HomeMy WebLinkAbout0016 STUDLEY ROAD - Health 16 STUDLEY ROAD,HYANNIS
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4plitatlon for NspoSal 6pStem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(41K]Complete System ❑Individual Components
Location Address or Lot No. /G S FYt�ltry ��J Owner's Name,Address,and Tel.No.
Assessor's Map/Parrc N�S306 —20 /C 0
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Cvj r�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) — U 0
Date last inspected:
Agreement:
Y
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of th.
Signed Date 117 CY
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. C f Date Issued _Z /
r
20 ( �I
No. — Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppfication for Misposal 6pstem Construction 3permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(v�❑Complete System ❑Individual Components
Location Address or Lot No. �G 5 ���pl �av Owner's Name,Address,and Tel.No.
Assessor's Map/Parc Gw N/S _ a SP/ 1 C 0
Installer's Name,Address,and Tel.No. 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
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
{
Size of Septic Tank Type of S.A.S.
Description of Soil
r
Nature of Repairs or Alterations(Answer when applicable) v c
f
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. `
Signed Date L' C
Application Approved by . 1 Date
s Application Disapproved by Date
for the following reasons t
Permit No. Z c� f Gl (� Date Issued .2 y
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS T CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned
at has been constructed in accordance
with the provisions of Title 5 and the for Disp'osaf System Construction Permit No. ( a dated
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit
�shall/not be construed as a guarantee that the system will fianctionr designed. '
Date �/,,-� y/%I + Inspector
---------------------------------------------------------------------------------------------------------------------------------------
r
No. G Z( .- � � Fee `r
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction 3pPrmit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( (�
System located at �? f or)Ir Y 7, i 0 v i�
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit./
Date / / Approved by ,� i'L ✓ }
' '
' Commonwealth of Massachusetts 3a�- oao
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Studley Road '
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is M"
required for every Hyannis Ma 11/28/18
page. City/Town State Zip Code Date of Inspections
Inspection results must be submitted on this form. Inspection forms may not be altered in arty
way. Please see completeness checklist at the end of the form.
Important: A. Inspector Information vc� f 3S/a-
filling out forms
on the computer,
use only the tab Chad hathaway
key to move your Name of Inspector
cursor-do not HPS
use the return Company Name
key.
P.O.Box
151
Company Address
Forestdale Ma 02644
City/Town State Zip Code
774 274 2581 12866
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
9 p Y 9 P
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
11/28/18
Inspector's Si ture Date
The system inspector shal ubmit a py of this inspection report to the Approving Authority(Board
of Health or DEP)within 0 da completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
�I
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes: .
® 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:
Septic in working condition at time of inspection. Leaching pit was dry tank is at working level and
pumping tank is reccomended. Regular maintenance pumping is reccomended every 2 years under
regular use
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
M
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
1
Commonwealth of Massachusetts
�n p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every -y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
Observation of sewage backup or break out or high static water level in the distribution box due
❑ 9 P 9
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
{
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
i
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
i
3) Further Evaluation is Required by the Board of Health:
I
❑ 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. ,
i
a. System will pass unless Board of Health determines in accordance with 316,CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/2 612 0 1 8 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ry Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
.required for every Y
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form)
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd. j
❑ ® 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.
i
,I
5) Large Systems: To be considered a large system the system must serve a facility',with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4 16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is required for every Hyannis Ma 11/28/18
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered,"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. CityrFown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Description:
Number of current residents: seasonal
Does residence have a garbage grinder? ❑ Yes ® No
I
Does residence have a water treatment unit? El Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? El Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? El Yes ® No
Last date of occupancy: seasonal
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Canons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? El Yes. No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: none known. recommend pumping tank for
maintenance
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a 16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1976
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2.25
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 25+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
no evidence of leaks or poor venting
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Studley
Road
.� Y
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18
required for every Y �
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 2'feet
Material of construction:
i
® concrete Elmetal El fiberglass Elpolyethylene Elother(explain)
i
i
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1250 gal
Sludge depth:
6"
Distance from top of sludge to bottom of outlet tee or baffle
26"
4'
Scum thickness
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined?
tape and sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tees in place . tank level at bottom of outlet pipe. no visable cracks or leaks . 2 inlet pipes from house
both have pvc tees 1 is 2" lower then other both are above outlet pipe. rise on inlet outlet cover has
no riser and is located under brick patio take caution while digging rear cover irrigation firing over
edge of cover.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is required for every Hyannis Ma 11/28/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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 Dbox
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
Type:
® leaching pits number: 1 6'x6'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
I
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
leaching pit was dry at time of inspection staining 1 foot from bottom above that level concrete and
visable stone is clean.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every - y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
0
5q
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5, Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 16'
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:
lot el 20' low in area that is wetlands is el. 4 per town GIS mapping. bottom of leaching 9' below
grade at el. 9
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
16 Studley Road
Property Address
Deraska- 16 Studley Road 1031 LLC
Owner Owner's Name
information is Hyannis Ma 11/28/18 H
required for every Y
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6(Checklist) completed
D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
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TOWN OF BARNSTABLE BAR-W 3139
Ordinance or Regulation `
WARNING NOTICE
Name of Offender/Manager ')aA) A 4LfA,. �. *
Address of Offender MV/MB Reg.# "
Village/State/Zip Q'' < MA �,+►� C f�
Business Name am/pm; on ��f 6 20t
�r
Business Address !V ^may
Signature ."of Enforcing Offic4r
Village/State/Zip
Location of Offense G� i.i_ # ` trv" r fjt V
s f Enforcing Dept/Division
Of f e n s e
Facts
, . a AO
This will serve only as a warning. At this time no legal action has beenUtaken_
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
.�:., .. ,-._ ..•,-.--,may. ..- . ,,,e-- ........-.-.rr.<-+:•r---'• v`^r'5�...•:.T.-...:'^?i+.e?'—•''.^c,^"('.;,eltar.. ?7`+„^^' .,.n....ti-BRA.."'r*-'7�';""*'^. _^r'.,".."' 0
TOWN OF BARNSTABLE BAR-Wn
Ordinance or Regulation
WARNING NOTICE , •
Name of Off ender/Mana er C ° ,✓' re,'.� ... '
Address of Offender , MV/MB Reg.#
V
Village/State/Zip 0411V� of 8 fq
Business Name I p s 163 LLC am/pm, on g� F' 201
Business Address S_
' .
