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HomeMy WebLinkAbout0014 WALTON AVENUE - Health 14 Walton Avenue Hyannis A ' 31.0-41.6 TOWN OF'EARNSTABLE LOCATION I`7' W A ` � /�y e SEWAGE VILLAGE T��YGi d1✓) S ASSESSOR'S MAP& LOT— INSTALLER'S NAME&PRONE NO. 'SEP11C TANK CAPACM J U®D LiACH NG FACILITY: NO,OF'E!~DCtOONS— : . . BUILDER OR OWNER, PEMI TDATLI: ,__ C()MPl IANCE DATE: Separation Distance Eetwee�the, Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility Fine Private Water Supply Well and Leaching Facility (If any weUs exist on site or within 200 feet of leaching faciUty) Fd�r t Edge of Wedand and Leaching Facility(if.any v ands exist within 300 feet caehiq f•ctit I/ � Feet burnished by `✓H r "7 � o a f, 6 4. j 0 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 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. A. General Information a 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 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. 1 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 Furthe Evalu ton by the Local Approving Authority 5-19-10 Inspector's Signature Date The system in shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the. report to the appropriate regional office of the DEP. The original should be sent:to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp official document-03/08 Tdle 5 Official Inspection Form:Subsurface Sewa Disposal System- ge 1 of 15 assachusetts Commonwealth of M w Title 5 Official Inspection Form* Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Hyannis MA 02601 5-19-10 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection.if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound;-not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑' obstruction is removed t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 y r Commonwealth of Massachusetts W Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and,the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh " 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption.system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 16 Commonwealth of Massachusetts x W Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form "Not for Voluntary Assessments ,M 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Hyannis, MA 02601 5-19-10 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are'tdggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow ❑ ® t Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. .5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 14 M M Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): ° `Yes `r No` ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® 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 El El 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. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every 'Hyannis MA 02601 5-19-10 - page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or``no" as to each of the following: Yes No , ❑ ® Pumping information was provided by the owner, occupant, or Board of Health El ® 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? El ® 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 CM 15.302(5)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every y H annis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330 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 ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? tiI_0�yes CK No Last date of occupancy: 4-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: rDesign flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): t5insp official document-03108 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection D. System Information (cost:) General Information Pumping Records: Source of information: N/A 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): Approximate age of all components, date installed (if known) and source of information: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary,Assessments 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12 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: 1000 gal Sludge depth: 12 Distance from top of sludge to bottom of outlet tee or baffle 20 Scum thickness. , 1" Distance_from top of scum.to top of.outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts i W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I wM 14 Walton Ave Property Address Bank Owned (Contact David Hoit @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 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.): Tank is in good condition with baffles installed and no sign of leakage. ' Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.):. *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (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.): Good condition with water at working level. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Subs g p y ry 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): r Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5-infiltrators ❑ leaching galleries number: leaching trenches number, length: ❑ 9 9 ❑ 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.): Infiltrators in good condition with no sign of back-up into d-box or surrounding stone. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today.Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp official document•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts` W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I 1 "ek d 3 .R 3?1 31 . I j t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Walton Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Hyannis MA 02601 5-19-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope , ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10, 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: Original design plans on file shows no groundwater at 10'. t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BARNSTABLE LOCATION T �-�� SEWAGE # VILLAGE ck Pt_ ASSESSOR'S MAP & LOTSil /G INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 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 1 3j Furnished by w � 9`' ..� � � A � � . r � � 1 � � --_ _ .� � _; r m - ,� �- � o �;. . . . No. LJU 5 33 I Fee �d �t THE COMMONWEALTH OF MASSACHUSE'fft Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ftplication for 30igpool bpgtem Con6truction permit Application for a Permit to Construct( . )Repair( )Upgrade( Abandon( ) El Complete System dividual Components Location Address or Lot No. I �TOti� Owner's Name,Address and Tel.No. Assessor'sMap/Parcel C A-IJ- / Y 1 ���G` L 3/D- �/lh Installer's Name,Address, and Tel.No. Designer's Name,Address and Tel.No. �C 75 PP. 01 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design.Flow gallons per day. Calc lated daily flow I ` O gallons. Plan Date I 3---bSNumber of sheets Revision Date Title Size of Septic Tank � d 11 Type^off,S,.AA..S. Description of Soil, L-o 11-111 T Nature of Repairs or Alterations(Answer when applicable) r 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 ha igned Date Application Approve Date J� Application Disapproved for the following reasons Permit No. C)0 Date Issued 5 I rl No. �C'�b 5 3 3 e s Fee ©Q -i, THE-COMMONWEALTH OF MASSACHUSE'4 11 Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 1. 01pplication'for Mfi5pogaf *pStem Con$truction Permit Application for a Permit to Construct( . )Repair( )Upgrade(vl-Abandon( ) ❑Complete System ttdividual Components ;p Location Address or Lot No./ /j /7ON I�V_je Owner's Name,Address and Tel.No. Assessor's Map/Parcel a y[q fit-/L i J 1 Installer's Name,Address,and Tel.!No. r Designer's Name,Address and Tel.No. `, 75 6,(/v C.C. 4 /N�— r � Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ! Other Fixtures Design Flow �e gallons per day. Calculated daily flow —� gallons. Plan Date I Number of sheets Revision Date Title Size of Septic Tank _ v Type of S.A.S. IT 7 Description of Soil INgo �.. Nature of Repairs or Alterations(Answer when applicable) _ , Date last inspected: Agreement: t The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system Y ` %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 beei&&Iied b.-thus-)_card f Hea } igned �- Date�� Application Approv Date Application Disapproved for the following reasons Permit No. 5:3 Date Issued ------------ - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY.that the On- ' e Sewage Disposal System Constructed ( )Repaired ( )Upgraded- Abandoned( (� )by at has been constructed in accordance with the prop sio o Title 5 tid the for Disposal System Cons ctioti Permit No dated ,�_ . Installer Designer The issuance of this permit shall not be conttrcueddaas a guarantee that the system-) 11 f don as desi tied. Date J �`i� Inspector No. -33( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi.5pogat *pztem Con5tru Con Permit Permission is hereby granted to onstruct( L�),Rnepair( )Upgrade4 )Abandon( ) System located at 'fV 1► /1 �i , /.