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COMMONWEALTH OF MASSACHUSETTS
A EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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TECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 9 Suffolk AVE
Hyannis,MA
Owner's Name: Francisco Toledo
Owner's Address: 9 Suffolk AVE
Hyannis,MA 02601
Date of Inspection: 2-26-08
Name of Inspector: Darrell Stone
Company Name: Cape Cod Septic Inspection
Mailing Address: P.O.Box 1466
Harwich,MA 02645
Telephone Number: (508)240-2500
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below
is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems.1 am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Yes Passes
Conditionally Passes
Needs Further E ion by the-Local Approving Authority
Fails
Inspector's Signature:
Date: 2/26/08 -'
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board- Health DEP,)
within 30 days of completing this inspection.If the system is a shared system or has a designof flow o6-0,000 dLor
the inspector and the system owner shall submit the report to the appropriate regional office the D_=1 I greater,
be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. i The original sliould
Notes and Comments:
co
****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: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
Yes 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:
n/a 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
r _ 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: _
Title G Tncr<nt;nn Fnrm 2
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" Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
C.Further Evaluation is Required by the Board of Health:
n/a 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. 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
failure criteria are triggered.A copy of the analysis must be attached lto this ormpm,provided that no other
3. Other:
Titles G Tncrartinn 1♦•nrm A/1 1z/1nnn "2
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
A System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
X 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 l 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
X
are triggered.A copy of the analysis must be attached to this form.]
_
No (Yes/No)The system fails.I have determined that one or more of the above fail
ure 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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Titla Tncruartinn Fnrm ti/1 S/�nnn 4 I'
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
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)]
T410 Tnc+'+artinn�'n.... G/iC/1nnn S
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
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
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): n/a
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): '06 17500 '07 22000
Sump pump(yes or no): No
Last date of occupancy: 2-08
COMMERCIALANDUSTRIAL
Type of establishment: _
Design flow(based on 310 CMR 15.203): _ gpd
Basis of design flow(seats/persons/sgft,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):
Pumping Records GENERAL INFORMATION
Source of information: 2007 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:
1996 tank d-box 3 infiltrators 2002 added more 3 infiltrators
Were sewage odors detected when arriving at the site(yes or no): No
Titles G T»enontinn Rnrm!/l eiInnn 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction: cast iron X 40 PVC other(explain):
Distance from private water supply well or suction line: _
Comments(on condition of joints, venting,evidence of leakage,etc.):
Apparent good condition
SEPTIC TANK: Yes (locate on site plan)
Depth below grade: 10"
Material of construction X concrete metal fiberglass pol eth lene
_ other(explain) _ — — y y
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): _ (attach a copy of
Dimensions: 1500 gallon certificate)
Sludge depth: 14"
Distance from top of sludge to bottom of outlet tee or baffle: 18"
Scum thickness: �/Z
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: 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.):
Normal liquid level No sign of leakage SCH 40 inlet and outlet tees
Recommended pumping every 2-3 years
GREASE TRAP: n/a (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.):
TiflA G Tnonnnfinn Form 4/1 c/,)nnn 7
Page 8of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
TIGHT or HOLDING TANK: n/a (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction concrete metal fiberglasspolyethylene
_ other(explain)
Dimensions: _
Cap
acity: _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: Yes (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.):
Grade to box 12" Normal fi uid level No si n of leaka a No solid carr over Good condition
No sil�n of Failure
PUMP CHAMBER: n/a (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.):
Ti+lo Tncrontinn Rnr All v101)1) R
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Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: _
x leaching chambers,number: 6
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.):
6 Infiltrators with 3'stone around and I' under No sign of Failure
Test hole at edge of stone encounters no water only clean and dry stone
CESSPOOLS: n/a (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: n/a (locate on site plan)
Materials of construction: _
Dimensions: _
Depth of solids layer: _
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
T41. Tnenprtinn Fn.,v,411;1jnnn 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
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.
