HomeMy WebLinkAbout0049 WAGON LANE - Health 49 Wagon Lane
Hyannis
A= 270-192
I
TOWN OF BARNSTABLE
-LOCATION SEWAGE #
VILLAGE y ASSESSOR'S MAP&LOT�?f — "7
IN ER'S NAME&PHONE NO. /7 �� S' '?
,;.SEPTIC TANK CAPACITY £ire �.1�.5'�� Cf i.
EACHING FACILITY: (type) (size)
4 -
NO.OF BEDROOMS
BUILDER'OR OWNER �/�L / 2 �- � £P°a�C rLrLT
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
-.on site or within 200 feet of leaching_facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
49 Wagon Lane
M
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
r •^ :�:..
on the computer,
use only the tab 1. Inspector: °
key to moveyour (n� �
cursor-do not Ricky L. Wright
use the return Name of Inspector
Y
B& B Excavation, Inc.
Company Name
14 Teaberry Lane
Company Address A
-Forestdale MA 02644
City/Town State Zip Code
508-477-0653 S14595
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
7/22/10
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority. i
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewag isposal System-Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M0 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. CityTTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50.feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
, 1 l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
t
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Lt5ms-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the'tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes E No
Laundry system inspected? ® Yes ❑ No
Seasonal use?
❑ Yes N No
Water meter readings, if available(last 2 years usage (gpd)): n/a
Detail
Sump pump? ❑ Yes ❑ No
Last date of occupancy: March 2010
Date
I Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pace 8 of 17
r
Commonwealth of Massachusetts
Menem
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 ' 7/22/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):.
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good condition -tee's in good shape
Septic Tank (locate on site plan):
Depth below grade: 2'feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No
Dimensions:
57-X 5'2"X 8'6"
Sludge depth:
1"
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pags 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y
�M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
39"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be in good shape-no sign of leakage
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle -
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan).-
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection d-box is in great shape-no sign of leakage or solids carryover
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Wagon Lane
M
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appears to be in good dhape-no sign of hydraulic failure or damp soils
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
I
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every Hyannis MA 02601 7/22/10
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 49 Wagon Lane _
Property Address
Bank of America
Owner Owner's Name
information is H annis MA 02601 7/22/10
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
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Q
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I.
t
At t 10.6
AZ= 26'
Pilo o S t
F2-
B I = 2G'
J. 82�38,
13 3t
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is Hyannis MA 02601 7122/10
required for every H Y i
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: > 12'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
hand augered hole- no groundwater encountered at 12'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 49 Wagon Lane
Property Address
Bank of America
Owner Owner's Name
information is required for every �H annis MA 02601 7/22/10
—
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
{
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
' TOWN OF BARNSTABLE G '
U.:t<cl.k`1101,q "�� LIJ� '1 ® K. L. A SEWAGE #
V LLAC-E s ASSESSOR'S MAP & LOT -7 I(1
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and-Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any we/ex6iston site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exis
within 300 feet of leaching facility) Feet
Furnished by
a�
s
r
c ,
}
t
No.
' THE COMMONWEALTH OF MASSACHUSETTS~� j Entered in computer: /
(/
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Ye
application for �Digpogal *pgtem congtruction 3permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No. 7 7 8—5 2 2 3
9 Wagon Lane, Hyannis Gloria Perreault
Assessor's ap/Parce 270 192 49 Wagon Ln, Hyannis
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4
Wm E Robinson Sr Septic Eco-Tech
PO BOx 1089, Centerville 43 Triangle Cir, Sandwich
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(no)
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
Nature of Repairs or Alterations(Answer when applicable) Install new Title 5 leach
system to plans of Eco—Tech, #ETE-1752.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
4 in accordance with the provisions of Title 5 of the E vironmenta Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this ar f Ha
Signe Date
Application Approved by __ 17 Date
Application Disapproved for the following reas s
Permit No. r Date Issued
No. i -�4i` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
f Yes `
PUBLIC HEALTH� DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZIPPricatton for Miopogal 6potem Con5truction Vertu
Application for a Permit to Construct( . )Repair(x)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owne ' N ,Add less and Tel.N5223
—
_ 49' Wagon Lane, ,Hyannis or a Ferreau°lt
Assessor'sN[4/Parcel 270/1 2 49 Wagon Ln, Hyannis
Installer's Name,Address,and Tel.No. — Designer's Name,Address and Tel.No. S — 4
Wm 41�Robinson Sr Septic Eco-Tech
PO BOX 1089, . Centerville 43 Triangle Cir, Sandwich a'
- -"Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(no)
`re Other Type of Building No.of Persons Showers( ) Cafeteria
Other Fixtures
Disign.Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
tr Title
Size of Septic Tank .,:. Type of S.A.S.
