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HomeMy WebLinkAbout0020 THIRD AVENUE (HYANNIS) - Health 20 THIRD AVENUE, HYANNIS A=246 085 a 'I • �� TO OF B STABLE LOCATION ���`� ���," SEWAGE # VILLAGE R(At,';SESSOR'S M &"LtT6 INSTALLER'S NAME&PHO 0. SEPTIC TANK CAPACITY LEACHING FACILITY:-(type) (size) NO.OF BEDROOMS l �' BUILDER OR OWNER ,c. PERMIT DATE: 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 byy� a � �j �-� � Q� —�cW �c a� � �� ��- �� � �1 . Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Third Ave 3> Property Address CA Steven Babineau Owner Owner's Name 3> required for is every West H annis required for eve Y port ✓ Ma 02672 2-24-17 � page. City/Town State Zip Code, Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information �w on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gllfoy use the return Name of Inspector key. B&B Excavation Q Company Name 374 Route 130 ML Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 2-23-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection'. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West HY P annis ort Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. ( installed 10-7-14 ) B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 FIND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is p required for every y West H annis ort Ma 02672 2-24-17• page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West Hy p annis ort Ma 02672 2-24-17 page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) 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 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less day flow than '/2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 o . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is West H annis ort required for everyy P Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® 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 design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ - the system is located in a nitrogen sensitive area (Interim Wellhead Protection .El 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West H Yannis port Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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 CM 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(Actual) _2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West HY P annis ort Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2015- 15,708gallons 2016- 196,724gallons (irrigation in use) Sump pump? ❑ Yes ® No Last date of occupancy: Off and on Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West Hyannisport Ma 02672 2-24-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not pumped since instal'Ied new Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type.of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M0 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is every West H annis ort required for eve Y p Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2014 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 11101, Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 21011 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallons Sludge depth: 0 11 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is every West H annis required for eve Y port Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NS Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West Hyannisport Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: concrete metal fi❑ ❑ fiberglasspolyethylene other ex lain ❑ 9 ❑ ❑ (explain): ) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Cisposal System•Page 11 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West Hy p annis ort Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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 was in working order with no sign of back up or carryover. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurace Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West HY P annis ort Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallon ❑ 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.): Leaching was in working order at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Y Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West Hy p annis ort Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West Hyannisport Ma 02672 2-24-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t- % 81. 