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HomeMy WebLinkAbout0053 SKATING RINK ROAD - Health 53 SKATING RINK ROAD, HYANNIS R A= 291 178 1 1 I i i Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Skating Rink Rd. V Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites Path. Company Address South Yarmouth Ma. 02664 City/Town State Zip Code 508-477-8877 SI 14430 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes - IIIIIIOtI � ZH h1gs����iii 2. ❑ Conditionally Passes ;o`ya�• ....... •s9�,%�� gam. MICHAEL '.N 3. ❑ Needs Further Evaluation by the Local Approving Authority 20. SEARS 4 No.SI14430 . ❑ Fails � • oF o :� ; �Sr N SPI�C,�````• 3-16-21 Inspector's Sig rAfure Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in working order 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments ,.• 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is H annis Ma. 02601 3-16-21 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): r ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): i� ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if, the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health; safety and the environment: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 8 4) System Failure Criteria Applicable to All Systems: 1 , You must'indicate "Yes" or"No"to each of the following for all inspections: - Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !% 53 Skating Rink Rd. V� Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ` ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or El Z tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme- Not for Voluntary Assessments 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? 0 ® 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: ® ❑ Existing information. For example, a plan at the Board of Health. 4 ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is H annis Ma. 02601 3-16-21 required for every y page. Citylrown State Zip Code Date of Inspection D. System Information i 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2019-29920 gal g ( y g (gp ))' 2020-47124 gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) t Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. .Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1985 #85-418 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 20"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet r Comments (on condition of joints, venting, evidence of leakage, etc.):. l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .w 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic,Tank(locate on site plan): Depth below grade: 10"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" -Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8„ Distance from bottom of scum to bottom of outlet tee or baffle 18" _ How were dimensions determined? Sludge judge, tape ' Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 gal tank with in tee and out baffle in place, both covers a 10" below grade t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �- Title. 5 Official Inspection Form `la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑,concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): r Dimensions: Capacity: gallons Design Flow: gallons per day l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 53 Skating Rink Rd. u' Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16x16 with 1 outlet pipe cover at 6" below grade r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,`z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Skating Rink Rd. V� Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: - ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: El leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 c , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS is a 1000 gal pit, pit has 4' of water with 16" between inlet and water, with no sign of failure I 12. Cesspools (cesspool must be pumped as part of inspection) (locate 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 f Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of pondin , condition of vegetation, 9 9 etc.): I l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is _Hyannis Ma. 02601 3-16-21 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t S% 17 3y -� MICHAEL :N? io. SEARS * No.SI14430 �FRTIF��G(��0�� I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Rd. V� Property Address Richard Jurkiewicz Owner Owner's Name information is Hyannis Ma. 02601 3-16-21 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 11'8" Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: No groundwater per last report, 10-18-18 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Skating Rink Rd. Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis Ma. 02601 3-16-21 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1; 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 0 Gr_✓„�1No^{C,l` t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pptitation for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(.X Upgrade( ) Abandon( ) ❑Complete System [(Individual Components Location Address or Lot No. 53 S�-tl'PO—, Q%j J K '� Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel �.� �° t4 51CI R1l�iLW1�Z � / ' R A9 Installer's Name,Address,and Tel.N . 50�-q- 7—gS-j-1 Designer's Name,Address,and Tel.No. dAP&Aj'Dd5 EUT P+ZSC$ I XBO 10 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(min.required) Al gpd Design flow provided gpd Plan Date 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) -x t is r rC_L_ (90 —.go Lo rw, Izi!ec Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by I Date �� Application Disapproved by Q Date for the following reasons Permit No. ?C> 0 Date Issued v No. Fee , THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rptication for Misposal 6pstem Construction Vermit Application for a Permit to Construct( ) Repair"( Upgrade( ) Abandon( ) ElComplete System ©individual Components Location Address or Lot No. �5 �/ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. � c:A D�U tbr✓s E1.JT�CD�S CS I lZ$p ��/�' 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(min.required) gpd Design flow provided AJ gpd Plan Date Number of sheets Revision Date i Title Size of Septic Tank Type of S.A.S. j Description of Soil Nature of Repairs or Alterations(Answer when applicable) DNS rAti— &1 CD.J —AOX W[Z 4 Q tS�72 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in r accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. ~ Signed c Date Application Approved by ) Date Application Disapproved by Date v for the following reasons Permit No.. ['� j r �� Date Issued ' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Comptiance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( ),by CA QCt4A Fwt O Y ' at . 53 _:SgT'[A+1G P./AJ(L, Ra) R has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. cM-3/3 dated Installer !Mrn,�lZLr e1 j 7292 [��S / (� Designer IVY #bedrooms �/T r Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wil funct de�gned. Date /V/�f(✓J� b Inspector ---' w o - - - -------- --. _ _ -- - ------- -- -- ---------- ----------------' ----- '----------------------------- No. 2-o ! C ^ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction i3efmit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at 53 .S L-A r t kj D-1 4,pArb VA-,,JAJL C and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with -Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this.permit. 7 f G ("^ /1 Approved by �% Date ��yq 3/11/2021 ShowAsbuilt(1700x2800) TOWN OF BARRNSTABLE LOCATION SEWAGE# VILLAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /oU C, Y•I LEACHING FACII..TTY:(type) 01-9; 'l- (size) NO..OF BEDROOMS__, BUILDER OR OWNER PERMIT DATE: //A19 COMPLIANCE DATE: /� 6 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Privatc Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) , Fee Furnishcd by (% 17' aa' as' 3� /ot7U�ah< y6 O-rJJ y https:Hitsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=291178&sq=1 1/1 . �gl -lam Commonwealth of Massachusetts Title 5 Official Inspection Form P�t Subsurface Sewage Disposal System Form • Not for Voluntary Assessments M; 53 Skating Rink Road = Property Address , Richard Jurkiewicz ` Owner ') Owner's Name e information is Hyannis 1/ MA 02601 10-18-18 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important.,When �� filling Cut forms A. Inspector Information Sly# / 33q�- , �� • sq�ti,; on the computer, use only the tab James D.Sears JA M E S :m key to move your Name of Inspector 3 U: SEARS cursor-do not Capewide Enterprises use the return — ke Company Name y 153 Commercial Street �F 5 INSP ITV Company Address 1110111 Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10-18-18 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. 