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HomeMy WebLinkAbout0381 STRAIGHTWAY - Health 381 Straightway Hyannis p 0 I! .E i � � f I I I� i�I i ,� r TOWN OF BARNSTABLE �- LCATION< r�4 Y" SEWAGE # ,PILLAGE A SESSOR'S MAP & LOToi—Z3® INSTALLER'S NAME&PHONE O. SEPTIC TANK CAPACITY / �Z On LEACHING FACILITY: (type) +l.c A�7��J(size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 h. _ e VN �qzr r— TOWN OF BARNSTABLE L0CATION,1y/ S60l C a-1 _ SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.Y&Q—A, k SEPTIC TANK CAPACITY � 0 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS $b1ffiHER-9R OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater to the Bottom of Leaching Facility Feet Private Water Supply Well and Seahing 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 -� `o 8�P Ves No. S � FeeTHE COMMONWEALTH OF MASSACHUSETTSEntered in computer:PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migpogal *pwm Cow6truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade("Abandon( ) ❑Complete System 2�Wdividual Components Location Address or Lot No. 3 v Q A I I S�r' y�F lkJ�� Owner's Name,Address,and Tel.No. Assessor's Map/1?arcel "L' l7� �Kcs �14 _ Installer's Name,Address,and Tel.No. (7A� �� Q Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures `` t Design Flow(min.required) L/ gpd Design flow provided `� �\ b gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank _— l 5T✓A�\ (70V Type of S.A.S. ram\612j, Description of Soil VV4V S .JL,� Nature of Repairs or Alterations(Answer when applicable) 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 Environm ntal Code and not to place the system in operation until a Certificate of Compliance has been issued b t i o h. _ Si ed Date Application Approved by Date eS Application Disapproved by: Date for the following reasons Permit No. a9aQ 5 SO Date Issued �, ��• .} } r I ., � � �� , �� � s ' 1 �. , v_ ��' Z= �; i � ' {� f _ I � . p No. Fee l Entered in computer: s THE COMMONWEALTH OF MASSkdHUSETTS• Yes PUBLIC HEALTH W1SION - TOWN OF BARNSTABLE, MASSACHUSETTS _ ZippYication for Migpont 6pEterrY Cougtruction permit Application for a Permit to Construct O Repair O Upgrade(I-J Abandon O ❑ Complete System individual Components Location Address or Lot No. ` �, rG1 i y CiE//�� Owner's Name,Address,and Tel.No. i 7 �ctiKtS �A Assessor's MapTarcel 9(ecl—t � �\ ��--� , Installer's Name,Address,and Tel.No. (� - f '•J Designer's Name,Address and Tel.No. l pe of Building: _ ' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t t Design Flow(min.required) '-/L-)(2 gpd Design flow provided `t �\ b gpd \,Plan Date Number of sheets Revision Date t Title Size of Septic Tank T7��I ;-r Type of S.A Sp i C- A G QJ, Description of Soil t Nature of Repairs or Alterations(Answer when applicable) 6A=(&C L ✓] t N 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 Environm ntal Code and not to place the system in operation until a Certificate of Compliance has been issue�hi aitil ofl�eal Signed Date -7'0C3 Application Approved by� Date �l3 Application Disapprov0d by: Date for the following reasons Permit No. 5 Date Issued ---------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance i THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (V Abandoned( )by Z lb , at �Tl f C-1 cti_ l-rA.5 has been constructed in accordance with the pro v s of Title 5 and the for Disposal Sys em Construction Permit No. 9X 17 L{ dated Installers Designer 5� #bedrooms Approved design flow gpd The issuance of thij permittshall not be construed as a guarantee that the system wil `uuncttion has ddesigned. Date I a /GS f Inspector ��' r�.t �✓ 1 ' ---No. ------�— Fee /00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS igo$al *patent Con5truction ermtt Abandon Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) ( ) System located at e3, .5-T f`'=-LeL��T --�-,..-V is and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the dat of this permit. A roved ^� Date ��,��� I`7 pp 3=---.1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS s DEPARTMENT OF ENVIRONMENTAL PROTECTION d � See TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 381 Straightway Hyannis MA 02601 Owner's Name: Stephen Plante Owner's Address: Same sL `� Date of Inspection: August 29,2005 Job#05-257 C' Name of Inspector: PATRICK M.O'CONNELL � _ 5 Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 i 3 :n CERTIFICATION STATEMENT c.n I certify that I have personally inspected the sewage disposal system at this address and that the inform ion repotted below is true,accurate and complete as of the time of the inspection. The inspection was performed bald 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: ���o11t1tttfll►ry��� OF•M,�sGi Passes ;• . '•.9 Conditionally Passes $ :• p RIC Needs Further Evaluation by the Local Approving Authority X F y` 'Ins ectors Signature: Date: 8/29/05 %. P g INSPE�� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeAffmo DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: Liquid level in leaching pit is 2" below inlet pipe with staining to top of structure. Outlet baffle in septic tank is missing. Leaching pit is in hydraulic failure however is not an immediate health hazard if house is occupied briefly prior to new leaching system installation. ****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 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 381 Straightway,Hyannis Owner: Stephen Plante Date of Inspection: August 29,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 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: Titles C Incnartinn Rnrm 4/1 snnnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 381 Straightway,Hyannis Owner: Stephen Plante 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)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for 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. 