Loading...
HomeMy WebLinkAbout0034 STRAIGHTWAY - Health 34 STRAIGHTWA-Y, HYANNIS A = 267 090 t. i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is H required for every annis MA 02601 11-10-10 y 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State = 'Zip Code " 508-495-0905 S13971 Telephone Number License Number _ re Ica B. Certification I certify that I have personally inspected the sewage disposal system at this address and that',fhe � information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11-10-10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner. and copies sent to.the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp official document•63/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection B. Certification (coot) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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 good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health„will pass. Answer yes, no or not determined (Y, N, ND)in the ❑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. ND Explain: ❑ 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 ❑ obstruction is removed t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora - Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that.the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ 'Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and'Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 - page. City/Town 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 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 16 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont): Yes No { ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water 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 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes"or "no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or "no" as to each of the following: Yes No ' ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with 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: ® ❑ Existirlg 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)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 8-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter. readings, if available: Last date of occupancy/use: Date Other(describe): t5insp official document-03/68 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate'on site plan): Depth below grade: 14 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.): Good condition. Septic Tank(locate on site plan): 8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gal Sludge depth; 10" Distance from top of sludge to bottom of outlet tee or baffle 22 Scum thickness 0 Distance.from top of scum to.top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 scup- 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.): 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): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora < - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town_ State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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.): Good condition with water at working level and no sign of back-up. Pump Chamber(locate on.site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-65x4x2 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach trench in good condition with no sign of back-up into d-box or surrounding stone. t5insp official document-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 ,page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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 official document•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. • fwe, R t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w a 34 Straightway Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 11-10-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10, 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: Original design plans show groundwater encountered at 10'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 16 COMMONWEALTH OF MASSACHUSETTS ORIGIRL 4 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS R d DEPARTMENT OF ENVIRONMENTAL PROTECTION °1 Svev- TITLE OFFICIAL INSPECTION FORM-NOT FOR VOL UNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ASSESSMENTS PART A CERTIFICATION Property Address: 34 Straightway Hyannis MA 02601 Owner's Name: Patrick Chaffe Owner's Address: Same Date of Inspection: August 29,2005 .lob#05-265 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION*SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: O�������g%k F/t X_ Passes �� •� �,...... �,s i,�� Conditionally Passes Needs Further Evaluation by the Local Approving Authority O% F ' 'yG rn --i • 4 Inspector's Signature: c, Date: 8/29/05 ` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of �4HI®HpEG DEP)within 30 days of completing this inspection.If the system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Leaching trench shows no evidence of backup,tank is not in need of pumping at this time. ****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. Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 j Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution 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): broken pipe(s)are replaced obstruction is removed ND explain: Titlo S Tncnartinn T+nrm �ii ci�nnn 2 S Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system. is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1 b that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system SAS a surface water supply or tributary to a surface water supply. (SAS)and the SAS is within 100 feet of a — 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that failure criteria are triggered.A c P at no other gg copy of the analysis must be attached to this form. 3. Other: I Titlo C Tnenartinn Fnrm �ii�i�nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 'clogged SAS or cesspool X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than %Z day flow,Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the 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. X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to.each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. T;tio f T..—,tine>~,,, .4i1 ci�nnn 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the follow' mg: Yes No _X_ _ 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 the previous two week period ? _X Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A _X_ Was the facility or dwelling inspected for signs of sewage back up ? ) _X_ _ Was the site inspected for signs of break out? i _X_ _ Were all system components, excluding the SAS,located on site? _X_ _ 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, scum ? P dimensions,depth of liquid, depth of sludge and depth of -X _ Was the facility owner(and occupants if different from owner)provided with information maintenance of subsurface sewage disposal systems ? non the proper The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _X_ _ Existing information.For example,a plan at the Board of Health. _X 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(3)(b)] Titic G incnantin" Fnrm �/1 S)7nnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 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 Number of current residents: 4 Does residence have a garbage grinder(yes or no): unknown Is laundry on