i
Description of Soil
Install new Title 5 ,leach
Natu pfi i lr :off rd I nsc ` n 6Vo 4p%vslicablhl) —
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 he vironment 1rCode and not to place the system in operation until a Certifi-
cate of Compliance has been' Ue0y t . oar I of ealth.
Signe �L� .,� w e,� Date�
Application Approved by U � B ' Date
Application Disapproved for the following reas U ns Permit No.No. Date Issued I
}
THE COMMONWEALTH OF MASSACHUSETTS
Perreault
BARNSTABLE, MASSACHUSETTS
Certificate of Comphance
x
THIS IS TO CERTII;Y,that the On-site ew e Dis osal ste Constructed( )Repaired ( )Upgraded( )
Aband ed l��� Wm E Robinson SJr �ept�'c ��rvice
dgUli ai v, NYCLilll.L 5
at h e nc atst_ c�je�i}� a/ccordance
with the provisions of Title 5 and the for Disposal System Construction Permit No ``Elated T 1 i / II-
Installer Designer r"
The issuance f�tz SpJ �t shall not be construed as a guarantee that the sy to wil�nction s' .ed.f�C
Date f Inspector � V )
1
$100.00—
No. i —' -----------------------Fee
Perreault- THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
li.5po.5ar *p$tem Con9truction Vermtt
Permission is hereby anted to Construct( )Repair( )Upgrade( )Abandon( )
Wagon Lane, Hyannis
System located at _
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Con struc ion. u t eted within three years of the date of this ermi
Date: Approved b
PP Y
i
Town of Barnstable
�FTHE ram, Regulatory Services
* Thomas F. Geiler, Director
RARNSTABLE,
v� MASS. Public Health Division
1639. �0
pTFo �A Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date:
Designer: Eco-Tech Installer: Wm E. Robinson Sr
Address: 43 Triangle Circle Address: pn -gpx 1 OR9
Sandwich Centerville
On Wm E Robinson Sr Septicwas issued a permit to install a
(date) (installer)
septic system at 49 Wagon Lane, Hyannis based on a design drawn by
(address)
Eco-Tech dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
OF
DAVIDD.
yG
HAN
(Installer's Sgnature) Ca�0993W
i Q 6
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
f
— TOWN OF BARNS TABLE1
SEWAGE # 317 ,
LOCATION
VILLAGE ASSESSORS MAP& LOT`
INSTALLER'S NAME&.PHONE NO. r�o Q s �' �7 `�^�?�
SEPTIC TANK CAPACITY U
Q
LEACHING FACILITY: (type) _/�" 3 r �"•(size)
i
NO.OF BEDROOMS
BUILDER OR OWNER
v
PERMIT DATE: 6 _COMPLIANCE DATE: 9 Z-
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility, Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
6
ASSESSORS
MAPNO• 6�'70
PARCq No,-
COMMONWEALTH OF MASSACHUSETTS
z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
c DEIF NT OF ENVIRONMENTAL PROTECTION
RECENED
350 MAIN STREET
F� � WEST YARMOUTH,MALRE
2004
w 508LAM -775-2900 TITLE 5 EPT.ALE
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
M-270 P-192
Property Address: 49 WAGON LANE _
HAYNNIS,MA.02601
Owner's Name: PERREAULT,WALTER
Owners Address: 49 WAGON LANE
HYANNIS,MA. 02601
Date of Inspection JULY 7 - 2004
Name of Inspector:(please print) _JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
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 CM 1.5.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
X Fails Inspector's Signature: Date: 9 7
— ®X
The system inspector shall su mit 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 tot he buyer,if applicable,and the approving authority.