3. Other: T41.C incnorhinn 17—m 411 cnnnn 3 Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 381 Straightway,Hyannis Owner: Stephen Plante 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 'h day flow —X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X— 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 I of a public well. X_ 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.i _Yes_(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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. I T;fla S Ine—f;nn Fn—Arl VIAM 4 r Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 381 Straightway,Hyannis Owner: Stephen Plante Date of Inspection: August 29,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: 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? _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,dimensions,depth of liquid,depth of sludge and depth of scum? _X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _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)] Titfs G Ine—tine Rn—411 v100n 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 381 Straightway, Hyannis Owner: Stephen Plante Date of Inspection: August 29,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): unknown Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Two years total: 121,500 gal.= 166 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): gpd Basis of design flow(seats/persons/sqft,etc.): 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): GENERAL INFORMATION Pumping Records: None Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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: 1978 Were sewage odors detected when arriving at the site(yes or no): No T41P S Incnartinn Fnrm 4/1 Vnnnn 6 I Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 381 Straightway,Hyannis Owner: Stephen Plante Date of Inspection: August 29,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 16" Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 25' Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK: XX (locate on site plan) Depth below grade: 16" 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:8.5' long x 5.2'wide— 1000 gal. Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 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.): No outlet baffle in tank,no evidence of leaks 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, liquid levels as related to outlet invert,evidence of leakage,etc.): Title C lncnunt�nn rinrm�ii si�nnn 7 I Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 381 Straightway,Hyannis Owner: Stephen Plante 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 working order(yes or no): Date of last pumping: 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.): Some solids present in box, no high stains 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.): Title; (ncn—tinn Rnrm 411 VIMA 8 I Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 381 Straightway,Hyannis Owner: Stephen Plante 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 _X_leaching pits,number: One 6x6 pit. leaching chambers, number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Liquid level currently 2" below inlet pipe previously full to ton Pit has no effective leaching 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.): T:NA C 1--t;— pnrm 4/1 Vlnnn 9 i • Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 381 Straightway, Hyannis Owner: Stephen Plante 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 Water service Driveway #381 25 23 29 30 54 39 T41. 4 10 f ' Page I I of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 381 Straightway, Hyannis Owner: Stephen Plante Date of Inspection: August 29,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water 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: 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: A perc test will be performed prior to repair to determine groundwater elevation. Title G Tncnaotinn Fnrm 611 v,)nnn 1 1 S-ep •"20-01 13 : 52 BARNSTABLE HEALTH DEPT buts IZ00013W" s2sro� )TICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - -- _ PERCOL,%TION TEST AN ID SOIL EVALUATION EXENIPTION FORM e.J hereby certify that the engineered pian signed by me uecec S coricenting the property located at _ �_.__ �'�e�C►:C.