A B C D
1 17-2 39-10
2 24-0 43-4
3 34-6 58-0
4 .36=0 50-0
5
6
lew(
Titlo 5 Tnenuntinn Fnrm�/1 ci�nnn 1(1
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFA
CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Suffolk AVE
Hyannis
Owner's Name: Francisco Toledo
Date of Inspection: 2-26-08
SITE EXAM
Slope
Surface water None
Check cellar Dry
Shallow wells No
Estimated depth to ground water >5 Feet
Please indicate(check)all methods used to determine the high ground water elevation:
x Obtained from system design plans on record-If checked,date of design plan reviewed: 2002
Observed site(abutting property/observation hole within 150 feet of SAS)
x Checked with local Board of Health-explain: Plan on file
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
.You must describe how
o you established the high ground water elevation:
Engineer certified
SAS ELV.90.5
Test Hole ELV.85.5 NWE
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T;tla G Tncrantinn Fnrm�ii si�nnn 11
Town of Barnstable
1HE r,
y�P ti� Regulatory Services
BARNSTABM ; Thomas F. Geiler, Director
1"AM _`erg
aTEp �p Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
not does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
I
r _
TOWN OF OF BARNSTABLE
LOCATION � 1�t9t� SEWAGE
VILLAG ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO cL✓��G-z.l �C_c�lrX�'��
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �� �Z-- (size) o�K
[ � T6Ta-�-cv�t(,c�rS�i�
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 'l 3'U COMPLIANCE DATE: 3l 7`U
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
Q�4
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No.
FEE
fBoard of Health, MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeX Abandon( ) - U Complete System Individual Components
Location V Owner's Name RtAtAc ca
Map/Parcel# , S Address SJ9;;obe S
Lot# -.*-aTelephone#
Installer's Name �� Designer's Nameu� � S GCS
Address Address f m
Telephone# Telephone#
Type of Building �ZaS1d.erT\-�Q\ Lot Size �� 3� sq.ft.
Dwelling-No.of Bedrooms V-0U V— C4- Garbage grinder (MIA
Other-Type of Building tAn M No.of persons Showers (I Cafeteria
Other Fixtures -CsI�C'� E �ct� C�OC� Snk uInx -M p,
Design Flow (min.required) gpd, Calculated design flow 440 Cy Design flow provided 449. 7.Ggpd
Plan: Date l e1 Number of sheets Revision Date
Title
Description of Soil(s) ` J
Soil Evaluator Form No. �� £. o� Name of Soil Evaluator r-A Y Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �S
The undersigned agrees to install ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further eWro-not-to_place t m o erM�Date.
Certificate of Compliance has been issued by the Board of Health.
Signed ���
Ir 'S
FEE!
'•� � to s«,,. � �.C.
COMMONW
,111 Of
Boa1'd—of'11eafth,
APPLICATION FOP, DISPOSAL SYSTI�
CONSTRUCTION PERMIT
.Application for a Permit to Construct( Repair( UpgradeX Abandon( - ❑Complete System XIndividual Components
_Location l 1 ���� V'�1 Owner's Name FV2 r)ke 6 v
Map/Parcel# Address }
Lot# a Telephone#
Installer's Name �! Designer's Name
Xddress?' Address ^
Telephone# Telephone# _U:�9(-
Type of Building aQ`:>1 r\P_C4,kG\ Lot Size sq.ft.
Dwelling-No.of Bedrooms ;:—nu Z,_ Garbage grinder (WI n
Other-.Type of Building C)V-12 No.of persons Showers (LK,Cafeteria (a/
Other Fixtures Lr,or,A t-:M , k,k c.v-,ac, -Srnk. L.cot)�M
Design Flow(min.required) �gpd Calculated design flow Design flow,provided ` /+q•9l)gpd
Plan: Date I oZ b - Number of sheets i, 1 Revision Date
_ . Title
Description of Soil(s) ^.0 - t� G. G �,4� :b�� For,t ojck 0�
Soil Evaluator Form No. �� 1� Name of Soil Evaluator CO 2M EfJ CD raY Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 'TJKC1 � -'ro kS
The undersigned agrees to install th- ove described Individual Sewage Disposal System in accordance with the,provisions of TITLE 5 and
further a • ees toY{rot to_pJace e, Z in o eration til a Certificate of Compliance has been issued by the Board of Health.
r Signed ! Date
No. 0 02 FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1S1<rw+J riGl , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by: /� n
at v "1 /`vv
has been installed in accordance with the pro isions'of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application 1V'o, e��5 'z date `-�� Approved Design Flow (gpd)
Installer !/V l I �1 fl / 2
Designer: Inspector: Date: G
t
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ? t)d 2- �' FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Kfaj 1x(��i MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
•.Permission is hereby granted Ito; Construct( ) Repair( ) Upgrade( ) Abandon( an individual sewage disposal system
at t S,/F f! At t �-�,.,�A�., / as described in the application for
Disposal System Construction Permit No. 00}- dated 3 -IT U—.
