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Home My WebLink About0022 SIMMONS POND CIRCLE - Health 22 SIMMONS POND CIRCLE, HYANNIS A= i LOCATION l./ SEWAGE PERMIT NO. ,40T VILLAGE I N S T A LLER'S NAME i ADDRESS 624 '} ® U I L DE R OR OWNER c'It )/.f DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �� ry � I �) U sp s w No.g.�- d Fx$. 5 d..... .................. THE 4L"CA4MONWEALTH OF MASSACHUSETTS 9 �1 o OF HEALTH ,�(� C �. 4 � d 7/_ BOARD _._..-... OF...:.........:........ ....,----_-------------.--------.-----..---_----_--_ 44 Appliration for 11ispnsal Warks C9angtrartinn Famit Application is hereby made for a Permit to Construct ( . ) or Repair ( ) an Individual Sewage Disposal System at � Location-Address �- or Lot No. .__: .� .: � ........ .C_o_..G.._. -_.._... ........................................................................•................. Ow/ner c Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............__.._____..__..._.....Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons........................_... Showers ( ) — Cafeteria ( ) a � Other fixtures ----------------------•---------- - •----------- •--------------------------------------..__..--- W Design Flow............................................gallons per person per day. Total daily flow_-__..__.. _._ ..__.._. gallons. WSeptic Tank—Liquid capacityfgallons Length---------------- Width---------------- Diameter---------------- De th------.-------_. x Disposal Trench—No..................... Width.................... Total Length.................... Total.leaching area....ZeLK-sq. ft. Seepage Pit No---------------- Diameter-------------------- Depth below inlet.................... Total leaching area...................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) // ~' Percolation Test Resul s Performed by....................0_ ._, _.. ................................ Date......e QQ �j�. aTest Pit No. L /-/..minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2>,t/ _minutes per inch Depth of Test Pit____________________ Depth to ground water........................ a --•-._...--•------------•------------•-•----••••----•••---------------•------•-••------•------•----.........................-................................ 0 Description of Soil................... .. .___ .. ...�.. r-f U ----••-----••--------------••••--------------•----�-......--=- ----• = _ - - - ................................................... W -•--------•-----------------•--•------•----•--•-•--•••-•-------------•--•------•---•----------••-------•--•-......---•-----------••--••---............................................................. UNature of Repairs or Alterations—Answer when applicable............................................................................................... ...............................-........................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'i U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss the bo r i alth. Signed- ----- --------------- -- ----- ate Application Approved By.................................................... 50.. f f Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------------------•-- .....................•----------•-•--•--.............----------------•-------------.............-•-------._...............----.._..------...----•----------------------------------------------...._.... Date Permit No.............. ---------------------••--------•-••-••••••• Issued..........................-............................ Date No......`..... ........ Fis....��................ THE 1GMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �.._.......oF............ .. .. Appliration for Disposal Marks Tonstrurtiun ranfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ................_.�.�/.............../�-...... °n f �`� " `` •---------.......0...................... Location-Address Q o .._._r Lot No. ...................._ G'.� ....._�...?C.:_� -.� _.._ :.1.__`.� .......----•-......--^_._.._......•......-...................................................... nry- Address-- G� ........................... .../� - :.r _.. = . _ 9J....----- --.._......_---•-••-•---..---•------_•. Installer Address UType of Building Size Lot-------------...............Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----------•--- ---•--•--•-•--•••-•--•-----•-•-••-•-..•••--------•--•-----••---•-•-•-----•-----•••••-•••--•--•••-•---•--.....--•-••••---------------- W Design Flow.............................................gallons per person per day. Total daily flow.......... .71....................gallons. WSeptic Tank—Liquid capacity/.Go?6_gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total.leaching area.....2.6..4rsq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) rr s Percolation Test Results Performed by....................... _._�.