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HomeMy WebLinkAbout0113 SIXTH AVENUE (HYANNIS) - Health 11.3 Sixth Avenue Hyannis A = 245 065 F • 4 �: • Nam. I fI I Y iQOAo`p .I e Town of Barnstable 05-=.L1�1 �oFfNB Tpw Regulatory Services ............ Thomas F.Geiler,Director • BARN 6E, 9MAS& Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: (() oS Designer: �/i 1�f ""` Installer: r Address: . �. V _ BOX Address:. 360 Main Street W. armouth, 73 On ,. -S AA-)C C was issued a permit to install a (date) (installer)/ septic system at It St X }f I I le�'e N U E based on a design drawn by (address) p YelR'Sdated b log (designer) Ycertify that the septic system referenced above was installed substantially accordingto the design, which may include minor approved changes such as lateral relocation of he distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e, greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. ,,\A OF 44 RR N oy o E co co staller's gnature) No. 1140 7 aISTS gMTA0, /�.�D S . l �o esigner's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNST LE 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:Health/Septic/Designer Certification Form VI/ TOWN OF BARNSTABLE LOCATION SEWAGE# ,7— VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. t� �,/�C4 s" L� b SEPTIC TANK CAPACITY 11T60 fAl y LEACHING FACILITY:(type)�7 fl Zy SD/Lr G�"�6 (size) NO.OF BEDROOMS 3 BUILDER OR OWNER ¢ CD W,41V PERMIT DATE: U /�r COMPLIANCE DATE: . Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r VA Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) N A Feet Edge of Wetland and Leaching Facility(If any wetlands exist N within 300 feet of leaching facility) Feet Furnished by � & � ����'® � c� �r w � � � � � N w , � � � � �^ �� �� "F ,. � �� ��\ �\ .� \ \ � . �; � � � k D � t,� I � � n : � � O �/ i J. i 7 � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZppYication for �Digonl bpztem Con6truction Permit Application for a Permit to Construct( )Repair(wltpgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No.11 ��x � Owne 's Name,Address and Tel.No. rG✓�i r'1 Assessor's Map/Parcel a 7/ O✓ • oG S Installer's Name,Addre*618.VANCO Designer's Name,Add ss and Tel.No. 350 Main Street rY►P�e 17 W. Yarmouth, MA 02673 3 a Type of Building: Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures C/ Design Flow 3 3 'i gallons per day. Calculated daily flow 330 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /.SOU Type of S.A.S. Description of Soil �2 r Nature of Repairs or Alterations(Answer when applicable) /4//)0-?, 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 Certifi- cate of Compliance has been issued by this Bq of H Signe �J Date • 5 Application Approved by - Date Application Disapproved for the following reaso Permit No. Date Issued v.ysr..,,,.«Y -. •w.'.• ...,;r'*'�,:� '., ♦ .�....- 4y" �*-...r.:r o '..+R.rr..- .✓--n f..+ r. 4y" 00- 1�,.,..-.No. � / { Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION,- TOWN OF BARNSTABLES MASSACHUSETTS Application for Miopaaf 6potem Con!6truction Permit Application for a Permit to Construct( )Repair(✓rUpgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No.//3 A' owne 's Name,Address and Tel.No. Assessor's Map/Parcel d V J_ . OG JS, / Installer's Name,Address,and Tel.No. Designer's Name,_Add ss and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow .33 Y, 5- gallons per day. Calculated daily flow C) gallons. Plan Date �i ' S� Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil (Nature of Repairs or Alterations(Answer when applicable) ,r` / A r1 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 Certifi- cate of Compliance has been issued by this B alN of H r Signe ( \ 11 Date �7 <� r 7 Application Approved by Date� G"/ ,C._-- e ' Application Disapproved for the following reaso J �- Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS 1 8 BARNSTABLE, MASSACHUSETTS (Certificate of (Compliattce THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( ) Repaired ( -TUpgraded( ) Abandoned( )by C/,q /U e,ca at 1/ J/ y1 1 14 LA-2 ",-A n,, has Weconstructed in accordance with the provisions of Title 5 and for Disposal System Construction Permit No `'(� ated Installer {.