15lnsp.doc•rev.712612016 Title 5 01fidal nspection Form:Subsurface Sewage Disposal System•Page 1 of 18 t a6ed xeJ dH W2 860Z 2 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is Hyannis MA 02601 10-18-18 required for every Cityrrown State Zip Code Dale of Inspection page C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal Tank D Box and pit 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes","no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7126)2018 Title s otfldal Inspection Form:Subsurface Sewage Oisposat System-Page 2 or 16 g a5ed xed dH W 2 2 6N 2 1)0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v` 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-18 Page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cost.): ❑ Pump Chamber pumpslalarms not operational, System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 3 of 18 9 a6ed xej dH St,:2 960Z 2 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S 53 Skating Rink Road Property Address Richard Jurkiewicz Owner d er-Name information is required for every Hyannis MA 02601 10-18-18 - -- page. CityJTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply- The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: ««This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form, c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool tWsp.doc•rev.7/26/2018 Title 5 O(bcia.Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 L a6ed xeJ dH W 2 2 602 2 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is Hyannis MA 02601 10-18-18 required for every y page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 41910M is less than 6"below invert or available volume is less than '/z day flow P 1 r ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4. 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 t5insp.doc rev.71262018 Title 5 Official Inspedon Form;Subsurface Sewage Disposal system•Page 5 of 18 8 a5ed xed dH 81;,:2 ME 2 130 Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form Not for Voluntary Assessments 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with El ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] 15insp.doc-rev.7126/2018 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 6 of 18 6 a5ed xeJ dH &V 2 2 60Z 2 130 y Commonwealth of Massachusetts Title 5 Official Inspection Form 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-18 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal Tank D Box and pit 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2016-77,000GaIs2017-34,000Gal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date 15insp.doe-rev.TJ252018 Title 5 Official Inspection Forth:Subswfaoe Sewage Disposal System•Page 7 of 18 06 abed xeJ dH 6t,:2 2602 2 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Road u Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-18 page. City/Town Slate Zip Code Date of Inspection D. System Information (cont,) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats(personsfsq,ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc rev.7/2612018 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 8 of 18 l,l, a5ed xed dH 05:2 9OF 2 130 Commonwealth of Massachusetts Title 5 Official Inspection Form in Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o r 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-18 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 4. 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)and a copy of latest inspection of the I/A system by system operator under contract Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of ail components, date installed (if known)and source of information: 1985 - Permit # 85-418/10- 2018 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.); Pipein is 4" PVC SCH -40. t5insp.doc•rev.W2612018 Title 5 Cffiaal Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Z i, abed xeJ dH 09:2 21.0Z 2 1c0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments i"�9—wk, 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name iniormation is H annis MA 02601 10-18-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1W Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 Gal. Precast H-10 Dimensions: 2" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 1' Scum thickness Distance from top of scum'to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17' AsbuHow were dimensions determined? t-Tape Slludgudg e Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank at working level. Tank and covers at 6" below grade. Inlet tee,outlet baffle. No sign of leakage or over loading t5insp.doc•rev.7/2612010 Title 