�J.__.. ....................... Date..... � . Test Pit No. 1 ._minutes per inch Depth of Test Pit.................... Depth to ground water--___-_______-__-___-._. GL, Test Pit N, .--niatipsper inch Depth of Test Pit-------------------- Depth to ground water........................ a ------------------------------••--------------- -------------------------------------- ------- ---------------------- 0 Description of Soil............................. . ........... -- x U ..._.....- —. --•----•---•---------•-•-••------------•-------•------------------------------- W --------------------------------------------------------------------------------------••--------------------------------------------------•--------------------------------------------.....--•-••••-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... .. ....... ---•---------------------------•------------------•-----------------------------------•-------•--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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 b e boar th. �� Signed .... •--•--•. .................... --•-- /D6a�t ..._..._ / Application Approved BY...................................................... . �---- ....... Zr' ---••------ Application Disapproved for the following reasons________________________________________________________________________________ ....••......Date-•-•--_..._.._ ...................................................................................................................--••---•-••••----•--••-•-•-•-----------•-•---•-••••-••------••---•••......---•-••---- Date PermitNo.......................................................- Issued.................................----•-----------•-.. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntifiratr of Tome inure THIS IS T R7IFSY/That thgJndividup1,Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------- ---- ---- - -------•--- ......... ... . ------ ........ ------------- ----- r Installer j at............... Zi----------------- ..............G `=" - ' -z•/-.- .. has been installed in accordance with the provisions of TIT 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...............A9.1.t-:_._____..... dated---............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / DATE.......................................... a c�=1 ................ Inspector............. ........................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No..AI/ '/Z ...........................................OF...............................................................----................ ^ r ... .......... FEE._...................... Raposal Worko Tnnst n ;Tit � Permission is hereby granted..................... /... ...�....... ------------ •----------------�-.... ...........-----•--- to Construct ( `�rRepair ( ) an Individual-Sewage Di osal ystem I,fStreet as shown on the application for Disposal Works Construction Bomit No...... ........... ated.......................................... DATE_ _______________________ and of Health FORM 1255 A. M. SULKIN, INC., BOSTON , Y; N Q , 8a. ° Sz 3 N 21$n o 4: 0.6 .r.F LET o c� �7• Q F 6' ISJ 2 � SvT,� e T i3 z n I / pv wrQE . 2� 4ZI x DlZA'IV /111 a nfs :. r v�77C s 'w,p E e � CERTIFIED PLOT PLAN 2 PTV �F Messti M M DN-s c�Ni G/2 ROBeR Cr L.nT /S S� 3 o ALB BRUCE f/,Y A /V/I//S �n R T. : ELDRE W 'N ' N } No.109510 VA Ap r(FG S 7 v V� ?f! Q SV�°�� A J! �r w.•J \r� J r : n� SCALE, / "--40: ' DATE,'-6 19gle � ;LDf�' DGE E/VGiAi !IIV�-�:� Bhl CLIENT ! CERT6FY THAT T.HE PROPOScD ; IG1S'P:ERE REGS$Tr:RE` . / CHINO. 8.. 23IB;�P14.O1N0 SFiAY��I OIL" `,THI<3-'pL AN , LAN <'�" w -- ,.CON1`ORMS ,I O.�-THE.'ZONIN(i 1�AYMS; - CIVfL IaR.BY� A-a�:/Yj x o '� sy,E'1GINItER � - -^�--�- OF BARNSTA81 E MASS. r M A V4, S TR E't' ='ark CH. �►Y r A _ y a NYANNIs; AAA,9S n x s, gH. ET. OF. - D T 'REO. LAND�SU V + EYo w'�h F. r+G , NOTF /F lcITNER THE.SEPTIC TANk OR e; EO PT. M//4/- - L.EAGNtiVG' Pt T AI L$ J'7DR� TN AJV m w aA%o pv Z4 a,P1AA11FT.ER CONCRAWT. C'0X4FA SNAL L SE ,®JFOCACSWT 7"0 6JTA 404r.CA1V.EX'TmA C.DA/�ETE q'PYL' P/PF JYE.4Vy CAST/RON A=0V,-'R SHALL BE USED CL. 3 0 P. M/N. P/TCeV /F/N OR/VEyVA Y' 2 w►ia. aoE CO NEF GL EAN SANG A BAC,+CF/L L LJfUID LEVEL z'LAYER /ROAI.P/PE `ppa PoP!°T.. SLEPT/C TAMfC D/ST. e • e • . • • • • • e e • • YVit SJ�/e0 S72�NE BOX a e1 ® e • e •• • .�� • " >� - .e s � I e.��7"ECTI✓C 1 ' : ,� 3/4�- 1 f2" tij e .►D • ► •e DpPTl+I* :go r WA3NJ_=D STOkE A 7Fsx /. �g : : i sa • • + e o e . •• • y r•e PPEC,/iSTSE , INB/Cl�" ��.��/�F��/.�; ��s �p�-=�T y ,GAG/vsF y a e e . • e o � e • • • � a pST OJ?_SUN. • e B �L-. NYE/�T .rlT �/!/d.O/A/G ZS 8 FT 6 PT. Del / . /IVLE7 JZC T.4I9/K. i5 .� F1,' ~ . /D t7. O/AAf. (��$g� 7�1@rUL.4TJ0/6, Dt/TLRT SEPTIC`rAeNK zs o //VLE'T A/STR1A"10N BOX Z� 7- T.F , GROsJNo TEN TAKE , . SEA'/®Al.OF 04TzETD,3-rR1ot1no N owl FT. //VLE-r L-EmCOINS ''®/T' 24.l9 FT S��CaE �/S'/ `�8 L SYS?'