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Home My WebLink About0053 VANDERMINT LANE - Health 53 VANDERMINT LANE , HYANNIS A = 251 133 i n TOWN OF BARNSTABLE v / LOCATION V- e�Nri v`''.:'�'".� -O,tl �'— 1 6.� SEWAGE #�� .� VILLAGE ASSESSOR'S MAP� & LOT 76 INSTALLER'S NAME&PHONE'NO. ,�-��` � J� o®-7 � Z SEPTIC TANK CAPACITY _S.-� =2. 4 �- � LEACHING FACILITY: (type) .A (size) f NO. OF BEDROOMS •� BUILDER OR OWNElt� PERMTTDATE:� COMPLIANCE DATE: " Separation Distance Between the: Maximum Adjusted Groundwater Table to e Bottom of Leaching Facility Feet Private Water Supply Welland Leac 'ng Facility (If any wells exist on site or within 200 feet of lea 'ng facility) Feet Edge of Wetland and Leaching acility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by r (�� _ —, =-__i � _ � � ai .� J �. � a S • d. a a � y ,�v� r` t� �� < ..f `- No. Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y t Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplic tion for Mig aal *p$tem Con5tructiun Permit Application for a Permit to Construct( )Repair tX )Upgrade( )Abandon( ,) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's n derarmint Lane , Hyannis Joe Nedera Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service PO Box 1089, Centerville 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S amd. Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting of a D-box and 2 cnnnrPta leach chambers with stene all ao�knd Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of He h. Signed Date,J Application Approved by Date f — o Application Disapproved for Re following reasons Permit No.z ana — 99' Date Issued No. QO9lOy Fee $50 ��/ i THE COMMONWEALTH OF'MASSACHUSETTS Entered in,computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS E application for ;Die;pogar *p! tem Construction Permit Application for a Permit to.Construct( )Repair )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 53 varidermint Lane, Hyannis Joe Yvera 'Assessors Map/Parcel . T staller's Nam A mss,and Tel.,No. Designer's Name,Address and Tel.No. rm. >J . to0xnson Septic Service PO Box 1089, Centerville V `Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building 'y No.of Persons Showers( ) Cafeteria( ) Other Fixtures � . � Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Descnption of Soil S amd. Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting 3. of a D-box and. 2 concrete leach chambers with stone all around . � r Date last inspected: Agreement: t 1 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 t s B and of He Ih. 1 Signed Date Application Approved by Date's"G Application Disapproved for t e following reasons Permit No. c��' ' 31 S° Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Medera BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE&JIFY4hat Pe D ervice n-site Sew a D's osa!, stem Constructed( )Repaired( X)Upgraded( ) epi c S Abandoned( )by .�0 • at 53 Vand.ermint Lane, Hyannis has been constructed in accordance with the ovisions of Title 5and the for Disposal System Construction Permit No. r`S' dated Installer%m. E. Robinson, S r. Designer A, !1„ C, The issuance of this permit sha) o't be a. ,s e .as a guarantee that the tem wi I7 function,astde/sig 1 d '( Date / Inspector f ii f 3�y ------------------------------ No. Fee THE COMMONWEALTH OF MASSACHUSETTS Medera PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS I=i!5pogat *pgtem Contruction Vermit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 53Vandermint Lane, Hyannis ( - and as described in the above Application for Disposal System Construction Permit. Tee 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 of this permit.L," Date: 00 Approved by 1�f w . / 1161" NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERb19T(WITHOUT DESIGNED PLANS) I, William E. Robinson,S1 eby certify that the application for disposal works construction permit signed by me dated o--6 , concerning the property located at 53 Vandermint Lane , Hyannis meets all of the following criteria: • tde failed system is connected to a residential dwelling only. There are no commercial or business uses associatedwith the dwelling. L-11he soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. y ere are no wetlands within 100 feet of thepfoposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed t ,Were are no variances requested or needed. • The bottom of the proposed leaching facility will n t be looted less than five feet above the maximum adjusted groundwater table elevation:(Adjust the groundwater table using the Frimptor method when applicable) • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will nit be located less than fourteen(1.1)feet above the maximum adjusted groundwater table elevation, Please complete the following; A) Top of Ground Surface Elevation(using G1S information) B) G.W.Elevation _ +the MAX High G.W. Adjustment . = s/� DIFFERENCE BETWEEN A and B SIGNED : / I. 4 rz"- ✓ DATE: _� �—/✓ [Sketch proposed plan of system on back]. y:IMM folder:cat C: n i "` • � �� c. 1 i TOWN OF BARNSTABLE LOCATION �� I/.y �-�N� �^'� ,,'� 1 �- SEWAGE # t VILLAGE�'�Y ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. �`6 h i �- �" J� 4 SEPTIC TANK CAPACITY /d LEACHING FACIL=: (type) ma's`g —2` �` (size) NO.OF BEDROOMS 3 BUILDER OR OWNER:d R A PERMITDATE:�/ L v �-'� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to.-the Bottom of Leaching Facility Feet i Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of lea ng facility) Feet jEdge of Wetland and Leaching acility(If any wetlands exist within 300 feet of leachin acility) Feet Furnished by G rr" ` E 0 CNr � i _ - r� TOWN OF BARNSTABLE LOCATION S 3 VA A [.