® Designer n� The issuance of this permit shall notI be construed as a guarantee that the sy tem w'1 nc ' , a desi n Date (U 14 Inspector `-�- No. Fee / 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwitpo5at *pgtem Cou5tructiou Permit Permission is hereby granted to Cor ptructj )Repair(✓Upgrade( )Abandon( ) System located at /)c" and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constr c, us be'completed within three years of the date of thi 6 t. Date:_. , / �� Approved by ✓ ! "4e Town of Barnstable. pit Department of Regulatory Services / • Public Heal R Date KM • th Division 1bsy ,e$ 200 Main Street.Hyannis MA 02601 Date Sch eduled 4-3 Time=�_ Fee Pd. ,Foil Suitability Assessment for Sewage Disposal ( -, R's Witnessed By: ►/6N I/�/� Performed By: LOCATION & GENERAL INFORMATION Location Address'. / 5�94X AV%Q Owner's Name C�L4rQaV1� !3 _ Address . �`•3' i Assessor's Map/P$tcel: �� s I Engineer's Name �.y.Lpyt 12-9 0!7 NEW CONSTRU(�1710N REPAIR X Telephone QPcj Q G�lT1 A�t� Surface Stones— Slopes(%) O L' ^ Land Use ft 7 S� ! ft Drinking Water Well �/y Distances from: Open Water Body ft Possible Wee Area 7 — A, Drainage way ft. Property Line !!7 ft other ,SKETCH:($treet name,dimensiods of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) lc a, s ( N Parent material(geologic) joz?mSN 'PZAyj ( Depth to 13ec(toek i Depth to Groundwater. Standing Water in Hole:' N . weeping from Pit Face i Estimated Seasonal I fth Groundwater DtTERMIN TION FOR SEASONAL ffiGrI 'V�ATL' TALE Method Used: In. Depth to soil Mottles: jn• Depth (14erved standing u<obs.hole - -�, ©mundwatcr A�Juettnent Depth toiweeping from side of obs.hole: , at _ j lio t undwale r LeVel— Index Well# Reading Date index Well level — - Date 7 r Time PERCOLATION TEST Observation ?i I Time at 4" 1/ ql Hole# ,� � Time at 8 Depth of Pere / to ! t ( Time(9"•G7 �. --^ Start Pre-soak Tune.0 - End Pre-soak L sMtNru Rate MinJlnch Additional Testing Needed(Y/N) Site Suitability Assessment: Site Passed ` Site Failed; Original:.Public Health Division Observation Hole Data To Be Completed on Back------ ***If percolaAion test is to be conducted within 100'of wetland,you must first notify the Barnstable C4#servation Division at least one(1)week prior to beginning- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other .Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis enc %Gravel 34 pj (DA*1 Sahel 1vYk YA } DEEP OBSERVATION HOLE LOG Hole# Z' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis enc Gravel) tt_ oN LOAM ►b R-16' N . �, t�t� � . nc.�l�( and �,•5 613 s DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Grave DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consist I .t Flood Insurance Rate Mau: Above 500 year flood boundary No— Yes Within 500 year boundary No X Yes Within 100 year,flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring per lops material? Certification I certify that on ' (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the requir ra i ,expertis and experience described in 3..10 CMR 15.017. I Date Signature OJ Q:\SEPTICIPERCFORM.DOC l t Town of B rnstable. P#_ Department of.Regulatory Services r Public Health Division Date b 200 Main Street,Hyannis MA 02601 A. Date Scheduled Time Fee Pd, ,Foil Suitability Assessment for Sewage Disposal Performed By: �� e_�Iy, 9J Witnessed By: 1/61q LOCATION & GENERAL DWORMATIQNi Location Address X7% Owner's Name Address Assessor's Map/P4teel: �7, /: MT Engineer's Name ,, NEW CONSTRUt-.MON REPAIR X i Telephone#Nra 34 2- 7-1 Z� NIA Land Use 11 D�7L Slopes Surface Stones Distances from: Open Water Body �00 ft Passible Wet Area 7 _ft Drinking Water Well 7/S�ft Drainage Way > ft Property Lane !!7 ft