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HomeMy WebLinkAbout0073 UNCLE WILLIES WAY - Health 73 Uncle Willies Way Hyannis P A = 292 313 a t 0 0 o v _ Y TOWN OF BARNSTABLE LOCATION 7 '',� yn. G145 WL!Ii eS L: . SEWAGE # VILLAGE /��J ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 1.7 S-7 7 ? SEPTIC TANK CAPACITY 10--0--0 LEACIfING FACILITYA ype) 1 G o--o (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 7 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: ` VARIANCE GRANTED: Yes No °� i 1 1 P I �, i � � 0 �, w I <, 3 t cn 7 I S.> � r J' i � . ; r J No.--)_0 1 -L _— 30Y Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS JtlYiLatj IDn for DI8tl08aY 6pstem COttBtCI LtIOtt Vrrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System �ividual Components Location Address or Lot No. 13 11 C C G6 // f eS er's Name Address,and Tel.No. Assessor's Map/Parcel Installer's Ad ress,and Tel.No. ®8^y20-973 Designer's Name,Address,and Tel.No. c/As�PGi � Type of Building: Dwelling No.of Bedrooms !y[A Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) U A gpd Design flow provided ] gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) .S' !4 /=a/ Zo D" /3G X !�! ,W/7 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date L� f Application Approved by Date Application Disapproved by Date for the following reasons Permit No.��.�1 uq— , Date Issued No.oC�� I / JJ - Fees v THE-COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Disposal 6pstrin Construction 3pe mit Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) ❑Complete System VIjatdividual Components Location Address or Lot No. �f 3 V���`= ��'��j �.$ 'aer's Name,Address,and Tel.No. Assessor's Map/Parcel fU1✓l�f' Q_ej a 11 Installer's Name,Address,and Te.No.p Designer's Name,Address,and Tel.No. �/vscdl� /.1c�3gvv©s K, Type of Building: Dwelling No.of Bedrooms /v M, Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) J gpd Design flow provided gpd -1 Plan Date Number of sheets Revisi n Date Title Size of Septic Tank L) Q Type of S.A.S. � — Description of Soil � V 2s 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 Certificate of Compliance has been issued by this Board of Health. Signed / Date Application Approved by XC4Date Application Disapproved by Date for the following reasons r r Permit No. \� � Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS /,3ox A(� �/% S,¢�G ofir/te of Compliance THIS IS TO CERTIFY,that the On-stf Sewa �ispdsal sy"Stem Constructed( ) Repaired( � Upgraded( ) Abandoned( )by,c%5� ` at r :'r 1i as been constructed in accordance with the provisions of Title 5 and the for Disposal stem onstruction Permit No.ZCj.4e �dated Installer ,v/, yr Designer #bedrooms Approved design flow gpd The issuance of this permits a I not a construed as a guarantee that the system will ctio designed. Date C1 Inspector ---------- - ------- --- -- -- ------------ ------------------------- --------------------------- No. ��f� //� f.3o)C ,S�¢!'f'!/= �G9CT�cr Fee ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pste /Construction Permit - Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at '1 _rfLy '� /� d4�/ and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date Approved by Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every y H annis ✓ Ma 02601 9/6/19 t page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information , on the computer, use only the tab Chad Hathaway key to move your Name of Inspector cursor-do not HPS use the return Company Name key. r� Company Address • Forestdale Ma 02644 City/Town State Zip Code return 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my ' inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/6/19 Inspector's Si ure Date The system inspector shall&0fCom f this inspection report to the Approving Authority (Board of Health or DEP)within 30ting this inspection. If the system has a design flow of 10,000 gpd or greater, the e system owner shall submit the report to the appropriate regional office of the DEP. should be sent to the system owner and copies sent to' the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4'and 6. 1) System Passes: „ ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancyof leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don'ts can be found at town health dept or mass.gov 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. ' The septic tank is metal and'over 20 years old*or the septic tank(whether metal•or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection.if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y. ❑ N ❑ ND(Explain below): - t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is Hyannis Ma 02601 9/6/19 required for every H y - page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.)` Y` ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due 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 ElND (Explain below): ❑ 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): 3) 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. a. 