Signature .bf Enforcing Officer
Village/State/Zip r _
Location of Offense OVAL. F wW 'le n, V_
V ! / Enforcing Dept/Division
Offense
FactsWl
This will serve only as a warning. At this time no legal action has beenVtaken.
It is the goal of Town agencies to achieve voluntary" compliance of Town
Ordinances, Rules and Regulations. Education -efforts and warning notices are
attempts to gain voluntary compliance. Subsequent, .violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
r ff t R
V
INE Town of Barnstable Barnstable
Regulatory Services Department 1 ecaC j
BARNSTABLE, ' I
` ,.� Public Health Division
fD"AAA 200 Main Street, Hyannis MA 02601 12007
i
Office: 508-862-4644 Thomas F.Gener,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL 7006 0810 0000 3525 6436
August 23, 20;11
Donald Deraslia
4 Foxcroft Road
Winchester, MA 01890
NOTICE TO ABATE VIOLATIONS OF THE TOWN OF BARNSTABLE CODE
CHAPTER 59-3 (a):
i
The property owned by you located at 16 Studley Road., Hyannis was inspected August
18, 2011 by Timothy B. O'Connell, R. S., Health Inspector and Robin Anderson Zoning
Officer for the Town of Barnstable because of a complaint.
The following violations of the Town of Barnstable Code were observed:
I
§59-3(a) of the Town of Barnstable Code: During the inspection the team observed a }
total of eight (8) occupants within this three (3) bedroom dwelling when only five (5) are
permitted above the age of twenty-two (22). The Town of Barnstable only allows a
maximum number of two (2) occupants permitted for each of the first two (2) bedrooms!,
and for each additional bedroom a maximum of(1) occupant is permitted.
You are directed to correct the violations listed above within seven (7) days of your
receipt of this notice by ensuring that ONLY the above mentioned occupancy
criteria is followed at said dwelling unit.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten (10) days after the date the order is served.
Non-compliance will result in a fine of$100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town !,
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
�AZmas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
1
e
Health Master Detail Page 1 of 1
CZAltDY /.d �Logged In As: TOWN\oconnelt Health
I Master Detail Wednesday,August 24 2011
Application Center Parcel Lookup Selection Items
Parcel I Septic Perc Well Fuel Tank
Parcel: 306-020 Location: 16 STUDLEY ROAD, HYANNIS Owner: 16 STUDLEY ROAD 1031 LLC
Business name: Business phone:
Rental property: ri Deed restricted: r Number of bedrooms : 0
Contaminant released: r Fuel storage tank permit: ❑ "
Save Parcei Changes a o Return to Lookup
Parcel Info Parcel ID: 306-020 Developer lot:LOTS 6 & 7
Location: 16 STUDLEY ROAD Primary frontage: 150
Secondary road:CROCKER DRIVE Secondary frontage: 150
Village:HYANNIS Fire district:HYANNIS
Sewer acct: Road index: 1549
Asbuilt Septic Scan: 306020_1 Interactive map 01
Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT
Owner Info Owner: 16 STUDLEY ROAD 1031 LLC Co-owner:C/O DERASLIA, DONALD
Streetl:4 FOXCROFT RD Street2:
City:WINCHESTER State:MA Zip: 01890 Country:
Deed date:5/11/2007 Deed reference:22015/277
Land Info Acres: 0.34 use: Single Fam MDL-01 Zoning:RB Neighborhood: 0111
Topography:Level Road:Paved
Utilities:Public Water,Gas,Septic Location:
Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms
1 1954 918 3050 Bedrooms
3 Full + 1H
Buildings value:$306,900.00 Extra features: $3,500.00 Land value: $346,700.00
http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=306020 8/24/2011
?:17 07. 16/07 IONL_ FAX 5087718089 CENTURY 21 COBB R E Gfii001/01
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f=r�lr�crui:h �;aad, Route 28 � Business Phone:5�0f�•T7SZI2i i_A-�c 71
Mary Y.Porlodc Home Phone, 508-790,SS70
i'E?PiE Iv1II0, Yllassachusetts 02632 Cell Prone:503-360.4917
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('501VI 771-8089 QUALITY VICE d GOLD MEDAL
AWARD WINNING OFFICE
FAXC®VE SMET
FAX # 508-771-8089
°E No. of Pages:
(Including this cover page)
�� ✓
FAX NO.-
. COMMENTS:
/ a 3))
Please call me at(508) 775-2121 it'thcre are any pro ble i with this Transmission
z ich C)ffc,*e iy Indopondenily OwnodAnil ilporaPe:d
150.00'f IL Schedule 40 NSF
11. Municipal' Water
----------------------------- ------------------ ----99 Properties Within
Failed
TEST HOLE #2 O LEACH PIT 2
THE PROPERTY LINE'
EXISTING J1-EV.= 99.50 COMPILED FROM THE
GARAGE D—Box LESLIE P. ROGERS,
"PLAN OF LAND IN F
DATED MAY 1940. 1
Q Exist. 1000 gal i'. TEST HOLE #1 OTHER THAN THE SE
I i � Septic Tank ELEV.= 99.25
i Q • p EXISTING LEACH PIT
NOTE: ANY STRIPPI
p I i - • :'-' o FROM THE EXISTING
OF AS PER BOARD
I I EXISTING ; t7 THERE ARE NO WETLAN
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ASSESSORS MAP 30
I I 21' .. • k y.
1 I HOUSE = _
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(40 FOOT RIGHT OF WAY)
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RIGHT OF WAY TO OLD ICE HOUSE PROPERTY
(SCALED FROM PLAN)
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Town of Barnstable Barnstable
Regulatory Services Department j
IARNSTABLB.