Provided: Construction shall be completed within three years of the date of t 's pet. All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 3 ' -UZ Board of Health ` r
1
i
TOWN OF BARNSTABLE
LOCATION [ S /I�—y4t.� SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
t I �
LEACHING FACILITY: (type) e iL (size) 6K —
IMTA-L k;k1- c�S'r i
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 3~U—0", COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
D
,s
CARMEN E. SHAY (508)-548-0796
ENVIRONMENTAL SERVICES, INC. 34 Thatchers Lane,East Falmouth,MA 02536
A
March 14, 2002
RE: Certification of'Title V Septic System Installation:
Residential Property—9 Suffolk Avenue,Hyannis, MA
Dear Sir or Madam:
On March 13, 2002, Roger Roberts, Inc. was issued a permit to install a Title V Septic System at
9 Suffolk Avenue, Hyannis, MA, based on a design drawn by Shay Environmental Services, Inc, dated,
March 12, 2002.
I Certify That The Septic System Referenced Was Installed Substantially According to the Plan
I Certify That the References Above Septic System Was Installed With Changes but in
Accordance With State and Local Regulations, Revisions or As-Built Plans will Follow.
The Septic System Was Not Installed Per State and Local Regulations and Corrective Action is
Required.
If you have any questions, please do not hesitate to call the undersigned at(508)-548-0796.
Sincerely,
CARMEN E. SHAY
ENVIRONMENTAL SERVICES,INC.
3 I r14 loa
CenE. Shay, R.S., C.S.E.
President
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:9 Sutfol k Avenue o _
Hyannjg , MA g 3
Owner's Name: Hld za rr7 rnrm; er 1V „t"s"
Owner's Address: 9 Suffolk Avenue F Cj
Hyannis MA 8
Date of Inspection: Nnvr=mht=r 2 , 2 L1p n 1�
CDP
Name of Inspector: (please print) James J. Schilling
Company Name: Preferred Home Inspection Services , Inc.
" luxl4
Mailing Address: P•0. Box 196
Halifax, MA 02338
Telephone Number: 781 294 0272
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
1 ,
Inspector's Signature: /YV,,r4 J f�/�i� ,,,,j` Date: !�J
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.
Notes and Comments
****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: 9 Suffolk Avenue, Hyannis
Owner: Edward Cormier
Date of Inspection: November 2 , 2000
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
Yes 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:
No 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:
2
1
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURYACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 Suffolk Avenue
Hyannis , MA
Owner: Edward C ormi Pr
Date of Inspection:NnuPmhar 2 ., ?n n n
C. Further Evaluation is Required by the Board of Health:
No 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:
3
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`FORM
PART A
CER I ICATION(continued)
Property Address:
Hyannis, MA
Owner: F.riwArH C'nrmi ar
Date of Inspection: November 2 , 2000
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_y 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'/z day flow
- - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
—X— Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public 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 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.]
(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: No
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
_ _X_ the system is within 400 feet of a surface drinking water supply
_ _X_ the system is within 200 feet of a tributary to a surface drinking water supply
-y— the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or.a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 Suffolk Avenue
Hyannis , MA
Owner: Edward Cormier
Date of Ins pection:November .2 , 2000
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
_ y Has the system received normal flows in the previous two week period?
_y 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?