� ►� TVeu meets all of the iCl:ov�n; �r;teria� • This failed system-is connected to a residential dwelling only. There are no _omrterzil! or business uses associated with the dwelling, T?he soil is ciass:;:ed as.CLASS I and the percolation rate is less than or equai 10 5 -rLnut:s per inch. The applicant may use hism-ncal data to conclude this f3c: or may -:onduc( :)re!lrnw.ary tests at the site without a health agent present • There :s no increase to flow and/or change. in use proposed • There w-e no vanances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen I fee: 3t)ove the maximum adjusted groundwater table elevation. (Adjust the ;Ynundwater table using the Fnrriptor method when applicable) Please complete the following: �. To, of Ground Surface E!tvanon (using GIS information) _4� •Oa g; G w' C_Icvat;on :d;uscmen( for high G.W..4�.2_., = •a '�'RF.R. "F EETWEEN A and B �C� •�O S:6NED DATE: II LR10%5 — ' �,asec j-0n, t^t move information, a repair permit wil! be issued For 'Dedmorr.s No ;dd�w:)n2l bedrooms ;ue authorized to the future without engtneerec :epi s_rae^i plans. --- — �cam!c:Oci �accxmp � A.1� � �9 r Town of Barnstable WE t °"'tip Regulatory Services Thomas F. Geiler,Director swvsresr.e, 116 9 ,0$ Public Health Division AlEDN1'�A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: ,;Z ,05 Designer: Shay Environmental Services Inc Installer: C\ - Address: P.O. Box 627 Address: East Falmouth,.MA 02536 CC'tYIP�'�M. On C was issued a permit to install a (da e) (installer) septic system at �� �\ based on a design drawn by (a ess) Sha Environmental Services, Inc. dated II V i --A-t C)S" �/�� (designer) na I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. of MAS S CARMEN s ignature) E. SHAY N No. '1181 Fa/STERN SgNI TAR% esigner's Signature) (Affix De i tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 1ti 1� COMMONWEALTH OF N ASSAC14USETTS �� 2 ;_ EXECUTIVE OFFICE OF E\V1RONMENTAL AFFAI RfAl VF© w DEPARTMENT OF E -NVIR01ME\TAL PROTE O'QCT 8 1997 ONE WINTER STREET. BOSTON. NIA 0:108 61'-:6=•cci,i T O HFALrHD Prr'8Lf N'ILL1.A\'F WELD R Dl�CIO\I Goverrnc• �, Se.retan ARGEO PAUL CELLL'CCI D.AVID B STRUM Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 38\ STRA�hTu,�va � , Address of Owner: zliyn N\tCR5 Date of Inspection: 51116 q, (If different) ?0.3oA aSb2 Name of Inspector: 1 11) .40 1,1t'-0QNtsI tf-to'. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 13.000) OLt•o Company Name:Ally H4-,•C Eis 0- /'r--2.% 01- P.k nL-00—/ Mailing Address: 3?Q /3ovc e_3;119!4 . H f9S9aee�L H - v q Telephone Number: r�0 J /[/. ZO CERTIFICATION STATEMENT I cenjt that I have personally inspected the sewage disposal system at this address and tha: the information reported beloN is true, accurate and complete as o'the time of inspec.o The Inspection Kas periormed based on m} training and experience to the proper iunction and maintenance of on-soe sewage disposa systems The system: APasses _ Cono�t-ona;i\ Passes N-eec= Furthe• Eva'uai ors, 5� the Local Approving Authority _ Fa.-s Inspector's Signature Date: The Srste r Inspecto, sha" submr, a cop\, of this inspection report to the Approving Authority within thirty (30! days of completing this inspection. If the sN stem is a shared s\-stem o, has a design flov of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate reg,or,al office of the Department of Environmental Protection. The orig:na! should be sent to the system owner and copies sent to the buve•, if applicable, and the approving authorir\ INSPECTIO% SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: —�— 1 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: _Syron is a\dya STRQT�un �e b2 0 MUT QMR 1,� c+.\1 '�lr. C�a�TL �� i'h� sTsitTt �• mACtirs� �'�(�S_- �� ®Q.ea4L At�i-r• o� �wetc.. �,P �.vte�t.wT' Bl 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. Indicate 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 (arached) 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 exfiltratton, 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. (reseed 0�/2S/97) sage 1 of 10 I)Eo on the wono Woe weo him 1h~magnet state ma usvoer Pnntee on Recycieo Pacer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner. Date of Inspection: BJ.SYSTEM CONDITIONALLY PASSES icontin.,-d Sewage backup or breakout or high static water level observed in the distr ution box is due to broken or obstrucvd pipets) or due to a broken, settled or uneven distribution box. The syste will pass inspection if(with approval oil* Board of Health;. Describe observations broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system requireo pumping more than four times a year due t broken or obstructed pipe(s). The system will pRL% inspection if(with approval of the Board of Health): broken pipes; are replaces ot,struction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board f Health in order to determine if the system is failing to pr®oe¢t d* public health, safery and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANM M WHICH WILL PROTECT THE PUBLIC HEALTH AND SA F AND THE ENVIRONMENT: Cesspool or prw� ,s within 50 fee,. of a surfac water Cesspoo! or pn) is �.