- rZ tyI it, 1 SEWAGE # d VILLAGE `y ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY )G 6 6 LEACHING FACILITY:(type) $f a .ti e; /�W (size) 'G NO. OF BEDROOMS PRIVATE'WELL OR PUBLIC WATER l6 w G- BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: —� VARIANCE GRANTED: Yes No . � �- e ,. ,� � � :.:�` ✓ .. V L !' /,�� ', /� �� .,.. �__ r. �� __— i } No.....71!: / Fiz$.13 Q...0 0....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratilan for Dispersal Works Trout rnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: .... ....Yjauderm.i.nt._. n...By. mnis +---------------- -------------------------------------------------------------------------------------------------- .. .Location-Address or Lot No. .... Q� d x�. .......................................................... --•---.........------------......................--- Owner Address .................. .—'? x 089....Centery lle__MA.:..... Installer Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling=No. of Bedrooms-------3...........................--------Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers — Cafeteria Pr yP g P ( ) ( ) 04 Other fixtures ----------------------_............................ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. fr. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---------------------•---•-•-----•---•-••---••-•------•---•-----•--•..... Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit------------........ Depth to ground water........................ G14 Test Pit No. 2................minutes per inch. Depth of Test Pit-------............. Depth to ground water........................ P4 •-------•--------------------------------------------------•-----.----•------------------------------------------- •---------------- •---------------------- •-- 0 Description of Soil............gxavP_l........................................................................................................................................... x w UNature of Repairs or Alterations—Answer when applicable.._.Pump__and...f ill_-_Old...cesspools.............. 11. t l 1-904..: bQX...and...c14ne_-P_acked-... eachpit------------•-••----•------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by he board of health. Signed -- .. ....: 8'' Q/ Date Application Approved By ..-- . i�r�-, ID---lt �...............................------ --------------------- .-... ems-.Y.� Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------- ---------------------- --------------------------------------- ------ -------------------------------------------------------------------------------------------------......------------------------------------------------ --------------------------------------- / Date Permit No. ..------ F - Q� 0----------------------- ued ..................--- Date-------------------------------------- $.M" ♦.T THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apptiratiun for Diupuual Works Tonstrnrtiun 1rrmi# Application is hereby made for a Permit to Construct ( ) or Repair' (X ) an Individual Sewage Disposal System at: ....5.O...V a—Y)rl=ni 4.at T:Tl..Rita n a s...MA................ ............••............................ ------------.......•..................... Location-Address or Lot. No. Jne� Maricax•a ................-- -. ----_ _.....----.....----•------•--•------•---•---........................... _....••-•--..........--------------•-------...._....---------..._.._..-------•----......_...---•-- Owner Address w TAJ_ ..R rt - ... ...C'At1,I eT'aai.l. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms.......3..................................Ex Expansion Attic� g— p ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) el Otherfixtures -------------------------------------------------------•-••-----•---••••--•--------------•--••••---•--•-•--••••-•-•-•-••-...........--•-•--•-•-------- w Design Flow-:,----------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank-Liquid capacity....---.....gallons Length................ Width................ Diameter--.-----........ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft. Seepage Pit No..................... Diameter............---..--- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground Water.------..--.-.---.------ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 ... -----•------------------------ --- ..--------..... ----------- ------------------------ -....----- ---------- •------ •----------------- ...... Descriptionof Soil----------- jl,- .��1------------•--------------•-------•--_....--------------------------•----------------.....--------------------------------._.............. U .....••-•---••••-•••--••-•--••-••--•-----••••••--.....-•••-----•--•••-•-•••--•--•--•................•---•--•-•--••-•----•--••-----•--••......--•••-•--.................................................. U Nature of Repairs or Alterations—Answer when applicable-----P?mn... nd...f a-??....1 ... e.s.spno1__5......_...... -----,..,.,. _ ,- 0 ----.... --�--....__-..•- D -x --is __-. - - - --.-....--v- .................................... Tn�i-.all---1--_('atl rxa• �-a�x,�k_..�----...1.�n._...an�ri•._c�- n�---n,��tc��---1�aac�T�><�_i�=•--•- � Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t e board of health. Signed ------ ..QL ---------------- ....-- i y n / Date Q� 1 C� Application Approved,BY = --------------------- ---------- J Application Disapproved for the following reasons: ;............................................................................................:..................................... ... ------------------------------ .. -- ----................---.....---....---................---------...---........ / Dare Permit No. -- ....... . 