�/'9 TAlL� AT140II/ LeACH!/i/G P/T SCALE � %` _ =o' vJa�EN.�ioJv A z JET DRSASN CJq/7'ETIA 01MAWSIOJV NUimISER OP'oE�OO/�S 3 - OJMENS/®N C _FT �R tG.EA/, O-SAL C/I1/t7- A/eW� -, - s®iL Low TOTAL ,-LO*V 3 3 0 G.4 .1AAv SO/L TEST#/- SOIL TE5T#2 NUMiMR OF 4rACMIN4 P/ice �Q.4 TE OF 50U, TEST / a S/D-E 4.eAC/d/I0G PEJ$RI-r �S9 .J:Ta' p _ Z ' b RESULTS IV/T/4/ESSED BY Al R cv 0o7—roz 4 L64cHINcr/Psit PIT $Q FTa k 4 O14 AEJ��OLRT/ON Rr$TA / Jy/"//iMCJy TOTAL LEACH/NG.AREA. 2!0 �' S47 FT. F'ENC®LATtON R.m7E Az T�o J`f/AI f/JV4M RR5,FR A=LEACN/A/6AREA 2fo 6 S4 FT Po o Y ' F cT2�v � So Lv.T /S .S/M,-1 UJVS FoAj RC3HCR7 �'%i, o`' . ALBS .. A .4/1r/S iiRUCE g ELPRE �o `��rs ELTtZ AlA/N 9Ta, yAMN/9, MASs- s E �� FFSc aV` N� SLgti+l /QPIA �']. Na 0T0'UN/?:yY,4 r&M JWC®UiVT'JREO • CL/EAtT: DATS' NiGCOl�s �'... A Ca/@'G UND N/.�TC.� AT �sLgY ✓OB v A r ri-• =.,_ .. CO.1i110:'\ E.AI.TH OF MASSACHL;SETTS _ ExECUTIVE OFFICE OF ENVIRONMENTAL. AFF?,IP.t r E= DEPARTMENT OF ENVIRONMENTAL PROTECTION � r '^a+c ONE 1tINTER STREE•:. BOSTON Kk 0210r t61"j 292-55uv TRUDY C0.L' Secretam ARGEO PALL CELLUCCI DAVID B STP. ,-uS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Add►ess:22 Simmons Pond. Circle Name of Owner Peter Palmer vannis Address of Owner: Date of Inspection: 4_ 4` di_� Name of inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved systerrl inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Wm. E . Robinsoneptic Service MaBingAddress: PO Box 0 9, Centerville . MA Telephone Number: 7 7 5—9 7 7 0 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sews e disposal systems. The system: i/Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 4f, k — Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS TO v� 1000 rev see 5/2/98 PaRclof11 . `• :. !ed on Ren•crcd Panc, t. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART A CERTIFICATION(continued) "roperty Address22 Simmons Pond. Circle , Hyannis .)wner: Peter Palmer Dane of Inspection: INSPECTION SUMMARY: Check B, C, or D: A. rSYPASSES: I have not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. 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. Indicat yes, no, or not determined(Y. N, or ND). Describe basis of determination in all instances. If "not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revise^ 9/2/98 Page 2of11 r r ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (co►ttinued) Property Add►ess22 Simmons Pond. Circle , Hyannis Owner: Peter Palmer Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the p blic health, safety and the environment. 1) S STEIN WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYS M WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUN IONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and,soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) THER revise 5/2/58. Page 3ofIl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:22 Simmons Pond. Circle , Hyannis Owner: Pater Palmer Date of Inspection: (� 7— D. SYSTEM FAILS: You must i dicate either "Yes" or "No" to each of the following: I h ve determined that one or more of.the following failure conditions exist as described in 310 CMR 15.303. The basis for this det rmination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to,be acceptable, attach copy of well water analysis for •coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARG SYSTEM FAILS: You must i dicate either "Yes" or "No- to each of the following: T e following criteria apply to large systems in addition to the criteria above: T e system serves a facifity with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public h alth and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well) The o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)• Please consult the local regional office the Department for further information. revised 5j 2/9S Pagc4orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 22 Simmons Pond. Circle , Hyannis Owner: Peter Palmer Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. V _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. d/// _ The site was inspected for signs of breakout. / _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) T/ 11.5.302(3)(b)] _ The facility owner (and occupants,if differeru from owner) were provided with information on the propermaintanaar"f SubSurface Disposal Systems. revised, 9/2/98 Page 5of11 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION sroperty Address.'Z2 Simmons Pond. Circle , Hyannis Own0r: Peter Palmer Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 36 D g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms (actual):-7 Total DESIGN flow C b Number of current residents: Garbage grinder lyes or no):Z0 Laundry(separate system) (yes or