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HomeMy WebLinkAbout0023 SIMMONS POND CIRCLE - Health r "23 'Sirnrnons"Pond Circie Hyannis P A► = 287 175 :I A 3n O' I C a �ybi '''s� ' CERTIFICATE OF ANALYSIS Page: 1 of 1 Barnstable County Health Laboratory (M-MA009) �c1 Report Prepared For: Report Dated: 5/10/2012 Sally Desmond Desmond Well Drilling Order No.: G1267486 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1267486-01 Description: Water-Drinking Water Sample#: Sample Location: 23 Simmons Pond, Hyannis Collected: 05/07/2012 Collected by: Customer Received: 05/07/2012 Routine ITEM RESULT UNITS RL MCL METHOD# TESTED Nitrate as Nitrogen 2.2 mg/L 0.10 10 EPA 300.0 5/7/2012 Copper ND mg/L 0.10 1.3 SM 3111E 5/10/2012 Iron ND mg/L 0.10 0.3 SM 3111B 5/10/2012 pH 6.1 PH AT 25C NA 6.5-8.5 SM 4500-H-13 5/8/2012 Sodium 23 mg/L 1.0 20 SM 3111B 5/10/2012 Total Coliform Absent P/A 0 0 SM9223 5/7/2012 Conductance 190 umohs/cm 2.0 EPA 120.1 5/8/2012 Sodium level is above the maxium contaminant level. Those on a low sodium diet may wish to consult a physician. Attached please find the laboratory certified parameter list. Approved By: — }: (Lab Director) /Z C.�J ry 77 ii +� iwaP ti.d"3 ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Massachusetts Department of Environmental Protection Bureau of Resource Protection WELL DRILLER Please specify work performed: Address at well location: New Well Street Number: Street Name: 23 [SIMMONS POND CIRCLE -. Please specify well type: Building Lot#: Assessor's Map#: Irrigation I— 289 Assessor's Lot#: ZIP Code: Number Of Wells: 175 102601 City/Town: Well Location BARNSTABLE In public right-of-way: GPS 4 Yes r No North: West: 41.64176 170.30386 SubdivisiontProperty/Description: Mailing Address: r click here if same as well location addres Property Owner _ Street Number: Street Name: COSTA 23 S9MMONS POND CIRCLE City/Town: State: IEngineering Finn: BARNSTABLE MASSACHUSETTS 1 ZIP Code: 02601 Board of health permit obtained: Yes 0 Not Required Permit Number: Date Issued: W2012 007 4/26/2012—� Massachusetts Department of Environmental Protection --— Bureau of Resource Protection—Well Driller Program ` Well Completion Reports(General) Well Driller - General Well Form DRILLING METHOD r Overburden Bedrock �uger �� --Choose Bedrock— WELL LOG OVERBURDEN LITHOLOGY From Drop in Extra fast or slow Loss or addition of (ft) To(ft) Code Color Comment drill stem drill rate fluid F67 IFine To Coarse Sand I Brown Ye r Fast r Slow Loss r Addition 20 35 Fine To Coarse Sand Brown r Ye Fast Slow tj Loss r Addition r WELL LOG BEDROCK LITHOLOGY Visible Extra From Drop in Extra fast or slow Loss or addition of To(ft) Code Comment Rust Large (ft) r drill stem drill rate fluid Staining Chips l Choose Code L--� r Ye 0 Fast G Slow Loss Addition r Ye FG Ye ADDITIONAL WELL INFORMATION ` Developed I f)Yes r No Disinfected r)Yes r No Total Well Depth 135 1 Depth to Bedrock _ Fracture Surface Seal Type None Enhancement r Yes tJ No CASING (Ul Is Casing above ground. From To Type Thickness Diameter Driveshoe 32 Polyvinyl Chloride Schedule 40 �J rD Ye SCREEN ❑No Scree From To Type Slot Size Diameter 32 35 Stainless Steel Well Point WATER-BEARING ZONES ❑DRY WEL From To Yield(gpm) 17 35 15 PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Horsepower Submersible 1/2 Pump Intake Depth(ft) 131 Nominal Pump Capacity(gpm) 110 ANNULAR SEAL/FILTER PACK r Massachusetts Department of Environmental Protection .,.- Bureau of Resource Protection—Well Driller Program ) � Well Completion Reports(General) 1 From To Material 1 Weight Material 2 Weight Water(gal) Batches Method Of Placement Choose Material Choose Material Choose One WELL TEST DATA Time Pumping Time To Recovery(ft Date Method Yield(gpm) Pumped Level (ft Recover BGS) (HH:MM) BGS) (HH:MM) 5/7/2012 Constant Rate Pump 15 1:00 18 001 17 WATER LEVEL Date Measured Static Depth BGS(ft) Flowing Rate(gpm) 5/7/2012 117 15 !� COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision,according to the applicable rules and regulations,and this report is complete a knowledge. Driller PATRICKDESMOND Registration# 877 Monitoring[M] F7 Supervising Drill Firm DRILL. Rig Permit# 1024 Date Job Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. 