-s and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty.to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the dat< f�thispei M. �`'� Date:_ 7 r Approved by ~ 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, �iR�L�M£rJ JN�r1� ,hereby certify that the engineered plan signed by me dated �} 15 n6 concerning the property located at meets all of the. following criteria: v • This failed system is.connected to a residential dwelling only. There.are.no commercial or business.uses.associated with the dwelling. • The soil is.classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests.at the site without a health agent present. 0 There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The.bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information). B) G.W.Elevation c�5' +adjustment for high G.W.a. DIFFERENCE B EN A and I CQ aq SIGNED : DATE: NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum.. No additional bedrooms.are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc Town of Barnstable �1HE r , Regulatory Services Thomas F. Geiler, Director r BAMSfABLE, MASS. Public Health Division 1639. �FD1A0�A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Designer: Shay Environmental Services, Inc. Installer: 5 �C Address: P.O. Box 627 Address: East Falmouth, MA 02536 On ���S S C was issued a permit to install a (dale) (installer) septic system at based on a design drawn by (address) ShM Environmental Services, Inc. dated (designer) XI'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. �y=IA OF Mgss CARMENE. (Installer's Sig re) SHAY N No. 1181 SgNITAR\ (Designer's Signature) (Affix De i tamp 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 OMN'D 4rrUlfCk r,, I /� NOTE. ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C. f : t VENT PIP � ea 4 I 1 - ., � i .^ �•.. 10 min. from- - Sc E Least 2 Inches Odor SECTION Ei A_ ( ALL OUTLET PIPES FROM THE ,...,._.:, Schedule 40 PVC w Charcoal Od` Ft7t ( �xron r "; ExistingFoundation [house / ar er a1slRieuTroN eo �, .• 3 t to septic took x SMALL BE : PROFILE VIEW OF ADDITION TO LEACHING SYSTEM SET FOR AT 72 CONCRETE COVER _ f TOP OF FOUNDATION ELEV. 10000 (Assumed) Septic took covers must be D-BOX cover must be LEVEL LEAST 2 FT.. CO within 6 In. of finished ode within 6 in. of finished grade f Grade over tic Tank 98.50 .Grade over D-Box- 98. 8 " -- >.. 3- 5 OUTLET .2 ::..<.-.,�. . 2 a ,: f"`,. Septic 7°5 ...over SAS 9 .75 3 of 1/8 T/2 Washed Peastone- >, `c U _ ---. >�.,�. .,,da, , ..,... , ^` _ _ KNOCKOUTS {. A s 7. J ..ti "r• FMtw Si 3/4" to 1 1 2 " Washed Crushed Stone j 9 t } ____ 5.5 INLET ," , OUTLET. ` 1 1T'. ET ... a,., 7 S 0.02 4 PVC(CAPPED)INSPECTION .PORT TO BE -{ - 3 HOLE H 1Q + �1; n". f +'+ ` ,n}. �'` �•`i$^-I . iST. BOX 3' Maximum Cover s INSTALLED AND TO BE."THIN 6' OF GRADE o tQ' EXiSL s=o.m or Top of system- Elev. 95 7s ;... r _ d W t+4 •a A _ _ Greatar 2 r , ME Se0B1. N, ExtsT. PIPE C! h 1,000 GAL o 35Per r 4 :FT2aN EXIST. FM MPATMN a, SEPTIC-TANK r.7 p oot 10" Effective Depth 4 - SCH. 0 Te m 1 N - / �. ,�. r� 5 �-`' PLAN SECTION CROSS-SECTION ��°''�i CONCRETE FULL FQUNDAI/ > 11 H-10 d- _ ____ is MsrPA,+c.e,.a. 3r .....,..,`r ,ra•.,•a,p'v.,:tr �., j r 11 5 Un1ts @ 6.25 - 30 a °i 0.$3` (10 inches) iu mf cR SYSTEM PROFILE s in.of 3/4--, v2- as a u; 31.25 3 HOLE H-1 O DISTRIBUTION BOX c _npocted stone ' o m m NOT TO SCALENot to Scale : 9 �- fi 37.z`J'- 1�9Dax � 5 4' 4' Ef"fective Length O Ma^Cs^9aA Na°V 1 x� 9 4.Iw NA T" y+a a c 3 ----11'----- °' SUIL_ABSORPIIUN SYSTEM (SAS) 6 In.of 3/4" 1/2' ti - GENERAL. MOTES' " compacted stone ao EOiective wkdth INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEURGE O'BRIEN NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6 BELOW GRADE :1 0 - - 1- Contractor is responsible for Di safe notification, Verification of Utilities o m (OR EQUtVALENT) Not to Scale and protection of all underground utilities and pipes. w Ground of rest Hole t`ENONE 7.75 OBSERVED NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" EFFECTIVE HEIGHT Is 10" 2.,The septic tank an distribution box shall be set Groundwater Observed NONE OBSERVED / level on 6 of 3/4'-1 1/2" stone. 3. Backfiil should be clean sand or gravel with no - _ stones over 3' in size. / T C 4. This system is subject to 'inspection during installation I-" F R�_.01_ATI O N I L.ST by Carmen E. Shay - Environmental Services, Inc: 5. The contractor shall install this system in accordance Date of Percolation Test: JULY 12, 2005 with Title V of the Massachusetts state code, the approved plan Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations Results Witnessed By. WAIVER (Per Barnstable B.Q.H.) ��....