no):A_q,; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):: •O Water meter readings, if available (last two year's usage(gpd): Sump Pump lyes or no): -0 Last date of occupancy: —G� /998 COMMERCIAL/INDUSTRIAL: Type f establishment: Design flow: god ( Based on 15.203) Basis o design flow Grease ap present: (yes or no)_ Industri Waste Holding Tank present: (yes or no)_ Non•sani ary waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available: Last dat of occupancy: OTHER: (Describe) Last da a of occupancy: GENERAL INFORMATION PUMPI G RECORDS a d s a of information: System pump as part of inspection: (yes or no) . If yes, volume pumped: gallons Reason for pumping: TYPE OF S TEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records:if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval ' Other APPROXIMATE AGE of all components, date installed lif known) and source of information: S Sewage odors detected when arriving at the site: (yes or no) C� - , rev Lsed 9/2�/9. Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropeny Address:22 Simmons Pond, Circle , Hyannis owner: Peter Palmer Darte of Inspection: BUIL NG SEWER: (Locate n site plan) Depth be w grade:_ Material f construction:_cast iron 40 PVC_other(explain) Distance rom private water supply well or suction line Diamete Comme ts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) tl Depth below grade: "Material of construction:_'concrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) J � � Dimensions: X Z Sludge depth: 4 2 Distance from topTof sludge to bottom of outlet tee or baffle: Scum thickness: 3— ` „I Distance from top of scum to top of outlet tee or baffle: ' Y Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet teems baffles depth quid I ve in relation to outlet invert, structural integrity, evidence of leakage, etc.) $ / �A of ' / (3 =y-� e n S c/TA b-.► o-� r GR TRAP: (locate site plan) Depth bel w grade:_ Material Construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensio s: Scum thi kness: Distance rom top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Com ents: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evide ce of leakage, etc.) T— r evised G/2/98 Page 7of11 ,; • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION Icorrtinued) ,,operty Address: 22 Simmons Pond. Circle , Hyannis Owner: Peter Palmer Date of Inspection: C-- TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth low grade:_ Material of construction:_concrete metal_Fiberglass_Polyethylene ._other(explain) Dim ons: Capacit gallons Design ow: gallons/day Alarm resent Alarm evel: Alarm in working order:Yes_ No_ Date f previous pumping: Com ents: Icon ition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: G/ (locate on site plan) Depth of liquid level above outlet invert: Comments: Inote if level and distribution is equal, ev end of solids carryover, evidence of leakage into or out of box, etc.) - PUMP CHA BER:_ (locate on s to plan) Pumps in w rking order: (Yes or No) Alarms in w rking order(Yes or No) Comments: (note condi on of pump chamber, condition of pumps and appurtenances,etc.) revises 5/2/58 Page 8or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) 'roperty Address: 22 Simmons Pond. Circle , Hyannis Owner: Peter Palmer Date of Inspection: ( _ 5;_ SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) 1f not located, explain: Type: leaching pits, number: / leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology:, Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp so con • ion of ve tion, etc.) ✓ J 6 � T % co CESSPO S:_ (locate on ite plan) Number and configuration: Depth-top of iquid to inlet invert: Oepth of soli layer: )epth of scu layer: Dimensions of es pool. Materials of co struction: Indication of gro ndwater. inflow cesspool must be pumped as part of inspection) Comments: (note condition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site Ian) Materials of co struction: Dimensions: Depth of solids Comments: Inote conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revise 5;2 7E PuFc 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) -rop"Address: 22 Simmons Pond. Circle , Hyannis lwrw: Peter Palmer .)ate of Inspection: C SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 4t V,/-C IL T revised 9/2/96 Page 10of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cortonued) rop"ty Address:22 S immond. Pond. Circle , Hyannis Owner: Pater Palmer Date of Inspection: NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow. Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater'S Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record :j'Observed Site (Abutting property, observation hole, basement sump etc.) 1 /Determined from local conditions Checked with local Board of Health _Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) G � f L0 �� rev se; 9/2/98 Page 11 of 11