0 No ------------- Fee--- ----------- BOARD OF HEALTH TOWN OF BARNSTABLE 01ppficat ion,forWell Con0ruct ion Permit Application is hereby made 1for (`a permit toConstruct (�), Alter ( ), or Repa�ir ( )an individual Well at: Z-o ft _-- Location — Address Assessors Map and Parcel Cale �— - ----- — -p'v 1�-ow.__ ��_, _ isbt ,,+j 5 Owner Ad r ss Installer — Driller Address Type of Building Dwelling Other - Type of Building-=---__--__— No. of Persons--- _.--._.-.--__—_—_____ Type of Well =4" 9VC- Capacity Purpose of Well-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed a.�- ----- Application Approved By-�����/ ate Application Disapproved for the following reasons: date Permit No. 00 -- Issued -------------- date - - - ----- - -- - - - - ---- --- - BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ✓ Altered or Repaired ( by V- ----- _---- ----- Installer at 23 Si yy-\nn.vn_S PCMA CAct. - ► "N i has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well,Protection Regulation as described in the application for Well Construction Permit No) --O?'Dated—1-Z61Z9 1Z THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- --— - - Inspector-- -- -- -- No. ----- ------------ Fee— BOARD OF HEALTH E TOWN OF BARNSTABLE .: 01ppCicat ion_IorVeli Congtruct ion Permit Application is hereby made for a permit to Construct (1), Alter ( ), or Repair ( )an individual Well at: _Z3_—S�,n.ur,._S_�c_f_r�-�s.�-l�'�urnsi— ----.___ Z-�`��-��-�-•----- —___ Location — Address QAssessors Map and Parcel Installer — Driller T _ Address Type of Building Dwelling -- Other.- Type of Building==-----__—______ No. of Persons-----------------_—__—_ Type of Well r,_S Mb VV<- Ca acit Purpose of Well-- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private We11/Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate.of Compliance has been issued by the Board of Health. Signed — —--------- _ 12— 1. da e r Application Approved By t ate — —^ Application Disapproved for the following reasons: ll JJ date Permit No. 7—© I Z — 00 __ — Issued ------- date ----------__.---------------------------------- BOARD OF HEALTH , TOWN OF BARNSTABLE (Certificate Of (Compliance THIS IS TO CERTIFY, Thaf the Individual Well Constructed (✓), Altered { ), or Repaired ( ) by U� S V,-,QY`-�-W e 1 � ,� -- ---______---- - -- -- -----_-—-- installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection {�ZQ� L- per- Z4 ,Z Regulation as described in the application for Well Construction Permit No. ------------_Dated—�--- --------- r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----—_— — — Inspector------- -- --- BOARD OF HEALTH - TOWN OF BARNSTABLE Vell Con0ruct ion Permit No. 4 Fee ---_—_ Permission is hereby granted � ti - -•,. •.;tip to Construct ( Alter ), or Repair ( ) an Individual Well at:1 . _ j mac^ p No. -.__ 2- L— ii�rn �_�v E�c�. C,L(.�4�YN -------L Street 1 as shown on the application for a Well Construction Permit IAOl _CDO Dated—_ y -/� Board of �J DATE ' L r z> o � s2 bG �.• 6 S oA Szto55- rJ rp R o Po5r2-b D L0Tin 7 P i.1' v 0 T l i I i DESMOND WELL DRILLING, INC.. 5 RAYBER ROAD,BOX 2783 R .`. :ORLEANS,MA 02653' (508)240-1000 T / tl Q 7- ��,��� � CERTIFIED PLOT hLAN S)MMOP/S y>01V& Cllr R� �B t r� y (� ELQRE IN �a su►r�.. SCALE, � ''_ �v DATE , S, 4. ( ,DREDGE ENGINEERING 0.INC /✓�ccr1l-.fit I CERTIFY THAT TN E 60uNDi4Tly)✓ OLiENT' �tE01STERED REGISTERED SHOWN ON THIS PLAN 13 LOCA*'[.D f__.._.._�_.. JOB N0. ....2..'. ..,,,. : OAI THE GROUND AS INDICATED tv-14U ' ( CIViL LAND CONFORMS TO THE ZONING LAWS l ENpIMEEfft ' �SURVEYOOt OR syi OF BAIiNSTAHLE MA8S ? 