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Home My WebLink About0085 TOBEY WAY - Health 85,To00Y Way; `247=227 k{, West Hyannisport i Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 85 Tobey Way s . Property Address.. Conner Haugh Owner Owner's Name information ie required for every H annis Port Ma 02647 3/1.2/14 y page. City/Town -State Zip Code Date oflnspection 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 A. General Information - filling out forms on the computer; use only the tab 1. Inspector: Key to move your cursor-do not Ricky L. Wright. �( Use the return key. Name of Inspector B&B Excavation rub Company Name -14 Teaberry Lane Company Address Sandwich Ma.::. 02644 City/Town State Zip CodeN (508)477-0653 S14595 - -uM 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: Tkae inspebtion 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 15000). Thesystem: ❑ Passes. Z Conditionally Passes ❑ Fails Needs Further Evaluation by the Local:Approving Authority 3/12/14 - ..Inspector's Signature - .. Date The.system Inspector shall submit a copy of this inspection report o 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. � I t5ins•3/13 Title 5 Official In Y.,m:Subsurface Sewage Disposal System-Page 1 of 17 t ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 85 Tobey Way M Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 page. Cityrrown 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: 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 ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 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): At time of inspection septic tank appears to be Ieaking.D-box has roots growing into it due to concrete deterating. ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 page. Cityfrown 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 than '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 page. Cityrrown 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. ❑ ® 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 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 f Commonwealth of Massachusetts . W Title 5 Official Inspec ion Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments H 85 Tobey Way Property Address ... Conner Haugh -Owner Owner's Name information is Hyannis Port Ma 02647 3/12/14 required for every. y page.e - 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 ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ Z 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 0 ® this inspection? . Were as built.plans of thesystem obtained and examined?(If theywere 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? ❑ El 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 El approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System.Information Residential.Flow Conditions: ... Number of bedrooms(design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): n/a Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Sept. 2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 page. City/Town 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: 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Tobey Way M Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 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: 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.6 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakaga. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other,(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gala Sludge depth: no sludge t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Tobey Way M Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be Ieaking.Water level 18" below outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 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: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(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 Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 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 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.): At time of inspection d-box appears to have roots growing into it due to deteration in concrete, and needs to be replaced. 