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: t51risp.doc-rev.7/26/2018 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Uncle Willies Way Property Address ' Gonsalves _ Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ 'Cesspool br privy is within 50 feet of a bordering vegetated wetland or a salt marsh. b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning 16 a manner that protects the public health, safety and environment: ❑• The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water , supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. „ ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water'supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided-that no other,failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: . , 4) System Failure Criteria.Applicable to All Systems: _ b 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 4 ❑ ® clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool • t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 • u cam, Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.� 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or El ® 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 water supply well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-. 10,000 gpd. El ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of an large system considered a significant threat under Section C.5 or failed P Y 9 Y 9 under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? " ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® El available as built plans of the system obtained and examined?(If they were not available note as N/A) ®' r ❑ 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? w ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for thecondition 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 Cis at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 min Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes E No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment:• Design flow(based on,310 CMR 15.203): t Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ;. , ' ❑ Yes ❑ No . If yes, discharges to: Industrial waste holding.tank present? ❑. Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: ` Last date of occupancy/user Date e Other(describe below):, 3. Pumping Records: Source of information: pumping company-cleans tank every 2-3 years Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped:, gallons How was quantity pumped determined? Reason for pumping: ' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: t ' ® Septic tank, distribution'box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑. ` Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ' ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age,of all components, date installed(if known)and source of information: 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5.• Building Sewer(locate on site plan): 1.5' ` Depth below grade`: feet Material of construction:' ❑ cast iron ®40 PVC other(explain): 10+ Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): i no signs of poor venting or leaks ` t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 • cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Uncle Willies Way .Property Address Gonsalves Owner Owners Name information is required for every Hyannis Ma 02601 9/6/19 page. Cityrrown State Zip Code Date of Inspection , D. System Information (cont.) , 6. Septic Tank(locate on site plan): Depth below grade:.,, - 1 J feet Material of construction: ` ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gal. H10 If tank is•metal, list age: years ' Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: ' 8'6"x5' , 2♦, Sludge,depth:; Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness less then 1" Distance from top of scum to top of`outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle + How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tee in place on inlet baffle on outlet. level is at bottom of outlet pipe. no major decay present. no visable cracks or leaks . 9 t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 118 Commonwealth of Massachusetts r� Title 5 official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 p Y rY 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is y required for every Hyannis Ma 02601 9/6/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom,of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) ' Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): K i "Attach copy-of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9.• Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into d out of box, etc.): . Dbox is new permit was obtained and signed off in 2019 Y • ,T t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): z If SAS not located, explain why: leach pit is located by maple tree. post hole dug down to stone next to pit. probed 2 feet into stone and probe was dry and clean Type: ® leaching pits _ number: 1)6'x6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: , El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 ` Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 73 Uncle Willies Way Property Address Gonsalves Owner Owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) '11. Soil Absorption System•(SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan). Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool ` Materials of construction, Indication of groundwater inflow ❑ Yes ❑ No Comments(note.condition of soil, signs of hydraulic failure, level of ponding, condition of,vegetation, -etc.): 4 . • t5insp.doc-rev.712 612 01 8 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official E.Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Uncle Willies Way Property Address ' Gonsalves Owner Owner's Name information is Hyannis Ma 02601 9/6/19 ' required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): „ 0 }. ! f • x. l5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18'• i Commonwealth of Massachusetts Title 5 Official Inspection Form ^a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 73 Uncle Willies Way Property Address ` Gonsalves Owner Owner's.Name information is Hyannis _ '` Ma 02601 . 9/6/19 required for every y -- page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: 4 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 bf the boxes below: ® ' hand-sketch in the area below ❑ drawing attached separately (J r Ap t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 t f J _ f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Uncle Willies Way Property Address i. Gonsalves Owner owner's Name information is required for every Hyannis Ma 02601 9/6/19 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 15. Site Exam: ® Check Slope ® Surface water . ® Check cellar ® Shallow wells Estimated depth to high 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: 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: town GIS mapping " You must describe how you established the high ground water elevation: lot el. 52' low wetlands diagonally across street el.29.50 bottom of leach pit 9'6" below grade s r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official ,Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Uncle Willies Way Property.Address Gonsalves Owner Owner's Name g" information is required for every Hyannis Ma 02601 9/6/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist t Complete all applicable sections of this form inclusive of: A. inspector Information:Complete,all fields in this section. 3 ® P < ® B. Certification: Signed & Dated and 1, 2,3, or 4 checked Z C. Inspection Summary 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: A For 8:Tight/Holding Tank Pumping contract attached For 14: Sketch of Sewage Disposal 4System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included ,t ..< — � .1 as jt+� tl c r � • � - r ,.'.. a . t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS +: EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIOPF-Ej�r;taL) \Vj NOV 14 2003 TOWN OF BA.RNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 9 (,I la S cf Alil'arlAit, VdLGVj Owner's Name: 0, o �.^ al. Owner's Address: 44r7 G k1 i (,.lct MAP t PARCEL ; � Date of Inspection: O i LOT Name of Ins ector• lease print fir o .tom Company Name:.A 4/i 6— Mailing Address: O O). I.L off EGs w Od 6 fit Telephone Numb,er• 08 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 Needs Further Evaluation by the Local Approving Authority Fails '2 Inspector's Signature: / Date: O z r 4 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A._ CERTIFICATION (continued) / Property Address: G[e ,�',eS t✓a ,�,) Owner: eD Date of Inspection: D Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy m Passes: . V/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: �7one em Conditionally Passes: or m �° >,ore system components as described m 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): " x broken pipe(s)are replaced obstruction is removed ND explain: . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ` (406 le JAI(111 Lo WR Owner: / !O Date of Inspection: Zo 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: T 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 su-rface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3 4etli d re-5 poi EO� v Owner: Date of Inspection: b D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No/ _ _VBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ V Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or iclogged SAS or cesspool V Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / spool v J.iquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow T T 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. y portion of a cesspool or privy is within 50 feet of a private water supply well. _/Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis most be attached to this form.) (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CUR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) es 