•►' 6_ If, during installation the contractor encounters any EXCAVATOR: Shay Env. Svcs. soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPi ® 40" from those shown on the soil log or in our design installation<must halt & immediate notification be Test Hole I Test Hole made to Carmen E. Shay - Environmental Services. Inc. ( No. 1 No. 1 7. No vehicle .or heavy machinery shall drive over the DEPTH SOILS ELEV, DEPTH SOILS ELEV.' septic system unless noted as H-20 septic components. I 0 98.50 0 98.75� 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. ��Sandy Loom Sandy Loam 9. Alt Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. I I ( 10. All solid piping, tees & fittings shall be 4 diameter 10 YR 3/2 10 YR 3/2 ( Schedule 40 NSF PVC pipes with water tight joints. 1 0'-12" Ae 97.50 0•_g^ As 96.00" PP 9 Loom Sandy Sandy 11. Municipal Water is Connected to ALL OF The Residence and Abutting Loam Properties Within 150 Feet. 10 YR -5/6 I 10 YR 5/6 PROJECT BENCH MARK THE PROPERTY LINES ARE APPROXIMATE AND l 12"- 32' B 95.8.3 1 9"- 40" B,r 95.42 t Medium TOP OF FOUNDATION ---_ COMPILED .FROM THE SURVEY PLAN GENERATED BY Sand Medium ELEV. 100.00 (Assumed) NNORMAN GROSSMAN OF OSTERVILLE, MA ' wand ENTITLED "FOUNDATIONLOCATION PLAN OF LOT30A WAL.TON AVENUE, 2.5 Y 7/4 zs Y 7/4 i-EST HOLE #1 HYANNIS, MA", DATED DATED OCTOBER 15, 1978 ',32"- 132 C, 40"- 132 C, 1 ELEV.= 98.50 AND IS NOT INTENDED TO BE A'SURVEY PLOT PLAN IT SHOULD BE USED FOR NO PURPOSE OTHER THAN EXIST. 1000 GAL 145.96 THE SEPTIC SYSTEM INSTALLATION. SEPTIC TANK -- 10 0+- D-Box 14' EXISTING LEACH PiT TO BE PUMPED OUT REMOVED. EXIST: ----� ----__ NOTE. ANY STRIPPED OUT S01 CONTAINING L C G LEAt,HATF 99 0 FROM H RO THE EXISTING LEACH PIT TO BE DISPOSED jz .• ED --- - _, _ 20 ,,. Fatled OF AS PER BOARD `OF T .- • >. HEAL H SPECIFICATIONS. l ry Leach Pi - TFEr[t-r�r�C-1vv rrci`I_Nr�t3J-Ar�E rr"�LStPJT: rvlTrlli�{ :�iv vF TFiE r'r2Ui�Er�TY _'- Perc #1 EXIST. v LOT 29A T• 3 bt e th o Perc. 4 F,DROfl ` D t 2 to .60 �- P ., co G ..� ARAG E I ASSESSORS MAP 310 PARCFI_ 416 Perc Rate- 2 MPI HOUSE N t r Groundwater Not Observed w LEGEND No Observed ESHWT 14 =- LOT 31A , # - -- TEST HOLE 2 # , ADJUSTED H2O Elev. = None -_ ELEV.= 98 75 I i _ �: • =�� DENOTES PROPOSED � 2-18' alnki:AccEss MANHOLES LOT 30 �_< s; 104X 1 SPOT GRADE a T # A i , 10,500 Square Feet f% Q -6, 0'_:.._ .----20.4'--- DENOTES EXISTING I , w , X 104.46 (n i 4~ PVG SPOT GRADE x - �1 w o o Vent ---- ------------------ ►-------i---•-------------------4-------- -------------------- ---99 pL PROPERTY LINE 99 I , r INLET-�- - 4.: otl ET a nr i 1.45.04' ------ L96P..- PROPOSED CONTOUR :I THE ACCESS COVERS FOR THE SEPTIC TANK, DISTRIBUTION BOX AND LEACHING COMPONET I _ I I - - - - -97 EXISTING CONTOUR :<"- -s- "",� .�- SET DEEPER THAN 6 INCHES BELOW FINISHED 98---------------------- ---------•------------------------------ ^' GRADE SHALL BE RAISED TO WITHIN 6" OF ---98 f---- { - _ ��-- -- - STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE ------------------ ---- ��-- 7-------- DEEP TEST HOLE & _PLAN VIEW INSTALL TUF-OTE GAS BAFFLES OR EQUALS PERCOLATION TEST LOCATION 3-24' REMOVABLE COVERS f W-A L �'0_ZV VAE IV ��..� •---* 6 FOOT STOCKADE FENCE 4' :.... - ':'_ „-f - 3 min. clearance 8' mln 2-,min. Inlet to outlet i I 3" BnET (40 FOOT RiGHT OF._WAY) �T INLET -- -1---- 6 mx. I Ligrild level _ OUTLET P --1a" min. :::JJ5' 7 --- `` 1- 0 PLAN ' E�' f '� 4'-0" min. _ Liquid depth a OF PROPOSED SEPTIC SYSTEM UPGRADE ;. ._ -:' y . # PREPARED FOR CROSS SECTION END-SECTION R U S S E lL C . M I C HAE E AT WALTON AVENUETYPICAL1000 GALLON SEPTIC TANK _ � # 14 NOT TO SCALE HYAN N I S, MA Design Caicu"lation_s 0 s PREPARED BY: Number of Bedrooms: 3 Equivalent to'330 Gal./Day (330 Gai./Day Min. per Title V) w Garbage Grinder: No o Ai <<. `. /� i� y l A Leaching Capacity Proposed: '330 Gal./Day Minimum (Min. Per Title V) r1 i:Yl 1 ► _F. A�H..C� Septic Tank - 2 x 330 Gal./Day 660 USE EXIST. 1,000 GAL. Septic Tank: H VI ON NTINC. R ME AL SERVICES, IN SOIL ABSORPTION AREA: Using percolation rate of <2 min,/inch.. p. 1 Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft, = 273.8 gallons O .0. ,BOX 627 Sidewall Area: 0.74 al. sq. ft. x 78 s . ft. _'58 gallons 0 20 40 50 R� g / i g sTE EAST FALMOUTH, MA 02536 ....:...Providing_ = 331:80 gallons SAN R\P� lrA TEL/FAX 508-539-7966 Use: (5) ' INFILTRATOR HIGH CAPACITY,H-20 UNITS, HAVING A 0.83' 10 INCHES EFFECTIVE DEPTH _. ( ) SCALE:` 1 "=20' DRAWN BY: CES DATE: JULY 13 2005 TO BE USED WITH 4:0' OF WASHED STONE ON THE SIDES,' AND 3.5' OF WASHED STONE. ' SCALE: ; 1,.=20' ON THE ENDS. Na STONE UNDER. PROJECT#SD770 FILENAME: SD770PP.DWG SHEET 1 OF 1 L--- -`--- - -- ----._. -- -- --