a separate sewage system(yes or no): No [if yes separate inspection on required]system inspected(yes or no). Seasonal use: (yes or no):No Water meter readings,if available(last 2 years usage(gpd)): Two years total: 122,250 gal,=167 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): and Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: — Last date of occupancy/use: OTHER(describe): GENEAL Pumping Records: Tank pumped woy ears ag�RMATION Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: allons--How was quantity Reason for pumping: g q tY pumped determined? TYPE OF SYSTEM _X_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) —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Compliance date: 4/29/98 Were sewage odors detected.when arriving at the site(yes or no): No Titles S Tnennrfinn Fnrm 4/1 ennnn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 2' Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: - Comments(on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 2' Material of construction:_X_concrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10.5' long x 5.8'wide—1500 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: trace Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees intact and clear,ligiuid level at bottom of outlet invert. GREASE TRAP: No (locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,li uid levels as related to outlet invert,evidence of leakage,etc.): q Titles Tncr�artinn 1 nrm �n�nnnn 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 TIGHT or HOLDING TANK: No (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/day Alarm present(yes or no): Alarm level: Alarm in workingorder Date of last pumping: (yes or no): Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: XX (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.): No solids or hi h stains. Box set level with a ual flow to both outlets. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): i i Titln Tnenartinn T:nrm Ail VIAnn 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Straightway,Hyannis i Owner: Patrick Chaffe 1 Date of Inspection: August 29,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: _X_leaching trenches,number, length: One 65' trench leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Probed area of SAS and found stone clean and W. CESSPOOLS: No (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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: No (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.): i Ti4�n G TncnArtin..L'...... G/t c/lnnn Q Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Straightway Driveway Water service 2 56 1 16 # 34 31 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Straightway,Hyannis Owner: Patrick Chaffe Date of Inspection: August 29,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 15 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _X_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: Grade at rear of house is 7-8' lower than grade where SAS is located. � (3� j � � `� � t I14 ��' � i � � l �! 1, i \��� V �� �... S� � � �v�. �.. ,� -, . � � � �F- ��_ � 0 ., ° L /, � ,. 7� .s 1_ e_ t 2 �1 { .. j M1.. L i �. I i } c 4�+UC� i i ,'S '�_ 4 ,.a r a I V Y `S n r Q n Cl S I a i ----�. -�ao S I COMMONWEALTH OF MASSACHUSETTS A r EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PRO `IOIft?VEQ ONE WINTER STREET, BOSTON. MA 02108 617-292-550 Nov 2 5 199�� ' TOWNOFBggNSTAB(f v W'1LL1AM F.Nt'ELD O �g NTMOEPT TRUDY CORE Governor p Secretary ARGEO PAUL CELLUCC] r ` d g DAtVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A Ron Wood. 34 Straightway CERTIFICATION Hyannis 5 Shady Lane Property Address: 9- 9-98 Fremont NH 0304,4--3557 P �'h' 2 - Address of Owner: Date of Inspection: (If different) Name of Inspector: Wm E Robinson Sr 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Serve e Mailing Address: PO Box 1089 , CPntPr ri 1 1 A r MA 02632 Telephone Number;' 5 0 8 ` 7 7 5—R 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature:li(J fv�`�...r—'C Date: /7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30)•days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] STEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon E• completion of the replacement or repair, as approved by the Board of Health, will pass. Indica yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 t , DEP on the World Wide Web: http://www.magnetstate.ma.us/dep C*j Printed on Recycled Paper w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 34 Straightway Hyannis Property Address: Ron Wood. Owner: 9-29-98 Date of Inspection: B) SYST CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broke-i, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cj FURT ER 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 the ublic health, safety and the environment. 1) STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER HICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SY TEM WILL.FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT T E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE E IRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tEnk and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from p011Ltion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHE (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 34 Straightway Hyannis Owner: Ron Wood. Date of Inspection: 9-29-98 D] SYSTEM FAILS: You m t indicate ei;r;er "Yes" or "No" as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis f r this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct th failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LAR E SYSTEM FAILS: You ust indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) The ow er or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program I require ents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 34 Straightway Hyannis Owner: Ro9Wood Date of Inspection: 9- )' -98 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yeses No Pumping information was provided by the owner, occupant, or Board of Health. _✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates daring 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. •.L/ _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. L _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Sail Absorption System on the site has been determined based on: ✓ _ The facility owner (and o:cupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 34 Straightway Hyannis Owner: Ron Wood. Date of Inspection: 9-29-98 FLOW CONDITIONS RESIDENTIAL: Design flow: .p.d./bedroom for S.A.S. Number of bedrooms:.2---3 Number of current residents: Garbage grinder (yes or no): C7 - Laundry connected to system (yes or no):N - Seasonal use (yes or no): 6:0 G�- 1996 t,hru 7-8-1998 17, 800 cubic feet Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):(0 Last date of occupancy: COM MERCIAUINDUSTRIAL: Type f establishment: Desig flow: - galloris/day Grease trap present: (yes or no)_ Industr al Waste Holding Tank present: (yes or no)_ Non-sa itary waste discharged to the Title 5 system: (yes orno)_ Water eter readings, if available: Last to of occupancy: OTH R: (Describe) Last ate of occupancy: GENERAL INFORMATION PUMPING RECORDS 4nd source of information: /U q System pumped as part of inspection: (yes or no),,4- d If yes, volume pumped: gallons Reason for pumping: TYPE OYSYSTEM _ 4/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) trevised 04/25/97) page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 34 Straightway Hyannis Owner: Ron Wood Date of Inspection: 9-29-98 BUIL G SEWER: (Locate site plan) Depth low grade: Material of construction: _cast iron _40 PVC_other (explain) Distanc from private water supply well or suction line Diamet Comm nts: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on $ite plan) Depth below grade: � � Material of construction: 1✓oncrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) i Dimensions: ae. Sludge depth:_ , Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 ► Distance from top of scum to top of outlet tee or baffle: > > Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: A,,c:;-[.