_ 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)]
5
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Page 6 of 1 I
OFFICIAL INSPECTION FORM' NOT FOR VOLUNTARY ASSESSMENTS v_
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI0NTORM
PART C
SYSTEM INFORMATION
Property Address: 9 Suffolk Avenue _
Hyannis. MA
Owner: Edward Cormier
Date of Inspection: November 2, 2000
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_aL Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):.3 3 0
Number of current residents:�—
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): N/A
Seasonal use: (yes or no):_No
Water meter readings,if available(last 2 years usage(gpd)): 2 l; GPD
Sump pump(yes or no):NO_
Last date of occupancy:1jakmzun
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 C 15.203): zDd
Basis of design flow(seats/persons/sgtetc.):
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
Source of information: owner has no record of pumping
Was system pumped as part of the inspection(yes or no): e
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):
Ap;prosin:ate age of all components, date installed(if known)and source of information:
P+zr RQT4 reror s s�4si-em was installpd 4/3/96 = 4 Years old
Were sewage odors detected when arriving at the site(yes or no): No
6
. y
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:9 Suffolk_ Aven_L_e
Hyannis., MA
Owner: Rciward C ormi Pr
Date of Inspection: NnvPmhar 9 ., 9 OAO
BUILDING SEWER(locate on site plan)
Depth below grade: 2 4"
Materials of construction: cast iron �L_40 PVC`other(explain):
Distance from private water supply well or suction line: Town sri I ; ed water
Comments(on condition of joints,venting,evidence of leakage,etc.):
Cast Iron from the foundation in , inspection revealed no leakage in the 1-
venting appears appropriate
SEPTIC TANK:y"locate on site plan)
Depth below grade: 12"
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: 1 ?n,, x 6 2 X 6 2'1 — 1, 500 gal
Sludge depth: 4
Distance from top of sludge to bottom of outlet tee or baffle: 2 6"
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: 16
How were dimensions determined: Tage Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.): The inspection of the septic tank revealed
no cPyi dP_nnP of leakage as the effluent was level w�t=h cAe Gut! t invert
hnth i-PPC are iriplace, strzactual -nt-e-g ity-was seiin
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.):
r �
7
x4tu#? grltia
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 Suffolk Avenue
13anni_s, MA
Owner: Edward Cormier
Date of Inspection: November 2 , 2000
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: Xe dif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: U" , effluent was level with 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.):
. There was no evidence of solid carryover into the D—Box, D—Box was level
and true to grade, structual integrity was sound
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.):
8
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
INFORMATION continued
SYSTEM ( )
Property Address:y Su{=fn1 k Avcnna
g� .;g MA
Owner:
Date of Inspection: November 2 . 2000
SOIL ABSORPTION SYSTEM(SAS): Ye_y(locate on site plan,excavation not.required)
If SAS not located explain why:
Type
leaching pits,number:_
-X —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.): The inspection of the SAS revealed no evidence of any breakout and/or
nnnHi nT thPYP yy1Ag ,An Piz Mimnrrm of hycL-raiil i e- fallllr'a a tb-a S9a-1S In the a,
d on-sit
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 o 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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address:9 Suffolk Avenue
Hyannis , MA
Owner: Edward Cormier
Date of Inspection: NnvPmh r z , 2000
x NOT TO SCALE
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.
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10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4 ce kkn[7
$�ann i S� MA
Owner: Edward Enrmi er
Date of Inspection: 2te,--2000
SITE EXAM
Slope 3 0 or less
Surface water None located
Check cellar Yes
Shallow wells None located
Estimated depth to ground water x feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
x Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
A test hole was augered to a depth of eight feet and observed for ten
minutes with no groundwater inflow obs rued
ll
PREFERRED HOME INSPECTION SERVICES, INC.
® ®� P.O. Box 196 Halifax, Massachusetts 02338
o (781)294-0272 • 800-268-4998 o Fax:.(781) 294-0261
November 2,.2000
Town of Barnstable
Health Division
367 Main Street
Hyannis,MA 02601
RE: Title V Inspection 9 Suffolk Avenue,Hyannis MA
Dear Health Agent
In conformance with the,Rules&Regulations and standards promulgated by the Department of
Environmental Protection, we conducted a Title V Inspection at the following location in your
jurisdiction.
Edward Cormier
9 Suffolk Avenue, Hyannis MA
Status of Inspection:
System Passed
The inspection included the inspection of the onsite domestic subsurface sewerage disposal
system and all its associated components as required per Title V regulations.
Enclosed as required by statute, is a,completed copy.of the inspection reports, If we may be of
any additional assistance please do not hesitate to contact.us.
Respectfully Submitted:
�� ��
eferre ome Inspecti i Services, Inc.
By James J. Schilling
State Certified Title V Inspector
"Your Complete Home Inspection Company"
PREFERRED HOME INSPECTION SERVICES, INC
P.O. BOX 196
HALIFAX, MASSACHUSETTS 02338
781294 0272
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
Property Address: 9 Suffolk Avenue, Hyannis MA
Date of Inspection: November 2, 2000
Owner: Edward Cormier
Status of Inspection: System Passed
We performed this inspection in strict accordance with the State of Massachusetts Environmental
Code Title 5, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, Sections
15:300 thru 15:305. Please be aware that this is a Title S Inspection and does not necessarily
mean that the septic system is of Title 5 design.
This inspection in no way implies a warranty or guarantee of the septic system being inspected;
but constitutes a report as required by 310 CMR 15.303 and a statement of the condition of the
system on the date on which we did the inspection. In inspecting the system, due diligence and
effort was exercised in locating all relevant information and materials; however,Preferred Home
Inspection Services, Inc. shall not be held liable or responsible for any omitted, misunderstood, or
incomplete information in this report, nor any services provided in reliance thereon.