Notes and Continents
*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.
Tide 5 Inspection Fonu 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 49 WAGON LANE
HYANNIS,MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS,MA.02601
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: N/A
I have not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
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, A ill 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 irnniment. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 49 WAGON LANE
HYANNIS,MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS,MA. 02601
C. Further Evaluation is Required by the Board of Health:N/A
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 enviromment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is witlun 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of 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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 1 h.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONT]NnM)
Property Address: 49 WAGON LANE
HYANNIS,MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS,MA. 02601 R/
D. System Failure Criteria applicable to all systems:/
You must indicate"yes" or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in pit is less than 6"below invert or available volume is less than%z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CM R 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: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes" or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"ves"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 49 WAGON LANE
HYANNIS,MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS,MA. 02601
Check if the following have been done. You must indicate"yes" or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received nornial flows in the previous two week period?
r
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
X Was the facility owner(and occupants if ditTerent from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 49 WAGON LANE
HYANNIS,MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS,MA. 02601
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CUR 15.203(for example: 110 gpd x#of bedrooms: 220
Number of current residents: 2
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CUR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTII:ER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A TO BE PUMPED AFTER INSPECTION.
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank-,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 49 WAGON LANE
HYANNIS,MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS,MA. 02601
BUILDING SEWER(locate on site plan): X
Depth below grade: 10"
Materials of constriction: Cast iron >✓40 PVC _ other(explain)
Distance from private water supply well or suction line:
Continents(on condition of joints,venting;evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 16"
Material of constriction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 GALLON PRE CAST
Sludge depth: 34"
Distance from top of sludge to the bottom of outlet tee or baffle: 26"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How were dimensions determined: AS BUILT&TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL,OUT LET BAFFLE
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of constriction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Sewn 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 ptunping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
I
Title 5 Inspection Form 6/15/2000 7
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 49 WAGON LANE
HYANNIS,MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS,MA. 02601
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Continents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):D BOX IS 16"X 21"—20"BELOW GRADE,ONE LINE IN ONE LINE OUT
BOX SHOWS SIGNS OF BEING FULL AT ONE TM E—BOX I IS NO GOOD,NEEDS TO BE REPLACED.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 49 WAGON LANE
HYANNIS,MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS-MA. 02601
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number: 1
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS ONE 1000 GALLON PRE CAST PIT.PIT&COVER 42"BELOW GRADE,PIT IS FULL,NOT
WORKING,NEED TO REPLACE LEACHING.
CESSPOOLS: N/A (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):
Conunents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
f
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM,INFORMATION,(conti(continued)
Property Address: 49 WAGON LANE
HYAN IS. MA 02601
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS. MA. 02601
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells witlun 100 feet. Locate where public water supply enters the building.
p
Title 5 Inspection Form 6i l5/2000 10
Page 11 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 49 WAGON LANE
HYANNIS. MA.02601.
Owner: PERREAULT,WALTER
Date of Inspection: HYANNIS. MA. 02601
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to NO groundwater 13 feet
Please indicate(check)all methods used to detennine the hish-round water elevation:
Obtained from system design plans on record-If checked.date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked aitli local excavators,installers-(attach documentation
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
HAND DUG TEST HOLE 13' NO WATER
TEST HOLE 3" BELOW BOTTOM OF PIT.
!v
l3`
/30Vo
Title 5 Inspection Form 6i l 5;'2000 i
CATION SEWAGE PERMIT N0.