4T A2;26 1312- : 3, 0. B3 2 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is West H annis ort Ma 02672 2-24-17 required for every _Y P page. City[T'own State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 18 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: Permit 9-12-14 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspectior Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 20 Third Ave Property Address Steven Babineau Owner Owner's Name information is required for every West Hy p annis ort Ma 02672 2-24-17 - page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE# .:Je 0 4-•3 3.3 ' VILLAGE &JAdMl( _Pn=%_ASSESSOR'S MAP&PARCEL =�4/. r<- INSTALLER'S NAME&PHONE NO. G C.,G>j( l 'L+� 1b 5"J'7'F•1 SEPTIC TANK CAPACITY /g'-O� -6�_ /�-16 LEACHING FACILITY.(type) --T-12, We_14— (size) ._X:!� X I.,•g3 ;eu! NO.OF BEDROOMS �- S� �-• ��1'l�'�'`��'� OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: s 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 i 300 feet of leaching facility) ? ! > Feet FURNISHED BYcr/�✓ __ �� a 4 � .0 O �� s 0 U I �,*. �:.. .,F «�� R No. i + 333 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repair PI/ Upgrade( ) Abandon( ) f�omplete System ❑Individual Components Location Address or Lot No. .20-71N tJ- Owner's N e,Address,and Tel.No.IF&$ Assessor's Map/Parcel.1 Aq rl.Spot � Oit 1�:� �Q Ainl S Installeir'ss Name,Address,and Tel.No. Zr4L--7A7,V' .399 Designe 's Name,Arddress,and Tel.No. .(ooZ yS / ° vtt�c... U•�bX �G� � /���G'7�i/'�'EI'i�3 Sj3�!' /�Q�%� Type of Building: ✓ Dwelling No.of Bedrooms 3 Lot Size l�e o�%s— sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Q Design Flow(min.required) 130 gpd Design flow provided �/ gpd Plan Date A-x.A 7,awV Number of sheets / Revision Date." Titlep��J�/ j`9i Size of Septic Tank Type of S.A.S. / Description of So' ° Nature of Repairs or Alte ations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme Co and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt . Si Date A y Application Approved by Date Application Disapproved Date for the following reasons Permit No.���� Date Issued o a n _ §1 No.OD) l- ✓J - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for -Misposaj1h&pstrm Construction Permit Application for a Permit to Construct( ) Repair P Upgrade( ) Abandon( ) R/Complete System ❑Individual Components Location Address or Lot No. I�l� Owner's N e,Address,and Tel.No. $ p Assessor's Map/Parcel� w„ f•-�k -►)r1 i S pot E" ? 1:J"�i►`4L � ao TAirJ AU2 5 4 Installer's Name,Address, nd Tel.No. '� ✓ Designer's Name,Address,and Tel.No. 44�3Co� S/S / ir{efo�c: ' � r 1, nc.�v �Cs7r '�GS/ ,G� n C�r�.i�e�r. `33ni/L/rcii� Sf. ► VArs . 1 V Type of Building: 1' Dwelling No.of Bedrooms 3 Lot Size ��� o��J�— sq.ft. Garbage Grinder( ) Other Type of Building,"A0 No.of Persons Showers( ) Cafeteria( ) - Other Fixtures c/q Design Flow(min.required)'} gpd Design flow provided �7 1 gpd ` Plan Date �� 7, as V Number of sheets / Revision Date L.2kSf- !.b'r `s Size of Septic Tank ( Type of S.A.St,411111i 2v1 .51 s uo.G clnrn Description of Soil-5 JV (� - f Nature of Repairs or Alterations(Answer when applicable) �. •°' () �Q ►STY �- �U `erica rz9 v S aS �.O/, raul Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the,afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm •tai Co d and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal / Date Application Approved by Date 4 Application Disapprove iver Date for the following reasons Permit No.;�bl(4 _ Date Issued ------------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by y POW-L�A at J6 jl"k�rr) filga ( �, }�T��E.�►,. �-�-- has been constructed in accordance with the provisions of Title 55 and the for Disposal System Construction Permit No?aj - dated /Z Installer �r� [ / �re_ ► Lac Designer��►,, �, _ -s r,, 11,„ #bedrooms Approved de iow „ gpd The issuance of sip i shall not be construed as a guarantee that the syste w I funt* designA Date Inspectori'�` �• � /, d --------------------------------------------------------- --------------- -------------------------- ------------_---------------- No. Fee 40 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 3Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair i ) Upgrade( ) Abandon( ) System located atc) / /�ip'C,/ Uo &t- (�• �9�c//lG�A" 5 0 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 permi . Date�_7 Approved by 1 OCT-09-2014 03:05 From: To:15087906304 Paee:1-�1 FROM :down cape engineering inc FAX NC. :1S08362-%80 Oct. 08 M4 02:42PM P2 !'CAW I o Thomas F. aaeil e r,�ir�a�nr grass a 'n� a Thomm.g.cKe i,Director 20o 1►l &Sdrect, -TyLk 07-601 Fix: 508-790.6' 04 off: 509462-46" f�asd 1r-➢ mqa ua B 4i -a—doasJ. (Po/q— 13�%q D ate. _ 3ewelgo Permit* Address; _ ;�aidff�e: Was isued a perroiC to itivl211 ote) (iastallex septic-,sq..