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.): I * 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•1113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every H annis Port Ma 02647 3/12/14 y page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): At time of inspection leaching appears to be in working order no sign of hydraulic failure.Leaching was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•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 GSM 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 page. CitylTown 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: 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 85 Tobey Way M Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 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 A aciC a A -22' 3 A Z- Z9' yt' M- Na' A5- s5' R5 - y9' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 85 Tobey Way Property Address Conner Haugh Owner Owner's Name information is required for every Hyannis Port Ma 02647 3/12/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >12 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection 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 ° 85 Tobey Way M Property Address Conner Haugh Owner Owner's Name information is required for every H annis Port Ma 02647 3/12/14 y 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 No. D Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co purer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 4phration for Misposal 6pstem CDnstrurtion Permit Application for a Permit to Construct( ) Repair grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 8 S ,lc7b*, U c.y' Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /_ ;Z Installer's Name,Address,and Tel.No. Designers Name,Address,and Tel.No. r qs),s A `1/\;( s 9W-�i5 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations/(Answyyer when applicable) �x��/.rF �( l'ic/y ' ee-/I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued Board of Health. gn d Date -z Application Approved by 1 Date _4w//� Application Disapproved by Date for the following reasons Permit No. Date Issued I ----------- No.. D� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s" Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliL0.tion for MisposaY 6pstem Construction J)Prmit } Application for a Permit to Construct( ) Repair(0--/UPgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 8.- 70 ie U t,�/ Owner's Name,Address,and Tel.No. y Assessor's Map/Parcel / N� 2 cj 7 _ 2 2 1)4t(/C7h Installer's Name Address and Tel.N i n e o. Des er s Name Address and Tel.No. g > �DosV s A tJ(C�var�� SCE3-YOO-7/55 Type of Building: r ,Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size.of Septic Tank Type of S.A.S. R Description of Soil Nature of Repairs or Alterations(Answer when applicable) Kr��GIPj(�)( GcitJ t'C ! Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued py-INS Board o ealth. ign c Date Application Approved by Date L✓ ir Application Disapproved by Date for the following reasons Permit No Date Issued -------------- ----'---------- ,✓ THE COMMONWEALTH OF MASSACHUSETTS . �aV, 14 �, BARNSTABLE,MASSACHUSETTS /G%�: 1 � �- c t� ; i J �' Certificate of COmtJYiaYYLP 415& j t'1 THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired X Upgraded Abandoned( )by71 f�/�t�V at 0 4;- he a a� has been const ucted'n Allted nce with the provisions of tle 5 an the for isposal System Construction Permit No Installer �k�/.e �r'x19nJ �� Designer #bedrooms c Approved des ow / gpd j The issuance of this permit shall not be cons�trged as a guarantee that the system wi lti as d i ,ed Date 1 Inspector ��47f% --------------------- - -------------------------------------------------------------------------------------------- ----------------- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS misposaY *pstr Construction permit Permission is.hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 7-akey �,c l�vuM/Vl� 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. 4 Provided:Constru ionV Je co pleted within three years of the date of this permit. Date Approved by 11�# , T'—�OX RP IG(-C'MeA,)4 aA.0 C � v TOWN OF BARNSTABLE LOCATION --ro I a SEWAGE # � � VILLAGE ASSESSOR'S MAP S& LOT INSTALLER'S NAME & PHONE NO.A.ZimAllollow SEPTIC TANK CAPACITY LEACHING FACILITY:(type) -'S C p size) /0049 NO. OF BEDROOMS -PRIVATE WELL OR diUBLIC WATEIt1 BUILDER OR OWNER KAAS EwrER PRIS°oS DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No __ �� !