Other "F Q ft SKETCH:($treet name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) �— 40 lo' a4*1 Parent material(geologic)OUn✓'4'S_N �LtPiN I Depth to Bedrock ' /✓ I Weeping from Pit Face NIA Depth to Groundwater. Standing Water in Hole:' f i P g Estimated Seasonal 14igh Groundwater N/� DtTERMIN TION FOR SEASONAL HIGH WATER TALE Method Used: In. In. .Depth to sall mottles: Depth CIb,c ved standinglin obs.hole: In, ©roundwnter Adjustment Depth tolweeping from side of obs.hole: ; Adj,{aclor,�., Adj.Croundwaterlival index Well# Reading Date: Index Well level PERCOLATION TEST ' Data 7 / 'll'ltne 36 Observation Time at 9" t j -----�— Hole# l l 1/ //q ��- - Time at 6" -- Depth of Pere M e IJ /o L� to I t j Time 61.611) Start Pre-soak Time.0 / - End Pre-soak I ZY 11 5Mt•v t S-n'a.�, _�_, i Rate MinJinch ' Al Site Failed: Additional Testing Needed(YIN) sr Site Suitability Asse�smeat: Site Passed._ • original:.Public He*lth Division Observation Hole Data To Be Completed on Back --- ***If percola#6n test is to be conducted within 100' of wetland,you must r1rst notify the Barnstable C44servation Division at least one(1)wedk prior to beginning- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. � Consistency,%Gravel b4m,,5t4od loYi�3/y Jhe1 DEEP OBSERVATION HOLE LOG Hole# Z" Depth from r' Soil Horizon_. Soil Texture Soil Color t Soil ,_ Other Surface(in.) (USDA) (Munsell) Mottling' '(Structure;Stones,Boulders. o sis nc Gravel) LOAM i b r 16, ,, tUt, he•M 1,444 1,•5 �A 4 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc o Gravel 'V DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon '( Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con ist n I c Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No 1 Yes Within 100 year flood boundary No X Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? Va If not,what is the depth of naturally occurring per sous material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with er is and experience described in 3:10 CMR 15.017. the re uir ra i ex t e P P _ 9 Signature A Date Q:VSEPTIWERCFORM.DOC Commonwealth of Massa .�t' tta title Z ,Official ] t . i 7 p Subsurface Se;ivage Disposal System Form Not for Voluntary,Assessments 113 6TH AVE Property Address - EDWARD COWAN' Owner . Owners Name information is required for every WEST HYANNIS PORT, MA. 02672 9/3/09 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 Important:When A. General Information filling out formsS1 on the computer, rn use only the tab 1.. Inspector. key to move your '. cursor-'do.not - DAMES DSEARS -_ ---.� -- -.- _ ----use the.return key.`_ Inspector - Name of Ins ector -- - -- - - — --- —_ :_..... , BLUEWATER d Company Name 350 MAIN ST - Company Address �2m W. YARMOUTH MA 02673 City/Town, State Zip Code 5087-775-2800 S 1623 Telephone Number,; License Number B, Ca Ifficatio -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 maintenencI;,gf on s4e sewage:dasposal systems.i am a DEP approved system inspector parsuanttwSection IU40 itle-54310-Ei R-11-5-00%.The--system 04 Passes ❑ Conditionally Passes, ❑ 'P� ` {] M4ss475- 03 ate ❑ Needs Further.Evaluation by the Local Approving Authority .' J MES 0: S ARS _ A 9/3/2009 spectors Signature Date IN S? �������` The systerri inspector shall submit a copy of this inspection report to the Approving.Authority(Board of Health br 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. 113 6TH AVE W HYANNISPORT.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Cotnmonw-alth of Massachusetts. 'i ffic l ` o Forte I:. Subsorfac-p Sewage Disposal ystem Form e Not for Voluntary Assessments 113 6TH AVE Property Address" EDWARD COWAN' Owner Owners Name information is required for every WEST HYANN1S PORT MA 02672 9/3/09 . page. City/Town State Zip Code Date of Inspection B. Certification (coot:) Inspection Summary: Check A;B,C,D�or E/air als complete all of Section.D A) System Passes. X. ❑" _ 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 z S) 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. Answer yes,'no or not determined (Y N, ND)a in the❑for the following statements' If"not d .: 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.thel Board of Health. 