✓ Td •a,)< Comments: (recommendation for pumping, condition of,�t and outlet tees or baffles, depth of liquid level in relation to ortlet inYgrt, structural integrity, evidence of eak�e, etcJZ46 � �a/ %� av . S' l'� P/�' GRE SE TRAP: . (locat on site plan) Depth below grade: Materi I of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dim sions: Scu thickness: Di nce from top of scum to top of outlet tee or baffle: Dista ce from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Comm nts: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integr' , evidence of leakage, etc.) f h (revised 04/25/97) Page 6 of 10 it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -Property Address: 34 Straightway Hyannis Owner: Ron Wood. Date of Inspection: 9-29-98 TIG T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (local on site plan) Depth low grade: Materi of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dime ions: Capa ty: gallons Desi n flow: gallons/day Alar level: Alarm in working order_Yes; _ No Date f.previous pumping: Com nts: (condi ion of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: 0 (locate on site plan) 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, etc.) 6 t, PUM CHAMBER:_ (locat on site plan) Pum in working order: (Yes or No) Alar s in working order (Yes or No) Co ents: (no a condition of pump chamber, condition of pumps and appurtenances, etc.) n (revised 04/2S/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: - 34 Straightway Hyannis Owner: Ron Wood Date of Inspection: 9—�9-98 SOIL ABSORPTION SYSTEM (SAS): •(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length:6 leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) < 'yam CESSPOOLS: _ (locate on site plan) Number and configuration: acl 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) Com ents: (note ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY _ (locat on site plan) Materi Is of construction: Dimensions: Depth tf solids: Comm nts: (note c r ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (raviaad 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 34 Straightway Hyannis Owner: Ron Wood. Date of Inspection: 9_2 9_98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) (�36 j 3S ' tiyA/ J (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 34 Straightway Hyannis Owner: Ron Wood. Date of Inspection: 9-29-98 ,Y- Depth to Groundwater- Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record I l Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own wor s how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 oFI E Town of Barnstable sa �nB Department of Frealth, Safety, and Environmental Services 9� 1MAM� .�� Public Health Division ArFD MA'l A 367 Main Street, Hyannis MA 02601 FAX Date: 9 Number of pages to follow: 3 To: d From: Phone: Phone: 508-862-4644 Fax phone: Fax phone: 508-790-6304 CC: REMARKS: Urgent For your review Reply ASAP ❑ Please comment ct No. v i... __... .,,r Fee J 5 0 .on THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Mi-4po$al *pgtem Conotruction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 34 Straightway Owner's Name,Address and Tel.No. 6 0 3-642-8 0 95 Hyannis MA Ron Wood 5 Shady Lane Assessor'sMap/Parcel 267 090 Fremont NH 03044-3557 Installer's Name,Address,and Tel.No. 7 7 5-8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service J K Holmgren & Assoc Inc PO Box 1089 Centerville MA 02632 4650 Falmouth Rd Cotuit MA 02635 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(n9 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil snn d Nature of Repairs or Alterations(Answer when applicable) Install Title 5 Septic System accord.ing to the Plans of J K Holmgren & Assoc Inc , to consist of a ..15009 septic tank, D-box and 2leaching trenches 30 ' x ' x ' _ " 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 Bied o ealth. Signc Date 3r Application Approved by o Date' Application Disapproved for the following reaso Permit No. —' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Wood Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(x )Upgraded( ) Abandoned( )by at Straightway Hyannis b constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoW4h dated Installerld :2 ReW14Se14 99Pt_Q-2-'y Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector •.�G,y ...1 .�,M.\"' .nry/`tf..w.i 4� No. L w s Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PU,B'LIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppricati'on for Mgaal *pztem`Con,5truction Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 34 Straightway Owner''sName,Address and Tel.No- 603-642-8095 Assessor'sMap/Parcel H annis MA Ron Wood 5 Shady Lane 2677g,0 Fremont- NH 03044-355.7 Installer's Name,Address,and Tel.No"' 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service J xK Holmgren & Assoc Inc PO Box ,1089 Centerville MA 02632 4650 Falmouth Rd. Cotuit MA 02635 ,._ Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(ng Other Type of Building No. of Persons Showers( ) Cafeteria( ) ;k Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Install Title 5 Septic System accod'ing to the Plans of J K Holmgren & Assoc Inc, to consist of - dj15009 septic tank, D-box and. 2leaching trenches 30 ' x x Date`iast inspected: Agreement: �r 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: ' t cate of Compliance has'been issued by this Bopd of ealth. Sign Date�..0Z 3� Application Approved by Date Application Disapproved for the following e so '`r ✓ ;. Permit No. ""— t .° i Date•°iss e -n- THE COMMONWEALTWOF MASSACHUSETTS - r r BARNSTABLE, MASSACHUSETTS Wood. , �f Certificate of ComOliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(x )Upgraded( ) Abandoned( )by ; at Straightway Hyannis has b e constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer T' 1a Robinson Septic S ry Designer !` The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector — ---!—� -------------------------------- '— Fee 0.