MASS ,0� Public Health Division
A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
9/26/2012
Donald Deraslia
4 Foxcroft Rd.
Winchester, MAO1890
The pool on your property in Barnstable, on 16 Studley Rd., was emptied on 9/13/12
into the street. The water was so significant, that it flowed from Studley Rd., onto Ocean
Ave. and to the end of Sea St. This is in violation of the Town of Barnstable's general
ordinance 206-3, which states:"No person shall allow any sink, or other impure liquid to
run from the house, barn or lot, occupied by him into any street of the Town." (Water
from an untested pool is considered impure, because it is not tested and may not have
been cleaned recently, or maintained for swimming. Moreover, high levels of chemicals
are problematic to natural waters that are impacted through street storm drains.)
Please let your pool maintenance company know that in the future emptying the pool
into the street is not allowed in the Town of Barnstable. Please let us know who you hired
to empty your pool, so we can also follow up and remind them of the by-law limiting
pumping into the street. At this time, there will be no further action from the town and no
fines have been incurred. Next year, it will be important to find another method of
removing the pool water, so you avoid any fines.
Feel free to call or e-mail me at the address below with any questions.
Karen Malkus
Coastal Health Resources Coordinator
karen.malkus@town.barnstable.ma.us
(508) 862-4641
11dap Page 1 of 1
Town of Barnstable Geographic Information System New Search Home Help
Parcel Viewer Custom Map Abutters Map Size ® Zoom Out I I I f A I PIn
JPG Map: 306 Parcel: 020 Full
Property
Location: 16 STUDLEY ROAD Info
oy �a o - �- Owner: 16 STUDLEY ROAD 1031 LLC
® '� Ql1 Location Information
® to d ® Map&Parcel 306020
qs�409 Location 16 STUDLEY ROAD I
Acreage 0.34 acres
B Current Owner
0 q Rt m
Mailing Address 16 STUDLEY ROAD 1031 LLC �a
C/O DERASLIA,DONALD
60 4 FOXCROFT RD
® WINCHESTER,MA 01890 z'
0 4 21 aoa
mr u, vep 6 15 ` Appraised Value(FY 2012)
4 6 Extra Features $31,800 s''4
Out Buildings $56,700
p FFF Land $346,700
N Buildings $285,600
Total Appraised $720,800
0 _�,. - Assessed Value(FY 2012)
CPFelt - Nar>fuckef 3orurrt' Extra Features $31,800
Out Buildings $56,700
S Land $346,700
- � Buildings $285,600
Set Scale 1" = 5087 Ae, I rial-PhotoS (' - I MAP DISCLAIMER Total Assessed $720,800
Copyright 2005-2010 Town of Bamstable,MA All rights reserved.Send questions or comments to GIS
BarnstableMA V1.2.4379[Production]
1
http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=306020 9/17/2012
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I
Town of Barnstable, MA Page 1 of 1
Town of Bamstable,MA
Friday, September 14,2012
Article I. Junk, Animals and Water on Streets
[Adopted 3-3-1914, approved 10-28-1915 (Art. I of Ch. III of the General Ordinances as updated
through 7-7-2003)]
§206-1. Placing trash, rubbish or noxious liquids on streets prohibited.
[Amended 5-18-1976, approved 9-13-1976]No person shall throw away or sweep into, or place, or drop, or
suffer to remain in any street, any hoops, boards, or other wood with nails projecting therefrom or nails of any
kind, shavings, ashes, hair, manure, rubbish, offal or filth of any kind, or any noxious or refuse liquid or solid
substance.
§ 206-2. Pasturing of animals.
No person shall pasture any cattle, goats, or other animal, either with or without keeper upon any street or way
in the Town, provided that nothing herein contained shall affect the right of a person to use of the land within
the limits of a street or way adjoining his own premises.
§206-3. Impure waters.
No person shall allow any sink water or other impure liquid to run from the house, barn or lot, occupied by
him into any street of the Town.
§206-4. License for junk collection required.
No person shall barter, or trade, and collect junk without a license from the Town Manager of the Town.
http://www.ecode360.com/printBA2043 9/14/2012
lo 7 PVV
Commonwealth of Mass
achusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessm nts
Property Address s
Owner 1�k�ell .:.I�;���1 � ✓ .. ,.
s Name
information is �1. ,required for L 1?�G� >(�:1 �r� C) l i
every page. y�/ n State Zip Code Date of Inspection`
Inspection results must be submitted on this form.Inspection fo
way. rms may not be altered in any
Important When filling out A. General Information
forms on the
computer,use 1. Inspector
only the tab keyt
to move your S 1%
Cursor-do not
use the return Name of Inspe or
key'
Company Name
VQ
Company Address
_NNA(c �ip t-\c /1M �'72
City/Town State Zip Code
Telephone Number License Number
B. Certification
I certify that 1 have personally inspected the sewage disposals stem at this address and Y 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(316 CMR 16.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspectors Sig ure 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.doc•o&os
Till®5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
UV
Property Address
Owner OM* Name '
information is .�'riz-x . ' t /^��
required for F t>—f � � ���t f'�C�(� S flZb C). j I
every page. Clty/rown State Zip Code Date of Insp xion
i
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E f always complete all of Section D
A) System Passes:
i
[� 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: 1
)MIS
��-Q(\e-fs -D J rc
B) System Conditionally Passes:
❑ Oh`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 Boar"f Health,will pass. I
Answer yes, no ro not determined(Y, N, ND)in the❑for the following statements. If"notes:
determined,"please explain.
❑ The septic tank is metal an,fd over 20 years old*or the septic tank(whether metal or'inot)is
structurally unsound,exhibits,,substantial infiltration or exfiltratio�.pr-tank failure is imminent.
System will pass inspection if the existing tank is replaced th a complying septic tank as
approved by the Board of Health.
i
*A metal septic tank will pass inspection i it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is-les`s-�han 20 years old is available.
ND Explain: �.