Sas Statement
The SAS was not physically located or inspected as part of this inspection as defined in Section
15.302 Mass. Title 5 Environmental Code. The SAS was determined to be functioning properly
by inspecting the liquid levels of the D-Box; however, to decide the actual state of the SAS, a
more intrusive method would need to be employed, which is not required by Title 5 inspection
criteria.
COMMONWEALTH OF MASSACHUSETTS
z x EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
o DEPARTMENT OF ENVIRONMENTAL PROTECTION
o�M SVe�e
350 MAIN STREET
WEST YARMOUfH,MA
509-775-2900
TITLE.5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.FORM
PART A
CERTIFICATION RECEIVED
'roperty Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601 FEB 0 7 2001
Owner's Name: PETER ASTIKNOUDAS
Owner's Address: 125 BELMONT STREET TOWN OF BARNSTABLE
BELMONf,MA 02478 HEALTH DEPT.
Date of inspection FEBRUARY 1,2001
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&i B Canco _
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection. The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems. I am a DEP approved system inspector pursuant to Section 1.5.34'0 of Title 5(310
CM 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: —0 _ Date: 2-1-01
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 1.0,000 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 Uie system owner and copies sent tot
lie buyer, if applicable,and the approving authority.
Notes and Comments
****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 1
r
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
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 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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
C. Further Evaluation is Required by the Board of Health: N/A
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 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 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
D. System Failure Criteria applicable to all systems: N/A
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 leaching is less than 6"below invert or available volume is less than Y2 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CUR 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: N/A
To be considered a large system the system must service 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 lI 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 is 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 CUR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
r
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
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)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 CUR 15.302(3xb)]
I
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 0
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): X
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 1999 1132/2000 1188
Sump pump(yes or no) NO
Last date of occupancy: VACANT FOR ONE YEAR
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CUR 15.203):
Basis of design flow(seats/persons/sgft,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
Source of information: N/A
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 copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1996 PERMIT#96-14
Were sewage odors detected when arriving at the site(yes or no): NO
Tide 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 8"
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: 1,500 GALLON PRE CAST
Sludge depth: F,
Distance from top of sludge to the bottom of outlet tee or baffle: 23"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 24"
How were dimensions determined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL,OUTLET TEE.TANK AND COVERS 8"BELOW GRADE.
GREASE TRAP(located on site plan) N/A
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 5 Inspection Form 6/15/2000 7
i
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
TIGHT or HOLDING TANK: N/A (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: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
D-BOX IS 16"X16", 18"BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS CLEAN AND LEVEL.
NO SOLID CARRY OVER.
PUMP CHAMBER: N/A (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 5 Inspection Form 6/15/2000 8
`r
f
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
X leaching chambers,number: 4
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.)
FOUR(4)INFILTRATORS 30'X7'.PROBED ABOVE AND AROUND LEACHING DRY.NO SIGN IN BOX
OF OVER LOADING.
CESSPOOLS' N/A (cesspool must be pumped as part of inspectionxlocate 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: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
I
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: AST[KNOUDAS,PETER
Date of Inspection: FEE3RUARY 1,2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benclwiarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
to
o
`3 s o �9
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 SUFFOLK AVENUE
HYANNIS,MA 02601
Owner: ASTIKNOUDAS,PETER
Date of Inspection: FEBRUARY 1,2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 25.7 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA—USGS WELL AIW 230 AT 25.7
R I
I
Title 5 Inspection Form 6/15/2000 11
TOWN OF BARNSTABLE
LOCATin€ON Aa-- SEWAGE# �"'.�G
VIL I AGE / y.�;/;� ASSESSOR'S MAP & LOTS 111
iNSTALLER'S NAME&PHONE NO. 107 T o3
SEPTIC TANK CAPACrfY
LEACHING FACILITY: (type)'11 Z"�'� �TOZ/ �br�'S (size) Z0 X 7
NO.OF BEDROOMS
BUILDER OR OWNER 460 C06Z/'7>le
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
W
.may .
0
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE r ASSESSOR'S MAP 6z LOT
mg S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY �£ o7c- /,/Sla�-C Zy
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
/,V.Y p'rcrrp
DATE
DATE COMPLIANCE ISSUED:
V
VARIANCE GRANTED: Yes No
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No. (iG Y �' Fee
THE COMMONWEALTH OF MASSACHUSETTS
Ko PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Di5po.5al *pgtem Con,5tructiun 3permit
Application is hereby made for a Permit to Construct( )or Repair(L,-j"an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
C-
S-A O ��
Installer's Name,Addres TI% C-ANCO Designer's Name,Address and Tel.No.