[em at � based on a desigm*Awn by (addesc) (fie. rx) cefeeritLjAbovew�1 cefy that the srp4ir, si iilled st�bst Bally scet,* to the desk,which rtt Y inc -dE:ulil I aVPT0'�ted (• ;i*apes Bch�.3 lau:rai tel,�ca DrL diudbulio;a boy andloz srp is tank, :F. unify that Thr, yc;gtia .Vjtc=xefaren� d above-wn instiIled WAh tDA-in' chan,�e-1 (i.e. g=rster,thou 10' 1nR sai relua.ation,of tbz SAS or aay v011tical l(locatiou of."any CW)-.V nnalAt dT of the segtiu SyMm)butirx ft,;C' �'rlauce Wit}i State& LoGal,RC:gUl�,Pus. :�lssn rrr�i� or��i Eied'as-�nuIt si to"olio—W. DANIELA QJAlA CNIL (�tx�ts3JJeri .�au�e) No,4e602 a ST ��SIONAL��yG Rtainp ` V RF�i713NT z .�N�� _,�' � t9avat�$c— ElUl ''.rI?><e aqt "_ r� �r ,'r ceu A , I1f'i"RE �iARL, 'VTAL'1 �Cii.`I. Towle .of BarnstableP# . • ors Departinnent of Regulatory.Services sr�H� Public Health Division Date MAM p� na34 �d 200 Maia street, annis MA 02601 $ lei fVF / r / o • (� Date Scheduled Time Fee Pd. • V So Suitability ,Assessment for Se Dis ' os Performed-BY: G ( '�'( V�?q!y es Witnessed By: � LOJCATION& GENERAL INFORMATION Location Address V r )Q• ,� Owner's Name ��1 ✓V ' {�/I`V Ot Address Assessor's :arcel Ma /P ��//6 Y b,, P 01 7 �Iv Engineer's Name ,!1 Q NEW CONSTRUCTION REPAIR Telephone# ��� (� Land Use:Loi y✓ / Slopes(%) G` Surface Stones Distance's from: Open Water Body r�G it Possible Wet•Area fk Drinking Water Well ?(O_O ft Drainage Way ft Property Idne �0 ft Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands•in proximity to holes) 1191 o CZ CzLn t . c -0/ qq 2q Parent material(geologic) �C" /L Depth to Bedmak ,/ '1 Depth,to Groundwater. Standing Water in Hole: /-T _ . Weeping from Pit Face 1614 Hstimated Seasonal High Groundwater ! DETERAUNATION FOR SEASONAL HIGH WATER TABLE Method Used: /V G w i Depth Observed standing in obs.hole: la Dppdt to a411 mottles: ln, Depth to weeping from side of obs,hole: In, ©roundwater Adjunment • Index Well# Reading Date: Index Well]01 al Adj.factor.,.,,...!._,_Adj.Groundwater have(-,,,,, PERCOLATION TEST matp�, xluxd___v_ Observation Hole# _ Time at 9" — Depth of Pere Jlf/ J Time at G" Start Pre-soak Time @ IV 10 Tima(9"-6") End Pro-soak /0. lJ Rate Min./Inch Z 21-7; /L ' site Suitability Assessment: Site Passed V Sitg Fallcd: Additional Testing Needed Original: Public Health Division Observation Hole Data To Be Completed ou Back------ ***If percolation test is to be conducted withiu 100' of wetland,you must first notify the Barnstable Consgvatlorl Division at least one(1)week prior to beginnbg. Q:1S EPTICIPER CFO RM.D O C l DEEP.OBSERVArffON HOLE LOG Hole# � Depth from Soil Horizon Soil Texture .Shcl Color Soil• Otbtr Surface(in.) (USDA) (Munsell Mottling (structure,Stones;Boulders, o i ten w,9 oliyel) L s �c DEEP 013SERVATION HOLE LOG Hole# � Depth from Soil Horizon Soil Texture Soil Color Soil . Other Surface(in.) (USDA) (Munson) Mottling (Structure,Stones,Boulders, ConsISLmov,9b Grave lG A 5 E l0-zz 1 71f DEEP OBSERVATION HOLE LOG Hole#. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C91WtaLrTiry, d t DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Sol] Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stoats;Boulders, Consistency, k )_+'food Insurance Rate Map: Above 500 year flood'boundary No Yes Within 500 year boundary No +/ Yes Within 100 year flood boundary No.i! Yts Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption systeml _y e S_ If not,what is the depth of naturally occurring pervious material? Certification / / • ' I certify that on�/ t'�l (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the requited training,expertise and experience described in�10 CMR 15.017. / Signature ���s--���'� Datb�/l �(f7 Q:MPl IaPR1tCF0RM.DOC COMMONWEALTH OF MASSACHUSETTS [� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS l� DEPARTMENT OF ENVIRONMENTAL PR T&M-MO /E� d i a APR 2 7 Z003 h ti TOWN OF BARNSTABLE 'v HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (� t Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner's Name: PATTIE CALASUONNO Owner's Address: 14 ELIZABETH DR AUBURN MA.01510 Date of Inspection: 3/31/03 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 _ Conditionall sses _ Needs Furthe valuation by the Local Approving Authority Fails Inspector's Signature: Date: 3/31/03 The system inspector shall submit a cop 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 de3ign 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 THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****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 incnPrtinn Fnrm Fill snnnn 1 Page,Tof 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3/31/03 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: THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n/a 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: n/a n/a 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: n/a n/a 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: n/a Page,3 bf 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3/31/03 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "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: n/a Page•,4 bf 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3/31/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: 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 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 NOT IN THE LAST YEAR.. 