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS �Digo!gal *p5tem Con6truction Permit Permission is hereby granted to Construct( )Repair(xx)Upgrade( )Abandon( ) System located at 'ALL Straightway Nva nn i g Tnsta_ller lnl F Rnhinenn Sa:tic; Sry and as described in the above Application for Disposal System Construction Permit. The applicant recognizes hi /her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m t -e com eted .ithin three years of the date of thje j :t! O Date: i Approved by t z ' t f NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated c�— �/ concerning the property located at 34 Straightway Hyannis, meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in now and/or change in use proposed. * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) p B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: 16r �l DATE (� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). - i CX 111 C> ti. TOWN�OF BARNSTABLE .ATION 1 j T 4 v�, �`1 J� SEWAGE It AGE /`I V ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER Cie* PERMITDATE: `'I COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland 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 I � � i � ! I Ii CIS— a a yi F i i i i i a E f TOWN OF BARNSTABLE LOCATION �% SEWAGE # ViLAGE All) ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. � � i ��3 •°- -7 4 SEPTIC TANK CAPACITY !� LEACHING FACILITY: (type) Y T 4-1 (size) 4l — NO:OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE:y`'.,-Q `"7 COMPLIANCE DATE: 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 �� �� . '�� '� ( t �� i, �' �. P E ){}� t � '3 r/(f i� �\ � �ti i � No. _46 7 DESIGNING ENGINEER MUST SUPERVISIFEE eta` THE C0MM0NWEALTjAqMMM"CAW5CM IN WRITING; THE SYST WAS INST�E,�STRICT c� Itr�t#t>�n for (fons#rurtion Ilermit Application is hereby made for a Permit to Construct ( ) or Repair( ) an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 3y STZ,hrt may, �ycteinrs. NA Qom- AEFclri y WaoA 5- Sk4L�Qy ��,(o & 7- 0 L> 66 - -so Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No. x((� d O l�!�o� HA O Type of Building: Dwelling No. of Bedrooms -- Garbage Grinder( ) Other Type of Building R t i q_1iZLX No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow L - -) gallons. Plan Date -;z �_99 Num er of s eets Revision Date Title �c�►t11iwv cSDAs� yS ' Crw`` A Description of Soil ho to W v sa ktal �. L19 a3 eu v $m a Nature of Repairs or Alterations(Answer when applicable) y- e . . . ... . .. PtflU ' Date last inspected: Y `Z 3 "g'K COM Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribe isposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the sys AL on until a Certificate of Compliance has been ' e y this Boar of Health. Si gned� G Date%` L Application Approved by / GEC / a. f Date 7 Application Disapproved for the following reasons Permit No. Date Issued 7 —1G -,;'"%. r h s. t '�,.- •. 'act. E4gM1v ♦.� 4 4, y"•.k• '� ..r at ::w r , .v:#' .i 1 a, t No. �� �t�•,�`° .��4j �f;` - � FEE '...--- i t THE COMMONWEALTH OF MASSACHUSETTS/ / M'ASSACHUSETT.S ._ �;. . 1t.ctt#tu�c £sir �ts�asttX, ��$#ez�t �u�tstxtx.c#iun �Przttt# Application is�hereby�made for a Permit to Construct ( ) or Repair( )an On-site Sewage Disposal System at: Location Addres's,or Lot No. r Owner's Name,Address and Tel.No. 3y `STra � �,�yt ��� k1y,2Mnt5, NA �� « ��y t FFr e_,-,o r1 t N H. o 8 o q y Installer's Name,Address and Tel No. _ Designer's Name,Address and Tel.No. �<�� /S ����-�'g�,,,' �� t7 K NoI►u�` �p st � 14ss�ac. ,-�rrc. !m *l. Rd.j Co1T /L/A to Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) Other Type of Building V-e-51 -e No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3(7 gallons per day. Calculated daily flow., gallons. Plan Date S`,-7 " � Number of sheets T Revision Date Title V i 5,0a Sca ,i S V 5I"c as Description of Soil. �Oct Itii v Set H rl ®—12 l 4",,4 scn n d l 2 -- 3 (Nature of Repairs or Alterations(Answer when applicable) E 5 !04 Date la t inspected: s Agreement: ' The undersigned agrees to ensure the construction and maintenance of the aforedescribe system in accordance with the provisions of Title 5 of the Environmental Code and not to place the syste a Certificate%of Compliance has been ' e y this Boar of Health. Signed / Date%</ `769: � "{ Application Approved by ��.gP". Date , 7"'�6'tl�7`• Application Disapproved for the following reasons q � Permit No. Date Issued 'f / • / a yy ` c THE COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS Tex#tftett#e of Gray tttnre THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/replaced( ) on by I for at has been constructed in accordance with the provisions of Title 5 and the for Disposal System(Construction Permit No. 5Vio�S"7 dated �^ Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on Q� DATE -1 �+ 1f Inspector THE COMMONWEALTH OF MASSACHUSETTS r No. ?9--�/s'7 13C `-1 3 AA(-k , MASSACHUSETTS FEE �ts�IIstt1 �5g$#extt �IIns#r�z.c#tun �erxrtt# Permission is hereby granted to ' 0.01 to construct( ) or repair Q/an On-site Sewage System located at ;a.J ` " 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. ; All construction must be completed within three years of the date below. DATE `A Approved by � C. FORM 1255 Rev.3/95 A.M.SULKIN CO._BOSTON,MA .f s• �tME l Town ofBarnstable x • � �AB Board of Health ' P.O. Box 534 Hyannis MA 02601 RFD MAC s Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Ralph A.Murphy,M.D. Sumner Kaufinan,M.S.P.H. July 21, 1998 Mr. John D. Kuchinski 27 Old Colony Drive Mashpee, MA 02649 RE: 34 Straightway Road, Hyannis Dear Mr. Kuchinski: You are granted multiple variances on behalf of your clients, Ken and Audrey Wood, to replace the onsite sewage disposal system at 34 Straightway Road, Hyannis, Massachusetts. The variances are granted as follows: 310 CMR 15.211: To reduce the separation distance between the property line and the soil absorption system to 6.5 feet in lieu of the required ten (10) feet separation distance. 310 CMR 15.211: To reduce the separation distance between the foundation wall and the soil absorption system to ten (10) feet in lieu of the required twenty (20) feet separation distance. 310 CMR 15.212: To reduce the separation distance between the bottom of the soil absorption system and the adjusted high groundwater table to four (4) feet in lieu of the required five (5) feet separation distance. 310 CMR 15.211: To reduce the separation distance between the soil absorption system and a catch basin to thirteen (13) feet, in lieu of the required twenty-five (25) feet separation distance. Part VM, Section 1.00: To construct an onsite sewage disposal system sixty-two (62) feet away from the edge of wetlands, in lieu of the required one-hundred (100) feet separation distance. kuchinsk i These variances are granted with the following conditions: (1) The engineered plans shall be revised to show the following information: • Setback distance to the edge of wetlands. • Percolation test locations. • Three (3) covers on the proposed septic tank. • Complete soil evaluation information including identification of layers and soil colors. • Variance request relative to the setback to the edge of wetlands. (2) No more than three (3)bedrooms are authorized at the site. Dens, study rooms, finished attics, sleeping lofts, and similar rooms are considered bedrooms according to MA Department of Environmental Protection. (3) The designing engineer shall supervise the construction of the septic system and shall certify in writing to the Board that the system was installed in strict accordance with the revised plan. The variances are granted because the existing cesspool failed a recent inspection. The proposed replacement system meets the maximum feasibility requirements of the State Environmental Code, Title V and is a great improvement compared to the existing cesspool. It is the opinion of the Board that the replacement septic system may alleviate a source of contamination to the groundwater in the area. Sincerely yours, Susan�RaS. Chairman Board of Health Town of Barnstable SGR/bcs cc: T. Geiler kuchinsk TFIE DATE: r • FEE: 0 BARNffr EIM _ p,E 19. 