'km s_eptic_tank well_pass inspection if I-it is_structurally sound not leaking and_if a °Certifcate of Compliance.lndicating that the tank is less than 20'years old is available. ND Explain:' ❑ Observation of sewage backup or breakout 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(witp approval.of Board of Health): ❑ broken"pipe(s) are.replaced ❑ obstruction is removed a 113.6TH AVE W HYANNISPORT.doc•03/08 Title 5 Official Inspection Form subsurface Sewage Disposal System Page 2 of 15 .� Commonwealth of M ssachusetts itOfficial Inspection Forte J �i� Subsurface Sevgage Disposal System Fi rn -Not for Voluntary Assessments 0 , � y 113 6TH AVE Property Addresg EDWARD COWAN Owner. Owner's Name information is required for every WEST HYANNIS PORT MA r 02672 9/3/09 page.. City/Town State Zip Code Date of inspection B. Certification (cont.) l3) System Conditionally Passes(cont): ❑ - distributionf box is leveled or replaced ND Explain:. ❑ :The system required pumping more than.4 times a year due to broken-or obstructed pipe(s). The system will pass inspection if'(with approval of the Board of Health): ❑Y broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is`°Required by the Hoard 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 awnless Board of Health determines in accordance vvith.3lfl CMR -15.303('l)(b)that the system is not functioning in a.rnanner which wilI protect.public health,-safety and the environment: ❑ Cesspool 6r privy.is within 50 feet of a surface water a ❑ Cesspool_or-privy_is_within_5.0-feet_of a-bordering vegetated-wetland_or_a-salt-marsh 2..`System will fail.unless the Board:of Health (and Public.Water Supplier,if any) determines'that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic tank and snit 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 aseptic tank and SAS anid: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.. 113 6TH AVE W HYANNISPORTdoc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Mass achu set#I ! 'I� Subsurface Seviage;Disposal;ystem Form.r,Not for Voluntary Assessments ., 1.13 6TH AVE Property Address EDWARD COWAN - Owner Owner's Name information is WEST HYANNtS PORT MA 02672 . 9/3/09 required for every page: CitylTown state Zip Code Date`of Inspection B. Certification (cont.); C) Further Evaluation is Required by the Board of Health (cont),. ❑ The:system has.a`septic:tank and SAS and the'SAS is less than 100 feet but 50 feet or more fro.ma private water'supply.well*`. Method used to:determine - :_ distance. **This system passes if the well water analysis, performed at a DI P certified laboratory, for 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 forrm 3:•Otlier: _ D) System Failure Criteria Applicable to All Systems: - You must indlbate "Yes" or"No"to each of_the following•for all inspections: :Yes . No , Backup of sewage into facillt orsY stem component due to overloaded or x _ I g --Y — clogged SAS or ce.—sspool r Discharge or pondmg of`efflueri o the su arr- ce of-t e ground nu d 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 leaching is less than.6" be'low�invert or available volume is less than Y2 day flow 4 Required pumping more than 4'tinies in the last year A/0T due to clogged or y obstructed pipe(s). Number of times pumped. - 0 Any portion of the`SAS, cesspool or privy is below high ground water elevation.: 0. Any portion of cesspool ortprivy is within_100 feet of a surface water supply or tributary to a surface water supply.' a , 113 6TH AVE W HYANNISPORT.doc•63108 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 1'5 Commonwaa'lth of Pilass_�chusett y Title ���CiaInsp c o .a j= Subsurface Sewage Dasposal System Form -Not for Voluntary Assessments' 113 6TH