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 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ 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. d Page,5'of 11 • I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3131103 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)] S f Page,6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3131103 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 0 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 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): NO Seasonal use: (yes or no):YES Water meter readings, if available(last 2 years usage(gpd));A CL_ Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIALANDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: NOT IN THE LAST YEAR. Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM _Septic tank,distribution box, soil absorption system X Single cesspool X 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): n/a Approximate age of all components,date installed(if known)and source of information: 1932 ORIGINAL CESSPOOL Were sewage odors detected when arriving at the site(yes or no):NO C, Pap.I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3/31/03 BUILDING SEWER(locate on site plan) Depth below grade: 14" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: (locate on site plan) Depth below grade: 0" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: n/a Sludge depth: 0" Distance from top of sludge to bottom of outlet tee or baffle: 0" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 0" Distance from bottom of scum to bottom of outlet tee or baffle: 0" How were dimensions determined: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): n/a GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a i Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page,S of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3/31/03 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no):NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): NONE PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a , t R Pagq 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3/31/03 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: I n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a j n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. THE BOTTOM IS AT 9' - THE PIT WAS EMPTY AND SHOWS NO SIGNS OF FAILURE.THE PIT HAS NOT HAD MORE THAN Y OF WATER IN IT. CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 Depth—top of liquid to inlet invert: 0" Depth of solids layer: 0" Depth of scum layer: 0" Dimensions of cesspool: 4' X4'` Materials of construction: BLOCK Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): MAIN CESSPOOL WAS EMPTY AT THE TIME OF INSPECTION.THE CESSPOOL AND CESSPOOL COMPONENTS ARE STRUCTURALLY SOUND AND SHOW NO SIGNS OF FAILURE. PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a I 9 Page,I,O of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3131103 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. 1 �n I A6 33 a O PA q c VO4 4, i 1n Page-hl of I I NTARY OFFICIAL INSPECTION FORM OR VOLU SYSTEM INSPECTION FORM ASSESSMENTS SUBSURFACE SEWAGE DISpOSAL PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV HYANNISPORT 02672 M266 P085 Owner: PATTIE CALASUONNO Date of Inspection: 3/31/03 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole wiihin 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: GROUNDWATER WAS DETERMINED BY AUGER-NO WATER AT 10' r APP,-01-2003 14:53 BARNSTABLE WATER COMPANY 508 790 1717 P.05/05 From Date . Serial Number . Cola$uonno Joseph Status ' Service Address. 101019 20 Third Ave Meter Position .. 1 Account ID • . Work Order . . . 0 Read Mtr Meter UM R R E S Account P Date_ Eja Rgadjn Consum12tion _ LI I T g .1 ID — 03/17/03 1 394 100 FC 1 N 1 00149799 - 12/12/02 1 343 100 FC 1 N 1 00149799 09/18/02 1 39E 1.100 FC 1 N 1 00149799 — 06/14/02 1 381 0 FC 1 N 1 00149799 _ 06/06/02 1 381 0 FC 5 N 1 00149749 03/12/02 1 381 100 FC 1 N 1 00149799 _ 12/11/01 1 380 600 FC 1 N 1 00149799 _ 09/24/01 1 374 800 FC 1 1 N 1 00149799 ,6;,rl@Ixt F,4,aDti,Isr r rF,Br=.D,a,t,er S.e,q, r ,F,1,2,=rD,is,prla,Yr ,T,or9,g,l,e. r .F,2,4.