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HomeMy WebLinkAbout0005 UNCLE AL'S WAY - Health 5 Uncle Al's Way 292-003-010 Hyannis k I� a 0 i} k li jl .I H P 'u I n li TOWN OF BARNSTABLE LOCATION UnGI�. /* W13q SEWAGE # 'iA LAGE 14y4A*11 S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /&W LEACHING FACILITY: (type) . PI^ (size) NO. OF BEDROOMS 3 BUILDER OR OWNER ST Gf-O/St- PERMTTDATE: 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 Edse of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by Tr►sOG2n� B � q B � 31 13 a a33 �s y 3 3 3°I 4b y 3� yy Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM .5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA _ 02601 2/1/2007 every 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. o�9, Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Brian K. Tilton cursor-do not Name of Inspector use the return key. The Building Inspector of Cape Cod Company Name P.O. Box 307 Company Address Eastham MA 02642 .. City/Town State Zip Code 508-255-9343 Telephone Number License Number B. Certification 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 16.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ����2/�2/2007� Onspectorr'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. 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every 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: ® 1 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: All components in place and functioning normally. 13) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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. 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 5 Uncle Al's t5insp•08I06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 z Commonwealth of Massachusetts F Title Official t e 5 0 cal Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] 0 E 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 V ❑ ❑ 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. 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every 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 CMR 15.302(5)] 5 Uncle Al's l5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 333 Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage (gpd)): 800 gpd. 9 ( Y 9 I Sump pump? ❑ Yes ® No Last date of occupancy: 11/2006 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(s.eats/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: Last date of occupancy/use: Date Other(describe): 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Uncle Als'Way 5 Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner 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{t(S be obtained from system owner) ❑ Tight tank. Attach,a copy of the'DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 9/20/2004 Design plans on file with board of health-Drawn by Darren M. Meyer, R.S. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Uncle Als'Wa Y Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): r . Depth below grade: 2'feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A(town water) feet Comments(on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks or back up. - Septic Tank(locate on site plan): Depth below grade: 1.5' 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 ❑V No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 5'8"x9'6"x4'10" (1000 gal.) 8" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 22" 6" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Dip stick,baffle stick and tape measuire. 5 Uncle Al's t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA. 02601 2/1/2007 every 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.): Normal levels and no evidence of leaks, back up or failure. All components in place and functioning normally, system should be pumped for regular maintanence at least once every year to protect pump. Property has an irrigation system and a toilet was not adjusted properly and was running slowly at time of inspection. Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: N/A Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): 5Uncle Al's t5ins •08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10of 15 I� i Commonwealth of ffiMassachusetts . in Title 5 Official Inspection Form _ Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments ^M 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601-` 2/1/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locateon site plan): 01 Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box is level with no evidence of leaking or backup of effluent. no solids. Pump Chamber(locate on site,plan): Pumps in working order' Yes ❑ No Alarms in working order: ® Yes ❑ No 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1!2007 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 100 gal. pump chamber with cast iron pump and float switches all operating properly as designed. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: 1 30'x15' ❑ overflow cesspool I 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.): no evidece of break out or hydraulic failure. lawn over top of mounded system. 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/112007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 5 Uncle Al's t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Witte 5 Official Inspection Form _ — Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Uncle Als'Way Property Address Elizeu Aguiar Owner Owner's Name information is required for Hyannis MA 02601 2/1/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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. j 604 wtl\l j h G� o 2 tR P/ `)COO Poliv t 3 r , IN !S �4 = � n ^ � r r p 1 To 5CALE' 5 Uncle Af s t5insp•08106 Ills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 5 Uncle Als'Way Property Address Elizeu Aguiar Owrier Owner's Name information is required for Hyannis MA 02601 2/1/2007 every page. City/Town State Zip Code Date of Inspection t D. System Information (cont.) Site Exam: j ® Check Slope ® Surface water ® Check cellar ® Shallow wells 5' Estimated depth to ground water: 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: 8/24/2004 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: System design plans on file with BOH. 5 Uncle Al's t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 �Z'ST HOL , LOGS SOIL EVAttJATOR:� . .��`I�z��/ WITNESS:.Nbfl��r � toOG VIDN SEMCTA . F DATE '._�..«._...<<_..._.PERCOLATION RA__...TE ,.:..._ __—__-- ....... .w�.......-._.----• 5.3°a 3'x2.15 x62.4= S.;UI z � �+�+r� trltrt{ c;xov xD covm. xS'x5,x.751K120` =3.81 = TH- ! -E4-%A TW2 r:�irr� r.�rtic a,oaoII SkN.17,-(s 4 GROI DCOVER+EU ''ntT.A-NK>'u 8.000 l,82Sihe: >57ott we)Z,vxY CHECK O.K. SAS ' ��f P'{ �,w7 1.000 t3.4t.!t►,rt-sir crlaniB>x _. r 8Yx5'x1.9'x62.4= 5,039s 1i12o1 XllCgA]g: x5'sS'xlj'x120 = 3,823k �X ESlP'I'1'TANK: 8,000 Ac�DT. G w »L. 3 2,U BUO ANCY CHECK O.K. Wec..•- tua z,b S E P T ! t; SYSTEM DES 1 GN FLOW EST I MATE aEDRoo GAL/DAY/ 33C GAL/DAY SEPTIC TANK r ' -�)<- L)GAUDAY x 2 DAYi-7 GAL USE �(ZOGALLON SEPTIC TANK — e_ws-riN� — 7J-�'�c, w !•Scc PWKI \ SOIL` ABSORPTION SYSTEM - OIL- UNIOE"►2Ett 1,A'P-2—A L 5 . :ODE AREA: NL4 UOTTOM AREA: 30 K 1�5-- -y' a,'?Y = 333 6 P > 336 SEPTI .. SYSTEM SECTI'O 4 .3 'Pump (µ+m �,sf�lt �� r�•� 136 a►��. Fc„ 38, o s' 3V,53 Pl_31 7,s6 0 GAL /r/w 37 D-BOX 3`?•'�S �¢'_ ' �pdbf� 3` 9 37,:Qf SEPTIC WANK re TV pqcw SITE AND S E.WAGe PLAN LQCAT ION C�� G. [+./.L��( 1t _- - �L.t'�4t�F�0 �,:...P►!.M��m� zoGic.��__2�.`�_..��'�vk�,,- W .- �jt 0 J ? ! -,... .... �c. .Mw -y. .t„ y�' ca+�,-rio .:............ ... PREPARED FOR . �Z. �7` C.•G► �RN._�2.o,tJ -. �L! ►2r!!I,_ T1?_ ...GI�Gh &,��. IN,S�,p ,t7 .N4. l� . � DARREN �M. MEYER, R.S.: ScAL +43,FAIN STREETDATE s. 2 =` DUXBURY; MA 02332 I HEALTH AGENT: (781,1585-0'293 y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 5 Uncle AI's Way AFSS Hyannis, MA 02601 Ao �RSMApN Owner's Name: Albert St. George !©�- Owner's Address: b Date of Inspection: July 8, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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: Passes Conditionally Passes NeedsjFher Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: Date: July 13, 2004 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that r_ time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5 Uncle AI's Way Hyannis, MA Owner: Albert St. George Date of Inspection: July 8. 