❑ O nervation of sewage backup or break out or high static water level fn4the distribution box due
�o broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.1 System.will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
t5insp.doc•08M
Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 2 of 15
Commonwealth Of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owne Name
information is (� /
required for t CK)Nr�t
every page. City/row state Zip Code Date of InspectionI
B. Certification (cont.)
i
B) System Conditionally Passes(cunt.):
\Explain.
stribution box is leveled or replaced
ND
❑ 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) ar replaced
r.,
El obstruction is remov
F.:
ND Explain:
C) Further Evaluation is Require`rd by the Boad_of Health:
❑ Conditions exist which req Iru a 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 detennines-Jn accordance with 310 CMR
15.303(1)(b)that the system Is not functioning In a mannbr which will protect public health,
safety and the environment: \
❑ /1Cesspool or privy is within 50 feet of a surface water
❑l Cesspool or privy is within 50 feet of a bordering vegetated wetland\or a salt marsh
2. System will fall unless the Board of Health (and Public Water Supplier, if any)
determines that the system Is functioning In a manner that protects the publI; h, ealth,
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. i
❑ 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.
t5irtsp.doc•08/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
t I
. Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1W_
Property Address
ownerA ire ' f
information is Own` Name
B required for (DI-6 c)\�_
every page. cdyfrow State Zip Cod Date of Inctio �� 7
I
B. Certification (cont.)
C) Furer Evaluation Is Required by the Board of Health(cunt.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 5 feet or
more from a private water supply well".
Method used\todedtelrmine distance:
This system passes if the well water analysis, pefformed 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 f� Iuf;criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
i
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all Inspections:
Yes No
❑ F4 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 overioaded or clogged SAS or cesspool
❑ F� Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
❑ Required pumping more than 4 times in the last year 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.doc•08106
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Pape 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner :T_�A\
formation is °wnon .
required for B. 'k C\1 S [v�' t J�O f(l
eve a e. City/rownl `
every p 9 State Zip Code Date of inspection
B. Certification (coat.)
i
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 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
d Ign flow of 10,000 gpd to 15,000 gpd.
For large stems, you must indicate either"yes'or"no"to each of the following, in on to the
questions in`Se ion D.
Yes No --'
❑ ❑ the system,"ithin 400 feet of drinking water supply
❑ ❑ the system is in�0'0 feet of a tributary to a surface drinking water supply
❑ ❑ the system Is located In a-n(trogen sensitive area(Interim Wellhead;Protection
r6—a IWPA) or a mapped Zbne II of a public water Supply well
If you have answered"yes*to any question in Section E s stem is considered Y n ed a significant threat,
or answered"yes"in Section D above the large system has failed\The owner or operator aof 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
t5insp.doc•08M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fort
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Tess
Owner t �-�
Owner's ame
info rma6on 1s
required for "�
every page. C1ty/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
U ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Ll Were any of the system components pumped out in the previous two weeks?
❑ LJ 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?
Ij ❑ Were all system components,excluding the SAS, located on site?
Ri ❑ 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?
Ivl ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
❑ 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)]
t5inep.doc•OBl08
Title 5 Official Inspection Form:Subsurface sewage Disposal system•Page 6 of 15
Commonwealth.of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
. �
Owner Owne ame
information is i
required for Cl.t1`�\ �_ s� � t ( 0 1 d
every page. c6/rown 'State Zlp Code Date of Inspection
D. System Information
Residential Flow Conditions:
3 �
Number of bedrooms(design): Number of bedrooms(actual): ?
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder? ❑ Yes '91 No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes d No
Laundry system inspected? ❑ Yes [/No
Seasonaluse? ❑ Yes El No
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes [� No
Last date of occupancy: ga6A i
Date
CommerciaUlndustrial Flow Conditions:
Type oTEstablishment:
Design flow(ba d-on 310 CMR 15.203):
Gallons per day(gpd
Basis of design flow(seats/pe ns/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? / Yes
/'� ❑ ❑ No
Non-sanitary waste discharged-to th" e Title 5 system. ❑ Yes ❑ No
Water Zof
er r gdifi s, if available:
Last da occupancy/use:
Date
Other(describe):
t5insp.doc•08106
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I
Property Address
Owner
inforrnation is O�wn�e ,ame
required for :�J4 K� / A 67LQL r)q /i n o-i
every page. Cityrr6wh State Zip Code Date of Inspection
D. System Information (cont.)
General information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? n Yes i Ej No
If yes, volume pumped:
gallons
How was quantity pumped determined? '\1
Reason for pumping: L�
Type of System:
Septic tank,disttbtxtimn-be-, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
I
❑ 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):
I
Approximate age of all compon nts,date installed(if known)and source of information: k
i d
I
Were sewage odors detected when arriving at the site? ❑ Yes [ No
t5in3p.d0c•0&06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 or 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner
Owne AAA required for A `<� �c 0� � ► C o-�
i eormatiry 9 is C���1.��1 S ovw State Zip Code Date of Inspection
Pew
D. System Information (cont.)
Building Sewer(locate on site plan):
ty It
Depth below grade:
feet
Material of construction:
LEI cast iron ❑40 PVC (�other(explain): - �� ` }Q 'PJ C
Distance from private water supply well or suction line:
feet
Comments(on condition of joints,venting, evidence of leakage,etc.):
CALN
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
[ concrete ❑metal ❑fiberglass ❑polyethylene
El other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------- ----------------
1 ' P
Dimensions: O l O ic) ,�
Sludge depth: Z-S
rr
Distance from top of sludge to bottom of outlet tee or baffle f
Scum thickness �_ % f
'` fr
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? -- pro Oe-d
t5insp.doc•08M Trtle 5 Official Inspection Forth:Subsurface Sewage Disposal Syslern•Page 9 of 15
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owners me
Information is
required for t� Cox i 5
every page. Cltyrrowr State Zip Code `
Date of Inspection
D. System Information Cont.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liqui levels as related to outlet invert, evidence of leakage, etc.):
4
I
Grease Trap(locate on ite plan):
Depth below grader
Material of construction:
❑concrete ❑metal El fiberglass ❑polyethylene Y ❑other(explain):
Dimensions: r
Scum thickness
Distance from top of scum to to of outlet tee or baffle
Distance from bottom of um to bottom of outlet tee or baffle
i
Date of last pumpin
ate
Comments(o pumping recommendations, inlet and outlet tee or ba a condition, structural integrity,
liquid leve s related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plant):
Depth below grade:
Material of construction: f
❑concrete ❑ metal ❑fiberglass ❑polyethylene Y ❑oti er(explain):
t5insp.doc•08108 .