=M,o,r,er r / I TOTAL P.05 CUSTOMER CONSUMPTION HISTORY ACCOUNT NUMBER 246 085 --. tSTO E R NAME:-- GEORGE TENAGLIA m SERVICE L.00A"f'ION 20 THIRD AVENUE READING ti DATES READINGS USAGE _... ._ PERIOD (MMDDYY) (CCF) (CCF) W ALLOWANCE BALANCE FIRST 09 24 01 374 A e SECOND 07 12 01 366 A i3 a -----AVE GE-,WATER--UEE 16 THIRD 04 09 01 353 A 13 W YEAR TO DATE WATER USE 34 FOURTH 01 ii 01 340 A 19 FIFTH 10 10 00 321 A 16 - - --t 8M--SEWER USE SIXTH 0.7 17 00 30 5 A 16 OTHER USE SEVENTH 04 it 00 289 A 15 EIGHTH 01 11 00 274 A 17 D -- ----- - NINTH f:0 07 99 257 A 17 m TENTH 07 OB 99 240 A 20 LO NON SEWER- FIRST READING ELEVENTH 04 08 99 220 A 20 - tJ0N-SEWER -SECOND READING TWELFTH 01 07 99 200 A 21 m NON SEWER METER h10. THIRTEENTH 10 09 9S 179 A 22 � FOURTEENTH 07 09 9B 157 A D 3) ENTER = FIRST SCREEN! PFKEY 14 = PRINT SCREEN o • 3 ---Z tO0JI W 1u vy A ---- --------------------- TO F B STABLE LOCATION- ®���. TIo ` t" SEWAGE # VILLAGE��� A SESSOR'S Ma&"LL T if 6f INSTALLER'S.NAME&PHONWO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS L l BUILDER OR OWNER 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) V� Feet Furnished by � I j I II 4A 33 i AO11 � O PA yay i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a � C i c TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 20 THIRD AV.WEST HYANNISPORT,MA 02672 Owner's Name: CAROL REED Owner's Address: BOX 662 W.HYANNISPORT MA.02672 Date of Inspection: 4/11/01 RECEIVE® Name of Inspector: (please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS WAY - 9 ��7 Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 -TOWN OF BA DEPT.BLE Telephone Number: 508-564-6813 FAX 508-564-7270 HEALTH 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: I� X Passes _ Condition Ily Passes _ Needs Fu hqA Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 4/11/01 The system inspector shall submit a opy 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 THE SYSTEM PASSES TITLE V INPECTION.THE SYSTEM CONSISTS OF BLOCK CESSPOOL WITH 1000 PIT AS OVERFLOW.THE SYSTEM SHOWS NO SIGNS OF FAILURE. RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG TI IE SYSTEM'S USEf ULL LIFE. ****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. Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 THIRD AV.WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 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: THE SYSTEM PASSES TITLE V INPECTION.THE SYSTEM CONSISTS OF BLOCK CESSPOOL WITH 1000 PIT AS OVERFLOW.THE SYSTEM SHOWS NO SIGNS OF FAILURE. RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits li 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: n/a n/a 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: n/a n/a 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: n/a Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 THIRD AV.WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 C. Further Evaluation is Required by the Board of Health: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance n/a "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: n/a Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 20 THIRD AV. WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. 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 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.'1'lie 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. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 20 THIRD AV. WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 20 THIRD AV.WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 2 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): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a 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: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a 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): n/a Approximate age of all components,date installed(if known)and source of information: 1932 ORIGINAL,CESSPOOL Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV.WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 BUILDING SEWER(locate on site plan) Depth below grade: 6" Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): THERE IS TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:3" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 4' X 4' BLOCK CESSPOOL" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED 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 