2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of i l OFFICIAL•INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5 Uncle AI's Way Hyannis, MA Owner: Albert St. George Date of Inspection: July 8. 2004 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. 4 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303.(I)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if.any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to-determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform -bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. d 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5 Uncle AI's Way Hyannis, MA Owner: Albert St. George Date of Inspection: July 8, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/2.day flow ✓ Required,pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. a _ ✓ 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 I 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 160 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 (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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 0,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface.drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or-operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional,office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 5 Uncle A1's Way Hyannis, MA Owner: Albert St. George Date of Inspection: July 8, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the folilowing: 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: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 5 Uncle AI's Way Hyannis, MA Owner: Albert St. George Date of Inspection: July 8, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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): n/a [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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 3 years ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason.for pumping: - TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes;attach previous inspection records,if any) Innovative/Alternative technology: Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 2/19/85-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 Uncle A1's Way Hyannis, MA Owner:, Albert St. George Date of Inspection: July 8. 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 pal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring 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.): Tees were present. The liquid level was above the outlet invert, backing up from the leach pit. GREASE TRAP: None (locate on site plan) I Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: , Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): i 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 Uncle AI's Way Hyannis, MA Owner: Albert St. George Date of Inspection: July 8, 2004 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: -- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was under water. 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.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 Uncle AI's Way Hyannis, MA Owner: Albert St. George Date of Inspection: July 8, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Liquid was above the top of the pit. The cover was not opened. The pit was underwater and in hydraulic failure. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: . Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 UncleAl's Way Hyannis, MA Owner: Albert St. George Date of Inspection: Jul 8 2004 p v , SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 6 a 31 13 a 33 s y 3 e y 31 �y 10 A J Page 11 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 UncleAl's Way Hyannis,MA Owner: Albert St. George Date of Inspection: July 8, 2004 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: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps, the maps were showing approximately 10'+/-to ground water at this site. This report has been prepared and the system inspected and failed 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. 11 TOWN OF BARNSTABLE LOb:T-161 unc1 /c. ALS Wau SEWAGE# dOOq- y91, VILLAGE_ 14 J ann i 5 ASSESSOR'S MAP& LOT RNSTALLER'S NAME&PHONE NO. B g EXcaauo.A;on 308 L0 1 -0653 SEPTIC TANK CAPACITY l000Sm ST l000 9a.) �eu`ino e!I mSzr' ' LEACHING FACILITY: (type) F—;e I d( (size) I S x 3 0 NO. OF BEDROOMS c3 BUILDER OR OWNER AL ST. Gco �-. PERMITDATE: ?