+ithin 50 feet of a bord .ing vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEA H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMI%13IrAT THE SYSTEM IS FUNCTIONING IN A MANNER AT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil bsorption system (SAS)and the SAS is within 100 feet to a surface water sq*or tributary to a surface water supply. The systerr, has a septic tank and s it absorption system and the SAS is within a Zone I of a public water supn'v viet The system has a septic tank and oil absorption system and the SAS is within 50 feet of a private water supply went; The system has a septic tank an soil absorption system and the SAS is less than 100 feet but 50 feet or more frormat private water supply well, unle s a well water analysis for coliform bacteria and volatile organic compounds indlcms ti w the well is free from pollutio from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equ d V or less than 5 ppm. "Method u to determine distance (approximation not valid). . 3) OTHER Page 2 of %a SUBSURFACE SEWAGE DISPOSAL SISTEM INSPECTIO♦ FORM PART A CERTIFICATION (continued) Propert. Address: Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate either "Ives' or "No' as to each of the following 1 have determined that the system'yiolates one or more of the following failure cr ena a< defined in 310 CMR 15.303. The oasis for this determination is identified below. The Board of Health should be conta ed to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an ove oaded or clogged SAS or cesspool. _. Discharge or ponding of effluent to the surface of the ground or rface waters due to an overloaded or clogged SAS or cesspool Sta;ic ho.uid level in the distnbutjon box above outlet invert a to an overloaded or clogged 545 or cesspool. Liquid depth ,n cesspool is less than 6" below invert or ava•able volume is less than 1/2 day floe. Reou,red pumping more than 4 times in the last year NO due to clogged or obstructed pipes . Numoer o�times pumped _. Any poi„on o'the So!! Absorption System, cesspool or rivy is below the high groundwater eieyation Am pon:on of a cesspool or privy is within 100 feet f a surface water supph•or tributan to a surface water supple. And pomon of a cesspoo' or prn� is w rthm a Zone of a public well. Arn pe^10- e-a cesspool o, pm-• ,s within 50 f t of a private water supple well An% por,or. o-a cesspool or pr,%1• ,s less than 1 0 feet but greater than 50 feet from a private water supply well with no acceotable Aate• ouahr\ analys,s If the well s been analyzed to be acceptable, anach copy of well water analysis for cohiorm baezer,a volatile organic compounds ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate ei he, "Yes' or "No" as to each of the Poll wing: The fo!iow:ng craer,a aop;\, to :arse systems in ad ition to the criteria above: The system serves a facility with a design floe, 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safety and the environment cause one or more of the following conditions exist: Yes No the system is within 400 feet of surface drinking water supply the system is within 200 feet o a tributary to a surface drinking water supply the system is located in a nit en sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system s 11 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR, 5.00 and 6.00. P ease consult the local regional office of the Department for further iniormation. (reviled 04/25/97i Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.-M PART B CHECKLIST Propert% Address: 155N Owner: N t K/}S Date of Inspection:q�1�'�� Check if the following have been done: You must indicate either "Yes" or "No"as to each of the following: Yes do Pumping information was provided b.•the owner, occupant, or Board of Health. Hone of the system components have been pumped for at least two weeks and the system has been receiving normal floe rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection As built plans have been obta:ned and examined. Note if they are not available with N/A. The iac:li� d�or .ellmg " f �o signs a. inspectedo`sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site %%as inspected for signs Df breakout _ All sv sterr components. excluding the So,l. ADsorption System, have been located on the site. •. _ The septic tank rnanho;es Aere uncovered. opened. and the interior of the septic tank was inspected for condition. of` baffies or tees. materia; o-construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and locat,on of the Sol' Absorption Svstern on the site has been determined based on The iacd.t\ ovine, ianc occupants. rf different from owner were provided with information on the proper maintenance of Sub-Surface Disposal Svstem. ' Existing information. Ex Pian at B O H. _ De-,ermined in the field of an% of the failure criteria related to Part C is at issue, approximation of distance is unacceatabie [15.302 3;b`? (revised 04/25/57, Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propem Address: Owner: Nt�tS Date of Inspection: 1` FLOW CONDITIONS RESIDENTIAL: Design flow s D.d./bedroo_rr. for S.4 S Number of becrooms D Number o:current residents Garbage g•, der (yes or no, Laundry co--ected to system (yes or no,. Seasonal use ryes or no,., 0 "later meter readings, if available (last twc :2 year usage tgpd . O3tQm2 _ 9 1141 a- A00 Co.