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 e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped e H of a public water supply well If you have answe "yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D t e the large system has failed The owner or operator of any large system considered a significant threat unSection E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: fir✓ Gill es V���— 0�C 0 Owner: & Date of Inspection:. Check if the following have been done You must-indicate`yes"or"no"as to each of the following: O o — — ping information was provided by the owner,occupant,or Board of Health —/ Were any of the system components pumped out in the previous two weeks t! the system received normal flows inthe previous two week period n i or fthi— Have large.vohmes of water been introduced to the system recently o s part o s 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 Track 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 es 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 ' information Fore e,a Plan at the Board of Health. — wsttng xampl _ — Deternvned in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMIt I5.302(3)(b)) Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Poolmrty Address: 93 We (e (A/,I 1(ej t/,q- �j� Owner. / '!D Date of Inspection: /O RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): O'U-0 DESIGN flow based on 310 CM1;15.203(for example: 110 gpd x#of bedrooms): aa'D Number of current residents: p� Does residence have a garbage grinder(yes or no):/f/0 Is laundry on a separate sewage system(yes or no) [if yes separate inspection required] Laundry system inspected(yes or no) ,q Seasonal use: (yes or no): L&r10 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): iG,p Last date of occupancy:�tit,r1V+1 COMMERCIALANDUSTRIAL_ Type of establishment: Design flow(based on 310 CM R 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/user OTHER(describe): GENERAL INFORMATION Pumping Records Q / Source of information: /"o -ye Q/ Was system pumped as part of the inspection(yes or no): If yes,volume pumped:�gatlons--How was quantity pumped determined? Reason for pumping: T7OF SYSTEM V 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/Altemative 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 appfoval —Other(describe): Approximate age of all components,date installed(if knowow� �Oce of information: Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C., . SYSTEM INFORMATION(continued) Property Address: u t'�G tt/I 11 t e� �a 4t Owner. A0 Date of Inspection: BUILDING SEWER(locate on site plan) l Depth below grade: Materials of construction iron _ 0 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ocate on site plan) l� Depth below grade: Material of construction: ncrete 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 x 7f Sludge depth: l/ Distance from top of sludge to bottom of outlet tee or baffle: 01 Scum thickness: 4-GSS / Distance from top of.scum to top of outlet tee or baffle: Distance from bottom of scum to bottom pf putlet tee or baffie: How were dimensions determined: f o� /�e /Za s Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as ated to outlet invert, 'dence of leaks .): % J Lt wi t o c Gs �' t S, 7—t ✓v: G✓►`✓ p " ,a Ll GREASE TRAP:A��ocat e on site plan) Depth below grade: Material of construction:_concrete metal fiberglass___polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _. PART C.- / ,SYSTEM INFORMATION(continued) Property Address: Vt n C le (Ali e_J 61,14 Owner:�O Date of Inspection: O 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/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.): DISTRIB TI U ON 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- or t of box,etc.): is lecle l It-o &o ier he PUMP CHAMBER_"(I 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.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION(continued) Property Address: � z G✓<lX es (,✓ci�_ h� 0d6o/ Owner: 0o Date of Inspection: /;/0-7 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type/ U"' e —c.— S d� �leaching pits,number:. ( �Q /l � s leaching chambers,number: leaching galleries,number: W leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Typelname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): i/ o✓� (emu O f c or, ce✓+c . 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:A(1 to 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.): Page 10 of 11 . . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM PART C_ SYSTEM INFORMATION(continued) Property Address: U 14 C l e (�t/!�(tGS li✓a ,i Owner: Date of Inspection: 0 /� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system inchiding ties to at least two permanent reference landmarks or benchmarks,Locate all wells within 100 feet.Locate where public wafer supply enters the building lJ y Fro v, >y . 