� s �� ,� '� s �� ` V � � �� ;� i �� /� �a.. � ,� i -�� ""�, �, � ti� a ` ` : r. i / i A Fs .`........ THE COMMONWEALTH OF MASSACHUSETTSA � ~ ail131(P) BOAR® OF HEALTH �s �-- oration for Diiipoott1 Workii Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....J, c I LIC(- �.......�.�. ............................................. ----C -......................................................... Lat-i_Qo�n- Address,.. 9 r 1No.�tA � x .... � am .....................•••-•-......._. wner Address ►fir .----•-• � ............ CSA................................... Installer Address Type of Building Size Lot.....C.211P5?.........Sq. feet ,., Dwelling—No. of Bedrooms........................................Expansion Attic ( } Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria a+ Other fixtures _--••--••-•-•-•-•----•----•----•••••••-•--••-_•••. .. ......... . ........•----•--•••--••-•••--•---••-•--•••--•-•-•...........•---•......_._.._. W Design Flow..................UD....................gallons per person per day. Total da&flow..............(v,6.0....................gallons. WSeptic Tank—Liquid capacityl�P�...gallons Length__._W________ Width................ Diameter................ Depth__________...... x Disposal Trench—No_ ____________________ Width Total Total Length_.__________._;____ Total leaching area....................sq. ft. Seepage Pit No............. ____ Diameter............lk.___ Depth below inlet.........6__...... Total leaching area__QY:_a...sq. ft. Other Distribution box ( ) Dosing tank ( ) '� Percolation Test Results Performed by---------- Date__.___________......."__...__._______. Test Pit No. 1_A___....minutes per inch Depth of Test Pit.....Nk !........ Depth to ground water..... ....... fx, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 --------------------------------------------------V_ _________i....................................._..__._...;....____.._._.........._._. 4- Description of Soil........��ku-•----TW._/_.S4'_.13,.............. 2 � .------� -...._cmtor.,T,Z ............Z-0...... *..........qcc.. -------------------- -------------------------------------------------------------------------------------------------------------------------------•---•-•-=----•----------•--•--.._-••-•------••-••--- U Nature of Repairs or Alterations—Answer when applicable------------------------------- •------------------------•--------••------------------•----•---•--------=-----------........----...----••---•--•-----•--------------...---•-•-----------------------------------•-••-•--••-••...__•_.._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIHE 5 of the State Sanitary Code—.T e undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued the board of health. oz C-< !o wed ---•--••_•---• ... �` — Application Approved BY =-- ••-•.................... .......................... ..........-J..:-----......---- Date Application Disapproved for the following reasons:.............................................--•-.............................................................. - --••-•-•--•-------•---•--:-_-••••-•----•••-----•-----•••--••-•-•-••r--••-••--••.................................••••--•••-•-----•-•-•------•---••----•••-•-•-•--•-•------•-----••------•--•-•--••------- �/ Date PermitNo..............-•---._... ---•-------C--f•J---------.__ Issueci-....................................................... Date l! THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '...... a wN ' Apphration for Uiopoottl Works, Tonotrnrtion rrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• r__ ......................................... ........................... ,mot..: ...............»...................-...... �j G Location-Address j or No. ........11 t.. ._....`... �...._....... ••..............•••...................... . ............!^--!i-- &.24 B,:1 .. .1Rr ............. »«..... (jwne ........... W "� t n Address 1=/�4i�i1 � ...... �s, Installer Address Type of Building Size Lot.....I 000........Sq. feet U Dwelling—No. of Bedrooms................ .._......