�r Sump Pump (ves or no; ?116197- poocu.V1 Las, dare o`occupant, N� COn1MEROAL'INDL'STRIAL• Type of establishment Design fmom. gahons,da% Grease trap present roves or no Indus,na! \taste Holding Tani; present ves or no_ Non-sanmtan wzste d,scnargec to the Tine 5 system ;%es or no_ \%ater meter readings if availabie Las:pate o, o c.:;,anc, OTHER: Describe Last o2te of occ,;Lanc. GENERAL INFORMATION PUMPING RECORDS and source of mniorrr,a:jor. tit i oeJ S�cTc � �.i4 Pckv�o s ►.b�J , S\stem pumper as par, pt inspection: Ives or no.Lv If ves, volume pumped gallons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Prn)- Shared system (yes or no) (if yes, attach previous inspection records, if any) Other VA Technologv etc. Copy of up to date contract? APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site (yes or not (rov.%xed 04/25/D71 page 5 of 20 f SUBSURFACE SENAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: $$► QSWk NTvzo Owner: (JtV t- Date of Inspection: I ►$ BUILDING SEWER: N� (Locate on site plan) Depth below grade. Material of construmon. _cast iron _40 PVC _other (explain! Distance from private water supply well or sucZi.on Ire Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK:�J (locate on site plan Depth belo% grade oAO%r material of construction Aconcrete _meta _Fiberglass _Polyethvlene _othenexplain° If tank is metal, lls: age _ I; age con';rmec o\ Ce-:;iicate of Compitance _()res"No Dimensions Ihhh QA Sludge depth e ^ �t Distance from top o: s�udee to bo^om of outlet tee o• ba�le a.t� Scum thickness :K _ Distance from top of scum to top of outle: tee or ba=,e 4 _ Distance from bottom of scar to bo-. o-n of outle: tee e• b2T%e 14,t Now dimensions N;ere determined tA�ni nI Comments trecommendation for pumping Condit on i rniet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. e:c.t ptzi %tz)A � %,-.& %o v � w o Ar- GREASE TRAP:�t (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: (recommendation for pumping, condition of i,,let and outset tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.: (re,3,v•d 04/75.'97) Pry 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: nl��,Mj, T O%ner. tj%V p S Date of Inspection: TIGHT OR HOLDING TANK: NO lank must be pumped prior to, or at time, of inspection! (locate on site plan: Depth below grade Material of construction _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions. Capacity gallons Design flo-A galions•da. Alarm level 4,a•r) in %%ork:ng order_ Yes. _ No Date of previous pu•np,ng Comments (condition of inlet tee, condition o' a'a,rr. and float switches. etc.) DISTRIBUTION Box:4S iiocate on site p a-. Depth o' licwd le%e' adore ouiie: in,e^ ftjoZ V-�OOTZa"T Comrne-,ts mote r:' leve! and d:sr-ib ,:,or is eoua, evidence o;solids carryover, evidence of leakage into or out of box, etc.) -®ox J:r, I- ,,,\ k %S �c1yo��t SOvr�e ��� Q�►_o�rr.4P m lKS Sc`\Ov l e-�- r PUMP CHAMBER: Ny (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.) (revised 04/25/9?) sage 7 of 10 • 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORki PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on srte.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.AM.X 6 VW9-r4- leaching chambers, number:_ leaching galleries, number. leaching trenches, number.length: leaching fields, number, d.^)ensions ovei4low cesspool, number Alternative system Name of Tecnroiog\ Comments to to condition of soli, s+grs of hydraulic failure, lever of pondmg, condition of v getatton, etc.( v QML o� t �t o il— dS CESSPOOLS: J�O (locate on site plar Number and conitgura:�On Depth-top of liquid to inlet rover, Depth of solids laye- Depth of scum layer Dimensions of cesspoo: Materials of construciior Indication of groundwate- inflow (cesspool must tie pumpeC as par, of inspection Comments: (note condition of soil, signs of hydraulic failure, level of pondmg. condition of vegetation, etc.) PRIVY: 00 (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments. (note,condition of Soil, sfgrs of hydraulic failure, level of pondmg, condition of vegetation, etc.) (revised 04/25/91) rage I of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM NFORMATION (continued; PropertN Address: g� $jpp O%ner: N%iCe-j � Date of Inspection: 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) 4F 3v � Z. 3 Pr2 -3) R3-35 i Pape 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Proper , Address: 3�B' ST�f11 T(/JWS,Q Owner: IWC. 5 �} Date of Inspection: 11I I k7 1 Depth to Groundwater x Fee; Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation o`Site (Ab.ming propert), observation hole, basement sump etc.) Determine it from local conditions Cnec'K with local Board o• nez!tr Check FEMA Maps Check pumping records Check local eacavato•s ins; Ivs lase LKS Data Describe m +c,r o+ +.once= re.+ \o- es:abLs^ec tie Hjgh Groundwater Elevation. (Must be completed. V• c�• '��O�t�tX SUC��t l'�"���,,�,.NVC.���1f�\�o.J` A��hS 4��pt• �D�Z. Page 10 of 10 LO`t TAON SEWA GE PERMIT NO. viLLAGE INSTA LLER'S", NAME i ADDR SS . BUILDER OR OWNER ,n 2 , ram, DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �r 11 � JP04 4-14�75,u y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .Crc2.N.............OF..........B.1 .b .11Q.`x.!/`�. _A ................................. Appliration for Uhipwial Works Tomitrnrtion ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: :... .D..T....... .................................................. ocation-Address or Lot No. o - ��-Lrit/ �ibiL_ 9�4 °L .d �! :.............. �`^.