811,July 2013 Domestic Return Receipt
Er
N® ( , , 1
�a
m 6d1
m Pos
o
Certified Fee $0 CIO �( f��
C3 Return Receipt Fee Po ark L
O (Endorsement Required) $�7,[)j i �@Fe QI
t3 Restricted Delivery Fee .
O Z� J
(Endorsement Required) "
�.
p
W Total Postage&Fees
r�
o I Peter F. & Mary J. Molander
, % Molander Family Trust -
!( 8 Woodcrest Drive ills^th 17a are.,
Certified Mail Provides;-
e A mailing receipt r
Ilk
c A unique identifier for your mailoi
e A record of delivery kept by the P _fal Service fjrluvd years
Important Reminders: 1M 10 41 t 23V00'#:A HT,t,4i
o Certified Mail may ONLY be combined with First-Class Mail®or Priority Maile.
a Certified Mail is not available for any class of international mail.
o NO INSURANCE COVERAGE,,IS"PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
o For an additional fee,a Retum'Rece1,0t may be requested to provide proof of,
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse,mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a P$PS®postmark on your Certified Mail receipt is
required. xc"
. n
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". 4 .at
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."�
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
FF
LEGEND
l'
12 -- EXISTING CONTOUR
x.11.98 EXISTING SPOT GRADE
91584 Avenue ;
W EXISTING WATER SERVICE i
G EXISTING GAS SERVICE
,.■..� ---0.H.IRE- OVERHEAD WIRES �
PE 158-PG 119 i'
�� TEST PIT
BENCHMARK '' '
BENCHMARK-1
COR./BOTTOM STEP EXISTING LEACHING SYSTEMS
EL.=11.98 (APPROX. LOCATION)
TO BE REMOVED ' 1
PROPOSED (SEE NOTE 11) LOCUS MAP
PUMP CHAMBER -�
FENCE N 02°40'45" W CBdh fnd ;
12.17 1 GENERAL NOTES:
1,59 x .00' x 13.13
x TP-2 O ✓ e. 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
BOARD OF HEALTH AND THE DESIGN ENGINEER.
2:
+ - DTP-1 ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS
11,85 11,31 OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE
LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW:
EXIST. SEPTIC TANK
O -310 CMR 15.405(1)(b): LOCAL UPGRADE APPROVAL
TO REMAIN PROPOSED S.A.S.
( > -�3 10' 2-500 GALLON CHAMBERS 1) A 9' variance, S.A.S. to crawl space wall, for on 1 1' setback.
TOP, EL.=9. 14 7.2 -I x SURROUNDED W/STONES 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
INV.(OUT), EL.7.80f x N BM •-WALK 029 12.56 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
10.80 10.64 MAC 11,98 stg ZO0NN(�q DESIGN ENGINEER.
x ern e NF q L 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
SLAB/BM2F\ FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN
iEXIST/NG 11,55 �� ENGINEER BEFORE CONSTRUCTION CONTINUES.
o HOUSE(158 �� BENCHMARK-2 5. ALL ELEVATIONS BASED ON NAVD88.
0) o ` COR./ENTRY SLAB 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF
O T.O.F. 1 1.9f EL.=11.55 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
0000
n FF EL.=12.3f SCREjN Z _ HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION.
x
PORCH
86 Q v _ 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE.
10,5 0 - 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S.
O_
x 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS
` AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE
DECK x 10.43 11,28 m DIRECTED BY THE APPROVING AUTHORITIES.
O \ 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY
9. L.5C5F THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING
x 9,47 t" CONSTRUCTION.
8.51\� \ 10.34 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
IN THE AREA BENEATH AND
D FOR 5' ON ALL SIDES OF THE S.A.S. AND
LAM 9,12•,;,•;:: REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3).
a 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE
LOT 64 + 10,26 (, INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL.
Q l�IVEwAY'::. ::: PIKE
/ G� 12,000 tSF 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND
OF NOT CONSIDERED TO BE A PROPERTY LINE SURVEY.
8.143
..: .•.:..>:;;•. Q� ASs9C' 14. THE ENGINEER IS NOT RESPONSIBLE FOR ANY UNDOCUMENTED SEPTIC
8,17 80.00 CB fnd �Q`
P R T. SYSTEM COMPONENTS NOT SHOWN ON THE PLAN.