3 4 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART_C n SYSTEM INFORMATION(continued) Property Address: /� 64 W le~° G✓t b yes Gla Owner: i� �c °/ Date of Inspection: O / SITE EXAM Surface water Check cellar Shallow wells Estimated depth to ground water 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;: QbwTved site(abutting property/observation hole with,0 150 feet of SAS) Checked with local Boardof health-explain:. q,O 5 Checked with local excavators,installers.(attach document on) Accessed USGS database-explain: You must de ribe ow you establish the grounds ate�,.elev �, wa 3 zflr roe pCA ��r 1 91 x _.x • LOCATION SEWAGE PERMIT MO. VILLAGE I N S T A LLEII'S NAME & ADDRESS �e t3f27 C�(.e�2 M rtlAS5 BUILDER OR OWNER ,g;7- Vel ti�- R f , DATE PERMIT ISSUED jZ DATE COMPLIANCE ISSUED 2 w 17�(oy 1 No................_....... y . • �. . £�$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® F H LTH ................... ..... (.f 71.-OF....... 3. --. ----- ---•--......----.....----------------- Appliratiun for Uiupuiiai Works Ton.itrgrtiun Permit Application is hereby made for a Permit to Construct (k) or Repair ( } an Individual Sewage Disposal r System at,, • r .....-- t.'..'..l.t�.les........ �i-r �-e d ......W ---- .. . Loca� I�(�dress t N It `,�,, ... v= U'. -•--------"----. ... � `'YGk. ............. _ .._.. Owner i Address W ...... .............. ... _•__ .... J .......... ....----"-""-"-"•-""""""-"............................. Installer Address... d Type of Building Size Lot.............................Sq. feet U DwellingNo. of Bedroom ......... .Ex ansion Attic Garbage Grinder — {{ = P ( ) g p., Other—Type of Building(314jeflA.. "No. of persons_______________•._•--__---_- Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------- ---------------"---_------------------------------------------- _-----.---- d W Design Flow...... ...... .._.._...gallons per person per day. Total daily flow..............�7.Q................gallons. WSeptic Tank-�Liquid capacity.I.OLC.gallons Length---------------- Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......J_........... Diameter----1_.J........ Depth below inlet..... T tal leaching area.Z G...sq. ft. Z Other Distribution box (VdS Dosing tank. ,V/ ve, — -7d Percolation Test Results Performed by................ .. .......... ............ Date.......�:.,��.-.7 ......... Test Pit No. 1.................minutes per inch 'Depth of Test Pit--------•--........ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------- --••--..i- - Description of Soil 2 � "•-"":"--l_�.. 2 �............................" . a�?c �"- ...... aL U ...-------•yam '44•= ..............••. = ---------------------------------------------- W -----------••---------------•-------------------•-----•-•-••------------•----••-•----------•---•----------•--•-•-------------••-----------....-------------•-----------••---•-------------.__._.....-;-- VNature of Repairs or Alterations—Answer when applicable___________________________•__-_______-___-__:-____--_--_--__-----."---__-_•___-_:----_"--_-_.. Agreement: ' The undersigned agrees to install the aforede'scribed Individual Sewage Disposal System in accordance with TI the provisions of L 11,1,. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. gned-- -•_ -•-.- -------------------------------------------------------- -•----- -----------------•------ (� Date Application Approved By.......... " --•---•-...... `e 1!== - Date Application Disapproved for the following reasons:........................................................................................... ................... ...........-""---""--"""":....----"""""-""-"""--"-"-"---------"--"-- ------------"-"-------""-"---"--""----------"""------"------"""-------------------------------------------------------------------- Date PermitNo................................... --------------------- Issued.----""""-""----"--------.............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ...........f n..OF............... . .... .����Z.................... Tnrtifiratr of Tumplianrr the Indivi 1 "ag J 'sposal System constructed ( or Repaired ( ) THI IS TO C RTIF 'That , "--•--" _. .:. ......•..."--" , nst lee + ... has been installed in accordance with the provisions of. TIT r'' S of The State Sanitary C•de as described in the application for Disposal Works Construction Permit No._-.,�`al. ..................... da.ted__. 4_..... a---_.Z� .......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE"................................."-"-"............_.,......------.._............ Inspector.......-............................................................. .............. 7 No... ...... �....�.. THE COMMONWEALTH OF MASSACHUSET.TS BOAR® M T. I-� � Apphcation'i`s hereby made for, a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal System tv at a / Loc .................... ....r ...... 7------------------------:'6", a AtldFess� t N Address aW •.. j' ... " A"!