5 Official Inspedion Form:suburteoe sewage Disposal System•Page 10 of 18 E I• abed xeJ dH 09:2 9 602 2 130 c�CI , Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form- Not for Voluntary Assessments v 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is Hyannis MA 02601 10-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass [] polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 15insp.doc-rev.7I2612018 Tide 5 Ofidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 b i, a5ed xeJ dH 69:2 2 XE 2 UO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Skating Rink Road Property Address Richard.Jurkiewicz Owner Owner's Name information Is _ MA 02601 10-18-18 required for every Hyannis page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16"xl6"-16"below grade w/cover at 6" One line out. Box is new 10-2018. t5insp.doc•rev.712612D18 TPoe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 1e gl, abed x2J dH 6g 6Z ME 2 130 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary kiwi 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-18 page. City/Tom State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soll Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: 0 leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 'Sinsp.doc•rev.7l26)2018 Title 5 Offidel Inspection Fam:Subsurface Sewage Disposal System•Page 13 of 18 g i, a5ed xe:1 dH 65:2 8 XE 2 100 `v Commonwealth of Massachusetts Title 5 official Inspection Form f s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owners Nam e information is required for every Hyannis MA 02601 10-18-18 page. Cityrrown State Zap Code Date of Inspection D. System Information (cunt.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is a 1000 Gal, precast pit. Pit at 20" below grade. Level in pit at 15" below inlet. No high stain line. 12. Cesspools(cesspool must be pumped as part of inspection) (locate 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 ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5lnsp.doc•rev 7/26/2018 Title 5Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 18 L I. a5ed xed dH 69:2 8 60Z 2 100 l s Commonwealth of Massachusetts' :. Title 5 official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-18 page. CitWTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•rev 712612018 Title 50fficial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 86 a5ed xed dH Zg:2 260E 2 ID0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owners Name information is Hyannis MA 02601 10-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 6I. abed xed dH Zg:2 8 60Z 2 1:)0 Sep 2818,11:11 a Capewide Enterprises 508-477.4977 p•23 TOWN OF BARNSTABLE LOCATION J S S Kea 47 t., k SEWAGE A S- VMLAG `e ASSESSOR'S MAl&LOT INSTAU EwS NAME&PHONE N0. �A SEPr..0 TANK CAPACITY_ /Ob O y LEACHING FACKJTY:(type) , G No..OF 6MROoMs—_T�T BUILDER OR OWNER PERMffDATE y�®RA T COMPLIANCE 12ATE: f 6 Sepa atka Disuaw Between the: Maximam Adjusted Groundwater Iabk tmd laotwM of Leaching Fheliry Feel Privi,te Water Supply Well and[wetting Fadliry (tt any s.als exist on bite or within Zap feet Of leaching facility) Fee Edge of Wetland tad L,txhmg Facility(If any wet'aeds exkt within 300 feet of leaching facility) Feet Fumiahed by 17 �a O fly 02 a6ed xed dH ES:2 8 6Oe 2 1:)0 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 53 Skating Rink Road Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-18 per. City/Town State Zip Code Date of Inspection D. System Information (cost.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 11'-8" feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Auger T.H.4' below bottom of pit. Auger T.H. 11'-8" below grade. Bottom of pit at T-8"below grade. Bottom of pit at 4'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 6Z abed xed dH 69:2 9 Xe 2 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Skating Rink Road v Property Address Richard Jurkiewicz Owner Owner's Name information is required for every Hyannis MA 02601 10-18-1 B page CitylTown State zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D.System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 7# _F// �ATM Nn G-w t5lnsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurtace Sewage Disposal system-Page 18 of'!6 ZZ a5ed xed dH £5:2 960E 62 lip YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. �w�-3 15' DATE: Fill in P_leas®: :. . APPLICANT'S YOUR NAME/S: , 9de1�o BUSINESS YOUR HOME ADDRESS: 5 4, %,7 r' �j 50 7 jQ 0.15 3 TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS S"1<411114 IS THIS A HOME OCCUPATION? ES N TO Y ADDRESS OF BUSINESS 3 5 ka i ( U G 1 MAP/PARCEL NUMBER C`Q I (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING CO ISSI NER'S O F)CE This individ al enin�o m d an per it require ents that pertain to this type of busirMST COMPLY WITH HOME OCCUPATION RULES AND REGULATIONS, FAILURE TO A thoriz Si ne OMMENTS 2 `� CC?NAPI..