350 Main Street
W. Yarmouth, MA 02673
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33y gallons per day. Calculated daily flow 3 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations n w in jgplicable� 1nSfA / /✓
1 - r7 3 6 X � Z � 1 � !J d �fDY►2 dY► .Side S- ` d� �h aPS
1' SAnrc_ ym.,)z2n.cA11* Infer .3SX kx )L ' - THS sc ?q = 331 G-AO
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed a Date /" Q -9 6
Application Approved by
Application Disapproved for the following reasons
Permit No. Date Issued
par-
THE COMMONWEALTH OF MASSACHUSETTS
r PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE: MASSACHUSETTS
0[ppfication for Ztgpoar *pgterrt Con.5truction Permit
Application is hereby made for a Permit to Construct( )or Repair(L,.-Ifan On-site Sewage Disposal System at:
Location Address or Lot�No. LOwner's N.,,Address and Tel.No.
SysF C'V "` A U�_
SAw O �aLi
Installer's Name,AddrelkON I.CANCO"N- Designer's Name,Address and Tel.No.
350 Main Street \ �►/f}
W. Yarmouth, MA 02673
Type,pf Building: A
Dwelling No.of Bedrooms 3 ~p Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
i
Design Flow 330
gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date j
Title
- Description of Soil
Nature of Repairs or Alterations
Yn$wp�.�W�$n h lid ble 1n3fA/t /— ls,4 a 4,+ f� �'/�11 �U
1
t' Shxar� .Ut;, rtn,cr�.Il fnfA( aBX '"A ' = '4148 k 331 C-po k
°-Date last inspected:
Agreement: _ J
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
date of Compliance has been issued by this Board of Health.
Signed Date
Application Approved by !
Application Disapproved for the following reasons
Permit No. .r Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
�Certtficate of Compliance -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(,y on
by CAA C 6 for -r �'a r,"
as Q Xo I 1k Ave / has boen constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth bel w:
No f Feed
THE COMMONWEALTH OF MASSACHUSETTS {
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
li!5pool *pgtem Construction Permit
Permission is hereby granted to C/q tiGQ
to construct( )repair( f)an On-site Sewage System located at �J-
and as described in the above Application for Disposal System Construction Permit. The applicant recog izes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction mu �be leted within two years of the date below.
Date: (/J Approved by
i
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350 Main St. • W. Yarmouth, MA 02673 • 775-6264
Division of Canco Energy Corporation Septic Services o Pumping • Installation
9 S� NC'd( L. A U c
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONS'I'KUGHON I'E1tM1T (WF1'IIOU'I'DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated j - - , concerning the
property located at �! - do o (Va ( L A meets all ofthe
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
✓• 'There are nb private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
✓• There are no variances requested or needed.
SIGNED: J `.) Cc2 _ DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
IAttach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
Date:
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OFBUSINESS: V rV F Q E' it 1 IJ h s r A P 1 0 (,
BUSINESS LOCATION: V 1'J is IN V r L( y 41 YV IV i' y Z ,(d l
Mail To:
MAILING ADDRESS: _� S r r 0 1 k
TELEPHONE NUMBER: .moo 0 .y Board of Health
Town of Barnstable
CONTACT PERSON:�_ .p , �; 4 c� ( ( P.O. Box 534
y ` 4
EMERGENCY CONTACT TELEPHONE NUMBER: _:j o ► i 3 Hyannis, MA 02601
TYPE OF BUSINESS:. K/ I)( C I-\ i v1/G
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own
use? YES NO
This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed
envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your mailing
address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health has determined that the following products exhibit toxic or hazardous character- ...
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS.
Quantity Quantity
Antifreeze(forgasoline orcoolant systems) Drain cleaners
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salt (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet Fuel Photochemicals (Fixers)
Diesel fuel, kerosene, #2 heating oil NEW USED
Other petroleum products: grease, Photochemicals (Developer)
{
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Battery acid (electrolyte) Swimming pool chlorine
Rustproofers Lye or caustic soda
Car wash detergents Jewelry cleaners
Car waxes and polishes — Leather dyes
Asphalt & roofing tar l 0 Fertilizers
Paints, varnishes, stains, dyes PCB's
Lacquer thinners Other chlorinated hydrocarbons,
NEW USED (inc. carbon tetrachloride)
Paint & varnish removers, deglossers Any other products with "poison" labels
Paint brush cleaners (including chloroform, formaldehyde,
Floor & furniture strippers hydrochloric acid,other acids)
Metal polishes
Laundry soil & stain removers Other products not listed which you feel
(including bleach) may be toxic or hazardous (please list):
Spot removers & cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
TOWN OF BARNSTABLE
LOCATION �t)T�o :/� Ave SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL �1'
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY P J (2)C)
LEACHING FACILITY:(type) C (size) 5 �.