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owner's`hnie
information is
required for f)
an
t ' "� (�Z(o( (o -I
every page. City � state Zip Code Date of Inspeaon
D. System Information (cont.)
Tight or Holding Tank(cunt.)
Dimensio
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No /�
Ff
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and floa witches,etc.):
f/
*Attach copy of current pumping contract(required). s copy attached? ElYes [INo
Distribution Box(if present must be pened) (locate on ite plan):.
Depth of liquid level above outlet invert
Comments(note if box is lev 1 and distribution to outlets equal\,\any evidence of solids carryover,any
evidence of leakage in/t�r out of box,etc.):
Pump C amber(locate on site plan):
Pumps in working order: El Yes ❑ No
c
Alarms in working order: ❑ Yes ❑ No
t5insp.doc•OW06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner
information is OwnercNanie -
required for )/4-t II,` krt 1 5 0 1 1 ��((N bl
every page. Cigmow' Zip 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:
f j
leaching pits number. �� X 21 Srl'c3r
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):\ 1
\�aN1 , U' .So\t S k
r (\ 5t1 Y\ C' "f OI CV RJW\►C PC\
t5inap.doc•08M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner Owhe&Aame
4u forts i— (r�1i1 _� � § 2�( (-)CA It 0 [.0`7
every page. City7rown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Nu ber and configuration
Depth— pp of liquid to inlet invert '
Depth of solids layer -/
Depth of scum layer
Dimensions of cesspob /
Materials of construction /
Indication of groundwater infi ❑ Yes ❑ No
Comments(note condition of soil, ns of hydraulic failure�evel of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments ote condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): /
t5in doc 08/06
� • Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Pape 13 0115
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
UIV 1 b -Cd
Property Address
owner owlie"
Information is �ire \ t '�,i
required for 11-4(a��115 S 1 Q1 0-7
every page. City/Tow taS to 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.
i
a �3Ac L
o 13
XN
t5insp.doc•Oa106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
_1k"
Property Address
Slit�2r
Owner Owner ame f
information is ���/`V1 1 Q l pp,,
required for
every page. Ckyrrow State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water. I r2-
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:
orn
t5insp.doc-08108 Title 5 Official Inspection Form:Subsurface Sewage Disposal
pecti g System•Pap 15 of 15
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--- _ - --- - O -
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II
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of
I
No. Cq COS �_(L Fee 56
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplicdtion for Miopozal 6potem Construction Permit
Application for a Permit to Constrict( , )Repair X Upgrade( )Abandon( ) `El Complete System Novidual Components
Location Address or Lot No. f(e --o=Tut)Lr-Y 2C1 Owner's Name,Address and Tel.No.
VW41J N o S A,q�e�t�iCl 1 oS OT t•11
Assessor's Map/Parcel aO
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms. 3 Lot SizeTsq.ft. Garbage Grinder(P9q_ .
Other Type of Building �+ No.of Persons Showers(�) Cafeteria
Other Fixtures Ca, � , arCG�, S��ks Lc�,c�t�tcz,�
Design Flow 4 4o gallons per day. Calculated daily flow 446 + -gallons.
Plan Date 101 q_I Q 5 Number of sheets Revision Date
Title a _ s
Size of Septic Tank t oo QN. eTcy-,0--- Type of S.A.S. "_-A'015
Description of Soil
i
Nature of Repairs or Alterations(Answer when applicable) A�C3c�
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 it me tal Code and not to place the system in operation until a Certifi-
cate of Compliance has be this He
Signe Date
Application Approved by Date Wo_
Application Disapproved for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CER th t the On-siteage Disposal System Constructed( )Repaired ( )Upgraded(��
Abandoned( )b c
at 1 e o has been constructed in accordance
with the prov o Qf Title 5 and the for 'sposal System Constructi n Permit No. dated
Installer ?1�y1�Y�A-s Designer `N ►!5'
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
s• `{S(\aI ' is �,�Si '; 1.v kv "
Nir
0 Q0 5 Fee
THE COMM61'&M►NTH OF MASSACHUSETTS Entered in computer:
�'' Yes
N OF BARNSTABLES MASSACHUSETTS• . PUBLIC'HEALTH DIVISION OW
. : ZIppYication forAigpozal *pgte'm Construction Permit
Application for a Permit to Construct( . )Repair X)Upgrade( )Abandon( ) Q Complete System t<hdividuai Components
(� STUD t� '
-Location Address or Lot No. �E 2 D � Owner's Name,Address`and Tel.No.
Assessor's Map/Parcel
30c� o ao
Installer's Name,Address,and Tel.,No. Designer's Name,Address and Tel.No.
�`9�c�S ��C �CS. S N AY s✓�� . S J CS.
T :cam 636 - 394
Type of Building: / t
Dwelling No.of Bedrooms Lot Size 15, 006 sq.ft. Garbage Grinder(/"/))4
Other Type of Building _ a. No. of Persons Showers(P/) Cafeteria(
Other Fixtures
Design.Flow 4 4o gallons per day. Calculated daily flow gallons.
Plan Date 'a-( 0 5 Number of sheets Revision Date
Title — �m PDs2& Skol C Su S\f,-,\ Q�g1_14c-c�
Size of Septic Tank C,ctS-r ► 50o o.o� etc,n)c Type of S.A.S. I��lt- ty2S
Description of Soil
r Nature of Repairs or Alterations(Answer when applicable) o -\-0 �R\ox,
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-En"immental Code and not to place the system in operation until a Certifi-
cate of Compliance has b�issae �thiarlof He t _
Signe Date r
Application Approved by Date
Application Disapproved for the following reasons
Permit No._ S , Date Issued t
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS .
Certificate of Compliance
THIS IS TO CE7Z th t the On-site Sewage Disposal System Constructed (' )Repaired ( )Upgraded
�-
Abandoned( )by S / C_
at ' 0,A cr w+.+. t has been constructed in accordance
with the prov sm s``ofTitle 5 and the fo Disposal System Constructi n Permit No. dated
Installer 7 s o C Designer S 1 ►A-1
The issuance of this permit shall not be construed as a guarantee that the system willifunction as designed.
Date Inspector
s,,... �J'�6 Fee No.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -.BARNSTABLE, MASSACHUSETTS
I a
M.5po$at *pgtem Con.5truction permit
Permission is hereby granted to Construct( )Repair( )Upgrade(✓ bandon( )
System located at
s
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. t<
Provided:Construction mu t be c mpleted within three years of the date ofathiserm cDate: `t' I� APProvedby ._ __---__...;..-_r�__._R ----;:fir..2---
1
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
�4\AY ,hereby certify that the engineered plan signed by me
dated S concerning the property located at
�`�i,���-�• a arc-,\S meets all of the.
following criteria:
• This failed system is connected to a residential dwelling only. There.are.no.commercial or
business.uses.associated with the.dwelling.
• The soil is.classified as.CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct deep
test holes and percolation tests.at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information). a�
B) G.W. Elevation +adjustment for high G.W. g. _
DIFFERENCE BETWEEN A an 14e a
SIGNED : DATE: s-
NOTICE
Based upon the above information-,a repair permit will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptic\percexemp.doc
TQWN OF BARNSTABLE
LOCATii:N I( SiU,L-%'Y /RD fig/17wil/S SEWAGE # ?6
PILLAGE A/WIVAIIS ASSESSOR'S MAP & LOT ax a o LGa7
INSTALLER'S NAME&PHONE NO. 111-F/Fea f-'vGG�f2
SEPTIC TANK CAPACITY 4g,4 L
LEACHING FACILITY: (type) 41r (size)
NO. OF BEDROOMS P,
BOOR OWNER F-5Ti9Tk' mil' Ft,: QWzg.Glc RWV7;�/C
PERMTTDATE: COMPLIANCE DATE: 7 -
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 / l
n
i
r
- 1
LOC4TIOPI ' 5E\fQ&C4E PERMIT UO.
Aji z
HALL AGE �'-- - - - -
IM5TIN ER 5 U& ADDRESS
BU1L ER 5 V J &MF- ADDRESS
DATE PER TED : =- - �- - -
r
D ATE COKAPLI &MqE ISSUED :
� /�'
"`�-..1�
�., _�� i
�✓ �
�"`� ,.-�
r a..:.�.
-� �L �
� `��"`
f R
• � � cg
� �.✓._._._.._.._..� 1
1 �f
�6
.,.���;;,;'�.v.�
�y ,fi �
. ""tltl �
/ - � .
No.. :...:........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ ... - ------- OF......................I........................... ..................................
Appliration -for 43hipwint Works Tomitrurttutt Vrruttt
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy at:
/�oraiio ress or'ET No.
r . --® •-- ...r• .
Address
C�SIf ................... -----------------
� Installer Address
Q Type o Building Size Lot----------------------------Sq. feet
U Dwelling a No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Grinder (d—)�
pa., Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ----- ------------------------ 1
W Design Flow...... ..............................gallons per person per day. Total daily flow----------P ...........-..........gallons.
9 Septic Tank 4 Liquid capacity�ftgallons Length-----------_-- Width................ Diameter-----...._...... Depth...-----------_
xDisposal Trench—No_ ____________________ Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No....../............ Diameter.%P.T"'L?._... Depth below inlet.................... Total leaching area-----.------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date................__--..------------._..
Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...---._.-.---..-...___-
fTA Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_--.-.-_-_---_----.._.
P ........................ ----•-----
O Description of Soil--------------------------` . ......... _ - —
U .-----------------------------------------------------------•--•.-•••--•--------•-•------•-------•--.-•••.•---•---•-••-----------.-•-----•--•-.---------•--...-----..----••--------•.--...._......------
VW ----••-------------•--------- ..........
Nature of Pepair or ration Answ r when applicable.__ �__ ���`. �.Ec��_.:- sit _____.____.__....
----- ---- -- -
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee s b e board of health.
Igne - --- - --- - -------`--- -"- ......_•----- ---------•-•--••---....•---_...
��--- Date
Application Approved BY - -:� � / = -��- --6------
Date
Application Disapproved for the following r asons_______ ____________ __________________________________________________________�_._.__�.
-
ate
Permit No......................................................... Issued....... ..: '-a ���. ---••---•--
Date
41
No................ f F>n$ ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... .. . _. _. ..._..... . .OF...................................... ..................... ....._.........-
Appliration -for Uhipoottl Works Towitrnrtion Vrrnfit
V
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
Syst at:
'oeation dress of No.... I
O er Address
��Bui Installer Address
UType of lding Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( '
aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
PL'' Other fixtures --------------- •--------. ----
W
Design Flow------'_�`_d..............................gallons per person pegd'ay. Total daily flow--_-__.--_a.�.................._.gallons.
9 Septic Tank--/-Liquid capacity eJ_6'rigallons Length________________ Width--__-- _...._.- Diameter...----.:_ ----- Depth..--------------
xDisposal Trench—No. .................... Width-------------------- Total Length------------------.- Total leaching area........____........sq. ft.
Seepage Pit No.......1-------_____ Diameter_A�__------ Depth below inlet.................... Total leaching area..---.-----.--___sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date..............____._---.-----------.....
aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water---------.-_-.---_.--.-.
fX4 Test Pit No. 2----------------minutes per inch Depth of Test Pit.-_--_--_---______ Depth to ground water------------------------
9 ------------------------------•----------•--•-----------
1 -
O Description of Soil ""'------------------------------------------------------ -----------------------------------
x
x ----------------------------------------•---------------------------------------------------------------•-------
U Nature of Repair or rations,—Answer when applicable. ._ _ _._.._ !ti _.. /o«-----
----- ---------------- -- -------- ......................