AVE Property Address EDWARD COWAN Owner Owner's Name information i e required for every WEST HYANNIS PORT MA 02672 9/3/09 x - page. City/Town =` state . Zip Code Date of Inspection B. Certification (coat.) oD) System Failure Criteria Applicabe tA!! S st erns (cont.); . Yes No ❑ An ortion of a cesspool or privy is within a Zone 1 of a public well. Yp . l ❑ 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 Nkater quality analysis. [This .:-system passes if the well water analysis, performed ata 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 roust be attached to.this form.] ' 0. 0 The system'is`a cesspool serving a facility with'a design flow of 2000gpd 10,000gpd, ' Th -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 l0; ?0 gpd'to 15,000 gpd. h following,, in addition to the indicate either yes or no' o each of e For large systems, you roust y 9 . 9 Y Y- . questions in Section_D: Yes No the sys❑ tem 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-l'WPA)or a mapped Zone 11 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. a _ r. .. 113 6TH AVE W HYANNISPORT.doc•03/08 Inspect .S wage Disposal System•Page'9 of 15 Title 5 Official ion Form Subsurface Se ' Commonwealth of Massachusetts tj qI �-- - Title . S Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 113 6TH AVE Property Address EDWARD COWAN Owner Owners Name information is required for every WEST HYANNIS PORT '. MA 02672 9/3/09 page. Cityfrown State Zip Code' Date of Inspection C. Checklist Check if the following have been done.'You"nnust indicate"yes" or"no" as to each of the following: Yes .No Pumping information was,provided by the owner,occupant,.or Board of Health. ❑ x❑ Were any of the system components pumped,out in the previous two weeks?. x❑ ❑ Has the system received normal flows in previous two week period? El �' y 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) x❑ El Was the facility or dwelling inspected for signs of,sewage back up?. x❑ ,❑ Was the site inspected for signs of breakout? . ❑' ' , Were all system�components; including 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; a ;dimensions, depth of liquid; depth of sludge.and depth of scum? 9 x❑ Was.the-facility owner(and"occupants if different from owner)_provided with infor_matCon-on the_pr_opE[-maintenan_ce_of subsurface sewage_dia osal s}tsteMs? _ tThe size and location of#rye Soil Absorption System (SAS)on the site has 'been determined based on: p Existing°information, For example; a plan at the Board of Health. 0, Determined in the field (if any ofthe failure criteria related to'Part C is at issue approximation of distance is unacceptable){31'0 CMR'15.302(5)] 113 6TH AVE W HYAWSPORT.doc•03108, Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 15 ate` CommonVisalth of Massachusetts Title UTTJc! o r Sewage -Not for Voluntary ryAssessmentsJ; Subsurface Dssoosa� System 113:6TH AVE Property Address EDWARD COWAN Owner Owner's Name information is required for every WEST HYANNIS PORT MA. 02672 9/3/09 _ page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design) 3 Number of bedrogMS"(aCtual): 3 DESIGN flow based on 310 CMR 15,203 (for.example:.110 gpd x.#of bedrooms): 330 Number of current residents. 2 < Does residence have a garbage grinder? ❑Yes Z No Is laundry on a separate sewage system? [if yes separate inspection required] ❑Yes 7 No Laundry system inspected? ❑Yes x❑ No Seasonal';use? ❑Yes x❑' No ° Water meter.readin s, if available last 2 ears usa e od NA , Sump pump? . ❑Yes x❑ Nd. " z-J `CURRENT Last date'of occupancy. pate Commerdial/industrial Flow Conditions ° Type of Establishment Desi9 n flow-..based:on_3.10_CMR-1.5 203 Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? Oyes ❑ No , Industrial waste holding tank present? ❑Yes ❑:_ No Non-sanitary waste discharged<to'the'Title 5 system? , r❑Yes El 'No Water meter.readings, if available: Last date of occupancy/use: , Date . . Other(describe): sal t Page 7 of 15 