CBdh fnd o ETE
D .46 x 9.95 ,t McENTEE
F
CIVIL PARCEL ID: 245-070
8,48 Z 8,31 ® `� �� 9-,02 No. 35109
O CATCH BASIN 8.75 $TAR PROPOSED SEPTIC SYSTEM UPGRADE PLAN
8.26 E 158 SEVENTH AVENUE, HYANNIS, MA
SEVENTH A VENUE -I-c4 -ns�' Prepared for: Philip MacAllister, 71 Child Street, Centerville, MA 02632
FLOOD DESIGNATION OWNER OPT RECORD Engineering by: SCALE DRAWN JOB. NO.
MAP NO. 25001 CO564J MACALLISTER; PHILIP C & VIRKUS, JANET M Engineering Works, Inc. 1"=20' P.T.M. 286-20
EFFECTIVE DATE: JULY 16, 2014 71 CHILDS STREET 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
ZONE AE(EL12) & 0.2% ANNUAL CHANCE CENTERVILLE, MA 02632 (508) 477-5313 10/26/20 P.T.M. 1 Of 3
�I
EXISTING SEPTIC TANK & NOTE: TO PREVENT BREAKOUT, .FINAL GRADE
SHALL NOTIBE AT, OR BELOW, EL.=10.5 .
PROPOSED PUMP CHAMBER FOR A DISTANCE OF 15' FROM THE EDGE
PROVIDE RISERS & COVERS AS DESCRIBED: OF THE PROPOSED S.A.S.
INSTALL WATERTIG
1) INLET MAMHOLES: COVER SET TO 6" OF GRADE. PROPOSED G BOX PROPOSED S.A.S. +
2) OUTLET MANHOLES: 20" OUTLET COVER SET TO GRADE. HT RISER & INSTALL RISER & COVER OVER ONE CHAMBER AND
MANHOLE COVER SHALL BE SECURED COVER SET TO 6" OF GRADE SET TO 3" OF F.G. TO SERVE AS INSPECTION PORT DECK
TO PREVENT UNAUTHORIZED ACCESS. F.G. EL.=13.0t
F.G. EL.=11.3f F.G. EL.=12.0t MAINTAIN 2% SLOPE OVER S.A.S.
F.G. EL.=1 1.2(EXISTING) PROVIDE ENOUGH WIRE I SCREEN
SLACK TO REMOVE PUMP ;
L = 13' PORCH /EX/STING
0 S=1% (MIN.) 2" LAYER OF 1 8 TO 1 2
HOUSE(158)
L %5 MIN. . 2 40 PVC BLOCKS 4"SCH40 PVC E »
5CH e DOUBLE WASHED STONE
4"SCH40(PVC) TOP EL.=8.39 PRp��pE THR BENpS
;. .. rIN
� s (OR APPROVED FILTER FABRIC)
fl,74.. �ip" INV.=10.20 aaBaaBa ---3/4" TO 1-1/2" DOUBLE CK OF HOUSE
10.37 31' 4.8' 3.1' WASHED STONE N rnse stgADD PROPOSED D-BOX NEFFLUENT INV.=7.64 3 OUTLETS (MIN.) EFFECTIVE WIDTHFILTER USE OUTLET 2 FLOATS7.39t INV.=10.00
KNOCK OUT177
2-500 GALLON LEACHING CHAMBERS WITH 3.1' 1 %K*%K
EXISTING .gam BOTT. EL.=3.10 OF STONE AROUND AND 4' OF STONE BETWEEN
SEPTIC TANK 1000 GALLON MONOLITHIC H-10 RATED CONNECT CHAMBERS 1 PROP. S.A.S. 1
INV.=7.80t PUMP CHAMBER (H-10 RATED) TOP CONC. ELEV.=10.8t 4" SCH 0 PIPE __
EXISTING (See Pump Detail, Sheet 3) -�
(FIELD VERIFY) BREAK I�-272•NV. ELEV.=10.00
ffiVWNOTES: eases aB s 1) PUMP CHAMBER & D-BOX SHALL BE SET LEVEL AND TRUE BOTTOM ELEV.= 8.00 TO GRADE ON A MECHANICALLY COMPACTED STABLE BASE 3.1' ENDS 8.5' 4 S.A.S. LAYOUT
OR 6" CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 4' OF NATURALLY OCCURRING --
15.221(2). PERVIOUS MATERIAL AND 5 EFFECTIVE LENGTH = 27.2'
2) INSTALL INLET & OUTLET TEES AS REQUIRED. ABOVE GROUNDWATER LEACHING SYSTEM SECTION
3) MAX. COVER OVER SEPTIC TANK, D-BOX & S.A.S. SHALL BE 36". JESTIMATED HIGH G.W., EL.=2.9 -
4) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INVERTS PRIOR 3/4" TO 1-1/2" DOUBLE ®®®® ® ®®®
TO CONSTRUCTION. WASHED STONE ®®®®®® ® ®®®
5) EFFLUENT FILTER SHALL BE INSTALLED ON OUTLET A R F 1 � 33"
3 LYE 0 8 TO 1 2"
TEE AS MANUFACTURED BY ZABEL OR EQUAL. FILTER / /
SHALL BE INSPECTED AND CLEANED ANNUALLY OR AS DOUBLE WASHED STONE N
SEPTIC SYSTEM PROFILE ®�®®®® ® ®®®
REQUIRED TO PREVENT SEAWAGE BACK UP. (OR APPROVED FILTER FABRIC) Z
102
DESIGN CRITERIA
SOIL LOG
DATE: OCTOBER 13, 2020 (REF.#TPT-20-214 4" KNOCKOUT
NUMBER OF BEDROOMS: 3 �/ SOIL EVALUATOR: PETER McENTEE SE#1542 20" DIA. COVER
� SOIL TEXTURAL CLASS: CLASS I
WITNESS: DAVID STANTON IRS HEALTH AGENT /DESIGN PERCOLATION RATE: <2 MIN/IN ELEV• TP- 1 DEPTH ELEv. TP-2 DEPTH 4" KNOCKOUT 4" KNOCKOUT 58"
:
DAILY FLOW: 330 GPD 13.0 A LOAMY SAND 0" 12.5 A LOAMY SAND 0"
0
DESIGN FLOW: 330 GPD 10YR 4/2 ,10YR 4/2 4" KNOCKOUT
GARBAGE GRINDER: NO 12.7 B 4" 12.1 B 4"
LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF LOAMY SAND LOAMY SAND PERC 500 GALLON CAPACITY, H-10 LOADING
.74 GPD/SF 10YR 5/4 �10YR 5/4 20"/38" CHAMBERS
EXISTING SEPTIC TANK: 1500 GALLON CAPACITY 10.3 32" 9.8 C, 34"
PROPOSED PUMP CHAMBER: 100'0 GALLON CAPACITY, H-10
PROPOSED D-BOX: 1 INLET, 3 OUTLET (MIN.), H-10 21 5Y 7/NE ° �. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
USE 2=500 GALLON LEACHING CHAMBERS IN SERIES WITH 3.1' SEWAGE EFFLUENT FINE SAND 158 SEVENTH AVENUE HYANNIS MA
OF. STONE AROUND AND 4' OF STONE BETWEEN (11' x 27.2') BROKE THROUGH r2.5Y 7/4 >,
SIDEWALL AT Prepared for: Philip MacAllister, 71 Child Street, Centerville, MA 02632
SIDEWALL AREA: 2(1 1.0' + 27.2') X 2 = 152.8 SF 84"+/-
BOTTOM AREA: 11.0' x 27.2' = 299.2 SF 2.5 oes. G.w. 120" Engineering by: SCALE DRAWN JOB. NO.
3.0 120" 2.2 _ 128" En ineerin� Works Inc. N.T.S. P.T.M. 286-20
TOTAL AREA.............................:.................................452.0 SF PERC RATE: <2 MIN./IN.("B"&"C" HORIZONS)_ 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO.
DESIGN FLOW PROVIDED: 0.74 GPD/SF(452.0 SF) = 334.5 GPD V1ESTIMATED HIGH GW, EL,.=2.9 (DATA LOGGING LUNAR CYCLE) (508) 477-5313 10/26/20 P.T.M. 2 Of 3
r
NEMA 4 JUNCTION. BOX CORROSION RESISTANT
& LIQUID—TIGHT CABLE CONNECTORS SUPPORTED
PROVIDE WATERTIGHT CONCRETE RISER WITH BY 1-1/4" PVC CONDUIT. JOINTS TO BE MADE
SECURED FRAME & COVER TO GRADE WATERTIGHT. USE SJE RHOMBUS—JB PLUGGER
OR EQUAL. PROVIDE ENOUGH WIRE
SLACK TO REMOVE PUMP
INSTALL 1' PVC CONDUIT TO HOUSE FOR WIRING
HOISTING CABLE 7x19 STAINLESS STEEL WITH WATERTIGHT JOINTS. WIRE HIGH WATER ALARM
1/8" DIAMETER. / 1,760 LB. STRENGTH.---,,,,,,,. FLOAT TO SJE RHOMBUS TANK ALERT XT ALARM PANEL
PROVIDE ENOUGH WIREON CIRCUIT SEPARATE FROM CIRCUIT TO THE PUMP.