Agreement: /
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been I su deb e board of health.
igned . ---• ..........1 _ ....... /�?----..---------------- ------ ................................
✓ ' � f Date
Application Approved B ___--_ _--- v� 1"!L - _.-- ` ` �-(,-----
PP PP y----• __ - -------
Date
Application Disapproved for the following reasons:----••---------•---•---•-----•-•----•--•-------•---------------•-------.--------------------•--------..........
...............•--•-•-----------•-•-•-••-•---•--------------••-•-• -----------•-•---•-------•----------.---------.----------------------------------------•---.--- -------------------------•--•--..----
Date
PermitNo......................................................... Issued..................... ..................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........�".`�... .. .. .OF......... .�'��Gy .............
%:.rrtifirnte of 600ntpliattrr
THIS S 0/L�ERTI Y�_ at h Individual Sewage Disposal System constructed ( ) or Repaired (�
-�
----------------- - - -----------• • . •--------------••--••.......------.
Innall�r ................................................
at..........zia-0 41_1•--- / • '-•-- --- ) C.• /� •• "�'�
` GK-t
has been installed in accordance with the provisions of Art e XiI of The St e Sanitary Code as described in the
application for Disposal Works Construction Permit No _... .._.`tl iyy-------- dated-..--- -_ .�.`.. .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM W LL FUNCTION SATI FACTORY.
DATE---- ----- 7 �� Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALT�
No. FEE_-`-�~-- --.......
�i� �attl r o r �a$t rntt
N
Permission is hereby granted---- -- ---- - --- •------- g� �
--------------------------------------------------------
to Construct L ) or Re air ( a -adividualr-SewaVe Disposal'System
/ Streets
/// - ' 2
as shown on the application for Disposal Works Construction Per 'No. --:____e_�__ Dated___._..,.-_---_---_-----__-_-_-•----
-� Y7� --
Board of Health
DATE-----------... .................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS .
*NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. SECTION A _A _ :'. --- 1
10' min. from VENT PIPE (® Least 24 inches toll) ' ALL OUTLET PIPES FROM THE -
Existing Foundation I house to septic tank Schedule 4 PVC w/Charcoal Odor Filter PROFILE VIEW OF ADDITION TO LEACHING SYSTEMrRIiFVELroR°�TSHALL
�srBz FT. - 12' �E ��R -
TOP OF FOUNDATION = ELEV. 100.00 Assumed Septic tank covers must be D-BOX cover must be
(Assumed) within 6 in. of finished grade }_.,.
within 6 in. of finished grade '�..`✓ 3 5'OUTLET .r `' °-i'_ 2 , 1`s a fast i _z.--
Grade over Septic Tank - 99.50 Grade over D-Box- 99,50 ode over SAS - 99.50 3" of 1/8" 1/2" Washed Peaston KNOCKOUTS ;, Lti - oL ..,, -.g Oggri
3/4" to 1 1/2 " Washed Crushed Stone i u ;51 yxx i j
f •` 5.5 OUTLET (��} 12" INLET n': " - m y"i
- $ 0.02. 4' PVC.(CAPPED) INSPECTION PORT 1.0 BE • ; - m-< parr J
3 HOOF H-10 INSTALLED AND 10 BE WI1HMi 6" OF GRADE \ 6" a Ma
O EXIST. ST. BOX 3' ►laxfmum Cover -`s at a t i 1�9fYNCJ Ad'.•'
u7 31.50' S=0.01 or Greater Top OF System- Oev. -96.50 :-., _ p i y
EXIST PIPE Ln 1,500 CAL. $e
FROM EXIST, fWNDATIITN, ` rn SEPTIC TANK d 35. 0.01" Per f Depth
4" - SCH. 40 Te t 7Yo p L�8 tsa .
---15.5 -,r3--' n foot 10' Effective D th
a, ao PLAN SECTION CROSS-SECTION a -
� /1 fl li H-10 o..e.n. co 5 7 Units 2 6.25' 43.75' a " ,a ptein Av
CONCRETE FULL.FOVNOATION-' II - a, �:isy; -.
7FVm 0.83' (10 inches)
6 in.of 3/4"-1 1/2' 0 s.7s' I 3 HOLE H-10 DISTRIBUTION BOX
SYSTEM PROFILE compacted stone rn
c 5 a 4 a - 45 75` NOT TO SCALE s fi
Not to Scale - c a, II ® RfM AaNaYydCawx,q®2L 2s NALTE4
5 5 2.5' "-2.5' n Effective Length
S - W JA
"3 `1 SDIL ABSORPTION SYSTEM (SAS)
in.of 3/4"-1 1/2' 0 8 - GENERAL NOTES
-- compacted stone Effective vidth INFILTAT;ROR HIGH CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE -i 1. Contractor is responsible for Digsafe notification, Verification of Utilities
o - (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes.
u' Bottom
rott m ie Test Hoe 1 OeON87.25 VED NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10" 2. The septic tank and distribution box shall be set
__ ____________ level on 6 of 3/4"-1 1/2" stone.
3. Backfill should be clean sand or gravel with no
-- stones over 3" in size.
4. This system is subject to inspection during installation
PERCOLATION
c I T by Carmen E. Shay Environmental Services, Inc.
f` E R C 0 LAT(O N TEST ST 5. The contractor shall install this system in accordance
with Title V of the Massachusetts state code, the approved plan
Date of Percolation Test: JUNE 7, 2005 5 and Local Regulations.
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. 6. If, during installation the contractor encounters any
Results Witnessed By. Waiver (per Barnstable BOH) soil conditions or site conditions that are different
EXCAVATOR: Shay Environmental Services, Inc. from those shown on the soil log or in our design
Percolation Rate: Less Than 2 MPI 0 30" installation must halt & immediate notification be
` made to Carmen E. Shay Environmental Services, Inc.
PROJECT BENCH MARK 7. No vehicle or heavy machinery shall drive over the
Test Hole Test Hole septic system unless noted as HJ-20 septic components.