__.. _Expansion Attic ( Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) OrOther fixtures -----------------•------•-------.................. ......---•---•--•--------•--•--•----...........-----------...-------••--•--•--••.....•••••.•-• Design Flow``..:...........11D.......--..........gallons per person per day. Total daily r low..............4f 0...................gallons. Septic Tank—Liquid ca.pacity.!5?*...gallons Length....W........ Width................ Diameter................ Depth...._.�...... x Disposal Trench—No..................... Width........_.._..._.. Total Length....._........�.._. Total leaching area...................sq. ft. 3 Seepage Pit No........".-- .... Diameter................. Depth below inlet.........6........ Total leaching area..KV!.1...sq. ft. z Other Distribution box ( ) Dosing tank ( ) .'!�- r • _ �... Date - o Percolation Test Results Performed by..........Z,. K .._....-_- ........................ as Test Pit No. 1.A.7-......minutes per inch Depth of Test Pit.....1ku't...... Depth to ground water,.....j,A&A.tX..... 1 4 Test Pit No. 2................minutes per inch Depth of Test Pit................... Depth to ground water........................ .. ---------- ------- �;------------i....."--•------------------------------••-----------*....................... ....... uj D Description of Soil. Pt......... + .- .... ...`./20.. Cl�ttL,sr..uSE�e� ......... Q._-t._".Y."..../.!t: V ------------ •--------- --------------------------- -------------------------- --• ... --------------- •....... .------- ------.------•---------•--------......-------.-._... -----•---------------------------------------------------•----------•-----------•--------------------------------------------•-----..............------......-----..............---._............_••.--• U Nature of Repairs or Alterations—Answer when applicable................t..........._............._...._............._...........,_...._.............. ...--•--•-••--•----------- . ..••••-•--••-•------------------------------•--•-•-•••-••••-•-•-••••....---•--.........•------•------...--------•------..............._.................................. f Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System,in accordance with the provisions of TITLE 5 of the State Sanitary Code—.TV undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue the board of health. igned.... .. ............. '"07.6••- rc' ...--••--.• •. ••- Dates Gtp J Application Approved B ... . .., -. Date Application Disapproved for the following reasons-----------------•-•--------------•-•------ »»» •...........................•-•----------•--.....---..........•............---..........--•---••----•-••-..-•---•------............------......-----.......................-----•----......-------•---- G 0-4 PermitNo.-••••••••-• ............. -._.... Issued....................__.....-•-•••.........nau Date ---.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH V................0 F.......... . N-c' . Trrtifirate of Tontphatur THK I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ..... .................................................................•=-•--•••••-•........_.................._.........................«....» `I _ Installer at has been installed in accordance with`I'he*ovisions of TITLE 5 of The State Sanitary Code As de .ribed in the application for Disposal Works Construction Permit No...... -':.': fox- ...... dated... .,..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...............•----•--..............---------------••-.........••••....._••---• Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N y...................a wry.......OF.....�.�' r�>�3 z�................................. o. �..... Otoposal Marks Tonotrttrtion prrrA t Permission is hereby granted..._ 4;�A S2 an................. to Constru ( or Repair ( an Individual Sewage Disposal System atNo..---....... .........................••--•........ Street �c�, as shown on the application for Disposal Works Construction Permit No. D ted........ c�. G;..... ...... --- ....-•........................... C� ��f7f_ Board,of Health DATE..... ... .. .._...1.t OCo.........................