1...-..02........ .... Issued .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tiertiftrate of (90raylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by-......r��I----�'-------- -�Tn .r?. !1?'?--...,'t.. $,-]S.f�7-...-_,�.' ,*'.5;:-' A=......----------------•---....---.....-.................................... .....------------------------------------------------------ + Installer at .....--5.3--.Vandermint...Ln-=....Hyann.l.s...,.....KA..............................---------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of—The State Environmental Code as described in the application fgr Disposal Works Construction Permit No. .......... ...�.'...�`ZQ....... dated ............................ THE ISSUANO i#'THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THA- 'E"' SYSTEM WILL FUNCTION SATISFACTORY. DATE.. Inspector ........ ...... `:..... ........... ..._= ----------------..... / L. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No........ ..... ... FEE.... Disposal Works Tonstrudivit Van it Permission is hereby granted...... ......................................................... to Construct ( ) or Repair ( X) an Individual Sewage Disposal System atNo.......5.3... ..... ---------------•-••-----........................................................... Street j as shown on,the application for Disposal Works Construction Permit No / ,�<.-_L�/ .. Dated........................................ l� ` • .--•----- Board of Health DATE........ .................... FORM 36508 HOBBS Q WARREN.INC.,PUBLISHERS -, CONBIONMT-ALTH OF MASSACHI:SETTS £ _ k EXECUTIVE OFFICE OF E,.N-m01;mE\TAN. AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION OSE ttZ\'TER STREE='. BOSTON ALA 0210t (617.1 292-550t, TRi.=DY COX--- Secretary ARGEO PAUL CELLUCCi DAVID B STP.-HS Governor Cotamissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM MISPECTION FORM PART-A CERTIFICATION . Property Addres:: 53 Vand.ermint Lane Narne of owner Joe Me d.era Hyannis Address Address of Owner: Date of Inspection: �� `��°icy- 6 Name of Inspector:(Please Print)Wm- E. Robinson Sr 1 am a DEP approved s errl inspector to Section 15.W of Title 51310 C%4R 15.000) compartyName: Wm. E . Robinsoen Septic Service MvAiingAddress: PO I30X 0 9. Centerville MA Telephone Number: '17�rj—A CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and-experience in the proper function and maintenance of on-site sew;ge disposal systems. The system: k. Passes _ Conditionally Passes Needs Further Evaluation By the'Local Approving Authority Fails Inspector's Signature: Date: '� �101-f-I The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty M)days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater.the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer. if applicable. and the approving authority. NOTES AND COMMENTS 10 EO S EP r ?WA0Fg4pNSTA0tv OfAmCEPT. +` reti se6 9/2/9E Pape 1ofr11 1:.J1 --led o-ReLvord Paw, _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Nvp"Address: 53 Vandermint Lane , Hyannis awnef- Joe Me d e ra Date of Inspection I Cr 'VSPECTION SUMMARY: Chet!!/a,�/B, C, or D. SYSTEM PASSES: 14�/ 1 have not found any information which indicates that'sny of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. CO S: B. SY TEM CONDITIONALLY PASSES: ne or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system.upor ompletion of the replacement or repair,as approved by the Board of Health,will pass. Indicate y s,no, or not determined(Y.N.or ND). Describe basis of determination in all instances. H"not determined'.explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance!attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection: or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration..or tank failure is imminent. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if{with approval of the Board of Health). broken pipets)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced 1/a obstruction is removed revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Add►ess:53 Vand.ermint Lane , Hyannis Owner: Joe Med.era Date of Inspection: *7 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS ,FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well; unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal'to or less than 5 ppm. Method used to determine distance (approximation not valid). .K 3) OTHER Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icorttinued) Property Address: 53 Vand ermint Lane , Hyannis Owrwr: Joe Medera Date of Inspection: ®� D. SYSTEM FAILS: You must in di ate either "Yes" or "No" to each of the following: I ha determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this deter ination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the faiiure. Yes No Backup of sewage into facility-or system component due to an overloaded or-clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or 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 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARG SYSTEM FAILS: You must ndicate either "Yes' or "No' to each of the following: he following criteria apply to large systems in addition to the criteria above: he system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public alth and safety and the environment because one or more of the following conditions exist: Yes o the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well) The ow er or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office o the Department for further information. rev.;.sPn 5%2/5t PaRt4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 53 Vand.ermint Lane , Hyannis owner: Joe Medera Date of Inspection: Check if the following have been done: You must indicate either "Yes"'Or "No" as to each of the following: Yes/ No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks snd•the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into-the system recently or as part of this C inspection. v _ As built plans have been obtained and examined. Note if they are not available with NIA. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. 4-11 _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) L✓ f15.302(3)(b)) _ The facility owner (and,occupants,if different from owner) were provided with information on the propermaintenaoc4i,.of SubSurface Disposal Systems. re,-_sed 9/2/98 '. Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: 53 V-and.ermint Lane , Hyannis Owner; Joe Medera Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:jf 6 g.p.d./bedroom. Number of bedrooms(de i n): j Number of bedrooms(actual): Total DESIGN flow L Number of current residents: Garbage grinder(yes or no):/ Laundry(separate system) (yes or no),4 ; If yes, separate inspection required Laundry system inspected,(yes or no) Seasonal use (yes or no):4'6 Water meter readings,if available (last two year's usage (gpd): '999 — 2000 60, 000 gal. Sump Pump (yes or no):jOa 0 Last date of occupancy: �*•(;--O =998 - 1999 69, 000 gal. COM RCIAL/INDUSTRIAL: Type of stablishment: Design fl w: gpd ( Based on 15.203) Basis of d sign flow Grease tra present: (yes or nol_ Industrial aste Holding Tank present: (yes or nol_ Non•sanit ry waste discharged to the Title 5 system: (yes or no)_ Water m er readings, if available: Last dat of occupancy: OTH :!Describe) Last of occupancy: GENERAL INFORMATION PUMPING RECORDS and so ce of information: System pump d as part of i spection: (yes or no) If yes, volume pumped:t!t�� gallons Reason for pumping: w Al rL TYPE OF STEM 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) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other t APPROXIMATE AGE of all components, date installed(if known) and source of information: r+.�;yL�• �` ��° , �-�� Sewage odors detected when arriving at the site: (yes or no)o—io rel'ise 2/-9E Page 6(if 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(eontimbed) 'roperty Address: 53 Vand,ermint Lane , Hyannis Owner: Joe Med.era Date of Inspection: --z 6 W�A BUIL G SEWER: (Locate n site plan) Depth be ow grade:_ Material IF construction:_cast iron_40 PVC_ other(explain) Distanc from private water supply well or suction line Diame r Comm ts: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_otherlexplain) If tank is metal,list�e T ls.age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: L/� le Sludge depth;_ ti Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: C %, Distance from top of scum to top of outlet tee or baffler i Distance from bottom of scum to bottom of outlet tee or baffle:L� How dimensions were determined:o a;'o' 'omments: (recommendation for pumping, ondition of inlet and outlet tees or baff es, depth cil liquid level in elation outlet invert,,structurall integrity, evidence of leakage, ' 4LSx S GR SE TRAP: (Iota on site plan) Depth elow grade:_ Materi of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimens ons: Scum t ickness: Distan a from top of scum to top of outlet tee or baffle: Dista a from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Co me, Ire Orrin for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, ev dence of leakage, etc.) '+ EZ', SeC 5/2/98 Pa,Rc7of11 �` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 53 Vand,ermint Lane , Hyannis Owner: Joe Med.era Date of Inspection: .,1 TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b ow grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain) Dimensio s: Capacity: gallons Design fl w: gallons!day Alarm pr sent Alarm le el: Alarm in working order: Yes_ No_ Date of revious pumping: Comme ts: (condi on of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:L/ (locate on site plan) Depth of liquid level above outlet invert:�Z Comments: (note if level and distribution is equal, a iden�e of solids carryover, evidence of leakage into or out of box, etc.) - PUMP C AMBER: (locate o site plan) Pumps in working order: (Yes or No) Alarms i working order(Yes or No) Commen s: (note co dition of pump chamber, condition of pumps and appurtenances,etc.) rev1seC, 5/2/SE Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coet6nued) top"Address: 53 Vand.ermi•nt Lane , Hyannis Owner: Joe Med.era Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number._ Alternative system: Name of Technology: Comments: (note condition of oil, signs o_f►yydraulic ailure,�vel of pondin damp soil, ondition of veget tion etc.) wl CESSPOOLS:_ (locate on site plan) Number and configuration: 12 Depth-top of liquid to inlet invert 7epth of solids layer: / - )epth of scum layer. L✓ Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) rondition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY _ . (locate on site plan) Materi Is of construction: Dept of solids: Dimensions: Co m ents: ' (no condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECMON FORM PART C SYSTEM INFORMATION(corttimmd) Nop"Address: 53 Vand.ermint Lane , Hyannis )weer: Joe Med.era Jate of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 9 . a�a + revised Pagcl0ofII . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION(continued) ropertyAddress: 53 Vandermint Lane , Hyannis Owner: Joe Med.era Date of Inspection: O—®-mod 4 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater;0 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole.basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps _Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 10 revised 9/2/95 Page 11of11