712 M A I N 5 T R E ET. CH,:®YO ,�•� ` I I Y A N I MASS BHEET qA E ttF 1�. I ANO StJHVEY'k.)A x fifl Page 10of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Simmons Pond Road Hyannisport,MA Owner: Ronald Perry Date of Inspection: August 28,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. A ►3 u tti. O� s fl 2 -tv r- 32 c 3F _ y6 • � I �O RECEIVED - l? 5- TROY WILLIAMS SEPTIC INSPECTIONS SEP 10 2003 Certified by MA Department of Environmental,Protection TOWN OF BARNSTABLE (508) 385-13DD HEALTH DEPT. 19 Hummel Drive South Dennis, MBA 02660 -\ COMMONWEALTH OF MASSACHUSETI'S EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS IFS; DEPARTMENT OF ENVIRONMENTAL PROTECTION f TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 23 Simmons Pond Read, C,I12C l Hyannisport,MA Owner's Name: Ronald Perry Owner's Address: 31 Eastern Point Drive Shrewsbury,MA 01545 0 Date of Inspection: August 28,2003. Name of in ector: . O p Troy M.Williams Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis,MA 02660 Telephone Number: (508)385-1300 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 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 s�stem inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system- Passes Conditionally Passes Needs Further [:valuation by the Local Approving Authority Fails Inspector's Signature: %S ,�,a,,;� Date: 8/z s /o 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15i2000 paee 1 OCII Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Simmons Pond Road Owner: Hyannisport,MA Date of Inspection: Ronald Perry August 28,2003 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 CNIR 13.303 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 r laced or repaired.The system,upon completion of the replacement or repair,as approved by the Board o ealth,will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statements. 'not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whe er metal or not)is structurally unsound,exhibits substantial infiltration or exftitration or tank failure is i tnent. Svstem will pass inspection if the existing tank is replaced with a complying septic tank as approved by t oard of Health. •A metal septic tank will pass inspection if it is structurally sound, leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out igh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or even distribution box.System will pass inspection if(with approval of Board of Health): brok pipe(s)are replaced o ction is removed istribution box is leveled or replaced ND explain: The system re tred pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if tth approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 'Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) Property Address: Owner: 23 Simmons Pond Road Date of fns ection: Hyannisport,MA P Ronald Perry C. Further Evaluations Reg8utied by the Board of Health: j 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- S)•stem 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 2. System will fail unless the Board of Health(and Public Water Sup ter,if.any)determines that the system is functioning in a manner that protects the public health,s ty and environment: _ The system has a septic tank and soil absorption syste AS)and the SAS is within 100 feet of a water ater supply or tributary to a surface water supp ____ The system has a septic tank and SAS and t AS is within a Zone 1 of a public water supply- - The system has a septic tank and SA nd the SAS is within 50 feet of a private water supply well. _ The system has a septic tank a SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Me od used to determine distance "This system passes if t well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile anic compounds indicates that the well is free from pollution from'that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteri a triggered.A copy of the analysis must be attached to this form. 3. Other: , : V. . „ ; Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 Simmons Pond Road HyannispoM MA Owner: Ronald Perry Date of Inspection: August 28,2003 D. System Failure Criteria applicable to all systems: You must indicate"Yes"or"no" Y to each of the following for all inspections: Yes No — --.V/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —Z 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%:day flow Required pumping more than 4 times in the last year IJ!O'�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. — M 11 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. W4 