`' MAY RESULT IN FINES. 2. BOAR OF EALTH MUS COMF�;h MTH ALL This individual ha infarme er qu' ents that pertain to this type of business. H/trARDOUS MATE RIAL$.REGULI�TIOI�IS Authorized ig ure** COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: r . ,;. Date:a/ Q 3/ 45-- TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: M ia. Lee BUSINESS LOCATION: 93 594,�;,,% ri k t,4 INVENTORY MAILING ADDRESS: 53 ra TOTAL AMOUNT- TELEPHONE NUMBER: ro CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: is- MSDS ON SITE? TYPE OF BUSINESS: Con ne-rial F-ts, b r, INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) 5 a /U c l Hydraulic fluid (including brake fluid) Refrigerants 5 �(Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, ( (Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Ap icant's Signature Staff's Initials 7 j ' TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road South Dennis,MA 02660 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property �; ti k ��( s 3 5 ka+-;�� Hy 4NH , s Owner's name& L Mailing address y,4 spry j Sf L-,k, 7o<< h/ �la. 0188 v Date of Inspection Iy5 PART A CHECKLIST Check if the following have been done: Ong Pumping information was requested of the owner, occupant and 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. ✓ 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 site was inspected for signs of breakout. All system components, excluding the SAS, 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 bales or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. ►� The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SSDS. Page 1 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential 3 number of bedrooms O number of current residents N° garbage grinder, yes or no _yF s laundry connected to system, yes or no o seasonal use,yes or no If nonresidential, calculated flow: Water meter readings, if available: J �^ 95 Last date of occupancy GENERAL INFORMATION Pumping records and source of information: ✓hc147i h/.Gc-T/ti•«� ��G�h� No System pumped as part of inspection, yes or no If yes, volume pumped 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) Other(explain) Approximate age of all components. Date installed, if known. Source of information: le-114 151 —C �.r-� Cis - 6� ; � � o � �, ; v 6 / O J7 Sewage odors detected when arriving at the site, yes or no Page 2 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: V/ locate on site plan) ( P ) depth below grade: / material of construction: se—/ concrete metal FRP other(explain) dimensions: 5 "' X' cf ZO o o G c—1/� H 3,, sludge depth distance from top of sludge to bottom of outlet tee or baffle Nwv�scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,recommendations for repairs,etc.) 4 714J to 17� fJ as c�LC In S� o t—UAC-Y b 7� bS 4y-y c—-tJ/y-c,. r 7�- -- 1 N 41 L-C J yy DISTRIBUTION BOX: (locate on site plan) e o e- depth of liquid level above outlet invert Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, recommendation for repairs,etc) /� JJ UV x yQ(.f '�✓!n d G iJ G k Ind e r A Ord P_✓ - �d �' i <. H 3 J� �G vtc tr�S.-G . PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber,condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) Page 3 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if poss.;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits and number dHc leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,recommendations for maintenance or repairs,etc.) a7 i ✓vt GA C IG" cr u n•+C —0 c S/ /k 1. S S D � N y r�act� � � C. � �v✓�- CESSPOOLS (locate on site plan) : IAI/i4 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, recommendations for maintenance or repairs,etc.) PRIVY: 11-111/4 (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, recommendations for maintenance or repairs,etc.) Page 4 of 7 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' S� �E 3Y' 3a t000 Y DEPTH TO GROUNDWATER 54 S<w,,j depth to groundwater adjusted high groundwater level method of determination or approximation:: Page 5 