•---- FORM 1255 A. M. SUL 4 INC.. BOSTON i i Speed Letter. To, From 95 Tobe Way y West Hyannisport, Mass. .. Subiect __ Occupancy-Permits Required for New Dwellings: —No.9 A 10 FOLD { MESSAGE Please contact this office regarding subject. Thank you. Date 10/14/8 8 V , G~ Sig d Richard Bearse/Bldg. Inxp. REPLY —No.9 FOLD —No.10 FOLD - Date Signed — r^� ,es CompanyCD ° "= 'L9A SENDER—DETACH AND RETAINS YELLOW COPY. SEND WHITE AND PINK COPIES WITH CAR N T,—1. JOB # 83-014 CERTIFIED PLOT PLAN PREPARED FOP: LOCATION: LOT-2 W HYANNISPORT SCALE. I "=30 ' DATE. 05/15/86 REFERENCE. P8 374 PG 72 KAAB ENTERPRISES I HEREBY CERTIFY THAT THE BUILDING _ SHOWN ON THIS PLAN IS LOCATED ON THE /`ts Of GROUND AS SHOWN HEREON AWE sG� ( N: down cape engineering ti 6JAiu CIVIL ENGINEERS \Ei fcis LAND SURVEYORS ROUTF 6A YAPMOUTH MA UnATF a$rr i AAin C1lovrvno I 4 A074LA, bQ G47 CCU 1 SECTION = SEWAGE I / —SEPTIC TANK— 7/ —"D"BOX— —LEACH TOP F F _� _SL-3S. - - "2"OFt/s TO ih' WASHED STONE t 3/ � Tr 39.7Fya IN• .v 22G , � IN TANK ELEV. ELEV. ELEV. r ELEV. • . �� _ ELEV. ELEV. Ee:LE Z I OF -.WASHED STONE• TEST HOLE LOG.. TEsTay R.FAIRt�Ar.iK.:PF, - J. ,I A(n�i 3?S4- �L. 2�,(7 TEST DATE 7-2-0-�' WITNESS DESIGPt: T.b: 0 i - 4 BEDROOM HOUSE T.H. 2 C3 9 (o> Q�' ELEV. ELEV. �3�•b� 21" SIL I sowPERC RATE L 2 MIN/IN._ oaSPOSER DISPOSER YI; OF FLOW RATE•/i O. {GAL/DAY) ....44 pu o SEPnd TANK 410 . . (/S1= FI \P- REQ'OSEPTIC TANK SIZE LEACH- MCILITY C. AN - ,. �. SIDE WALL Z . £ BOTTOM /' �.I= Z /:o ) 1. G/D: . u M TO A L 534 its-( (zs.G) USE: T U LEACHING _ EELS /o'/0 AC-H WAEE NOThS.'(tJNLESS-.OTHERWISE NOTED) --'j 1.DATUM(MSU!.TAKE N FROM YA QUADRANGLE MAP.> I'9 2.'MUNfCIPAL WATER AVAILABLE �tH OF 3.PIPE PITCH:416"PER FOOTto 4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO- H- I n. •44 y d S.MIN.GROUND COVER OVERALL SEWAGE FACILITIES:(1)FT. ARNE'H? Gam. 6:PIPE JOINTS SHALL 13E MADE WATERTIGHT OJALAA 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. `� I;IVIL'D STATE ENVIRONMENTAL CODE TITLE S NO 30 �-.IOT aE u•�fl a=�. �a��`'C �...,G- ��d.e.r...ac. . ,�' REG. ZONAL ENGINEER CONTOURS (EXISTING)............. BOARhOO�F,{H�E,2ALTH (PROPOSED) APPROVED 0aTE_ I�1CI�I7INVLE MA mom LCDT .LLJ C �- 106 OCR` /40 p.� ILA Z \cp � 25 I AY st;TbAGKs r/115 iv' af� i i OF PLAN Lodw: ��2 To aFY rn/�Y��ARt.lS(hC3t.� RN y to AH E �\� W;K2HIkIG'(01� rARf.� 'fAT S) OJALA U8 of REF: ?t7K 292 f7Ai5�� -71 down cope eali7eqn?, ��fp /51E s PREPARED FOR: Ei. ERPC�ISEJ CIVIL ENGINEERS ifs LANOSURVEYORS M.Mala REG.LAND 5 EYOR DATE . U-A !x e � � y r 1 BOO Jill Kom ,Ao m„w^ COMMONWEALTH OF MASSACHUSETTSN EXECUTIVE OFFICE OF ENVIRONMENTAL AFi�Fc6IRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)�9 ?55(aQ, ^I(y/C l l ? 0,, l�Of ool/ TRUDY COXE Secretary ARGEO PAUL CELLUCCI I 1DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 85 Tobey Way, West Hyannisport, MA Name of Owner: James Malver Address of Owner: 1 Old Ridge Road Date of Inspection: August 2, 2000 Canton, MA 02021 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: Telephone Number: (508)862-9400 Parcel. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluatio B the Local Approving Authority ails Inspector's Signature: Date: August 3. 2000 The System Inspector shall submit py of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. NOTES AND COlvWFENTS Jo- revised 9/'2/9 g Page 1 of lI Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �� 85 Tobey Way, West Hyannisport, MA " Owner: . James Malver Date of Inspection: August 2, 2000 r` INSPECTION SUMMARY: Check A, B, C, or D.- A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health: Sewage`backup or breakout orryhigh static water level observed in the distribut1onbox is`due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system'will pass inspection if(with approval of the Board of Health) broken pipe(s).are replaced obstruction is reeved distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 85 Tobey Way, West Hyannisport, MA Owner: James Malver Date of Inspection: August 2, 2000 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 the public health,safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank.and soil absorption system(SASS and the.SAS is within 100 feet to a surface water supply or tributary-to a surface water supply.P The system has a septic tank and soil absorption system and the SAS,is within a Zone 