Any portion of a cesspool or privy is within 50 feet of a private water supply well. I 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. lThis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A.copy of the analysis must be attached to this form.) No (Yes/No)The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the vstem 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 de 'gn flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the crite ' above) yes no the system is within 400 feet of a surface drinki water supply the system is within 200 feet of a tribu o a surface drinking water supply — _ the system is located in a nitrogen nsitive area(Interim Wellhead Protection Area—1 WPA)or a mapped Zone 11 of a public water sup p well . if you have answered"yes"to an uestion in Section E the system is considered a significant Y gn cant threat,or answered "Yet"in Section D above the 1 e system has failed.The owner or operator of any large system considered a significant threat under Sec ' n E or failed under Section D shall upgrade the system in aaceordance with 310 CMR 15.304.The system o_ should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: . 23 Simmons Pond Road Owner: Hyannisport,MA Date of Inspection: Ronald Perry August 28,2003 Check if the following have been done.You must indicate'yes"or"no"as to each of the following: Yes No (`:::-,ping information was provided by the owner.occupant,or Board of I lealth 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? - Z Have large volumes of water been introduced to the system recently or as part of this inspection? — Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up') _ Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site.? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the Soil Absorption System(SAS)on.the site has been determined based on: Yes' no _ 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 15.303(3)(b)] Page 6 of l l OFFICIAL INSPECTION.FORM-NOT FAR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART f SYSTEM INFORMATION Property Address: 23 Simmons Pond Road Owner: Hyannisport,MA. Date of Inspection: Ronald Perry RESIDENTIAL August 28,2003 FLOW CONDITIONS Number of bedrooms(design): 3 Nurnber of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 3 o Number of current residents: o — 2 Does residence have a garbage grinder(yes or no):Aio Is laundn on a separate srH•age system(yes or no):nro (if yes separate inspection required) Laundry system inspected(yes or no): /Ljq Seasonal use: (yes or no): Yes Water meter readings,if available(last 2 years)rsage(gpd)): o I- -o 5 Sump pump(yes or no): No Z,00u��,_ o� z = j.,,-, , Last date of occupancy: - �K t u r q 1F -r:s +j C_• COMM ERCIALIINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or n Non-sanitary waste discharged to the Title system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Al,--i��t9T ��; ; Was system pumped as part of the Inspection(yes or no): ivo If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _/Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology..Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval Other(describe):. Approximate age of all components. date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Ala q. AA 6 1 � 2 Page 7 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Simmons Pond Road Owner: HyannispoM MA Date of Inspection: Ronald Perry August 28,2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron Z40 PVC_other(explain): Distance front private water supply well or suction line: N/-9 Comments(on condition of joints,venting,evidence oC leakage,etc.): �I Pik C-b- SEPTIC TANK: ✓(locate on site plan) A/- : -�f� ; s , F Depth below grade: p f t lr, C. A C J} r4+ Material of construction: ✓concrete metal fiberglass,_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: S 'x - loop 5e�eroh Sludge depth: y Distance from top of sludge to bottom of outlet tee or baffle: 2 Scum thickness: :2�L,; I Uy 11 Distance from top of scum to top of outlet tee or baffle: 6 �' Distance from bottom of scum to bottom of outlet tee or baffle:y' 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.): —�—_.. J- � .