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no or not determined(Y, N, or ND). Describe basis of determination.in all instances. If"not determined", explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? N�Liquid depth in cesspool<6"below invert or available volume< 1/2 day flow? /V Required pumping 4 times or more in the last year? Number of times pumped // Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration?tank failure imminent? Is any portion of the SAS, cesspool or privy: _ below the high groundwater elevation? /_within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? /Y within 50 feet of a bordering vegetated wetland or salt marsh(cesspools and privies only, not the SAS)? �l within 50 feet of a private water supply well? 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. Page 6 of 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector: Troy Williams Company Name: TROY WILLIAMS SEPTIC INSPECTIONS Company Address: 40 Old Bass River Road, South Dennis, MA 02660 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. the inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check one: V0'/I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature S 4�(-1 Date Original to system owner Copies to : l Buyer(if applicable) 13 Approving authority PROPERTY ADDRESS: hey C, Page 7 of 7 05%30/1-395 13.46 =RO^t T.31jin of Barnst.aole TO 0.0c^ S A T ION stwarat ' , O N Aww , LLA..SE d �INS.1A t�EER'S NAME D ADDRESS. R a I E-0 E 4 ot OWNER DATE -PERMIT ISSUED DA1 tOMPLIANCE ISSUED /t_Fl l 5 oo �kt 7_• TJTAL P.02 s'- G 73 2 - TOWN OF BARNSTABLE V LOCATION -�.� S � -}-i r^ �. �. SEWAGE # VILLAGE /-ft,4f "`°�' S ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. A yL SEPTIC TANK CAPACITY f d 9 LEACHING FACILITY: (type)` (size) NO.OFBEDROOMS BUILDER OR OWNER PERMIT DATE: e!:� / 5'— COMPLIANCE DATE: SAZ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ® Feet Furnished by lam). I u vti s ar•��� 0 � k ® I,n v ^1 � I - s 1 M - LgCATION SEWAGE PERMIT NO. VJLLAGE , fNSTA LLER'S NAME & ADDRESS � 7-5- UILDE R OR OWNER DATE PERMIT I S S U E 0 U - ® AT E COMPLIANCE ISSUED xL THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH rw..............._0F........ �ssT B< ......................... Ap pliration for Rapasal Worko Tongtrn.rtion ramit Application is hereby made for a Permit to Construct (/ or Repair ( ) an Individual Sewage Disposal System at: r LGT f ................./�V�......�1 . ..�1✓....... h�/5'!ii^![.5------ -------------................------------------ .................................. Locat n-Address or Lot No. ;_``;:. • ZCd!91.....l:..... t ! ................................ ..... ..................• Owner Address a -------------------------------- ---••.... ....................................................... Installer Address Type of Building Size Lot../$,� 43........Sq. feet Dwelling—No. of Bedrooms......... _.4&..................Expansion Attic ( ) Garbage Grinder ( ) pa•, Other—Type of Building ............................ No. of persons__..-___--__-_..-__-__-____ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------•-----------•------------ W,a Design Flow................ .................gallons per person per,day. Total daily �ow-------- ..........................gal}onsa 9,,-. Septic Tank—Liquid'capacity/4.0Pgallons Length___ Diameter................ Depth(s..- ... � x Disposal Trench-=No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......../........ Diameter...A'.).......... Depth below inlet__............ Total leaching area.l26�.sq. ft. Z Other Distribution box ( ) Dosing tank '-' Percolation Test Results Performed by-_....45je XI .....G _/E ------------------ Date.... __ _`_ .......... Test Pit No. 1__ _._minutes per inch Depth of Test Prt_-/2,6....... Depth to ground water..Zao............ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .............................................................=............................................................................................... 0 Description of Soil....&..Z!V-- .S&&-64S ..------... .......... 4::&Y---........... 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 TI.I, 5 of the State Sanitary Code—The undersigned furtl ees not to place th syste i oper 1 u it a ert'-sate of Compliance has been issued by the boa d of health. . S• d.......- 'r -. ............................ ..........•-Date......-- --- Application Approved By-•••-•-•�--- - ----------------•------ --........