CESSPOOL AND ALL COMPONENTS APPEAR TO BE STURCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a t tee or baffle condition,structural integrity, liquid levels as related Comments(on pumping recommendations, inlet and outle to outlet invert,evidence of leakage,etc.): n/a f Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV. WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: _'(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R ' Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV.WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' H10 leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a t: innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 3' OF WATER IN IT AT THE TIME OF THE INSPECTION. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a Page 10 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 20 THIRD AV.WEST HYANNISPORT, MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 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. O �g q�� C� pA Page 1 I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 20 THIRD AV.WEST HYANNISPORT,MA 02672 Owner: CAROL REED Date of Inspection: 4/11/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 10+FEET LOCATION SEWAGE PERMIT NO. VILLAGE F i A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER // /\ DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ��j �,' � �.. �� � ' i i S '� i .,\ � \„� �� ._� ? .\ e �� ' � _, yt _ p l� F�s._..�...15.00..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...----.........-.T.w.n..............OF......BainS able...._...-.------._...........---------...-•-------...---.. Applira#ion for Dispersal Works Tonstrnrtinn Vamit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: .....ZQ-.Tlaa.xd.__A.Yeala We5t.--HYaaniaP-Q1 t....M....02.672......................................................................................... _Address or Lot No. ............... 2Q..Tl xrl_Avenue_._..I� st.. y nis�ort.,..MA.....02672 Owner Address A & BCesspool__ _ _- ........., eryice - nc___________________________ 128__Bsho..sT�r --- 02601I _. sc A..- ...s .............................. Installer Address vType of Building Size Lot............................Sq. feet �., Dwelling—No. of Bedrooms......................2....................Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ____________________________ No. of persons---------2................ Showers ( ) — Cafeteria ( ) p' Other fixtures __________________________________ W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity......,.....gallons Length................ Width................ Diameter__._____________ Depth_.______._____-. x Disposal Trench—No_ ____________________ Width.................... Total Length......._............ Total,leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................. ---•---•---------•-----------------------•------------------..._..----------._._...-------•-------.......------------•--•--•........_.__.._.....-----.---- 0 Description of Soil......Sand........................................................................................................................................................ x W x •-••---•-•--------------•----------•--•---•-•-•-•-------••---•-•••-••---•-•-••-------------•--•••-•-------------•-•••----••---------•---------•-----••--------•--••••-•-•-•---•----•-------•---------•-- U Nature of Repairs or Alterations—Answer when applicable_installation••of__a... ,000...gallon,-__re-cast, .stone----lacked_.leach--pit--4-9Vexf.1Qw)-__to._re,�lace•_a--cave in. . • . -------------•--•-••.._....------.......-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of HHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of al �p 02 14 8 /`% --------- ----•- -•------ Signed... 5 = --------------- --•--•--- Application Approved BY ----••-•----. ._... . •-------------------•-•- 0..714./85 Date Application Disapproved for the following reasons:................................................................................................................ --------------•-----•-•-•--•-•-------•••-•---•-------••-••....-----•--•-----•---------.......------....---•----••-----••-•-•••-------------•••-•----------------------------------------------------•--- ---------- -- Permit No....--...1••�...C............................... Issued..= 02 14-85 Date Fms...s ...�Sa.QQ.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T.oF Tl:.:...........OF.....R3 l tabl@---------------------------------------------------------- AVVfirathin for Uhiposal Works Tunitrurtinn JIrrutit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: r� •!