06. Town of Barnstable REC. BY Board of Health 367-Main Street, Hyannis MA 02601 Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Ralph A.Murphy,M.D. VARIANCE REQUEST FORM LOCATION cf j PCI Property Address: c V 1 (`@.LG l�L i�POL%J, N/ tit Y((.S Assessor's Map and Parcel Number: o�,�0 7 09Z) Size of Lot: a1 1 I ? S VT A) ) Wetlands Within 300 Ft. Yes i/ Subdivision Name: No Business Name: APPLICANT ,` CONTACT P H ERSON Name: 0A, Jg,,p v Ir✓c�)aeV Name: 1ncr?e� l`rle waarH Address: 1`5 —re-WC96 y W17 Address: Tk1 o v� -°� Assek. Phone: 603 ` 6 4/2 — gO`!6 Phone: ©<�— "120- ?Q® �2 FAX: FAX: �16,io 0_a vc HA �aCoa� VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIAiNiCE(Mayattach if more space needed) is , a211 — U&dey-Si7-10 SU11l T- I �ge�beck u✓-� he�we�rt hvuse . a.. Awd )o* Irrte 2 12 To na er I k T ' Y Check list(to be completed by office.staff-person receiving variance request application) Four(4)copies of plan submitted(including septic system plans-and/or restaurant floor plans) Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) - .. Variance request application fee collected `fee fur lifeguard modification renewals,grease trap variance renewals[same ownedleasee only),outside dining variance renewals[same ownertleasee only],and variancesZ repair failed sewage disposal systems[only,if no expansion to the building proposed]) Variance request submitted at least 15,days prior to meeting date VARIANCE APPROVED U� Susan G.Rask,R.S.,Chairman NOT APPROVED �9 Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL 1998 Ralph A.Murphy,M.D. Q:/WP/VARIREQ ��� J.K. HOLMGREN & ASSOCIATES, INC. Registered Professional Engineers,Land Surveyors and Environmental Consultants 1308 Belmont Street,Brockton,MA 02401 (508)583-2595 FAX:(508)588-7518 4650 Falmouth Road,Route 28,Cotuit,MA 02635 (508)420-7900 FAX:(508)420-3819 Toll Free: (800)439-2595 June 29,1998 Dear Margaret Crowley: Re:Notification of A Request for a Variance for repair of Septic System located at 34 Straightway,Hyannis On June 29, 1998 a Variance Request form was submitted to the Barnstable Board of Health. Ron and Audrey Wood of 34 Straightway Lane,owners of the same,are requesting variances for the repair of their Septic System. Variances are being requested of the following regulations.# 15.211 &#15.212. # 15.211 -A variance for approval of setback area between house and lot line. # 15.212-A variance for approval of separation to groundwater. Hearing on the above will take place on July 14, 1998 at the Town of Barnstable Board of Health, located at 367 Main St.,Hyannis,MA. Sincerely, The Office of. JK Holmgren&Associates,Inc. Land Surveys Subdivisions Septic Design Wetland Filings • Site Design Environmental Site Assessments J.K. HOLMGREN & ASSOCIATES, INC. Registered Professional Engineers,Land Surveyors and Environmental Consultants 1308 Belmont Street,Brockton,MA 02401 (508)583-2595 FAX:(508)588-7518 4650 Falmouth Road,Route 28,Cotuit,MA 02635 (508)420-7900 FAX:(508)420-3819 Toll Free: (800)439-2595 ABUTTERS LIST—RONALD&AUDREY WOOD Philip A&Caryn V. Vilah 48 Straightway Hyannis,MA 02601 Arthur Stearns III&Derek J. 27 W Hypt Circle Weymouth,MA. 02189 Ernest L Wood Jr. 36 Wequaquet Lane Centerville,MA 02632 Theodore and Pauline Gelinas 47 W Hyannisport Circle Hyannis,MA. 02601 Ruth Clark C/o Haddlelon&Collins PC 10 Straightway Hyannis,MA 02601 Concetta A Werner Munafo,James Jr. &Alice 33 Straightway Hyannis,MA 02601 Margaret Crowley 48 Straightway Hyannis,MA 02601 Land Surveys Subdivisions Septic Design Wetland Filings Site Design Environmental Site Assessments P 195 860 146 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse to gt t O tJrt rest Numb r f- P t Olfi ,State, ZI Cod �k e d& Z Postage Certified Fee 1 "3 "— Special Delivery Fee Restricted Delivery Fee N Retum Receipt Showing to ¢� Whom&Date Del' D Q Return R tom , Q Date,& e9 ' O TOT Est e&Fees CO Pos ark pt pldid 2 91998 0 a i Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optioral services(See front). 1. It you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). m T 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the ro i return address of the article,date,detach,and retain the receipt,and mail the article. M Ln 3. If you want a return receipt,wits the certified mail number and your name and address M on a return receipt card,Form 3811,and attach it to the front of the article by means of the _ gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested.in the appropriate spaces on the front of this ff receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti 6. Save this receipt and present it if you make an inquiry. a J.K. HOLMGREN & ASSOCIATES, INC. Registered Professional Engineers,Land Surveyors and Environmental Consultants 1308 Belmont Street,Brockton,MA 02401 (508)583-2595 FAX:(508)588-7518 4650 Falmouth Road,Route 28,Cotuit,MA 02635 (508)420-7900 FAX:(508)420-3819 Toll Free: (800)439-2595 June 29,1998 Dear Ernest L Wood Jr. Re: Notification of A Request for a Variance for repair of Septic System located at 34 Straightway,Hyannis On June 29, 1998 a Variance Request form was submitted to the Barnstable Board of Health. Ron and Audrey Wood of 34 Straightway Lane,owners of the same,are requesting variances for the repair of their Septic System. Variances are being requested of the following regulations.It 15.211 &# 15.212. # 15.211 -A variance for approval of setback area between house and lot line. # 15.212 A variance for approval of separation to groundwater. Hearing on the above will take place on July 14, 1998 at the Town of Barnstable Board of Health, located at 367 Main St.,Hyannis,MA. Sincerely, The Office of: JK Holmgren&Associates,Inc. Land Surveys Subdivisions Septic Design Wetland Filings Site Design Environmental Site Assessments d SENDER: �. ■ / v ■Corripfet tems 1 and/or 2 for additional services. I I ;hh]jo,?r�aE 8 �_ r ai ■Complete items 3,4a,and 4b. ,r fol s' � eD rn ■Print your name and address on the reverse of this form so that we can ret his card to you. C.98 'c-"'•a�° � b� :; > ■Attach this form to the front of the mailpiece,or on the back if space does no g e 5. -..,. permit. d ■ftte'Retum Receipt Requested'on the mailpiece below the article number. 2, ❑ Resinc-ted Delivery N:? The Return will show to whom the article was delivered and the date M c delivered. Consult postmaster for fee. a 0 J.Article Addressed to: _ u - 4a.Article Number d 1 ` a .� E 4b.Service Type Q u�Q v.P- ��K`e ❑ Registered [Y- ertifled ' . �e '-{-'eA Ids (� A ❑ Express Mail ❑ Insured j G I V t (( ) J / FI ❑ Return Receipt for Merchandise ❑ COD 1 a a z 7.Date of Delivery .° Z I 5. Received B Print Name Y ! Y ( ) 8.Addressee's Address(Only if requestedLU I and fee is paid) r c ig 6.Signature:(Addressee or Agent) i PS Form 3811, December 1994 ; 102595-97 B-0179 Domestic Return Receipt � T �. • � .. j .r `„!. ;' $ �..S�sib a �?T •w.. f�, r r i i i�°i 3 i r 3� 'i i:v t ' a; CoCD Q0 x rt - Zo, `91j G1.f O 0t��13 L;�G �1 ii ❑ C" - Ar ape�11�be9£-' ° r_CMGs }C t3t t31i+C $a, Poo .:K`I lsaaig ;, riG F�' NIL., rri ° SV _ t m.`-;fix,r� i�.l :.',•,. , w 0' o• tzi OWL .� y On - -- - - - oNonm. Cn � k b 0 9 S 6'C d P . 