113 6TH AVE HYANNISPORTdoc•03108 Title 5 Official Inspection Farm:Subsurface,Sewage Dispo System•P g ' Comm timvealth of Mas�sac;nissitts :. a iTitlio 5 Official ,Inspaption Frm. Subsurface SejRjage Disposal System Form Not for Voluntanj Assessments / 113 6TH AVE Property Address - EDWARD'COWAN Owner Owner's Name information is WEST.HYANNIS PORT MA 02672 9/3/09 . required for every page. City/Town State Zip Code Date of Inspection Da System. Information (Cont.) . General Info rnatio Pumping Records: Source of information NA Was system pumped as part of.the inspections ❑Yes ❑x 'No If yes volume"pumped - gallons'' How.was quantity puu ped'determined? Reason for_pumping= n Type of System: 0 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 l/A system by system operator under contract r ❑ Tight tank. Attach a copy of the'DEP approval. ❑ , Other(describe): <Approximate,age of.all.components, date,i,nstaIleflif;known)and source of'infor-mation. 2005 PERMIT`#2005-441 Were sewage odors detected when arriving at the site? ❑Yes ❑ No 113 6TH AVE W HYANNISPORT.doc•03/08 'Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 15 Y Commonlillealth of Massachusetts i;� I Subsurface S,eviage.Dlsposal Syst:em,I=orrn- Not for Voluntary.Assessments � _ Imp � IF 113 6TH AVE r: Property Address... EDWARD COWAN Owner Owner's Name information is WEST HYANNIS PORT MA 02672 9/3/09 required for every page. City/Town State Zip Code Date of Inspection . D. System Infor ation (cont:) Su ildia�g Se%;der(locate on site plan). . . 2, Depth:below grade: :. .. feet. Material of:construction: A ❑'cast Iron 7 40,PVC 1771-other(explain): ~ Distance from private wafer,supply well or suction line: feet Comments (on condition.ofjoints, venting', evidence of leakage, etc.): CAMERA LINE, CLEAN&SOLID Septic Tank locate on site.plan): Depthtelow grade:; 1.4, feet Material of construction: x❑_concrete'' h ❑ metal ❑fiberglass ❑ polyethylene'. ❑ other(explain) ..... _d. ,t s If tank is metal, list age: years -: Is_age_confir-med_by-a Certificate--of Compliance_?-(attach_a-copy_of_certificate) aY_es-0—No Dimensions: .. 1500 GAL PRECAST H-20 Sludge depth: a .• ♦ 28 • Distance from top of sludge to bottom of outlet tee or baffle 2,' Scum thickness 811 Distance:from fop of scum to top of outlet tee or baffle , 10 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? PLAN-TAPE-SLUDGE JUDGE 1136TH AVE W HYANNISPORT.doc 03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^Page 9 of 15 _ Commonwealth of Nlas'sao usetts Title cialIns io , Form. 21 :— Ia Subsurface Sevriaga Disposal.System Farm . Not for Voluntary Assessments 1136 Property Address EDWARD COWAN ° Owner Owner's Name information i e required for every, WEST HYANNIS PORT MA 02672 9/3/09 ' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont) inlet and outlet tee o baffle condition, st*ructu a to rit Comments on pumping recommendations,, , ( P p 9 . 9 I liquid levels as related to outlet.invert, evidence of leakage, etc.): TANK AT WORKING LEVEL. IN &OUTLET TEES. NO SIGN OF OVER LOADLNG OR LEAKAGE. Grease Trap (locate on site plan);, Depth below grade: feet Material of construction: concrete metal ❑fiberglass 0 polyethylene, ❑ other(explain): ,. o' Dimeny:sions: Scum thickness ` Distance from top ofYscum to top of outlet tee 9r'baffie a " ' Distance fr'orn bottom`of scum`to bottom of outlet tee or baffle. Date-of last pumping `Date Comments'(on,pum pin g recommendations, inlet.and"outlet tee or baffle condition; structural.integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight of Hoiirig Tank(tank must be pumped at time of inspection) (locate,on site plan): Depth below grade' Material of construction: ❑concrete � metal. fiberglass polyethylene El other,(explain,) 113 6TH AVE W HYANNI6PORTdoc.