NO.OF BEDROOMS 7
OWNERCO�C.
PERMIT DATE: COMPLIANCE DATE:
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 CG, �(1S C�� Q,a6,ra
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10' min. from-- *NOTE s►uu: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.v.C. -- SECTION A -d Au ou>�T sus Fraaw »e — s —_ 1' = 2000'
PROFILE YIEW OF ADDITION TO LEACHING SYSTEM atsl»>el,Tialt eox BE
E',r
Existing Foundation house to septic tank SET LEVEL FOR AT LEAST 2 FT 1Y CONOWIE COV"
tank corers must be 3" of 1/8' - 1/2' Washed Peastan tr q y
8 In. of flttisFrod grad.
---Grade ever SAS - 9a50 /4' to 1 1/2 ' Washed Gushed Stan 3 -KNOCKOUTS'U1171.Ef O
wad. over sertk Tonle - se.00 Grade ovv D-0oa - Oa�O ¢
— ay- O!lRET 'ir PLEEI"
S - 0.02 3 HOLE M-20 1 r
_ I'_ 14' EXISTING S-•0.01 DIST. BOX 3' Anam Oow Tap of SAS - Elev. -97.25
r'Ym, PI h 1.500 GAL s- O.o10' per foot I � 4- - SCH. 40 T I y t.,w
FROM �+TM Cl! SEPTIC TANK 8 '4• TE
H-10 �� m00
10
PLAN SECTION CROSS-SECTION $`
CONE FULL F01111D4 b j i C� cv 1 �j O t� O
Y o 1 0> 3 Units ! 6' = 1B" Sµo 7q
SYSTEM PROFILE 6 n.of a/4"-"� d 1 1' $ V STONE UNDER CHANHERs 3 HOSE H-10 DISTRIBUTION BOX
Not to Scab a � store -9 o e "' 8 ---Exist. NOT TO SCALE
3' 0 0, LOCUS MAP
c c I �2' Effective Length _
6 In.of 3/4'-1 1/2' - 8'
oorn;wctsd .t,,,, rn of a vtasrt m SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES
CULTEC MODEL 125 (H-20 LOADING)/ SHOREY PRECASTE
(OR EQUIVALENT) 1. Contractor is responsible for Digsofe notification
Not to Scale and protection of all underground utilities and pipes.
2. The septic tank a d distri u$ion box shall be set
NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 12" level on 6" of 314 -1 1/2 stone.
3. Backfill should be clean sand or gravel with no
NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE stones over 3" in size.
4. This system is subject to inspection during installation
3-24.0". A00M MANHOLES FROM THE EXISTING TO BE DISPOSED by Carmen E. Shay - Environmental Services, Inc.
10 -6 OF AS PER BOARD OF HEALTH SPECIFICATIONS. 5. The contractor shall install this system in accordance
with Title V of the Massachusetts state code, the approved plan
-��-=� '•�^--`-�•• , and Local Regulations.
b 6. If, during installation the contractor encounters any
soil conditions or site conditions that are different
from those shown on the soil log or in our design
t>tl.E'itllL.T � T installation must halt & immediate notification be
J " THE ACCESS COVERS FOR THE SEPTIC TANK, made to Carmen E. Shay - Environmental Services, Inc.
�. DISTRIBUTION Box AND LEACHING COMPONENT SHALL BE RAISED TO WITHIN 8" OF 7. NO vehicle Or heavy machinery shall drive over the
r FINISHED GRADE. septic system unless noted as H-20 septic components.