1'of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 AP , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART A CERTIFICATION (continued) Property Address: 85 Tobey Way, West hyannisport, MA " Owner: James Malver Date of Inspection: August 2, 2000 D. SYSTEM FAILS: You must indicate either"Yes" or"No".as to each of the following: _ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than'h day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any,portion of a cesspool or privy is.within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a,cesspool or priyy,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." If the well liar been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 85 Tobey Way, West Hyannisport, MA Owner: James Malver Date of Inspection: August 2, 2000 h `" Check if the following have been done: You must indicate either"Yes"or"No as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. *✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. (*The house has weekend use.) ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ` ` -• ✓ Existing information. For•example,Plan at B.O.H. ...... 4 ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)]• ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. 4 # .i/K:, �..'li ac.Y T wr:.i�.t .a.x..: , . .. .t� .. .,.. c ♦ R ` revised 9/2./98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,,INFORMATION Property Address: 85 Tobey Way, West Hyannisport, MA s ' Owner: James Malver Date of Inspection: August 2, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): 4 Number of bedrooms(actual): 3 Total DESIGN flow 1099 Number of current residents: 0 Garbage grinder(yes or no): No Laundry(separate 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 two year's usage(gpd): 2000-25.500 gals.:1999-14,250 gals. Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: sad(Based on 15.203) Basis of design flow 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: _ . .. OTHER: (Describe) Last date of occupancy: GENERAAIL`t INFORMATION PUMPING RECORDS and source of information: Never pumped-per owner. System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other ' ea.taFr .1 APPROXIMATE AGE of all components,date installed(if known)and source of information: Approx. 1987-per owner: Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 a ,a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8.5 Tobey Way, West 11yannisport, MA Owner: James Malver M' R Date of Inspection: August 2, 2000 d BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence_of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) { Depth below grade: 12" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: I500 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 30" W Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 8" How dimensions were determined: Measuring stick Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) i Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,.etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Tobey Way, West Hyanntsport, MA ,•a - :.:..# Owner: JamesMalver � August 2 2000 «� �: . . n: Au Date of Inspection: g , TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection): (locate on site plan) � Depth below de: P Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ (locate on site plan) u.. Depth of liquid level above outlet invert: Even Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level and distribution was equal There were no signs of failure in the leach pits PUMP CHAMBER: None (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) _ Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Tobey Way, West Hyannisport, MA }. t4 Owner: James Malver Date of Inspection: August 2, 2000 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: 2-6'x 6' leaching chambers,number: leaching galleries, number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.) One pit 04)was dry. The scum line was 6"up from the bottom. The bottom to grade was approximately 10'. There were no signs of failure. The other pit(#5)was located, but not dug up. There were no signs of failure in the D-box. CESSPOOLS: None (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(cesspool must be pumped as part of inspection). Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) PRIVY: None (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.) , -revised 9/2/98 Page9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Tobey Way, West Hyannisport, MA Owner: JamesMalver Date of Inspection: August 2, 2000 ,i sta c: i•C'• Map: Parcel: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) L3,��k i Al - Pi I- IU, A,- as, . . . .. .... ... . ;3a- 9-4-1 a o A$- y I f33- 38 Aq- 14 As- 5s 85- yq . w N revised 9/2/98 Page 10of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 85 Tobey Way, West Hyannisport, AM Owner: James Malver Date of Inspection: August 2, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 25 +/- Feet Please indicate all the methods used to determine High Groundwater Elevation: ✓ Obtained from Design Plans on record Observed Site(Abutting property,observation hole, basement sump etc.) Determined from local conditions Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) The bottom of the pit to grade was approximately 10'. A perc test was done when the system was installed, and no water was encountered at 168". Using the Barnstable topographic map and water contours map, the maps were showing approximately 25' +/- to groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site(MI W 29, Zone C, 6100)was 3.1'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. n I revised 9/2/98 Page 11of11 AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION 3!5 1 O_LCti L�4 :J SEWAGE# VILLAGE W. PVT AAI_f Doer ASSESSOR'S MAP dt LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACrrY 15ob LEACHING FAC LrrY: (type) 1TS (size) NO.OF BEDROOMS 3 BUILDER OR OWNER A A AIVcr PERMPCDATE: 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 J3a- ay A3- / 63- 3$ gay- wg a J3H• 53 A5- rs 3 � S http://issgl2/intranet/propdata/prebuilt.aspx?mappar=247227&seq=1 3/27/2014 _} TOWN OF BARNSTABLE N O& LOCATION U/4�:J SEWAGE # VILLAGE W. AVOA ►' DAt "":' ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Mob LEACHING FACILITY: (type) 1'` !TS (size) NO.OF BEDROOMS 3 BUILDER OR OWNER 5AeneS !M A I Vt(- PERMITDATE: 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 AI- A3- 83- 39 Ay- y9 a 8l- 53 A5- y P, < 4 SECTION SEWAGE ' N SEPTIC TANK- 7/ "D..BOX- / -LEACH TOP OFII n ,( 'V -(MSL)ar ..2..OFI/sT044" WASHED STONE 39 IN• OUT• LN• LGG Q.UT.• IN• I1� SEPTIC 131 -, ' T..Z // nn zl ELEV. TANK ,(DU 12 W.D ELEV. ELEV. ELEV. S-F 3? 2 �;y ELEY. ELEV. Y•; (D /O' °�C , i U` r rrL� 2/ i4":. Yer /? OF l `� y ` i (•R. I�n� - -WASHED STONE o, 1 Io TEST HOLE LOG - .TEST BY R.EAIRI3&W J. ,IAQ[31 yit3254- ajl�(� - � o All � WITNESS TESTDATE 7-2-0- 84 f - DESIGN:• Q BEDROOM HOUSE �� <V T.ti: >w► 1 T.H. 2 C39 (o� ELEV. ELEV. NO (27 511- _ PERC RATE. 4 2 MINAN.. DISPOSER DISPOSER N j, j /` / H. L Y15k of FLOW RATE /1 d. (caL�oAY) 94 SA ADS E a� SEPTIC TANK 410 , . US).- Hill V�L REQOSEPTICTANKSIZE I.(n� 9[0" LEACH" FACILITY �>. / t 29` IN G I EAN SIDE WALL .2 /a 1- (.�5.i G/D. S,cA I C AiZ, BOTTOM Z /0 yzi=% 7 /to i / .7.,.• !. G/D: . w `?� �� NI TO A L -�53�I r I S- ./0 9 .. p• t �^- /o U•O U' • __ AY USE: 1�Y�1(� LEACHING . PITS J� _WATER ENCOUNTERED H : l0'�FF wl �X. �o'I7FPTH j . 1 NOTES: (UNLESS.OTHERWISE NOTED) SI;`T"[A6r-S 1.DATUM(MS)±TAKEN FROM 4 l.5 QUADRANGLE MAP.: '• FRO�,rr —70,MUNICIPAL WATER 3.PIPE PITCH:No"PER FOOT VAIU4BLE j�i Q� �aa�,Rrq asII/.1 �U/ 4,:DESIGN LOADING FOR ALL PRE-CAST UNITS:AASHO- H r 1 U. -44 pC •5 `� S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. `� ARNE I I 6:PIPE JOINTS SHALL BE MADE WATERTIGHT OJALA 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. CIVIL �- SITE PLAN STATE ENVIRONMENTAL CODE TITLE S No. 30 2 8. Tyty Qt��. , FQL Ptf> O t� GIC C►�:t_`f Lr..►d �+LOc1a_l? t` ` i P� k OF ►-to e- urn �a� �sro�zz1� t_.`sG �-aC:+.►G. �� F E�✓ /4 . `". ��ya� Jai;., LOCUS: LCSr 2 TO a EY L/Q`[, 6AR 1�15"(A C L- ,s� A ant E ,�N I KI�.,'>'ON FAR M 9!LATi%51 REG. 5 IONALENGINEER o Q.IAtA �> �A&F -7I • I � � � '' >s4a o�' REF: L9(?Z7K 29 2: down cape eagineer�ng �g �ss� ISiE� ' PREPARED FOR: A [3 !Ef M5RM12E5 _ CIVIL.ENGINEERS LAND SURVEYORS V/P- �9 ICI AV �'�11V1 QI2 I t7/,E �� C'2/39 CONTOURS (EXISTING)--••--•- BOARD OF HEALTH REG.LAND S VEVOR• P „=36 (PROPOSED)-O-O-O-O- APPROVED ARK121Al3L F SCAL GATE MA 1f11.Jti�. DATE #g 3 q