- go - O q COMPLIANCE DATE: G� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S' Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility), AI A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) IV A Feet Furnished by AIR 30, AZ 82 = /9' Iq 3 = p79 1 (car off' dwo I1 i n9 $3 ° 095 ' A .DccK A q t as Bq :3t ' ' AS : ys " y 3 z BS = qS- d No. 0 00 7i'► j0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppliCdtton for �DtgogoY *p$tem Congtrurtioll Permit Application for a Permit to Construct O Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. �- z^ _ O J ) Y At s+• oeorge 939 q Assessor's Map/Parcel 2 Q 2 ! /® 5 u n U e p i F 1 1 Q O zLp Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. _ 7� l — 5957 -DZ9 �Zober-t Cx�t �y at�3�xC�VGtion ��Q«en M° Meyer 3 i Teaber�� 3 V the 5+°MO 02 1 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �' Ito gallons per day. Calculated daily flow 33 0 gallons. Plan Date S U4 (7 Number of sheets Revision Date Title Size of Septic Tank I000 Type of S.A.S. Description of Soil; Nature of Repairs or Alterations(Answer when applicable) Date last inspected: ` Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Board of Hea4h. Sig Date - 0 Application Approved b Date Application Disapproved for the following reasons Permit No. 9P9�j - e-19,6 Date Issued =2W „-*r.'•-r^ja, r... .r t��irw-n...:d.{+.-.- •"4._..�. �• y+._Vt ��'� .,.,*-^t^•"'�.- f4.. .-r+t .y.,,y's:�.°�1"`.''•r......t`^ a .-v. , \ ` No. `”' 'op� 4V Fee N r THE COMMONWEALTH OF MASSAC:HUS �7 Entered in computer: , E S Yes PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLEs MASSACHUSETTS' Application for Mi5po.5ar 6petem Coin.5truction Permit Application for a Permit to Construct X Repair( )Upgrade( {)Abandon( ) ❑Complete System ❑individual Components Location Address or Lot No. ��` 7_g t _—r a 1J j "} / O er's Name,Address and Tel.No. 1 H A� S+ C7eorge Assessor's Map/Parcel 2 q 2 f 3V,Q 5 U n GI e. A 1 5 W o\l o n n i 5A n oz. , _I st er's Name, ddre� and Te No. signer's Name,Address d Tel.No. {{(( �� - �3�g3�xccl�at�vn ct��en M• �p-ye� l eCs ber\. i-ny 3 V i ne 5+" - DreS+-c�ait� Aa oz,lty wibgrV, Mn 02-;3 2— Type of Building: Dwelling 'No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) s Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow 1 gallons per day. Calculated daily flow 33 o gallons. +• Plan Date Z 4- U Number of sheets Revision Date Title t Size of Septic Tank 1000, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) r —,Date last inspected: -" Agreement: :f,� The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ",by-� Board� of.Hl th Sig e ` Date 9-Application Approved Approved by 1<- i`f Date L� Application Disapproved for the,following,reasons rf < _ Permit No. � .^ � Y '� Date Issued �p THE COMMONWEALTH OF MASSACHUSETTS - 1 ( BARNSTABLE MASSACHUSETTS Certificate of Compliance rTHIS IS TO CEIT`Y , that the On-site Sewage Disposal System Constructed ( k�Repaired ( )Upgraded( ) .. Abandoned( )by e at urd! 4�J w H b`l '1 been construeti / .d in acc9.rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. ` t ated '.' d ��` Installer Designer The issuance o his a all not be construed as a guarantee that the sy to will'f on as g ed t7 Date `� Inspector W - t No. �—"i--------------------------—Fee— — k' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Di5po5ai *p5tem Construction Permit Permission is hereby gra ted to Construct( pair( f rade( )Abandon. ( ) System located at VNC J A _ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ' Provided: Construction must-be completed within three years of the date f thi-"`s nerrrifit. Date:_. 9 Approved by Town of Barnstable y�P�OFtHE Tp ReeulatO y Services Thomas F.:Geileri Director • BABN$3'ABF.E• • IM, �0 Public.Health Division rED A Thomas McKean,Director 200 Main.Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: r Z2 i , Designer: Installer: $ &czct ocxi i O Address: 0 BO�c ��� ,. Address: I �• �J�7'�b�ILN A4 025-37 Fo►-cs^talo.,.(c .