✓�- Sh.l.a..._J/'+. �'�t� el cry��. ..�/0 1ti:in �✓al-�r,....1�p •�'i'��.� J GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:_concrete_metal fiberglass_polye ene_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 affle: Date of last pumping: Comments(on pumping recommendations,inle d outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leaks ,etc.): 7 Page 8 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Property Address: 23 Simmons Pond Road Owner: HyannispoM MA Date of Inspection: Ronald Perry August 28,2003 TIGHT or HOLDING TANK: (tank must be pumped at time o spection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiber time _polyethylene other(explain): Dimensions: Capacity: gallons Design Floe: gallons/day Alarm present(yes or no): Alarm level: Alarm in workin der(yes or no): Date of last pumping: Comments(condition of alarm an oat switches,etc.): DISTRIBUTION BOX: ✓(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carrygver,any evidence of leakage into or out of box,etc.): /� L c. ,A �lo u /t,..e,.a L. i c..✓1, j' F c.......1 d-6 o y 1 h u 1 *��.� ('. o✓ f Via i u3' 6✓i �f, l�'���e W�^f /v c c •� ✓ 1^J<r U�� h W n o S PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition o umps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM'—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Simmons Pond Road Owner: Hyannispom MA Date of Inspection: Ronald Perry August 28,2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why Type ` leaching pits,number: I - ' k t ' L t, 10. leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): L c 111 L, w• 9- , - , —A t W c✓'F+ qv-c-S tr. ► �-f /h� � ",t o� i h S c-,v�•oy �7�ru i l:c l.v o r pw 61-- i 4 '7 �. * w w•� {a.i.��• CESSPOOLS: (cesspool must be pumped as part of inspection) Cate on site plan) Number and configuration: Depth—top of liquid to inlet invert: _ Depth of solids layer: Depth of scum layer._ Dimensions of cesspool: Materials of construction: _ Indication of groundwater inflow(yes or no . Comments(note condition of soil,signs hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraul' ailure,level of ponding,condition of vegetation,etc.): Nr E. Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Simmons Pond Road Hyannisport,MA Owner: Ronald Perry Date of Inspection: August 28,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A i3 w�k . t � `K • • •. Novo 5�.'�A/t��h ,3r - 37 ' �,� ft 2 ����. 'Page 11 of 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address: 23 Simmons Pond Road Owner: Hyannisport,MA Date of Inspection:- Ronald Perry SITE EXAM August 28,2003 Slope Surface water ✓ Check cellar Shallow wells Estimated depth to ground water I-7 + feet - Adjusted high ground water elevation _ feel Please indicate(check)all methods used to determine the high ground ssater elevation: Obtained from system design plans on.record- if checked date - Ob of design Ian rev'served site(abutting roe 6 P sewed. 8 P P Y nervation hole within thrn S Checked with local Board of Ilealth-explain: I-0 feet of SAS) Checked with local excavators, installers-(attach documentation) v_Accessed USGS database-explain:�, ,,••, z►• 1 C You must describe how you established the high ground water elevation: V. /y /✓ i I�^� "�` �h �j vZ,u�-..( �.r�..r�<v �•c.✓-v! c�'�" '^< 7j�-s. .,g, � � ., �S`J�c. �i u c,, This report has been prepared and the system inspected as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed,written or Implied, relating to the system,the inspection and/or this report. 11 - > LOCATION SEWAGE PERMIT 140. VILLAGE INSTA /L,I_E_R'S NAME 8 ADDRESS eZ I3 U I L D E R OR OWN,ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��� �� 33 r' �V �C a r ol �2i otJ T SSf Al HaAJ .3 �.vQ1 .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....---...a7-r5.............OF.......... 1 -"�I�,--------•-•---•---•---ep •- Appliration for Uhipvii al Workii Towitrnriiun ramit Application is hereby made for a Permit to Construct ( ) or Repair n Individual Sewage Disposal System at: Ze #6 ....................... ---------------!� ---------- Location-Address t No. 1.