195 8-60 151 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Se tto Street& um r _ os Otfice,State,& od ®a7� Postage Certified Fee 15 Special Delivery Fee Restricted Delivery Fee ,n Return Receipt Showing to it Whom&Date Delivere , (J a Retum Receipt Sh m 0I Q Date,&Addr dr 0 TOTAL Page&Fees $ _ Postmark o DaMUIV Z q1998 LL Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). I 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service a window or hand it to your rural carrier(no extra charge). m Q) 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti { 6. Save this receipt and present it if you make an inquiry. Cl) i ' J.K. HOLMGREN & ASSOCIATES, INC. Registered Professional Engineers,Land Surveyors and Environmental Consultants 1308 Belmont Street,Brockton,MA 02401 (508)583-2595 FAX:(508)588-7518 4650 Falmouth Road,Route 28,Cotuit,MA 02635 (508)420-7900 FAX:(508)420-3819 Toll Free: (800)439-2595 June 29,1998 Dear Arthur Stearns III&Derek J Stearns Re: Notification of A Request for a Variance for repair of Septic System located at 34 Straightway,Hyannis On June 29, 1998 a Variance Request form was submitted to the Barnstable Board of Health. Ron and Audrey Wood of 34 Straightway Lane,owners of the same,are requesting variances for the repair of their Septic System. Variances are being requested of the following regulations.# 15.211 &# 15.212. # 15.211 -A variance for approval of setback area between house and lot line. # 15.212-A variance for approval of separation to groundwater. Hearing on the above will take place on July 14, 1998 at the Town of Barnstable Board of Health, located at 367 Main St.,Hyannis,MA. Sincerely, The Office of: JK Holmgren&Associates,Inc. j Land Surveys Subdivisions • Septic Design Wetland Filings Site Design Environmental Site Assessments m SENDER: also wish to receive the ■Complete items 1 and/or 2 for additional services. ai ■Complete items&48,and 4b. ,.-,w f0llOWln�Services(for an �' d ■Print our name andladdress on the reverse of this form so that we can return th=s I � v . - .. :. extra fear.o ;.. i .. card to you. _ cai ■Attach this form.'to the front of the mailpiece,or on the back if space does no; �'' Q Addressee's Address — d permit. ! ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N I ■The Return Receipt will show to whom the article was delivered and the date « C delivered. Consult postmaster for fee. i 3.Article Addressed to: 4a.Article Number t U / C�"�v r• re � s leQv'HS c a 4b Serve Type d 1. ❑ Registeredertified {. l �� ❑ ExptBss Mail ❑lea Insured 5 _ia RecelptforMelchandise [I COD 0 7.Date of Delivery w° Z 0 S.Received By: (Print Name) S.Addressee's Address(Only if requested W and fee is paid) r Mi g 6.Signature: (Addressee or Agent) 0, X I � � PS Form 3811, December 1994 102595-97-13-0179 Domestic Return Receipt x Y.: o x ID 0 + Tit l,2w, ern H M LZ c tir_ _ ala qW FL Z opolean ui li$tuai aou Q o w IT oQ �---�— a ul FWD i? 9 00 2 - s-►--- ri`r;i11_ �3N�!(Z13� n ,O'S '��' Q- y Y' aYr r EP.V'EhJtl 'n 1 2HMNSS O Jti 01 a T P 195 86.0 148 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sqfqto �( V (_ &Nu r n J a O did' 0 a OS Post Post State,&, P ode 0 !` 4Xz pU( Postage Certified Fee Special Delivery Fee Restricted Delivery Fee ul rn Retum Re n D _ Whom.& ry O , cl�= ReWm Pto Whom, A Date, essee's Address TOT P U 1 Postm rk or D tae o u_CO a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). i 1. If you want this receipt postmamed,stick the gummed stub to the right of the return t. address leaving the receipt,attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). In 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m return address of the artide,:date,detach,and retain the receipt,and mail the article. CIC in 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,For 3811,and attach it to the front of the article by means of the gummed ends if space perils. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restrictec to the addressee, or to an authorized agent of the G addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of For 3811. ki 6. Save this receipt and present it f you make an inquiry. a P. 195 860 149� US Postal Service K.a Receipt for.Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse cQ Street rNumber P ce,State,&ZIP Cod Postage $ (3 R Certified Fee Special Delivery Fee Restricted Delivery Fee LO Return Receipt Showing to y'1 _ Whom&Date DelivemiJ.. (J Return Receipt Date,&Addr 4 0 TOTAL P e Fees $ €co P°S°" °'MN 2 9 1998 0 co 0- Stick postage stamps to article to cover First-Class postage,certified mall fee,and charges for any selected options'services(See front). 1.If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attadied, and present the article at a post office service window or hand it to your rural carver(no extra charge). m Q) 2. If you do not want.this receipt postmarked,stick the gummed stub to the right of the m return address of the article,date,detach,and retain the receipt,and mail the article. uO 3. If you want a return receipt,wrte the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. co 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. to 6. Save this receipt and present it if you make an inquiry. a d SENDER: _ .� �a�,�a�-��-�+� V ■Complete items 1 and/or 2 for additional se ' 9 9� w" "�aZ`�n to-r-j Celve,tFde w ■Complete items 3,4a,and 4b. �V 4� .-' IIOWInyS cwces.�#or a d ■Print our name and address on the revs e 1 ���so,that we can retum^th card i you. ■Attach this form to the front of the mailpi br gbad�c space does.not _❑,.ardressee S A permit. J 31/ of �.�_ - �- d ■Write'Retum Receipt Requested'on the tpie low the rticle number .' estocted Deli_very� JZ ■The Return Receipt will show to whom th art'-eTwas3dall' d and the date,., . delivered. msalt"postmaster fog fee. v 3.Article Addressed to: 4a. JJ Ar le Numb a C ��- d / `� 4b.Service Tp e 0 2z1 0 Dcal leS �` $ l`f'`rc P ❑ Registered Certified 0� r� ❑ Express Mail Insured E- W 33 S ham :., o .''// c� 'y ;'w ❑ Retum Receipt for Merchandi ❑,COD a 17�(Q a X(S Qi� oZ > 7.Date of Delive II 77) 5.Received By:(Print Nam_) ` �s 8.AddresseellAfidlesi(CTnly if requested W 0 � and fee is id) C 6.Signature:Ulddressee o :99�nt) 0 X N PS Form 3811, Decemb r 1994 102595197-B-0170..i Domestic Return Receipt UNITED STATES POSTAL SERVICE First-Class MailPostage&Fees Paid USPS Permit No.G-10 O Print your name, address, and ZIP Code in this box O I J K S'OLAZGREN&ASSOCUTES INC. COTUM MMAO 2U 635 RT 28 O 4 P 195 560 1:47 US Postal Service'- Receipt for Certified Mail No Insurance Coverage Provided. Do not use for Intematlonal Mail See reverse SenJ to Street&Number P Office,State,&ZIP P ge Certified Fee Special Delivery Fee Restricted Delivery Fee LO Retum Recei ww��� Whom&D ert'T! a Retum R o Q Date,& Address 'S O TOT PoingF CO Cq Postm a e o Cn USPS I N Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). r 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service y window or hand it to your rural carer(m extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m return address of the article,date,detacn,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the.article by means of the gummed ends it space permits. Otherwise,affix to back of article. Endorse front of article .a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the Cr addressee,endorse RESTRICTED DELIVERY on the front of the article. � 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,cieck the applicable blocks in item 1 of Form 3811. ti 6. Save this receipt and present it if you make an inquiry. a d SENDER: C ■Complete items 1 and/or 2 for additional services. I also wish to receive the ■Complete items 3,4a,and 4b. following services(for an d ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address permit. y ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N .t. ■The Return Receipt will show to whom the article was delivered and the date o delivered. Consult postmaster for fee. 0 3.Article Addressed to: 4a.Article Number d S60 E 4b.Service Type `� ° /r/ y.