1.o*r WAGON LAIV
VILLAGE
c9�/,4rvw
INS—S-T�-A.�LLER'S NAME i ADDRESS
a U I L-DDEE R� OR OWN ER
V
j
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
r
�d
v
tv
1 �
C
7
a
1 �
No.'v..... .. Fxs..l... .. .........
THE COMMONWEALTH OF MASSACHUSETTS
BOA OE HEALTH
�_W.Q........OF....... . . ...S.74 L,e. ...............
Appliration for Uhipasal Workii Tonstrurtiun rprmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
...........................................................-
Loc -Addres or Lo No.
` .� ems. -- - .kli.._ �s'.L��� r� ��
Owner Address
a I ler .. .................................
Address
U Type of uilding Size Lot___j0f..77.q......Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
<' Other fixtures ............................
-• •-•--•----••--••---•--.••--••--•---......-•--•--•----•..-•---••.
W Design Flow........././,0.........................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......._.r..__---- Total leaching area....................sq. ft.
Seepage Pit No...J�_ .... Diameter.....` p......... Depth below inlet....6.............. Total leaching area_.®vsq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I...1.72=__minutes per inch Depth of Test Pit.................... Depth to ground water-____-__-__-_•_--_---_-.
fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a De r> do of Soil-,----------......................... u �" �- r- ----------- - -
O p � d-•---•-_G 2 t 2 /v� ---�D-� -
v �-.... �' ... %�. __..._._ .� . fit . a
--- ---------- --------
l � . --------
W -------------------------------------------------------------------------------------------------•-------••--•-------•-•-•••--•------•----•-••---•-•---••••--•-••-•-•---•----•-------•-•-------•-------
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIliLE 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.
Si •. • -- ------ . • ......--••-•.......... ._.._._.
ApplicationApproved By----------•----•- . -- -•---- -----------•----•--•••.......--------------_. .. .. --------
Date
Application Disapproved for the owin easons:.--...••••••------•------••---•-•-••-•................•---••------••--••-•-••---------•-•--••-••-•••-•.....-•----
.....................•-----.....---•--------------•-----------------------•----------.................----------•---•-•-•-••--•--------------•-------•••-••----•---•---•------------••---••••-----------
Date
PermitNo......................................................... Issued.....................................-.................
Date
*VNo:A - .= Fps.. ........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR OF HEALTH
.. C . : .......OF...... .. .R.N... J7�6 l. � ..............
Appliration for Ravviial Workii Tonstrurtinn Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
................ ,°"T _ -,ta - o n ... !+ -- ------•---._....---...
LC at' Address or t
°. Owne ddress-
so
._... ... ._.._... _ ..... ..ii-A Q _•__...___ --•' --------------------
1.4
� g I t ler %fit Address
Q Type of uildin Size Lot............................Sq. feet
Dwelling—No. of Bedrooms__________________ 0. Expansion,Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ of persons_............._......__..... Showers ( ) — Cafeteria ( )
QOther fixtures ..................................................... -- --•--•••------••........_ --------..........---••-
w Design Flow.........l ........................gallons per person per days Total daily flow �. .....................gallons.
9 Septic Tank—Liquid capacity .gallons Length......' ..... Diameter----------------..Depth................
Disposal Trench No ............ .....'Width ............. Total L agth � �_..___. Total leaching area_____ --sq. ft.
Seepage Pit No._•�j_: __. Diameter _...7,'...._--- Depth below inlet_ ............ Total leaching area. . sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by...................... -------------------•------•----- Date..- ..................................
Test Pit No. 1.... "`_......Iminutes per inch Depth of Test Pit.................... Depth to ground`water........................
Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to groundimater........................
O "
o D ti . " �
� ►
x
w
V Nature of Repairs or Alterations—Answer when applicable._..._......................................................................................V-..