•"'� ,"`: " .......... .............................. •.. Installer Address tax Q Type of Building Size Lot..... ......... ........Sq fee U Dwelling—No. of Bedroo Expansion Attic ( ) Garbage Grinder Qa, Other—Type of Building' - _:___.._ No'. of persons_ ________ ___________ Showers ( ) — Cafeteria ( ) a 4 Other fixture �-------- •--------------•-----------------•------------------------ -------------------------- ' . Design, Flow__:___ ' ______.: ______.gallons per person per day. Total daily flow............... ................gallons. WSeptic Tank j—Liquid capacity1A.CV--gallons Length................ Width..........•..... Diameter................ Depth.............. x Disposal Trench No ____________________ Width.................... Total Le gth_. ...... T�al Leaching-area....................sq. ft. Seepage Pit.No......._�............ Diameter _ __0._______ De h inl�� ""_.�f o��3'leac nng area.. _( _sq. ft. Z Other Distribution box oce Dosing tanlh G Percolation Test Results Performed by-- ----------............................................................. Daie........................................ Test Pit No. l________________minutes per inch Depth of Test Pit.................... Depth to ground water...__....._.._;,__._... . Test Pit No: 2.... u per inch Death q Pit th to grow ate 0 Descrii Soil_ .... W •---•--•------------------"--------•------------•-- --------------- ----• ------ ----••----- ................................................... UNature of Repairs or Alterations .:.Answer when applicable .__-_-_ _________________________________________ r Agreement The undersigned;agrees to install the aforedescribed .Individual Sewage Disposal System in accordance with the provisions of iITL;; p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Corpli a has en i ued b the board of health_'••.. " ApplicationApproved By.................,'.................................................................... ••-••..... i Date Application Disa 'roved for the following reasons:................................................................................................................ ..............................---•----•-••-•-•-••--••--•-•----•--•-•-•-•............---•--•--- ---------- --•---------------------------------------------- Date Permit No.........................................:.... : Issued-_............_..-----------------::. Date r _ THE COMMONWEALTH OF MASSACHUSETTS y�OARD Ol?�#I ��',I�, OF.............................- .............................................: .:....... • C�rr#i�irtt#.� laf f�la�t��i��t�r lo-- TY %_TO a I "I sp 1 -stem o tructe ( ) r Re • red ( ) « < nstal er �►'i/T • ..�..._.. by .... .: : .:... at.............. ' Ft ,h•-- -- --------------- • ---•••......---• .---------------- has l een nstalled in accordance with the provisions of TI L '-�bf The State Sanitary de e5crllfd in the app 1. tibn for Disposal Works Construction Permit No________________________________________ dated.............................-_..__..__.._._____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE:"CONS.TRUE®�AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Ins ector ............................................ �a P COMMONWEALTH O M'ASSA`CHUSETTS a ,LBQA R D � ,,.., ....................................... FiE........................ No......................... OF.... Permi o s her y gra d... +--••• -----• .......... ---•---- •-••••••-- to Const or� � � ear e'Dis al t at No j - -------------- --•---- d'- 71........... as shown on the application for Disposal Works ConstrucrionPe it Dated.,.-_:__..__.______________________________ Board of Health n DATE......... .................................................--- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS M1 - '�>,... �` . •rash'`'.. SOIL L.OS • %,)fti y1110\V"ro-AM�(/.iaa�.e,Jr,AavRT R Z"PEAS TONE LOAM 0 GILL 12'•MAXr— j -� PI BOX 71 � ,�' -/O MIN - 1000 "M/IN.• I° � 1000— GAL. �` GA °° PRECAST OR ` ° A SEPTIC 6 �o e� BLOCK °. o ;go TANK I�'° • • / SEEPAG�E�/y PIT o — 20' MINIMUM "io,° �o 3a'7 FOUNDATION i I %:" WASHED STONE —' W47. f ELEVATION SKETCH 10' 't A C. 11 AT 6 6 40k,-- ?*./i►�� SCALE: I"= 4' TEST BY +c-r�, „ r+zl.� •�_ f TOWN INSPECTOR: j.qr •z .�+ ,.1 /�� BACKHOE OPERATOR -4-evoC C. >bc" •s- _ —r TEST MADE ON s k . tbVCL E. eAJ.,1/r03 4,0-1.0,y f� 09, qA. , 9 - r ;.,�� 'lift!-....:. ..... ...* •�..�^"""" ""�• .�• S _/•♦7� 5-M4A9: ' J1,4TI. S..e „ K t ;� l 4 wr�.nM/i ♦ • _ _,,,n, -..O'M1.r.T�,+ya,r. • � .!} - t Q/� //�ii /DI�'�il, LII� .. ^•.., "' ..'N1'-4�i1r'.�ylw�' ?�..I ,.,.�:. ..�;�;`..... .{�;; � , r, 't.. 1 '.,, f/ t + f db 1, srki► /I�I�M�O�i�'• ��+�:X'.�I,� � ` �;�1� 6 (L .(fit 141./. � t .. . -ra*6/ —J",r)o d 3 jT wm /I**0 006M44k Tr 7204,L./T ELEVATION SCHEDULE ,.t OROPOSED OSITE' PLA14 I. INV. AT F'OUNDATI;.N L�L•!� /o%.� 17 SEWAGE SYSTEM DESIGN 2. 1 NV. INTO SEPTIC TANK - IN 3. ! NV- 0L1 OF SEPTIC TANK = /'Z 71 c i+W /40 61104'el& flv*.rW°S, 4. INV INTO DISTRIBUTION BOX = SCALE! I"=20' sours Jj Ig)s 5 INV OUT OF DISTRIBUTION BOX AV C-431 6. IN•V INTO SEEP"E PIT , JAm.'Y9� CAPE COD SURVEY CONSULTANTS ROUTE 132 7. BOTTOM OF PIT HYANNIS,MASS, 4% 0IV181p N.b"TON SURVEY CONSULTANT#, INC. 8 BOTTOM ;OF STONE LAYER = C ,r • y. 1