�_�.....0 47" Location-Address or Lot No. ....Keith..Pacrc..............•---•_.._-•---••--•-•--••-•-•----••---•...._....-•-• 2�...T_.h1Yd--Au�tt T..t�Ft�s B3► -n1spa;t-r---KA--42672 Owner Address W A..$�_B__GenspQol._Servic ,-..Inc ........................... s ersce lI�a r 1a Installer ' tlddress t---'-M A-----0260-1.----•---- Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.....................2.....................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons ................. Showers W YP g -----•--••-------•---------- P ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------•--------------•--•-------------------•---•----------•---•-----. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length............... Width................ Diameter................ Depth-------_........ xDisposal Trench—No.......:............. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-._-_--_______-_•-----_. 44 Test Pit No. 2................minutes per inch Depth of Test Pit...._............... Depth to ground water........................ Descriptionof Soil Sand •...................••------•--•---......-•----------------------------------------------------•----------•------------------•----------....._.. W UNature of Repairs or Alterations—Answer when applicablegnsta.1-1-ati.G ..Of---a... 1-040-.j�a_j.0RV.pre—t3.fts+jt stonne Wicked--beach--pit-- -ouc�rlcxa�--ta-zeplace••a--cave-in------•------------------------------------•-------•---------•-•-------- Agreement: The undersigned agrees to -install the aforedescribed Individual Sewage Disposal System in accordance with, the provisions of TITL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o eaI .. ---._••-- 02�14�8� D t Application Approved By....... � �..__.�` 02 1 8 Date Application Disapproved for ther`f ollowing reasons:................ ____________________________________________ •-------------•----.------_ ----•--------- .............................................. '----..--------•----•-•----•-••......• •• ------------------.-----------------------------------------------------------...--•--- J Permit N o .;! t_ ........-•-----------•------------- Issued_ 02/14/8 Date . Date I !, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........::.`town.......oF......Earnstable .................................................................... ( ; Trrtif iratr of Tuutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X ) b3A-&B-Cesspo ol%,Servi ce2.Inc•-----128_B.if - exx' � _,...1tX, nni; . A..... ... I / Installer at--_2p..T•,ird Avenue, 'West'Hy-annisport,--�A----02672-_jeitY�.PQ ' ' has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Wjork's Construction Permit N@S"-----J.Z-_4................... dated....02/i4/a5_.,..................... THE ISSUANCE OF/THIS CERTIFICATE SHALL NOT BE CO STRIDE® AS A GUARANTEE THAT THE SYSTEM'WILL FUNCTION SATISFACTORY. DATE:..............02��.`�"'/.. F!...................................... Inspector¢ / . 1 _ ___________________ __________ __ _......_................. i ! THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH stable N01..�. ..�t._ 7,... FEE .15...00---_.... Ilk urkv Ta anstrurtion amit Permission is hereby granted:.A_& _.Cesspo0 ,__aS�rvi.ce,...Znrl_g....................................................................... to Construct ( ) or Repair) ) an Individual Sewage Disposal System at N�OTird-Avenue,•_West .Hyannisport.t.._M�.:'.Q2?72 ' K� th.l' zy Street as shown on the application for Disposal Works Construction Permit NMI .......... Dated.._.....__2/14/85............... /85 DATE........... --•-i. ........................................................ }�'�• FORM 1255�A. M. SULK�I�N• INC.. BOSTON f1 I LOCATION'.— 1 SEWAGE PERMIT NO, . VILLAGE hr '.- fb �c � . 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II ! ! c I I I _ I I I ro ' : I I jll IT T , t- - I - -- I ' I�--� ! I� I�---!� I y- -�� -i- - ---r----� r---T -�-- -1-- -- _ _'_ ,C• I ---I I � _ ,- I I ---;- r -I � --- - .. _I ._I _�� r -�-��-_�� I� �_�(o �-�-- I- I-- I I _ Imo-- � __ I ► i { {--a-!-- ���-—' .