�..,. �wnerddress . 000 do Installer Address U Type of Building Size Lot.....f - �Sq. feet ------:----- Dwelling—No. of Bedrooms.................. .......--.Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers Pa YP g ---------------------------- P ( ) — Cafeteria ( ) a' Other fixtures ----••-•---•------•------------• . W Design Flow............................................gallons per person per day. Total daily flow.......... 0.................gallons. WSeptic Tank—Liquid capacit !Kdgallons Length................ Width................ Diameter--.--....---.... Depth................ x Disposal Trench—No. ..................... Width.................... Total Length.................... Total leaching area-Z.6-- ... ft. Seepage Pit No..................... Diameter.....---.---........ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by............................CC. ..C....................... Date...... � •} � Test Pit No. . _minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ (i, Test Pit No. do-- inutes per inch Depth of Test Pit.................... Depth to ground water.---................---- a ---- -------------------------------------------------------•-------..........• ---------- -- --------------;.-.- 0 Description of Soil.................................................................... •. -•--- 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 issue t�bo �IthSigned--- - -- - -- ------ ;, Date Application Approved By...... ........................... •... ................ Date Application Disapproved for the following reasons-----------------------------------------------•-----------------------------------.............................. --•--....-•------------------•---•----••-----------•---......--------------------•---........---..........---.........------------......---------•-------------------------------------------•••--------- Date PermitNo....7 ................................ Issued....................................................... Date .......................• •,..I .n--------------------- Fps... .... THE COMMONWEALTH OF MASSACHUSETTS EOARD O�,NEALTH OF.......... .t..................... .... Appliration for Disposal Works Tnntrnrtinn Prrut �. ^Application is hereby made for a Perm* o Construct ( ) or Repair ( ) an Individual Sowage Disposal System at: Location.Add res or t No .. t �� �.,r _.....l, z..,l�� f.�' Cam,,?'.......................... ,G..P-.r-`� r. r OH r Address ---- ,G-�..r ,'�. '`!Y-clf�- _____________________________________________ Installer U Type of Buildin Address g Size Lot............................Sq. feet Dwelling—No. of Bedrooms....__________ ______________Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Building YP g .................-•--------- No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures . -•--• -----• W Design Flow............................................gallons per person per day. Total daily flow......... .._._____._._._gallons. Septic Tank—Liquid capacitylll_!5gallons Length................ Width................ Diameter.................Depth................ W Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area____.�G'_.G_sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( Percolation Test Res rformed by___________________ _�. _..._C.____.__..___............ Date.... aTest Pit No. I. .____ tes per inch Depth of Test � *fF � P P t Pit.................... Depth to ground water..........-............. f� Test Pit No. _minutes per inch Depth of Test Pit____________________ Depth to ground water........................ x Description of Soil.... i-L (� ----------------------------------- •---------------------------- UW -=--••-----•-----------••---•...---------•••----•-•-----•-••-...•--•----•----•------•------•-•-••-----••--••-•-------------------•------••-•------•--•---•••-•---...-•--•••-•-----•••-----..._...