------------------------------------•----------------------•-----------------------•-----------•--•------•-••-------------._.-------•--•---------------•--------------------------------..........------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate-of Compliance has been issued by the board of health.
'�...
Sign
--- --:-- ...... . --- "------...._•--•••-•--- ---• .
Application Approved BY e .
Date
I Application Disapproved for the f owing easons-.................................................................................................................
...................................................... .................................................'...............................................................................................
Date
PermitNo.............. ........................................ Issued.......................................................
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
•
'up rdifirate of it It re
T CERTIFY, That the Individual Sewa Disposalk.System constructed ( or Repaired ( )
b ...
w I taller
'�'t �- ----------
has been inst, led in accordanceUns
le provisions of TI 5 of The State Sanitary Code de r'i in the
application for Disposal Worksction Permit No.- �_ . --------- dated___ /A . ................
THE ISSUANCEOF THIS CERTIFICATE SHALL PLOT BE CONSTRUE® A G ARA4TEE THAT THE
SYSTEM WIL CTION SATISFACTORY.
DATE..../1 12.. ..................................................... Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.....
N ...................... FEE........................
14,5vollat Works Tonotr ion Fermi#
Permission is hereby granted......................................... ---...........-••----------•------------...••-----...............--....
to Construct ( ) or Repa r,.-7 dividualle age Dispos ystem
atNo.................. •.---•-....... --_-_.. f ll>,,.,,"�-. .��.. `" �.n.•-----------•-•..... .... ......
Street
as shown /theac on for Disposal Works,, ruction Perms ............... Date� .------ - ----- ----------------------••.•-------------•-•------...-----...--.--...........---.................................••------•-^ fBoard of Health
DATE.__
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
l
pE s1CN DATA•
51W FAMtt.Y - :6 BC- OP-OOM 5 .
►.!o GAZBA•GE. 6Q'wr>EP-
D�att_Y FLOW = 110 A 3 = B30C- PC?
SEPTIC, T.A► <' = 330xI5o% = -495G.PP I
u5E loon GAL.
ot5Po5AL PtT v5E too GAL.
22 t3 I �
$►Dc.wlA�u Ac2.CA. t�o S.F I ,
150 6.F X -
8oTT0/4� AQ1=.A= �� S,F._ I ///. Lv � .• w
5a S.t= x I. 0 = 5•o G.Pp" " . ..
-IOTA 1- DEIGN : 42- (�•P. D. ! ' t
'TOTAL DA►►-Y F1-ov�! - 33oG•Po 9 8� ►
j PE2COt_AT►014 FZATE j I''IN ZPA N oP-L5=' 5540
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FLOW PROFILE
TOP OF FOUNDATION RAISE COVERS TO WITHIN
6 in OF FINAL GRADE
EL - 57.46 +- ONE INSPECTION RISER FOR
LEACHING GALLERY
2" LAYER OF 1/8"
/D BO I/2" STONE
3- DROP d
FLOW LINE
3/4--1 V4-
48- GAS�� sN DRYWELL STONE
BAFFLE BOTTOM OF
52.15 +- 6 in SOIL ABSORPTION
STONE 51.33 LEACHING SYSTEM
EXtSTNO BASE
EXrs m
Li51.50 GALLERY
EXISTING 51.20 5.00 fr
03 TWO1000 GALLON (END VIEW) 49.20
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1 14 fr ESTIMATED 29.90
SEASONAL HIGH
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SOIL TEST DATE OF. .TEST: AUGUST 14. 2004
WIITINESSEDU EOU REMENT WAIVED I WA NO VARIANCES D.
UG NO R
O GIANCES "SOUGHT DESIGN CALCULATIONS
NO
TEST PIT I PAREN�UMATERIAL:NDWATER EPROGLACIALDOUTWASH DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD
ELEVATION - 55.40 +- PERC AT 62 in 2 MIN/INCH IN C SOILS SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS
DEPTH SOIL USDA SOL SOIL COLOR SOIL OTHER USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL
(INCHES) HORIZON TEXTURE IMUNSELL) MOTTLING CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED)
0-12 FILL DISTRIBUTION BOX: USE 3 OUTLET D-BOX.