No. 1 No. 2_ TOP OF FOUNDATION ��
ELEV. = 100.00 (Assumed) 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends.
DEPTH SOILS ELEV.' DEPTH SOILS ELEV: 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
0 _ 99.25 0 99.50' 10. All solid piping, tees & fittings shall be 4" diameter
Loamy Loamy r
Sand Sand _ 150.00 Schedule 40 NSF PVC pipes with water tight joints.
ito rR 3/2 to YR 3/2 11. Municipal Water Is Connected to ALL OF The Residence and Abutting
0"-6" A 98.75 0"-9" A 97.75 ---99 Properties Within 150 Feet.
�.------- Failed ---
Loamy Loamy TEST
LEACH PIT 2 THE PROPERTY LINES ARE APPROXIMATE AND
Sand � Sand i TEST HOLE #2
10.1R 5/6 70 YR 5/6 - ..
s"-3o" B" ssas s'-2a" B. s7.17 EXISTING ELEV.= 99.50U COMPILED FROM THE SURVEY PLAN GENERATED BY
-- GARAGE
D-Box LESLIE P. ROGERS, P.E. ENTITLED
Md' m e to Medium ,
"PLAN OF LAND IN HYANNIS MA" PLAN BOOK PAGE 125
Sand Sand
2.s v s/s z.s Y e/6 DATED MAY 1940. IT SHOULD BE USED FOR NO PURPOSE
z - ' 4, TEST HOLE #1 OTHER THAN THE SEPTIC SYSTEM INSTALLATION.
l30"-144" C, 87.25 28"-144" C, 87.50 Q
/•. Exist. 1000 gal.. • z. ELEV.= 99.25
Septic.Tank 4 _ - _- -
^q EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE
e ' OO NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
i • o FROM THE EXISTING LEACH PIT TO BE DISPOSED
I I ....; OF AS PER BOARD OF HEALTH SPECIFICATIONS.
O t x
--
-_ -
_.. I v'r THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
EXISTING
j Pere #1 3 BEDROOM i:. -- ------- ---
Depth to Perc 32" to 50' IIOlISE 21 ASSESSORS MAP 306 LOT 020
I Perc Rate= 2 MPI >` -
Groundwater Not Observed I rrr»r `r � LEGEND
No Observed ESHWT
#16 4„ PVC ------
ADJUSTED H2O Elev. = None i ASPHALT
- ------- - --- -- --- ------ i I = ' Vent C-- -� DENOTES PROPOSED
3-24" DIAM. ACCESS MANHOLES I DRIVEWAY I rSL�' 104X 1
- f0'- 44'- SPOT GRADE
10,
- ; I DENOTES EXISTING
-- -� -_-
y------------- -- - ------ -T-- ---------- -------- -------- ------ ---- 99 x 104.46 SPOT GRADE
LOT ##6 & LOT##7
PL PROPERTY LINE
1 1 I I 15,000 Square Feet t/--
INLET - _ I p
INLET 1, W ET I _.-' --- ----"- ---.-- 9U
_-I ----------------- --- ------ ------------------------------
THE ACCESS COVERS FOR THE SEPTIC TANK, I - I j' 150.00' {9BP�--- PROPOSED CONTOUR
DISTRIBUPON BOX AND LEACHING COMPONENT ------- --- - ---� - 141
---- -- -- - -
{_ SHALL BE RAISED TO WITHIN 6" OF I I - - - - -
+1:'. FINISHED GRADE. I I -97 EXISTING CONTOUR
STEEL, REINFORCED PRECAST CONCRETE INSTALL TUF-PTE GAS BAFFLES OR EQUALS - i 1
ON ALL OUTLET TEE ENDS �_-_
PLAN VIEW - --- - ------ -- ------ --- - --- ----------------------------------------------- DEEP TEST HOLE &
3-24' REMOVABLE COVERS PERCOLATION TEST LOCATION
I { - 6 FOOT STOCKADE FENCE
Y /T�� I�
j 3 min. ciecronce - f IJ .lC �-/ �_E.i "...l , .l, 0.'0-A
is'AIWEI'r
l INLET Jr' min T 1Y. min inlet to outlet g n,ti _ -OUTLET
INLE A Lwa�ie (40 FOOT RIGHT OF WAY)
t o' ". u '5' -7"
�- PLOT P LAN
4'-0' min.
v ae.e"n. •` 1lquld depth
OF PROPOSED SEPTIC SYSTEM UPGRADE
PREPARED FOR
CROSS SECTION END-SECTION
ANTONIOS FOTINI
TYPICAL (1-1- 10 'LOADING) 1500 GALLON SEPTIC TANK AT
NOT TO SCALE # 16 S T U D L E I ROAD
HYANNIS , MA
O- Design Calculations -- -- -- -- -
Number of Bedrooms: 3 Equivalent to 330 Gal./Doy FM Sy�y PREPARED BY;
Garbage Grinder: No /�� /�/rT/,�T E. S A Y
Leaching Capacity Proposed: 440 Gal./Day Minimum (PER CLIENTS REQUEST) E.A YLNVIRONMENTAL
L it lJ 1 1' L 111-1Septic Tank - 2 x 440 Gal./Day = 880 USE EXIST. 1500 GAL. Septic Tank, SHY SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch . 118
Bottom Area: 0.74 gal/sq. ft. x 500 sq. ft. = 370 gallons p P.O, -BOX 627
E EAST FALMOUTH, MA 02536
I Sidewall Area: 0.74 gal./sq, ft. x 99.6 sq ft. - 73.7 gallons 0 20 40 50 G R
Providing: = 443.70 gallons _ SA/NV TAR\P�
TEL/FAX : 508-539-7966
Use: (7) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, _--_ SCALE: 1 "=20' DRAWN BY: CES DATE: JUNE 7, 2005
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3' OF WASHED STONE
ON THE ENDS. NO STONE UNDER. SCALE: 1 20' PROJECT#SD757 FILENAME: SD757PP.DWG SHEET 1 OF 1