------ 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 TITI-E 5 of the State Sanitary Code— T ersigned further agrees of to place the system in operation until a Certificate of Compliance has been iss the boa lth. •�� Signed • ----•-•--•----•-----•---•----- ----- � Date ApplicationApproved BY.................................................................................................. Date Applieation Disapproved for the following reasons-----------------------------•---------------------------------------------------•------------------••-.....•••-- .................................. 7tJ -------------••-•--------------------------------------------------------------------...--• Date PermitNo. .......................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tOF Tatifiratr of Tompli atta THIS IS TO CE I That th Individ Sewage Disposal system constructed ( ) or Repaired ( ) by -"- , ' ------... ........ ....................................................... Installer at................... 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 No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. DATE.....7 %l..Xy.--'•......:_ ''- Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ._. ..._.............---.._.__..............._._............ No......................... ...........................................OF...---............_..._-_. FEE........................ Disposal 7nr� ��f r tn/n- per 'f Permis&n is hereby granted...........• �'J � . - 1�. .�f.` ...... to Cons�rif rt )Arl,.�2epaif��y'� SIndivi lASOe'vage 13 .S:ystfem Street as" hown;,on the application for Disposal Works Construction P Date - ................. .............. _.....-•---- -...........................--- Z Board of Health DATE.------- --_ �. ----•-•...................•--•-----•--.__..-----... ' FORM 125,5 -A M- SULKIN INC BOSTON �.,. '"c 1p �R1 VA re--' soy w�b r : 99 a , 99 obu I rj ZIV �.' �o aC �Sor� H 3 ' 7`Fsr An e39 ( 9� i/ y SS r Ni L OT O ,� 1/ H11 57o SF w 0 4 LET Zo - 9 �j" OF a �p OF �gA �'�` '?�, CERTIFIED PLOT PLAN ROBERT BF;UCE LoT 21 S/M M oNS PoNO CI 1LGLp. 1 U 1N aF'ar ELDRED a YyAAIA/!S ?0Rr . 3G6 ` .off GAF IN 2�/gall° 9r.. ;lha 5 f-AJ � ... pMJ\�.�� SCALE, yam ' DATE 3I�9 - !. ,94 rI.DREOGE' ENGINEERING Ca..ING CLIENT 1ck�t.r�g' 1 CERTIFY THAT THE PROP03ED EGISTERE REGISTERED JOB NO. wvL3 BUILDING SHOWN ON THIS > PLAN . CIVIL LAND CONFORMS TO ,THE- ZONING LAWS .F W. , ENGINEER R Y OR.BY ._ OF Bl�RNSTAB� E' MASS. , 712 M A I N STREET:" �:N'.8Y -, J�, ✓ �- l� : ............... } . HYANN131 MASS:' + , 2 OF ATE REO. 'LA TD SUftVEYAR /VOTE /F E/7W— THE SEPT/G TANK' OR 4E/4CI•!/ivG P/T -AN& MORE THAN /$"EELOyV /O Pt M/K GRAOE, A R4'O/AM ETER C'ONCRET� COMAnVi SWALL &,F 9R0V6,V7- T OE O ISMA . AN ETRA X CONCRrTE , q"PVC Pier 4--.4VY CAST /RO/Y CoV�R SHALL S,- US�O COVERS P/TCII /F/IV DR/VEWA y �PFiQ FT.. I 2� MiN. CD/VC,�E'TE Q a AaE CO✓ER CLEAN SANG BACK/=/LL. -=- LI<Q[//D LEVEL A_ - 2 L FR Y PIPE /oc GAL. • a o • QIF �/e"-s/e" MIN.PITCH • 0 t • . . • . •• • b • � S.EPT/C TANK D/ST. �.• s • • , • • • • • , o+ WASHED 570NE BOX v of ® • • • t ♦ ev all . • . o ��Ecrrvc :: , r • • DEPTH • • t • • o IVASNED STONE I 40 a. • . • • • t • • p ,♦v PRECAST SEEAb6E I AIVZAT eL EYAT/Q/9�.1 OF ►• • 0 • ' • • • 8 a oV- /UBi6-/ZS =. A171 s INVERT AT Cr —�"'—' L FT D/f1 J►'1. C(SEE 7,PWZI 4TIO/V, INLET 'SEPT/G TANK �'-`/ FT DU7LET SEPT/C.TANK g7,Z /cP INLET DISTR/13!?/ON BOX 9T`, FT. GROUND JCATER 7.AW-E 0C/TLETD JSTR/Bt"40N 49" gGK3 FT, SECT/ON OF Z0V4R .cEAcs+/NG PiT AFT SEN/AGL� O/SPOrS'A L SYSTEM TA 417140N 4LEACH/N6 P/T- SCALE '/s _ /=4� DiMENSJON A .FT. DES/GN CRITERIA D/rlEevs/ON 8 FT NUMBER DID BE®Ro0/►�S 3 C+RaAGEo%sPOSAI-UNIT wows SO/L LOG So/L 'TEST TOTAL EST//yIATEG FLOW 330 G.4L.1DAv SOIL TEST A/ $OIL 7—IS7-02 MUMBER aoW Y,EACRINC- P/73� - - f^ELRY. �'-'ELEY• PATE OF SO/L TEST S/OE LEACHING PER P/T .SYtt fT. _.o-�" eiUS RESULTS IVJT/VESSED BY OGTYO/►!LEACH/NCr PER P/T SLI• FT z"f -Z-W PERCCLATJON RATE#/ MJA I/NCH { T07AI. LEACN//YG AREA Z 617 Sip. FT .CL COLT'/oN RATE 1k2 M/N.11 VCH j RESERI�E LEACNJN6 AREA Z 4,7 So. FT. r Z55 T • - ,,, za o f.4f ^ ,. Si/I1N101J5 �O G �� RJt EP7 ELW E!~ ' >. n � I BERG ELORED6EENG/NEER/JVGCQ,/NC. / _ •o Noy 366` •` 7J2 MAIN 9 F� PYANNJ9, MASS. �! ; NGGRC?UND YW•t:TER E/VCOUNTlr- 4. : CL/ENT VICK1 LA-5 ,O�lTE d � SJig '�ssioNal EN���� G1 GROUNCo W,47-4-- AT. ELEY