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-T1TE GAS BAFFLES OR EQUALS 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
PLAN VIEW ON ALL OUP TEE ENDS 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
3-2e IEMOVAKE COVERS 10. All solid piping, tees & fittings shall be 4" diameter
4 Schedule 40 NSF PVC pipes with water tight joints.
4- r 11. Municipal Water is Connected to The Residence and Abutting
"i'• d'v'1O• ,2 ,r r}-.axe *� Properties Within 100 Feet.
its ET nth Y Wive Net to outbt r, 1' ^�/
' nice �TM u } OUTLET -IL�11-
UQMI
-rS 4•-0' "Nt. .T� -r � 95_ N >1 d 124, a THE PROPERTY LINES ARE APPROXIMATE AND
$ .. LkiW dWth --_ 3o COMPILED FROM THE SURVEY PLAN GENERATED BY
t - 4.30' WHITNEY & BASSETT, SURVEYORS. OF BARNSTABLE, MA
b 01- ENTITLED " PLAN OF LAND IN BARNSTABLE, MA" (JUNE, 1963)
-` --__ LC 14034-H SHEET #1
_ 9S D0, AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
CROSS SECTION EN —S T N e :. _ - - IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
--95 THE SEPTIC SYSTEM INSTALLATION.
TYPICAL 1500 GALLON SEPTIC TANK r.
c 3 TEST HOLE #1
NOT TO SCALE (ll � ELEV.- 95.45 � 'Exist. x Leo28'�) Exist. D-Box
(H- 10 LOADING) 0 LEGEND
o DENOTES PROPOSED
� 0 104X1
�- ASPHALT DRIVEWAY SPOT GRADE
PERCOLATION TEST o 96__ ----_-_ DECK 1500 ya. h
septic Tank CO-96 DENOTES EXISTING
______
Date of Percolation Test: MARCH 13, 2002 0 '� SPOT GRADE
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. I to
Results Witnessed By. DAVID STANTON ( for Barnstable B.O.H.) a I
Excavator: Roberts Septic Services �r aJi1STI1VC v� PL PROPERTY LINE
Percolation Rate: L MPr 3 B1rDR00Af
�I v ' � � i EOUsa' 96 PROPOSED CONTOUR
#8 97- - — — —97 EXISTING CONTOUR
Test Hole � �
No. 1 �
oEPTN SOILS ELEv DEEP TEST HOLE &
I - �- -----------_ __-97 PERCOLATION TEST LOCATION
t aYe 3f� �O
i
o ; LOT #2 6 FOOT STOCKADE FENCE
f tr 73o sge4a+y 1►et:t +/- � � co •-•--•
- 98
_------ - _____ _______ _ P LOT P LAN
S 2sd >*s' 40~ Pit ; 99 OF PROPOSED SEPTIC SYSTEM UPGRADE
Perc #1 PROJECT BENCH MARK— PREPARED FOR
Depth to Perc: 3 TOP OF FOUNDATION MR . FRANSISCO TOLEDO
Perc Rate= L;Z MP t ELEV. = 100.00 (Assumed)
Groundwater Oby ESH Observed ! .S UFF O L K A VEN UE AT
ADJUSTED H2O Elev. = None i 9 S U F FO L K AV E N U E
(40 FOOT RIGHT OF WAY) H YA N N I S, MA
esion Calculations
Number of Bedrooms: 4 Equivalent to 440 Gal./Day) ^�?�OF MAN q�y PREPARED BY:
Garbage Grinder: No CARM�'N E. ,SHA Y
Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) E. �``
Septic Tank : - 2 x 440 Gal./Day - 880 USE Exist. 1,500 GAL. Septic Tank. aA 'ENVIRONXENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of Q min./Inch 0.
Bottom Area: 0.74 gal/sq. ft. x 384 sq. ft, = 284.16 gallons
0 20 40 50 �F R�a ,.. P.O. BOX 627
c�
Sidewall Area: 0.74 gal./sq. ft. x 224 sq, ft. = 165.76 gallons s STE EAST FALMOUTH, MA 02536
Providing: 449.92 gallons "4NITAR�P '
Use: ADD (3) INFILTRATOR UNITS OF MATCHING SIZE TO EXISTING 8' x 28' TRENCH. TEL FAX : 508-548-0796
UNITS TO HAVE A 1' EFFECTIVE DEPTH. TO BE USED WITH 3' OF WASHED STONE ON THE SIDES AND SCALE: 1"=20' DRAWN BY: CES DATE: MARCH 12, 2002
2' OF WASHED STONE ON THE END AND 1' OF STONE BENEATH ENTIRE ADDITION TO SAS. SCALE: 1*=20' PROJECT SD298 FILENAME: SD298PP.DWG SHEET 1 OF 1
FINAL TRENCH DIMENSION TO BE 8 FEET WIDE BY 48 FEET LONG AND 2 FOOT EFFECTIVE DEPTH.