�, ❑ Registered M Certified °C W ❑ Express Mail ❑ Insured cc Ti 1/ce�vt t S HA ���`0 13.Return Receipt for Merchan ise ❑ COD o° art JUN �(.A Date of Delivery z 601 p, 5.Received By: (Print Name) 8.Addressee's Address my if requested 1�7 and fee is paid) rc �( 6.Si e4Ad r ss a or t) M PS Forr►a , Decem er 1994 102595-97-B-0179 Domestic Return Receipt UNITED STATES POSTAL SERVICE11111 First-Class MailPostage&Fees Paid USPS Permit No.G-10 o Print your name, address, and ZIP Code in this box C J K HOLA.ZGREN&,ASSOCIATES INC. 4650 FALMOUTH ROAD,RT 28 COTUIT,MA 02635 D� P 195 860 144 US Postal Service;' y Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse to I i` d n w Pvsymce,State,&ZWIC d Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee W Retum Receipt S Whom&Dat Date,& s ess c�` O O TOTAL CD M Postmark r Date 0 LL Stick postage stamps to article to cover First-Class postage,certified mall fee,and charges for any selected optional services jSee front). 1.If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service m window or hand it to your rural carrier(no exta charge). m 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach,and retain the receipt,and mail the article. CIC LO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise affix to back of article. Endorse front of article RETURN RECEIPT REQUESTED adjacen:to the number. 4. If you want delivery restricted to the addressee, or to an authorized agent of the G addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. 0 LL 6. Save this receipt and present it if you make an inquiry. d SENDER: 13 ■Complete items 1 and/or 2 for additional services. I also wish to receive the ■Complete items 3,4a,and 4b. :,` following services(for an ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address permit. 4 A;, d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery to ■The Return Receipt will show to whom the article was delivered and the date ., c delivered. Consult postmaster for fee. a 3.Article Addressed to: 4a.Article Number d, Ohl �oP .4 V V/0-1" o 196 V6d /y� E Y �i 4b.Service Type d� CertN ❑ Registered fied � al J811 qgyp Express Mail ❑ InsuredLU 1 ` 0 =p Retum Recgipt for Merchandise ❑ COD t o a ®� (1 6 ( \� �l��� V Date of D live � ` o z 5.Received y:(Print Name) 8.Ad ressee's Address(Only i/requested and fee is paid) t t— Signature: (A dr s e orA ent X PS Fo 11, December 1994 102595-97-B-0179 Domestic Return Receipt First-Class Mail UNITED STATES POSTAL SERVICE Postage&Fees Paid USPS Permit No.G-10 C Print your name, address, and ZIP Code in this box o .3 J K HOLAIGREN&A;WCIATEig INC. 4650 FALMOUTH ROAD,RT 2g COTUIT,MA 026M litiii`eiJ,'IS .tI'M'11141.i4.iii.i: P 195 860 150 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse to Stre & Y P Office,State,&ZFPIC M G Postage $ 132 Certified Fee 35 Special Delivery Fee Restricted Delivery Fee Retum Receipt Showing to Whom&Date Delivered CJ Q Retum Receipt Showi Q Date,&Address �S 0 TOTAL P es Postma or Date ,- LL JUU 2 9 1998. 0 CD J rL -- - -- -" - - -J - ------- i Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 11.If you want this receipt postmarked,sti."k the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service y f window or hand it to yout rural carrier(no extra charge). m I 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q cc return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,wdte the certified mail number and your name and address rn r on a return receipt card,Form 3811,and attach it to the front of the article by means of the _ gummed ends 9 space permits. Otherwise,affix to back of article. Endorse front of article I RETURN RECEIPT REQUESTED adjacent to the number. I O t 4. If you want delivery restricted to the addressee, or to an authorized agent of the C M addressee,endorse RESTRICTED DELIVERY on the front of the article. co 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti 6. Save this receipt and present it if you hake an inquiry. d I I d SENDER: 97 ■Complete items 1 and/or 2 for additional services. I also wish to receive the w ■Complete items 9,4a,and 4b. following services(for an 4) ■Print your name and address on the reverse of this form so that we can return this extra fee card to you. ai d ■Attachtt this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address s permit. Receipt Re uested'on the mail piece below the article number. m d P 4 a 2. ❑ Restricted Delivery rn ■The Return Receipt will show to whom the article was delivered and the date .. 0 delivered. Consult postmaster for fee. E 0 v 3.Article Addressed to: 4a.Article Number d d b 6 45—D CL ¢ E y- / 4b.Service Type d 5{a`cp rt�ivtt/ _ ❑ Registered Certified ¢ to _ c �/ ❑ Express Mail/ ❑ Insured c /7�� NA S it ❑ Return Receipt fo"rchankdise ❑ COD a f�o?�D l 7.Date of Del�ery,� ro G Z ¢ r� 5.RePeived By: (Print Name) r . - 8.Addressee's Address(0-ily if requested 9 w a ' and fee is�paid).,�y ��' t g 6.Signature:(Addressee or Agent) �. 09Z >. I X N PS Form 381 , D camber 1994 102595-97-B-0179 Domestic Return Receipt 11 UNITED STATES POSTAL SERVICE First Class Mail Postage&Fees Paid uses Permit No.G-10 C Print your name, address, and ZIP Code in this box o J H HOLMGREN&ASSOCIA.TES INC. 4050 FALMOUTII ROAD,RT 28 COTUIT,MA 026S8 isIteft�t1e11E�itfitl:le�i}�el�!il LdCATIOa SEWAGE PERMIT NO. 3 V Ill AGE Ol 101ST i LLER'S CIA ME A ADDRESS 6 U I L D E R OR OVC3ER G(P t DATE PERMIT ISSUED _ w DATE . COMPLIANCE ISSUED G n No................ 7 �Q .� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliration for UiipnoFal Works Tonstrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair (M an Individual Sewage Disposal System at: L . :n-Addres N Owner rY1�... l��f� ........................... Installer Address Type of Building Size Lot..................•------_-•Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aa Other—Type of Building No. of persons............................ Showers YP g ---•----•------•-------...._ P ( )..— Cafeteria ( ) 04 Other fixtures ---------------------------------------------------------•-•......---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter--------........ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter..........--........ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ►-' Percolation Test Results Performed by............................................................................ Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..--..--.............-.. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..-.-------.------------ O Description of Soil.................LL;�.d� ..�.. - ------....---------------------------•----------------=--------------•--------...................... W -••------•-•-------•---------•--..................... ---•-- -- -...... x //_ U Nature of Repairs or Alterations—Ans 'er when applicable..-------l..--1 s�lT�..... )......fc j- ---------------------------- -•--------••-••••---•••---•....