-r���y�/ On nj -0p0 -o q E (3 exc4 ya4;o/% was issued a permit to install a (date) (installer) septic system at 5. U NL(.E Al.S W�m based on a design drawn by � aa (address) ✓ tvk lvt G� dated Z4 ZG0 (designer) x 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved-changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or an verti I relocation of an component Y Y P of the septic system)but in accordance with State lions. Plan revision or certified as-built by designer to fallow. DARREM. M E (Installer's Si e) ASTER ��� SgNITAR\P� esigner's Signature} (Affix Designer's Stamp Here) ' PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH`DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form LOCATION � � SEWAGE PERMIT NO �11-o C 0 v Ald-Le- w W, �F VILLAGE IIJ Q�l INS LLEIt's / NAME A ADDRESS ` B U I L D E R OR OWN ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� �� � _ ,� � �� t �' `�' � �� . , w „. r n rm fVNts�9� .. ASSESSORS MAP : '2� Z' TEST HOL = LOGS NOTES: a RG Una d"< ,� PARCEL : 1 �.T - 010 I) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH ix IBUOYANCY CALCULATIONS w FLOOD ZONE : �DN RkIA-�—OSOIL EVALUATOR IM R•S C� THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF �-`'I 1,000 GALLON SEPTIC TANK: BOARD OF HEALTH REGULATIONS. WITNESS UIl REFERENCE: DATE: tT -I: UPLIFT: 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, 8.5'x 5'x 2.15 x 62.4= 5,701# PERCOLATION RATE: �- 2„"-lN lml+ SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO s <'�aa� I�0 GROUND COVER: INSTALLATION. 3 3a z� z .� 8.5'x 5'x.75'x 120 =3,825# SG ffi[oi ° �q 11 � ® TH- I �tf3(��.I0 TH-2 EMPTY TANK: 8,000# ' 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION I t is PoONLY, AND SHALL NOT BE USED FOR PROPERTY LINE wKi �c waa �a� sicAiNo �M CtR S (o`IR�Z. GROUND COVER+EMPTY TANK)UPLIFT DETERMINATION. r - . � au "- � (�' 3,825+8,000 =ii,825 ins. > 5701 Ins 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS A-AD1 � � � BUOYANCY CHECK O.K.(py12s( SPECIFIED OTHERWISE) LOCATION MAP (9 fi-S) ZZ 31277 1,000 GALLON PUMP CHAMBER 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A ? i���� UPLIFT: GARBAGE DISPOSAL. /'? 1• 3.5'x 5'x 1.9'x 62.4= 5,039# 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) C GROUND COVER: MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON 8.5'x 5'x.75'x 120 = 3,825# �+ "7 �Z. A BASE OF 6 OF CRUSHED STONE. EMPTY TANK: 8, � z E�--- 000# l �_N_ ._L_F�t,H-__P.cr...T�_ 1� ILL S p� - 2-S GROUND COVER+EMPTY TANK P UPLIFT _-_-- _ -___..T__w.______,.....w..._.____.___. __ . _ ......_.__.._.._. ©✓�• qiA) C FiL ,t 7 3,825+8,000 11,825lbs. > 5 0391bs bW 4 PAJ V�A'M w V 1 N or-.W. �1.._ BUOYANCY CHECK O.K. -- q. win b5_._.Wb-Al 50'. ®FI ,.._.f, IhNC _-- �tlw zz SEPT I�. SYSTEM DES I G N '73.7t � C> f FLOW ESTIMATE .. I I-� ��'_ .-�U.�" ►�tt.. U N�i U R i�.....��L. ..-5' �v,�_ �,at q �� \ A 4 � )ROOMS AT 110 GAL/DAY/BEDROOM - 330 BEDROOMS GAL/DAY Gt.,..3y�Z�Y 6176P 6 Cc. �n �R r� P.�� I , SEPTIC TANK '0 I2 (1.1��40 wtl �pl��-hn IQhe (1v�....r tl `D G...... T�t�t= FY—Il l_ 'I �. _ { � C?GAL/DAY x 2 DAYS �Ga� GAL � �• .38 !S Flo EL 3� L7 7a. ���U`► t� tV �vA.� E-ksnAj USE c�GALLON SEPTIC TANK — CAST N l --I I Gc,. 36:0 C 3 F3IZ �� �Il c,oc G�c2 6�w►2P S�vM � I--- _ � � \ SOIL A9SORPT,I bN S•J'STEM OR-- V N'06Y�12E , a W �E--A-� - �E�m ii 22 1 ',I DE AREA: IVL4 c 1 IOTTOM AREA: 0 IS K 0,2 Y — 333 GPL� EYER 01140 2 �XlSTNI 27 -. > 336-C t O s(-vo-Is-?L ^ r� 3 � I SEPTIC; SYSTEM SECTION Tor Et 4i, 10 '",—� /��t�o of ��S��Y� C ('C• y�( 3 3S.oZ l�,sfull �,,d r �� (has (3afflt 39,S3 fon� '-3 au�l c a tic �ffED �S� gt C 3y, D BOX1,7r 3/ ���� '� fe 37:Sa D00 GAL 3?.9Z Wca - Csf' 3"7,�,5" wasAtA SivM �Z"' 37,o SEPT I C TANK y l�✓� es ~ tO j f� XtsTrN -- In sJ 1 3�X6 ' -- r C ) l�%�" A1 .pv1q)0 04jo t�j,36 p-- 0a7�/L D 5. 4 3-I Iy EL- 3q.Z? o,� l �`� ,cr�45 4L) UST Et> Calk) 6L .� 8 Tb P DF- C L„AYIE12,,,, back-- 1 611- SITE AND SEWAGE PLAN LOCATION S (U/J61-6 4L A/0 6L 38,15 'IU Et... 3 2 7 / PvM/�.Crfq,►'IB�R E Gv+4kt�FEp 3, UMP t3E. ZOG c..E t`26'�� Ole �QUItL W Tit' , PREPARED F 0 R 9- _ GIR�V!T F,�oM .�°vr r° .__.._- _.._.__..___ .c,-nuc, �E +�r tzE +►zw._. __..__.__ III•- ( - _ �b17W DARREN M. MEYER, R.S. SCALE 2U� W <C:. S 2y1l��/ U : AL 43 VINE STREET DATE — Z _ v P LXO9 I'`� `it &A��, (,AYE ��,S DUXBURY, MA 02332 DATE HEALTH AGENT (781) 585-0293 W Z It l �e