�. r� `�� --�C=�✓ �! � (/�� �,�a ,p Owner dress W ..... :k.�TTl! ................•----........................... ... .l�t d 7.:!(i®j/�� a ..................................... Installer Address d Type of Building per Size Lot.1.�.Q..�.�...Sq. feet V Dwelling—No. of Bedrooms............... -__-_--- _---_...Expansion Attic (�) Garbage Grinder (4;6 `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Otherfixtures ------------------------------------------------------.............-----------------...---------•--.........----------------....................---- W Design Flow. .1/ ....................gallons per fA �c ay Total daily flow--------- .......................gallons. WSeptic Tank Liquid capacity,1Q0w?..gallons_ Length&.r6_-' Width..Y/,P."". Diameter................ Depth..-S_......`�. x Disposal Trench—N --_---. .---. Width.................... Total Length___................ Total leaching area....................sq. ft. o Seepage Pit N .......!_____________ Diameter... -_`--....... Depth below inlet.....6 -------- Total leaching area..02_0-J_-...sq. ft. Z Other Distribution box (� Dosing tank ( ) - aPercolation Test Results Performed by.. �iat.tA�7 .....�!�_.4Ft.F �, _/r.S,.... Date.../Ps'a/ .t....... ,,,.lp�� a Test Pit No. l�..2_...minutes per inch Depth of Test Pit---/_a..._.. Depth to ground water.+'ld..0. 4h6 ,__. Test Pit No. 2.::.:...........minutes per inch Depth of Test Pit..................... Depth to ground water........................ a 0 Description of ----•-•-------I Z... .........45204A'a.e........ W --••----••-••----------------------•......------•-------------••••-•-•-•----•-----•-•-_-•-••-•---•----•---- ---••••--------••----••••--•--•••--•-•-•-••---••••--••......•------•----...._..... UNature of Repairs or Alterations—Answer when applicable................................................................................................ •----------------------------------------------------------------------------•--•-•--•--................---------------------•------------------------------...-----------------..............•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issue py the board of health. Date Application Approved By..... ...---• --- --, -- '-- - -----...................... ---- -- -----Dace-----�'"--- Application Disapproved for the following reasons---------------------------------------------------------------------------------•--..._......----•._.........--- .............................................. ---------------------------•----------------•---........---•----•----••-••--••---•-•------•............................................................ Date PermitNo..........:.............................................. Issued......f....c.... Date -•-Y'•--------------- P ,• _ r � � t � /,. . . . ,. rC",� i t 3 No............ / Fss,... .'`.......................... THE COMMONWEALTH OF MASSACHUSETTS g BOARD OF HEALTH J .U. .. ........OF...........Ta'-A.A.11.S.ZA 13.4 1 r........................... ..:.. }s # Appliration for ihipolial Works Tomitrnrtion Vamit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at ....4.4 2.7.".`... ..........•---•........................................... L tion- dress or - -- __ ..A --.... D. ...... ........--•......:--•:.... Owne Address . l ............................. -' --•- Installer Address Type of Building yfX Size Lot__O.0_9_0__.Sq. feet U Dwelling—No. of Bedrooms_______________.__.____._._________Expansion Attic (40) Garbage Grinder Other_Type of Building No. of ersons___________________ _. Showers — a YP g ---------------••---------•• P -•----- ( ) Cafeteria Otherfixtures ...............---------•-•-•------•-----...••----••.-----�--•---•---------------.. ............................................................. W Design Flow__.___, ................:.::gallons per Q�ay. Total daily . A.. WSeptic Tank .•, -Liquid capacity/~-_gallons Length&'__45_ Width.i✓Y.A__ _ Diameter________________ Depth. __i __ x Disposal Trench—Np_ ____________________ Width__✓...___.._____.. Total Length_.__:,___._.:....... Total leaching area__._.__...___.__....sq. ft. � r Seepage Pit No....................;,Diameter____ ____._.____._. Depth below inlet.....C.__.___.___ Total leaching area__ ._.__ ___.sq. ft. Z Other Distribution box (�) Dosing tank ( ) Percolation Test Results Performed by..�t Date... s . _____ 1 Test Pit No. 1=C_'......minutes per inch Depth of Test Pit___ ..... Depth to ground water_ '.1.0./V. .__. GT, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....................................-......----....Y"••................•----...--•---......-••-•••••............... Description of Soil "�l `'�.r' 1Y ..... 1. . •�+� � / 4 l .t� ?.>.......saasW4. U Nature of Repairs^or•Alterations—Answer when applicable................................................................................................ ..................................................- ------------------------------........_..