•03108 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page.10 of 15 Commonwealth of Massachus' etts ..... Title1 1corm 1., Subsurface Sewage Disposal System Form—Not for Voluntary Assessments; M,:: -; 113 6TH AVE Property Address EDWARD COWAN Owner Owner's Name - information i e .required for every WEST HYANNIS PORT MA 02672 9/3/09' page. City/Town State Zip Code Date of Inspection D. System Informatlbn (coat.). Tight or-Holding tank(cont.) Dimensions: Capacity: . 9 aliens Design Flow. gallons per day Alarm present ❑Yes ❑ No • Alarm level'... F Alarm in working order: ❑ Yes ❑ No Date of last pumping Date Comments (condition of alarm and float switches, etc.): e *Attach copy:of current pumping contract (required). Is copy attached? ❑• Yes ❑ :No Distribution Box(if.present must be opened)`(locate on site plan): . Deptlrof liquid-level-above outlet-invert y - Comments-(note if'bon is level and-distribution=to outlets equal,,any:evldence:of solids carryover,any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX IS 16"X1'6"-28" BELOW.GRADE WITH COVERS AT 8"..ONE LINE.IN, THREE LINESOUT. BOX IS.CLEAN & SOLID WITH.NQ SIGNS OF OVER LOADING OR SOLID CARRY, OVER. Pump Chamber(locate on site plan): Pumps in working order: ❑Yes ❑ No Alarms in working order: : [] Yes ❑ No 113 6TH AVE W NYANNISPORT.doc•03l08 Title 5 Official Inspection Form,Subsurface Sewage Disposal System-Page 11 of 15 , common-wea h of Maaa.aohusatts X. Ins gp!j i Subsurface Sewage Disposal System nor -Not for Voluntary Assessments ,. 113 6TH AVE Property.Address ' EDWARD COWAN Owner Owner's Name information i e required for every WEST.HYANNIS'PORT MA 02672 9/3/09 page. Cityrrown State. Zip Code Date of.Inspection ' D. System Inforatjoh.(cont.) - Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soli Absorption�System(SAS)(locate<on site plan, excavation not required) If SAS not located, explain.why: Type { s ❑ leaching'pits F number .. , ,3 leaching chambers- number, ❑ V, eaching galleries number leaching trenches number, length: ❑- leaching fields number;_dimensions ❑ overflow cesspool number. ❑ inriovative/alternative°system. Type/name of,technology: Comments (note condition of soil signs of hydraulic.failure; level of ponding,`damp soil,-condition of ° :Vegetation, etc.): LEACHING IS THREE H-20 500 GAL DRY+WELL WITH CENTER COVER AT 20".2",WATER IN LEACHING AND NO SIGN OF OVER LOADING OR SOLID CARRYOVER. 113.6TH AVE W HYANNISPOR`rdoc a 03108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts'_- I, ,J Tit] ��� ii ( � --II Subsurface Sewage Dispo.sal'System Eorrn Not for Voluntary Assessments 113 6TH AVE \ Property Address EDWARD COWAN Owner* Owner's Name information is for every S rewired WEST HYAfVNIS PORT MA ; LL 02672 9/3/09 4 ' page. City/Town State Zip Code Date of Inspection D. System Inforat! h .(coat ) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top ofliquid.to inlet invert Depth of solids layer , Depth of scum layer Dimensions of cesspool Materials of construction r Indication of groundwater inflow 11Yes 0 No - Comments (note,condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a 3' f a ° Privy_(locate_on site-plan) Materials of construction: Dimensions ° Depth of solids Comments (note condition of soi[, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a > 113 6TH AVE W HYANNISPORLdoc•03/08' Title 5 Official Inspection Form:Subsurface Sewage DispcsaP System. Page 13 of 15 C.0mm0n14V9alt 0f NlAssachusats - ' I - j M: ar raj+ 3; 1�OOSaI S' arn.For-Su.b�ur;.aca S ,rag y Noi for\(oluntary A�sessmen�s c 113 6TH AVE Properly Address EDVVAIRD COWAN Owner Owner's dame information is required for every WEST HYANNIS PORT 11AA 02672" 9/3/09 page. City/Town State Zip Coder Date of Inspection D. Systmml, nformat]CT (cont.) Sketch Of Sewage Disposal System` Provide a sketch of'lie sswaee disposal system including ties to Gt least two permanent reference landmarks or benchmark L6cate all wells within 100 feet. Locate where public water supply enters the building. t ,. D .� • r.. /gyp 0.•. . t�.s.7 - v 7. J = I - .: 3 SvaYa o . 1 n C ¢^ I i Subsurface S ,gag Disposal Systarn, Form,-Not for Voluntary, Asse sments. 