12-14 O SANDY LOAM 10 YR 2/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: A 24 ft . x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH
14-18 A LOAMY SAND 10 YR 4/4 NONE FRIABLE A b o t - ( 24 x 12.5 ) - 300 s f
18-42 B LOAMY SAND 10 YR 5/6 NONE FRIABLE A s w - ( 2 4 2 4 + 12.5 + 12.5 ) x 2 - 146 s f
Atot - .446 sf -
42-10 CI COARSE SAND 10 YR 6/4 NONE LOOSE-25% STONES V t 0.74 x 446 - 330.04 G P D
110-144 C2 MEDIUM SAND IO YR 6/3 NONE LOOSE - USE A 24 ft x- 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD REQUIRED
GROUNDWATER
ADJUSTMENT LEACHING GALLERY
EXISTING GROUNDWATER LEVEL CONSTRUCTION DETAIL.
BASED ON BARNSTABLE GIS
DEPARTMENT RECORDS DRYWELL UNIT
INDICATED GW: 25.0 e'-o'= 4'-10'x 2'-9' STONE
INDEX WELL: AIW-230 2 ft EFF, DEPTH
ZONE: D 24.0 fr
READING: JULY 2004
LEVEL: ' 24.2 '
ADJUSTMENT: 4.9 f t
ADJUSTED GW: 29.9 Z_ N
NOTES LnN
1) GARBAGE GRINDER NOT ALLOWED WITH .THIS DESIGN. EXISTING GRINDER TO BE REMOVED.
2) ALL LINES TO BE SCH 40 PVC AND PITCH AT 1/8 INCH PER FOOT MINIMUM. 3.5' 8.5' 8.5' 3.5'
3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS 24.0 ft NOT TO
OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) SCALE
4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES
BEFORE EXCAVATING FOR SYSTEM,
5) EXISTING LEACH PIT TO BE PUMPED. COLLAPSED.. AND FILLED. OR REMOVED
6) ALL STONE TO BE DOUBLE WASHED WASHED AND FREE OF IRON. FINES AND DUST IN PLACE
7) LINES EXITING D-BOX TO -RUN LEVEL FOR 2'-0- BEFORE. PITCHING DOWN .
8) ECO-TECH ENVIRONMENTAL' RECOMMENDS .T-HE INSTALLATION OF LOW FLOW FIXTURES SEWAGE DISPOSAL SYSTEM PLAN
AND APPLIANCES. AND BIANNUAL PUMPING ,OF THE, SEPTIC TANK -TO SERVE EXISTING DWELLING
9) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT
PARK OR. DRIVE VEHICLES OVER SEPTIC SYSTEM. WALTER & GLORIA PERRAULT gym;
STARTING WORK.
10) INSTALLER TO OBTAIN DISPOSAL'`WORKS PERMIT BEFORE S
49 WAGON LANE HYANNIS. MA '
I) SEPTIC TANKS SHALL BE INSTALLED LEVEL- AND, TRUE TO GRADE -ON A LEVEL
S"TABLE BASE THAT HAS BEEN MECHANICALLY_'COMPACTED AND ON TO WHICH
SIX -INCHES ,OF CRUSHED ,STONE HAS-BEEN -PLACE;D,TO MINIMIZE UNEVEN SETTLING - L�
w
ECO TECH_ ENVIRONMEN A
1 2)- SEPTI& DANK`TO BE -PUMPED` DRY AT,-TIME :;OF, SYSTEM REPAIR AND CHECKED'" ""
FOR STRUCTURAL INTEGRITY. INSTALL PVC. OUTL,E7.-TEE FITTED .WITH GAS BAFFLE.. 43 TRIANGLE CIRCLE SANDWICH MA:02563 4
ETE-1752 AUG 17. 2004