--•-••••-•...•---•-•••---••••-•-••••-•••--•----••-•••.0...---•.......---••--••-••---••-•--•-•-----••-•-----••••••-•--•-••-•-------•-••••-••••......•-•....---•-.......... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI TALE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has teeq issued by the board of health, sig d.. t` ate Application Approved By...... ..... ----- •--............. .......•... � �� Date Application Disapproved for the following reasons-.......-.................... ..................................................................... ------------------------------------------•-----------------••------------....------------------....-----I-•--•-•---•-••••••--•--•--------•-•-•-•••...----••----•------••------------•-•---•••••••....... p� Date PermitNo......................................................... Issued....! ___A:-•H--•.....-------------------- Daze 7 eye; No...............`��..1 Fps.t `r C��.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............................................. . OF.... .Pro.......r................................... --puIiratilaa ,for Disposal arks Tonstrnrtinn anti# i Application is hereby made for a Permit to Construct ( ) or Repair (Y) an Individual Sewage Disposal System at ---•--3--y -- _=- ....�'-�-�:��.L 1-1....--......P... - - .. -------------------•--- ---- --•--••-----..................---•--•.......•. L cation-Address } or Lot No. ti - C) f- y�_ ....................................�)7- ..... 1l..........j_� _../............. ..Owner.._....._._./..... ............... _ ..............Address ..^•__ � Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building F.______ No. of.,persons Showers — Cafeteria 0.1 YP g P ( ) ( ) Q' Other fixtures ----------•••-• ...1•-•------•-•--•----•----...._•----•---•• ---- -= -- f W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length________________Width................ Diameter................ Depth................ xDisposal Trench—No. Width.................... Total L•ength_:"._,_____...:___.__. Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box Percolation Test Results Performed by.......... .;-------------------------------------------------------------- Date........................................ ,4 Test Pit.No. I........._......minutes per inch D pth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch eptli of Test Pit.................... Depth to ground water........................ ---------------------------•-----•.....(!!!'-----------------..._.....-------------•---.......----............_..................-----......................-••- ODescription of Soil ........ = -='........._..'f........'......-•----------------------------------------------------------------------------------------------- V ------------------------------------------------------•---------- ---------.._..... W U Nature of Repairs or Alterations—Answer when applicable....................................r.........r_ �� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITAIL 5 of the State Sanitary'Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has f� been_ issued by the board of health. /1 51g f ............................................... .: vv� Al. ....._ is ...r'lJ_.l�I. r_......... J..v<' _�.._ ------ Application Approved By...... Date Application Disapproved for,th'e following reasons------------------------------------------------------- ...................................................... s �• [�� Dam PermitNo......................................................... Issued............-`(F' ----•-J--•--•------•-- ------ Date THE COMMONWEALTH OF MASSACHUSETTS _ _ BOARD OF HEALTH ................................. ..t':.OF..... ...'.�.d`+/1.......�:: `�t�........................ Trr#ifirFa#r of ft ompliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed"`( ) or'Repaired ( ) by---------- =' Installer -..... at............................-............................ ---------------------------- has been installed in accordance with the provisions ofel7� / State Sanitary C ie as descy,'.bed in the application for Disposal Works Construction Permit N _______________/_._______.____ dated__....°-_"....._... THE ISSUANCE OF THIS CERTIFICATE SHALL;NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �!�G�DATE... .... ` :.. _s Inspector ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...C'..:C::..:........OF.... ..'% _:::-7 'r.1-J..................................... No......................... FEE.............. Disposal Works Tn�trudion tier � Permission is hereby granted. f .............................../j ?"/. ......................................_.. to Construct.( -_)-or Repair (IV) an Individual Sewag Disposal System / _ /- atNo.. == ,�..... f Street------------------------------------------ _ -•--- � �f�) as shown on the application for Disposal Works Constructio rmit ,,�Dated............._rV'..._....__4/......_........ � -•• --••-•-• Board of Health F DATE.... --•--------------•---.......-----•------•••-- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS EX pool , rI AMR? V111 off ►il .,r ,. r a.. , -:... , .. .. :. ,:: : ,h t 0... ,.. o. e �. ... .... ,. ,..... �: ... e ,. ,.. a. , dY. .. i. ..-t _ .. ti.. _ - .w.. • *:.. :. .. ,, , m n ,. x . ........, -. e.! ". , ..... •:-... k. ... Ea. ... ,.- :. a r ,, ,: r ,.' .. : .. ,. }'. ,. ,... .:. , C o Y: �. :.. f^ } .. , .. a rt. .., ,., t. zr, ..,,a .: .. ,v J .-. ,. ..' 1, , J : , a .. x T .r•.. b: «.. :, .., � ,.. a ., s• f ,. R,. a+%.. �t. 'w:. S:, ... -k<A .:.. ,, 3w y... ... r.,, Y i. .,. ... .ad'.. #. �.. x. ,, k S. k' `ti'.- '4 h" 1v` '^% m:.: r '!,' �� w^, .5 „yb �. f y, Y•:' Ww, e•C G Y .,K M _..5 . <T' �?q«" N�y � e, �::tw° 3•. X? �T` ;,sq '�' ...:. ,. . .. ,,a. ..:: .. r.... .. r -, .. . ., `rY , r .. ... 4 , M , ,. . rtd ,"...:.. ,. ,. > ,.. .::, x..,,:. ,. ... r. ,- _ .. ,.. , v... , ., s.. , , , k.. ,. . ... !. a. ,< ... _. ♦ :.... .'4 ,. .. ., ._ .. ,..� ,. .r .. .. _,. • -,:. .i�'... . .a' v t ,�:): <. ♦. :. ,... s .,fir •w'." <"'.tip�. .. .. ,. .... rY.r. ... ., .. ,. .. .:. ,....,..,, .. d � ., _ ». .. • �.,, n es`,cr >.... .. v.. 4...a av t ..',lw # ,. .,:.. KN!°. ,. ... f- .. x• m. ::4a. .: ..:. r... , Y r F C: .. :: d. .: ..... X.. ✓R ... > .. a.-. ., .... ., .,. v t .,rt4 w .,.. ... v. ...n.,-. , , s xtr., ... CR h "'R. iQ- f ^. nhf+ - ,i u'� ✓9.: .... ,. .: k .... ; ... :, �. .,. .. f.. r x. ,..x ,. �.. ... ..e ,..r•, :.� ...., < a. ,.... x Z•Ssi' ,.. �:.. _£ ... .... .. �. a. ,.. �. .. ,Y'.'. hie 4. yy '-"X• -0 ..:,. v.. "5..r. ., .,,_ � w. N .r ,. ,<, .. 'ti. , -✓ .. ;:e � '�' :k 'S "#v"� �.x., a'tv 3"M8;"^^tu8 .. ,"{' :..v.. i•"J.r...,. '+S :aS W n.. .. �H`. 0. ,. 'd a,. .TAR.. .... .., r ...rn ,. ii`,. .. .«..... u.. >. .Y r �,�., r: � ,.... F. r. .rK'' :i f "r ,Ni' a'i.^l .. .r..t°r' "L'` ,. '. .. r u:. a. s.. .. � s «. «. ,x,. ,. ,., i, ...Y +. 1 _, t. f ,k¢ ,i�U b r `aF;:'%'�M�i'.. n.,.c �, .... �.. «s,. ..i'•:.. ..,. nx.. x. r Y' ,... ...,... z ., .. r n � Z 4 a .. , r. r 4 .. � �'4.:�.. „ a + Mayyvri& ... K uY fir,.. 'f. �' »'s,r��a�.,9,�.+,Uw��A1, .k Y"».. �s� ,—w.�:rwr�ria _..�,rr ��Suaa.,a�,r,.'4rr.,, ,<!H?14�5 sk.. •:,^ra .. ... ,... _ .. W.. re w ,�d,._ ..... r ,:. ,.._s...,.....,3.�=Aa„re.s.,..*Gffn,r..�sr,U..�.,...a.n,,.a,.r<.,, ,. a*ra v,.�l,.,. a,bR.-.b. ,;.,3, .i'�^.,.��': ._., .r. .. �. aku. ._ I :f :,. ^.. v. ,�,.x✓ ., .....>a. ,. ..