--------------------------------------•---------------------------------. ............................... Agreement: The undersigned agrees to install the aforedescribed°-Individual Sewage Disposal System in accordance with ^^ the provisions of TTiE, p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in '•� operation until a Certificate of Compliance has b issued,,by the board of health, Date Application Approved By...... ___ _�__ :. ................................. -- - f/� Date Application Disapproved for the following reasons_______________ ................................................................................. ... Date k Permit No....................................................... - �j Issued--••-----•----------------•---=-•--•--•------•••-•---- Date THE"COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Fi✓� p F.... ' ........................... J� . .....:,.:.......... ........................._... (Inrtiftratr of Tontpliatta THIS IS TO CERTI Y, That the Individual Sewage Disposal System constructed O or Repaired ( ) f -Q ".f / ... s aller . at.................................�....: �'/•'�? Td./� :i 0�!��✓'�-� ------------------------------------------------•------------ has been installed in accordance with the provisions of T Of�he State Sanitary Code as described in the application for Disposal Works Construction Permit No . dated_.6tt ................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r DATE................................................................................ Inspector`._ c'f-'art' THE COMMONWEALTH OF,MASSACHUSETTS BOARD OF, HEA TH- � . ................OF.._.,� ....J.....�c. / - N ....... .._.. FEE........................ ':'o�1 ork� onofr�tuan �ernti#� Permission is hereby granted Yam{�` �-•--•••---•-•-••••----..._•••---•---••---•::....................................... to Construct ,A") or Repair ( ) an Individual Sewage Disposal System f dl .tf2 � ✓� .. :. �✓ _N ....... at No.. �2 ''` ------------------------•--•------ Street dd�� as shown on the application for Disposal Works Construction P t No. Dated Y -� ................. ---------;;nol J .................... DATE................................................................•-------........ Board of Heal r-- �/ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ------------- L0 4 LDT a-1 J : , ,r PP�� . 3� s <f 79 � NS TOR ESL.EV -3�; o PPOPOSED p j 0- )a „ L-DAM HOU5 r r 1.0 1 39.5 s PROP SEPTIC ( 4 LDA RSE SA N D fi TANK - 5 LINE 0IS7. TEST T ' LEACH HOLE P/T 0 e u ELEV. �.� -` 38•o RESERuC OrJfi ,�- �; p t t T• W N WA'I- R 'S AVA.ILA IF Z � (uN DEF/► CD PURL tC WAY) F20/V TE4 Tz s —� E3E-D1200MS. SE P T l C 5 y5 TEM CONS 7 2 UC T/OAJ . SHALL CpnlF02M TO MASS L7E5/GN FL0W `' GAL.iD~A —L1 0 r 7 C-/VV/eONMC--nlT,4�. CODE 7-17LL2ATERE VIS4�,b PiZo/�os�L� - GSA T , t )CE(p2J/RC-D LrAC,S/ A e� � 2_._.�Ul_A . /0 n/S a T4F� /-/E�LT.v � T" p.�;�:n.OSL= �� : �,�t�.�-,/ .��� 'F-•� 40•O 5C MA/V/-/0LL -0VE2 70 TE/JD i / '1/�L-l2V/OUS c=OtiE". 1 TO p26 V,�E.vT /niZ j W/ T,�-!//1/ I' OF F//�//5/•��D �IZAD� ,�20�•-� /NF/LT2-QT/.tl� S 7-a,vE D/ST" ( ;'� A//a//NuM i coV4e 2% G,eA pE s - ¢ �15r/�2 — �+- "Mini ! I r PiT /,v p 4y /4' ��( /O L g .rcti/¢,. /4 /Poor 2.• Mini �rc�� CQ A- rJ,A ! Y 1 My 3<'95 �4 moor ' ,( WAS.L lei - - /N//EZT ?d Gam' \CV / STONE Get L L O N1 /N✓E,e T f C �.�� 4 Z_ } /NVE.2T I CA TEA C/ T Y �` ELEV• �i 2©UA/Q i SE!-;1T/ •TA A/ G �WATE.TzT/GN7) //VVE,QT 3G (/ �Sd EOM of N4 GA,C5A6E G,2;AjDEP- C�;w -- - --------- j S / TE PLAY PP L 0 7-/0/l/ �L -�� 1`�J Ct!<, �f I7 _ _." _ r� r 1<; SEPT/C � U/�TQ/BUT/ON 601 OUTLETS AND LEL�Gi�✓/�/G F�/T 4. TO ESE GAF ,2,_/A/F0.2CED CO.VC7�GTr Co/vC2ETE Sr�E.v�r�/ 3000 psi /_l/,v. t �� �'/���`��.•�... �a��LC� 20000 � �j} -:� ' /O LOAD//V6 , `Lo.l ;;':" '� ,i >� Lek:'/�`� �'v y' t�/0 7- TO �3E ' 4 A,-T 0,LJ7-X( R avee sysT�M ti- 00 •+�r.- cv 16 I r"E I':-W! !8'f' ON ." t, • t T FAA 'r ram(. A,,,# %5 Rr-,i' «i r° %r"` y - x,: �� .o} e }, 4_ ., 6� i � +� li •' `� *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. SECTION A -A ALL OUTLET PIPES FROM THE 10' min. from - DISTRIBUTION BOX SHALL BE 12' Existing Foundation 1-house to septic tankPROFILE VIEW OF ADDITION TO LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 FT. CONCRETE COVER TOP OF FOUNDATION ELEV. 100.00 (Assumed) Septic tank covers must be D-EIOX cover must be within Bin. of finished grade wtnin 6 in. of finished grade 3 - 5*OUTLET ycq Grade o� Septic Tank 97 50 Grade over D-Box 9&DD SAS 9&00 3' of 1/8" - 1/2' Washed Peostorve KNOCKOUTS 3/4' to 1 1/2 Washed -shad Stone 12* 15.5, 04LET o'er OUTLET S 002 4- PVC(CAPPED)INSPECTION PORT TO BE INLET 2- TLET ___ -,-W, 2 OUTLET 3 HOLE H-10 INSTALLED AND TO BE VATHIN 6' OF GRADE ST. BOX 3' Maximum Cover Top OF System- Elev. -95.75 2 Te 12' EXIST. S-0-01 Greater 1-4 EXIST, PIPE Ul) S_ 001. A 4" YSCH. 40 Te -1.75"1,000 GAL. m. (0 1`1 0 Per foot • OA- Effecthiv Depth FROM EXIST. FOUNDATICIN 0 SEPTIC TANK u7i U? 00 PLAN SECTION CROSS-SECTION in 5' a) U) 0 > H-10 CONCRETE FLU FOU Cui� M 0.83' (10 inches) 7 Units R 6 25' 43.75' > Cl) 0 D kn C� 3.125' 3.75 3.125' 3 HOLE H-10 DISTRIBUTION BOX 6 in.of 3/4"-1 1/2- > SYSTEM PROFILE >. > NOT TO SCALE ISO. c compacted store .2 5W f! Not to Scale 3.5' 11 Effective Length 3 5 C 3.5'-1 0` 0 SOIL ABSORPTION SYSTEM (SAS) 6 in.of 3/4"-11/2' -to,_1� 6 -GENERAL NOTES compacted stone QEFfectNe vwth INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN 0 0 1. Contractor is responsible for Digsafe notification, Verification of Utilities NOTE. ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE m (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. Z Bottom of Test Hole I Elev-87.50 NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" 2. The septic tank and distribution box shall be set Groundwater Observed NONE OBSERVED level on 6" of 3/4"-1 112" stone. 3. Backfill should be clean sand or grovel with no stones over 3" in size. 4. This system is subject to inspection during installation PERCOLATION TEST by Carmen E. Shay - Environmental Services, Inc. 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan Date of Percolation Test: NOVEMBER 17, 2005 and Local Regulations. TestPerformed By. CARMEN E. SHAY, R.S., C.S.E. 6. If, during installation the contractor encounters any Results Witnessed By: WAIVER (Per Barnstable B.O.H.) soil conditions or site conditions that are different EXCAVATOR: Shay Env. Svcs. from those shown on the soil log or in our design Percolation Rate: Less Than 2 MR 0 36" installation must halt & immediate notification be --I I made to Carmen E. Shay - Environmental Services, Inc. Test Hole Test Hole LOT #23 No. 1 7. No vehicle or heavy machinery shall drive over the No. 2 septic system unless noted as H-20 septic components. DEPTH SOILS ELEV DEPTH SOILS ELEV. 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. 0 97.50 0 9&00 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Sandy Loom Sandy Loom 10. All solid piping, tees & fittings shall be 4" diameter 10 YR 3/2 10 YR 3/2 Schedule 40 NSF PVC pipes with water tight joints. 0"_9" A, 96.75 0"-6' A, 97.50 11. Municipal Water is Connected to ALL OF The Residence and Abutting Sandy Sandy Properties Within 150 Feet. Loom Loom 96 --------- THE PROPERTY LINES ARE APPROXIMATE AND 10 YR 5/155 10 YR 5/6 ED Failed D-Box COMPILED FROM THE SURVEY PLAN GENERATED BY 9-- 36-1 Be 94.501 6'- 36'1 B, 95.00 Medium/Coarse Medium/Coarse LEACH P GEORGE LOWE, RLS OF YARMOUTH, MA ------------------- ENTITLED "CERTIFIED PLOT PLAN OF LOT #22 STRAIGHTWAY, HYANNIS, MA Sand Sand 97 -------------IT 7___0------- DATED JUNE 7, 1979, AND PLAN BK 331PG 58 2.5 Y 714 2.5 Y 7/4 TEST HOLE #2 01 TEST HOLE #1 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN 36'- 120 136-- 120' C, 88.00 ELEV.= 98.00 L---- ELEV.= 97.50 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN EXIST. 1000 GAL. I ITHE SEPTIC SYSTEM INSTALLATION. -------- -------------- SEPTIC TANK I L I EXISTING SAS TO BE PUMPED OUT AND FILLED IN PLACE. 1 --- - - -98 Q:l NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE FROM THE EXISTING SAS TO BE DISPOSED PROJECT BENCH MARK TOP OF FOUNDATION CO I OF AS PER BOARD OF HEALTH SPECIFICATIONS. ELEV. = 100.00 (Assumed) (Z) I EXISTINC • THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY Perc #1 Q!C\1 4 BEDROOM 4 Depth to Perc: 36" to 54" LOT #21 O 1HOUSE ASSESSORS MAP 269 PARCEL 230 Perc Rate= 2 MPI i Groundwater Not Observed II #4 ✓ LEGEND No Observed ESHWT ADJUSTED H2O Elev. = None I 16.2'--10'---10' DENOTES PROPOSED 1 04X 11 SPOT GRADE 2-18' D(AM. ACCESS MANHOLES C, 1, 8 --------------U --------- -- DENOTES EXISTING X 104.46 SPOT GRADE L A LOT #22 97 --- EXIST. PL I PROPERTY LINE 10,090 Square Feet PRIVEW INLET -,EEE:: PROPOSED CONTOUR 7 ou-n ET 9 6 J EXISTING CONTOUR THE ACCESS COVERS FOR THE SEPTIC TAW, 90.00, - - - - - -97 DISTRIBUTION BOX AND LEACHING COMPONENT f-7 PL n:�J ; __ SET DEEPER THAN 6 INCHES BELOW FINISHED RAISED TO VATM 6" OF GRAN SHALL BE DEEP TEST HOLE STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. rp PLAN VIEW INSTALL TLIF-TITF GAS BAFFLES OR EOLIALS ----------- ---- PERCOLATION TEST LOCATION 3-24' REMOV ABLE COVERS 6 FOOT STOCKADE FENCE 4- " J" WA I-- 3' min. clearance INLET­EE_�Ej _12- min. Inlet to outlet �;EB OU TLE T Liquid level „ 'T (40 FOOT RIGHT OF WAY) 5' --7- P LOT P LAN E a 4'-0� . . 'n G_DOM Liquid depth OF PROPOSED SEPTIC SYSTEM UPGRADE PREPARED FOR 4' -10' ''1 ' , 11) YETHYLENE LINER FROM_ ELEV._""' M R . S T E P H E N PLANTE CROSS SECTION END-SECTION Pa LINER FROM TW6 95.00 SIDES to 92.25 AND TO EXTEND AT TYPICAL 1000 GALLON SEPTIC TANK E�O TWO DES AS SHOWN #381 STRAIGHTWAY NOT TO SCALE HYANNIS , MA or-1" Design Calculations 0, 111A PREPARED BY: Number of Bedrooms: 4 Equivalent to 440 Col./Day Garbage Grinder: No Leaching Capacity Proposed: 440 Col./Day -ICARYWEY E. SHA Y Septic Tank 2 x 440 Gal./Day = 880 USE EXIST. 1000 GAL. Septic Tank. NVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch Bottom Area: 0.74 gal/sq. ft. x 500 sq. ft. = 370 gallons CIS T P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 99.6 sq. ft. 73.7 gallons 0 20 40 50 \11 EAST FALMOUTH, MA 02536 Providing. 443.70 gallons VARIANCE REQUESTED: ANITAPOl" TEL/FAX : 508-539-7966 Use: (7) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83- (10 INCHES) EFFECTIVE DEPTH, 1. REQUEST A VARIANCE TO LOCATE AN SAS 16 FEET FROM THE HOUSE FOUNDATION. SCALE: 1 "=20' DRAWN BY: CES DATE: NOV. 18, 2005 TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES, AND 3.125' OF WASHED STONE A 40 MIL RUBBER LINER HAS BEEN PROVIDED. ON ME ENDS. NO STONE UNDER. SCALE: 1 "=20' PROJECT#SD832 FILENAME: SD832PP.DWG SHEET 1 OF 1