--•-•--•--..-. �y ............. DaYh Application Disapproved for the following reasons--------------------------------•---......------------------------------------------------------------........._ ....................•----•----------------------...-------------•---------------.............-------------•--------•••....--•--•••-••--•-•••-•-••••---------------•------------------••-•-•-••-••-...... Date PermitNo......................................................... Issued....................................................... Date No..... -� _.. 1 Fes$.... THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ...................OF........G�'... . Tiat3Gr-------------- =' ._............ Appliration for Disposal Works Tonstratrtion Pumit Application is hereby made for a Permit to ,Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: ...........�C'. �!iC........�....!�....�`-'�✓�i.� /`���•vrv/5:............•----•-•--- ��� --� .................................... ...._... Loca'on-Address, or Lot No. owner Address Installer Address , dType of Building Size Lot,&,/ .........Sq. feet U Dwelling—No. of Bedrooms.......... ..&...................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No, of persons....__.._..____.._...._:__.. Showers ( ) — Cafeteria - dOther fixtures --------------•-----•--•-••-•-•--•--------------•-.... -----------------.....•-----•--..........-•-•--•---------------- •---_. w Design Flow............... .................gallons per person per,day. Total daily flow------&&0---_-----_---_...........gallons. WSeptic Tank—Liquid capacityAC 0.gallons Length__: _._ Width.5;.e..X�_1 Diameter---------------- Depth,$... ..... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------/-.-____-- Diameter._-/O.......... Depth below inlet... ........... Total leaching area/�C%4_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) .........Date.... Test Pit No. 1.{_�-�_•-.... minutes per mch Depth of Test Pit,/,36........ Depth to ground water-42-a.•........... LTA Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -------------•------------------------------------..........---------........_........_.................................................. 0 Description of Soil----Lt' Y------ ............eL-7.?..---. --------- -� w U Nature of Repairs or Alterations—Answer when applicable.......................................__ -•---------------------------------••-----•-----•-------•--•------------------------.....---........-----------------------------------•---------------•--------------------------------......_•-•-•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposa System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned furth ees not to place the syste in operation until a Certificate of Compliance has been issued by the board of health. thi -•---------•-----------------------------•--------------.................--- _DApplication Approved By....._."... _ __ --._.. D e Application Disapproved for the following reasons----------------•----•----------•---------------------••------------ .......................................... --------------------••----------------•----------------•---...--•---•----•••-•---••-•---........--------•......••....•----••-----•------•---•--•--•--•--------.....•----•---•••---•--•••-••••---........_ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS li~ BOARD OF HEALTH T w � yl ; 1• �' C OF:....... ............................. (Irdifiratr of ToutpliFanr�e T JI_ TO CFRT. FY, That the Individual Sewage Disposal System constructed (�) or Repaired ( ) by.......--•--- --•--.----- ---------------- - .........--•-... •. r" Installer { has been installed in accordance with the pro ' s of TITLE 5 of The.State 6anitany Code as described in the application for Disposal Works Construction Permit ................. -------------------- THE 11 ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A THAT THE SYSTEM WILL FUNC I N ATISFACTORY. DATE._.......... .........-••--••................ Inspector...._....."._.- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF....` %' ' ..................................... -� •:: No......................... .......- FEE__ -- •.....:... DiDisposalarks Tonstrttrtion rrutit LL T •->, ;• , ,:�,,.,,: Permissionis hereby granted........ ................................................................................................................ to Construct Qr Re air an,individual Sewage Di osal S stem �� C at No ` ...............................3 ... �. ..... .fir.. ------r .h�tt�'` .......................................... Street, as shown on the implication for Disposal Works Construction Permit-lNo:. `-°.•...l ..: D`a�tf d ___;..�_� -'P ... t T.. .--� �.�P•~f U�... Board of Health DATE =- - z`3 - �;, FORM 1255 A``Nt:'SULK[N. INC., BOSTON 1 f — A — \ 41 3ot � NG 10 41 1 tL L 7 v I rz yap of /¢8!v Sys Fr.* 34 y par c' PIT 4!6 NoTt- i!u /% �7ZV/ovs MATC7BA9t ?J(' 38 70 6t3 =O VE''A 1W 77d d Le c y �affrq Av✓a BOO J&4 y6"A> A4v,o eep4A)c4,D W,7w LOCATION . .All s ?%ss,... .. SCALE . / "=30 . . . DATE 4Pa14 Zr SAS PLAN REFERENCE L3Lo 'f� D Co rz7---. . OF Eta I c E D G ' o F{ELLEY n No. 26100 a I CERTIFY THAT THE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF . . . . . WHEN CONSTRUCTED. DATE . . . . . . . . .. W�GCIA�9 F. SW/FT ��°77T/o.VG- REGISTERED LAND SURVEYOR TOP OF FOUNDATION s„ CONCRETE COVER CONCRETE COVERS 24¢ a 4"CAST IRON 1I2"MAX. OR SCHEDULE 4d 12"MAX. P.V.C. PIPE 4"SCHEDULE 40 P.V.C.(ONLY) PITCH 1/4"PER.FT. PIPE- MIN. LEACH PITCH 1/4"PER.FT. PIT PRECAST INVERT e a LEACHING ern EL..39�. SEPTIC TANK INVERT DI St INVERT 3 �% w � ��� PIT OR EL..".�.$. . EL...:..�- >_ •e INVERT BOX — e GAL. INVERT oF-�- 0• �, EQUIV. EL3'f�R/ INVERT w w o: :;�. 3/4 TO I V2 WASHED • � '• W ` •;'• STONE •';, /o' g � '% mot.L9•� :.: PROFILE OF GROUND WATER TABLE SEWAGE. DISPOSAL SYSTEM s uscs 4//c// NO . SCALE l&VeZ Ca ,OU7-.9770 4/o z e&r*7 SOIL LOG WITNESSED BY : DATE i RA/4. !B!9lfr TIME!o-Pa,l':? ^/4^/, BOARD OF HEALTH TEST HOLE I TEST HOLE 2 A-LG-Y ENGINEER ELEV. . S. . . W A'') wooDLe z¢" 1t$1cl DESIGN DATA a,3v,4'0 NL 3Z. N�wy� NUMBER OF BEDROOMS :Z., . �bMts� C,es+v�z. . . . . . . . . 7e TOTAL ESTIMATED FLOW . . 2!20 GALLONS/DAY 60 . ez. ZG,•�v �7.Z9.fo . . . BOTTOM LEACHING. AREA 78So. . . SO.FT. /PIT/C,p,D. Z�4v ) " SIDE LEACHING AREA . . . ?S`. SQ.FT./ P1 4 �,3i¢ZC.p,D. �Mzs� "J Cass S,gir o /Zo'� ws► L sAr/� GARBAGE DISPOSAL (50% AREA INCREASE) zs� TOTAL LEACHING AREA.. SQ.FT PERCOLATION RATE MIN/INCH LEACHING AREA PER PERCOLATION RATE '39z 7 SQ.FT/C,P.D. � .WATER ENCOUNTERED on/� �T NUMBER OF LEACHING PITS : . . . . . . . . . . . . . . APPROVED . . . . . . . . . . . . . BOARD OF HEALTH •7•7Vv �� DATE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AGENT OR INSPECTOR UAA LZH OF <�q `,.��jM OF i,11 E :N ��J s _rs . . . . T. . . . . . . , . . ELI_EY N o. .eiN/G Z4D No 2v`�0 �; 9 PETITIONER I,yilsL/ ?-i, .-s►�/,�T Completed by } HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 5A! 7'iAIC ,elAlle- •e&/aD ''r&VI, Lot No. Owner: WWIAri F 5W/?E Address: Address: Contractor: Notes: -------------- STEP 1 Measure depth to water table w o to nearest 1/10 ft. _'¢/ie 19f date STEP 2 Using Water-Level Range Zone and Index Well Map locate . site and• determine: . . . . Z3v. . . A) Appropriate index well B) Water-level range zone . . . . . . . . . . . . 3 �� i STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well . . . . . . 3 /Bj mo yr , STEP 4 Using Table of Water-level Adjustments for index well STEP 2A , current depth to water level for index well (STEP 3) , and water-level zone (STEP 2B) determine � o water-level adjustment . . - • - • • _ . . . ... . . . . . . . . . . . . . . . . . . . . . . . . STEP S Estimate depth to high water by subtracting the water- level adjustment (STEP 4) . _from measured depth to water level at site (STEP l) . . figure 3 -7- e; Completed by k HIGH GROUND-WATER LEVEL COMPUTATION Site Location: SA,,,�A/G "R//`1l e. "ram A-1 s Lot 'No. Owner: W/LL/Ar7 F Contractor; SG✓/�� Address: ��STiAC3Gc�`- AIddress: - Notes: STEP 1 Measure depth to water table w.c 4 Ile, /8T � to nearest 1/10 ft. . . . • . . . . • • . . . . . . . . . . . . . . ._ date ------------- STEP 2 Using Water-Level Range Zone and Index Well Map locate . site and. determine: . ► A) Appropriate Index well . . . Z3v. . . B) Water-level range zone =-# STEP 3 Using monthly report"Current Water Resources Conditions' determine current depth to water level for index well . . . . . 3181 mo yr STEP 4 Using Table of Water-level Adjustments for index we.11 STEP 2A , current depth to water level for index well vie (STEP 3) , and water-level zone (STEP 26) determine o water-level adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STEP $ Estinate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water 7 p level at site (STEP 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . • - - - • • . . k Figure 3