�-- I- ' I +— = � � I - �-- ! i I - -- --- --E--= I _�rp__L Ln 1. .............. , : ALL SYSTEM COMPONENTS SHALL BE Cam+ SYSTEM PROFILE MARKED WITH MAGNETIC TAPE OR NOTES PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NGVD T �� ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" PEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE 2. MUNICIPAL WATER IS EXISTING TOP FOUND. EL. 35.9' FILTER FABRIC OVER STONE to ey \ 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 33.5' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 33.0' //le Beach Rd. NOTE: 2" MIN. WALL 4. DESIGN LOADING FOR D'BOX AND Croig PRECAST H-10 THICKNESS REQUIRED BLOCKS OR UNITS TO BE AASHO H-20: SEPTIC TANK H-10 RISERS04"0SCH40 PVC MORTAR ALL PRECAST RISERS ,,•,. PIPES LEVEL 1ST 2' 4, COMPONENTS HtZ04 4, 5. PIPE JOINTS TO BE MADE WATERTIGHT. ENDS (TYP.) 1 28.91' SIDES 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE 10" 1500 GAL H-10 14" P°° 000° 000 - °°° ° ° � � °° ° ° ° °-°' Locus 28 5' TEE SEPTIC TANK TEE \28.25 , ���� OQQE-2 MQM® ���� WITH 310 CMR 15.000 (TITLE 5.) a ° ° o °o°0°0°0°0°0 6" MIN. SUMP o o°o ®®a®oao�ao�� aoa�0000ao� ;o°0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND ro GAS BAFFLE::' ,_ ° ° 0_ En 12" MIN. INT DIM. �i G o NOT TO BE USED FOR LOT LINE STAKING OR ANY Nantucket BASE. FL ����������� r 4' LIQ. LEVEL (ACME OR EQUAL) ' 28.15' 27.98' °°°°°°°° �o�o�o�o, 25.91 OTHER PURPOSE. Q *28•7' o°o'o 0 0 0"0•0 0 0 0 0 0'0'0 0 0 1 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. Sound .°00000000000000000000°0000000°0000000000000°0 'o°o°000 °000°o0 .000 Oo_�o o�o�00000. 3�4"-1-1�2" DOUBLE WASHED STONE 4' MIN. H-20 500 (,AL LEACHING CHAMBER BY ACME PRECAST OR EQUAL (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR ALL AROUND PRECAST STRUCTURES 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00, X 1:':,83' + CONCEALED WITHOUT INSPECTION BY BOARD OF COMPACTION. (15.221 [21) **3.4' HEALTH AND PERMISSION OBTAINED FROM BOARD OF HEALTH. G % SLOPE) ( 1 % SLOPE) ( 1 % SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR '�•2 CALLING DIGSAFE (1-888-344-7233) AND LOCUS MAP LEACHING 22.5' BOTTOM TH-1 & 2 VERIFYING THE LOCATION OF ALL UNDERGROUND & FOUNDATION- 10' SEPTIC TANK 10' D' BOX 9' FACILITY NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF NOT TO SCALE WORK. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 11. ANY UNSUITABLE MATERIAL ENCOUNTERED ASSESSORS MAP 246 PARCEL 85 G-W EXPECTED EL. 7f PER SHALL BE REMOVED 5' BENEATH AND AROUND THE PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM TOWN GROUNDWATER MAPPING PROPOSED LEACHING FACILITY. **SUITABLE SOILS AND NO GROUND- 12. EXISTING LEACHING FACILITY SHALL BE PUMPED WATER TO BE CONFIRMED TO EL. AND REMOVED OR PUMPED AND FILLED WITH CLEAN 20.9' PRIOR TO INSTALLATION SAND. VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE OF ANY PORTION OF SEPTIC SYSTEM IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR BY HEALTH INSPECTOR PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED BY THE BOARD OF HEALTH REVISED DURING A PUBLIC HEARING HELD ON AUG. 4, 2009 3) FAILED SYSTEMS ONLY : SOIL ABSORPTION SYSTEM SYSTEM DESIGN. INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) GARBAGE DISPOSER IS NOT ALLOWED AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS BE LOCATED MORE THAN SIX FEET BELOW GRADE. EXISTING CESSPOOLS SHOWN AS APPROX. (AS-BUILT UNCLEAR) 31.90 DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD � _ x 32 II/ USE A 330 GPD DESIGN FLOW PROP. VENT WITH CHARCOAL FILTER Oy CP/ AND BUGSCREEN (FINAL PLACEMENT BY ORES 118.70 CONTRACTOR WITH HOMEOWNER X SEPTIC TANK: 330 GPD (2) = 660 _CONSULTATION) 32. 2 33 r USE A 500 GAL.".SEP T iC TANK _ N CAUTION: GASLINE 3� 3 .4 - LEACHING: G 1, OO 11' SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD I fr TEST HOLE LOGS EXIST DWELL. TOP FNDN• = DECK BOTTOM 25 x 12.83 (.74) = 237 GPD x 3 . C. W K ELEV. 35.9' o 91 CO ENGINEER: DANIEL E. GONSALVES, SE #13587 EXISTING WATERLINE I - - v - - - BASE. FL EL. _ TOTAL 472 S.F. 349 GPD (RE-ROUTE TO BE MIN. 10' DONNA MIORANDI, IRS FROM SEPTIC COMPONENTS) o 33.70 28.T USE 2 500 GAL. LEACHING CHAMBERS ACME OR EQUAL WITNESS: o O ( ) 0 DATE: 7/17/14 2t -4.04 _ WITH 4' STONE ALL AROUND (H-20 LOADING) PERC. RATE _ < 2 MIN/INCH PROP. RE-ROUTED I 1 3 71 / 3?1 GARAGE WATERLINE CLASS I SOILS P# 14427 ELEV. ELEV. I N I I I I GRAVEL DRIVEoff Ott o x 32,86 18. 09-- A A 6 ,5- BENCHMARK.• GAR. FLOOR j LS LS AT ELEV. 34.5' MA 10YR 3/2 10YR 3/2 TH1 , APPROVED DATE BOARD OF HEALTH 10" 10" 4.10 o TITLE 5 SITE PLAN B B I T-H2 o LS LS OF 89 10YR 4/6 10YR 4/6 134 x 33. 6 22„ 31 .1 22 31.1 x 3 .18 x 33.,9 20 THIRD AVENUE T_"EE/SCRUE LINE PARCEL 85 12,215t SF WEST HYANNISPORT C C 33.39 .39' PREPARED FOR PERC I BORTOLOTTI CONSTRUCTION/BABINEAU M/CS M/CS AUGUST 7, 2014 i 1 OYR 7/8 1 OYR 7/8 �0� 0 ,n off 508-362-4541 _w fax 508-362-9880 IDA" 'El A %r DAB L ' downcope.com down cope en iaeerin , iac. 126" 1 22.5' 126" 22.5' 02 s 5-'/ civil engineers NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 land surveyors ,, Yir, �, { 2 -� 939 Main Street ( Rte 6A) 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 > 4- 155 i --- i