SLACK TO REMOVE PUMP
INV.(IN)=7.64 2" BALL VALVE (FIELD ADJUST FOR 20'GPM RATE) DOSING & STORAGE REQUIREMENTS
(INSTALL QUICK DISCONNECT FOR EASY REMOVAL)
ALARM ON EL: 4.60 2"SCH. 40 DISCHARGE (THROUGH RISER{ SEE PROFILE) DESIGN FLOW: 330 GPD
PUMP ON EL: 4.43 2" 90- ELBOW W/ 1/4" WEEP HOLE M DOSING REQUIRED: 4 CYCLES/DAY (SAND)
FOR SELF—DRAINING FORCE MAIN t 330 - 4 = 82.5 GALLONS/CYCLE
BOTTOM OF PUMP OFF EL: 4.10 15" 13" 2" SWING CHECK VALVE DISTANCE REQUIRED BETWEEN PUMP
PUMP CHAMBER 9" 2" SCH. 40 PVC DISCHARGE PIPE ON AND PUMP OFF FLOATS:
ELEV.= 3.10 ADDITIONAL 3/16" VENT HOLE (MIN.) ABOVE PUMP FLANGE 82.5 GAL/CYCLE --a- 250 GAL/FT = 0.33 FT/CYCLE (SAY 4")
PROVIDE 2 FLOATS: 3" (TO PREVENT PREMATURE PUMP BURNOUT) STORAGE REQUIRED ABOVE WORKING LEVEL: 330 GALLONS
FLOAT NO.1: PUMP ON/OFF—SJ RHOMBUS (PROVIDED WITH PUMP) STORAGE PROVIDED:
FLOAT NO.2: ALARM ACTIVATION FLOAT—PROVIDED WITH ALARM PANEL LIBERTY LE40 SERIES PUMP .4 H.P. 115 V INV.(IN) EL: 7.64 — PUMP ON EL: 4.43 = 3.21'
(ON SEPARATE CIRCUIT FROM PUMP SPECIFIED) WITH 2" DISCHARGE, OR EQUAL
STORAGE PROVIDED = 3.21 x 250 GAL/FT = 802.5 GALLONS
PUMP AND ACCESSORIES AVAILABLE AT:
CAPE COD WINWATER WORKS CO., HYANNIS, MA. (508) 862-0166
NOTE: APPROVED ALTERNATE MAY BE SUBSTITUTED.
PUMP DETAIL
k
4" TOP 24" DIA. COVERS
8'-3-1/2" (TYP.) /
INLET
OUTLET — T—I— — —I F BUOYANCY CALCULATIONS
I I I I
5' 3 1/2" 3" A I i i i i I A NOT REQUIRED
I I I I
54-1/2" 48" 51-1/2" 5' S 1/2"� I — i i — I PUMP CHAMBER IS ABOVE ESTIMATED HIGH GROUNDWATER
REINFORCING RIB LIQUID 3" _ i
\ 3„ LEVEL
i
I I I I
9'-1/2" j
CROSS SECTION A-A 4" KNOCKOUTS PLAN VIEW
(TYP.)
SPECIFICATIONS
1.) CONCRETE 4,000 PSI AFTER 28 DAYS.
2.) CONSTRUCTION CONFORMS TO DEP TITLE V REGS.310 CMR SECTION 15.226. PROPOSED SEPTIC SYSTEM UPGRADE PLAN
3.) REINFORCEMENT PER ASTM C1227-96. APPROXIMATE WEIGHT =8,380 LBS 158 SEVENTH AVENUE, HYANNIS, MA
APPROVED ALTERNATE MAY BE USED. Prepared for: Philip MacAllister, 71 Child Street, Centerville, MA 02632
Engineering by: SCALE DRAWN JOB. NO.
Engineering Works,
1000 GALLON MONOLITHIC PUMP CHAMBER ' Inc. N.T.S. P.T.M. 286-20
WIGGIN PRECAST CORP MODEL#1000MONTH 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO.
(508) 477-5313 10/26/20 P.T.M. 2 Of 3