'Property Address EDWARD COVI/Ai\1 Owner Owner's Name - information i e required for every VVEST HYANNIS PdRT MA 02672 9/3/09 ' ' Page. City/Town State" Zip Code , Date-of Inspection D. -SySt9M.InforMatiOn (Cont.), sits Exam: OX Cheep Slope NO1\JE- x Surface water NONE _ -- Z : Checiccr✓IIGr . NONE C ShaHow wells NONL Estimated depth to high around water: , ' 12"6"+ feet Please indic2te all metl-Iods Used to determine the nigh ground water elevation: ❑' Obtained from system design plans on record x If checked, date of design plan reviewed 7/1`3/05 Date , ❑ Observed site (abutting property/observa ion hole within 150 feet of SAS) . s 5 ❑ Checked with.aocal"Board of Health-explain.` ❑, Checked with locahexcavators, installers (attach documentation) P Accessed-USGS-database-explain USGS.WELL aMlW 29.AT 8.1 ZONE A=1-6 You must describe how you-established the high ground'wiater.ielevation; i —.R r <.ru�v i orwnn R=nnrt dnr..r,3 n; _ i itle o 0riciarinspsctiom Form:Subsurface Sewage Disposal System•P2oea5 or 1.5 L/1 ASSESSORS MAP : 2q-� TEST HOLE LOGS E r NOTES: vvw� PARCEL: v�"l — 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH C SOIL EVALUATOR :TD. Mr elr �_7 C WN-76 THIS PLAN, 1995 MASSACHUSETTS TITLE V & TO OF M FLOOD ZONE : i\IUrI }��� WITNESS : Q�1 D �t 1S fb 11h G �� �� BOARD OF HEALTH REGULATIONS. 15. Rv OF REFERENCE: U_ (6Z24 DATE: 31JU l 057 PI � PERCOLAT I O�E: L M I� ]M(�}} 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, p� D6 3 Z SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO CL A196, I S o j t_y LTpM__0.7 INSTALLATION. so" ��/- pj ore% pTH- I 6L'. 20-40 TH-2 6t,- i0.75 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION I �,' f D ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE SITE, �LpCN (Dpt�►N�O y 1��P.C�_SM1 ��.�- �i �SA� 149.1I1, A ,� LOAmV IOy1�3�2 DETERMINATION. n_` q IO 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "B FOOT. (UNLESS � �� A�ur�usT �PJ 13 L�AM� (,pA-My Sl SPECIFIED OTHERWISE) LOCATION MAP Sa�l� b � SAID I��-1$ ,I 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A I7 37j �(e,D GARBAGE DISPOSAL. 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) MEt�IVM i? �- N6E�lV MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A4 G I�,34• A BASE OF 6"OF CRUSHED STONE. j �► v 2 SY P13 7) LOT?N _l-E llCM�''� 7V 86 PV,M PE Pi (-k the IZro q.q ZS 1 �f 126 WiQUG_D o E� T7 T L e V_ 8)110 KNvwN FlavAIS VvEt kI7 w/W 1567 or- P.40 . LC-A-Ct 7 nl . 9 No w> Tom-* w /ry--- SEPTIC SYSTEM DESIGN _ �_ _ ISO' or- Pa,o p. FLOW ESTIMATE N 7.0SI (�• ��CI�17]A/ 7a �6 MD1�1 FI K rkj /�^� / r ^ l j ) BEDROOMS AT ` GAL/DAY/BEDROOM - 33d GAL/DAY _PQU p(xEY) OU_RE7 (,,0&A- 'IDN � 6C Ft)A-- j0t4, SEPTIC TANK M)Mo vF1']Z1 m t a-(7 r-.wAl T]-,Z.F, v oK. Tmpj 0p BLS. So fv 1 TBM =TAP OF 330 GAL/DAY x 2 DAYS n �0�� GAL 50- OF �J,/}.� Gk--�c USE ��� GALLON SEPTIC TANK - NELJ- HZo Lc)k-c 13� I Ie-NOT1(.� �vi1P-�fl foe, �N II T �1�Ito' T14-r , 1 � EL. 20. � �► 32 �o SOIL ABSORPTION SYSTEM � �I�cA�r �-'zv 60. w ., , � :`'..�.->.�- v r v:y i'`►v i Y''Lr"`l�% ..,+ .. � e.''1 I Y 1: {J IPV C:� 1' („i,+i+. y {I�r_A:.to�'s, \ "�, ` ?� �10'M�►� S DE AREA R32) N ) 2]x X 0•-?y l 21 .3 BOTTO,4 AREA: 32 X 0 -7 y - Z.i3. 12 33y , GPp � � \ 4 r✓x lST7n q � > 330 �PD r�y'�I 3 Be, - SEPTIC SYSTEM SECTION G , TOP= CL. Zd.6 'a4CevuI7 7v ql l�') (0 ' OF -Ft w,sh q�ade 9'i►r�N v Iy � r� I�.�o Instal( 14- 3b X _/7_0 Z►►_3� ►► 12 dSl�e ,S +yam I�;5a g, o "[VV ' D-BOX 1 n L� t� d2. ,� y GAL 17,0 l4►So $,0A) + (HZo)SEPT I C TANK Caw �P.u2Lr1CSS �EvJ P&- 3 3/�''- ���2" Do�bie n gp,o AShdd 5 fne- '" ZS t1H20 Gofio� W, (o. Bay or Lo 7E s%�C,e EL� g 2 s (00 A OF SITE AND SEWAGE PLAN DA N ILOCATION : 113 SlXv �v � EYER cn No. 1140 F�`ST PREPARED FOR : ep-,Aj� Sce6 77/ -UVS I S An;,r a v� 4� pr�G (ol0 336 - 973 DARREN M. MEYER, R.S. SCALE: I Z DATE: P.O. BOX 981 o� _ EAST SANDWICH, MA 02537 W 3 DATE CWALTH A'/ENT Ph: (508) 362-2922 [ P77O y, Z