HomeMy WebLinkAbout0118 WALTON AVENUE - Health 118 Walton Avenue _..
Hyannis
A = 310 439
a
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TOWN OF BARNSTABLE
LOCATION ! SEWAGE #
VILLAGE �PCAJS - 4 S SSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY '
� r
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER G ��
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 feel of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished,by
i
:s
S
r��3
No. — 6 Fee
THE COMMONWEALTH OF MASSACHUSEVTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
Zipplication for �Digpaal *paem Con5truction Permit
Application for a Permit to Construct( )Repair�Upgrade( )Abandon( ) O Complete System >Qndividual Components
Location Address or Lot No. (s3A 0M fWF_ 1 H1?gNN15 Owner's Name,Address and Tel.No.
C4a2 L.ES EUASoM
Assessor's Map/Parcel ,Q ` AME
Installer's Name,Address,and Tel.No. LOSS-S3\O Designer's Name,Address and Tel.No. 6 Lk - 3_-9 G
Pzb'��5 SEPTIC ScejkcE ErW1Z_ NMV1,I"iWL_ SVCS-
S ST-) Y1,,&M0VTRt M� ��•�c�� to��, �,F�1mcv�� r�
Type of Building:
Dwelling No.of Bedrooms Lot Size Csq.ft. Garbage Grinder(MI01
Other Type of Building NC9N E No.of Persons a Showers( el Cafeteria( vj
Other Fixtures Lr,vr:�Tnc,Y t k'.-rc a eri 'Sia k Lacs of O M
Design Flow ?J1J 0 gallons per day. Calculated daily flow 331.6Q gallons. i
Plan Date L, i k 6+ Number of sheets I Revision Dateit
Title c a
Size of Septic Tank ��c��T. \ .e�tit� \ 'Coc�)c ype of S.A.S. 13 'X,3j-.,25 5 i1,4ST9#4 oe_s
Description of Soil `s _5�aC' Ad-3 ca\cam
Nature of Repairs or Alterations(Answer when applicable) �a� � •n��. ,
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 provisioi of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance hasCned &
Board of 1
Si Date l� du V
Application Approved Date
Application Disapproved for the following reasons
Permit No. cr)ZO OR .5 Date Issued O
' No.
/
Entered in computer: e
THE COMMONWEALTH OF MASSAeHUSET .9},,,,V Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
_ l
ZIpprication for Migpogar *pgtem Coilgtruction Permit
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System >4ndividual Components
Location Address or Lot No. WR L_Tbi> flVE.I HY41n1MS Owner's Name,Address and Tel.No.
Assessor's Map/Parcel `4 �j A M E
Installer's Name,Address,and Tel.No. �0yg``j3\Cl Designer's Name,Address and Tel.No.
C-�5 SEPTIC ����tCE sNRY E�U1P�bNMEt,,13WL.. 5VCS•
.. S T� To� 5 •, �ACZMCUTN, MR '?a, r�3ox foa�� �.Fc 1n,OvT�1, MQ 251�1P
Type of Building;
Dwelling No.of Bedrooms a Lot Size \D 4QC Q sq.ft. Garbage Grinder
Other / Type of Building N om f No.of Persons Showers( rl Cafeteria( P
Other Fixtures L f-"J P bZY, i-,TCN C,.I S i,v k` L a U N O RY
Design Flow J O gallons per day. Calculated daily flow 331-V�O gallons.
Plan Date � 1 t\ b Number of sheets Revision Date �.
Title '�K Cc�C7t� _ S�em I�UCl�c eta
Size of Septic Tank tST. \ �t>UO Cso\ \Grcl lc Type of S.A.S.' i L7 x3 �� iraGT2fiT0eS
Description of Soil e>?"a Izpc -\-x \cx1
f
r
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected;,
Agreement: °
The undersigned agrees to ensure the construction and-maintenance of the afore described on-site sewage disposal system
M in accordance with the provisio s of TiithisB
of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has •een Z • b oard of/p1tth
S ed Date 6
Application Approved bY Date >>
Application Disapproved for the following reasons \
Permit No. c "" Date Issued
THE COMMONWEALTH OF MASSACHUSETTS'
BARNSTABLE, MASSACHUSETTS
(fertificate of (Compliance
THIS IS TO CERTIFY that the -site Sewage Disposal System Constructed Repaired U raded X)
g P Y ( ) P (lVJ Pg
Abandoned( )by 0,' Wks f 7
at f 6 e �h17�.5 has been constructed in' accordance
with the r si/ones►o Title tion Permit No. o�O�t�-d�� dated (WI P
Installer !r�.�/� OV!&ystedConstruc
Designer
The issuan a of this p6rmi shall not be construed as a guarantee that the sy m il_l fu >ion as de ned. n
Date /) j Inspector ll fu -
� j
No. CT`'��� "' ^ Q� -----------------------Fee
n THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
x1h9pont *pgtem Congtruction Permit
Permission is hereby gr e t'o�9ns u t( Re ,tr( )Up rade( )Abandon( )
System located at rl T V V O / /I�/
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/hef duty ab.;
comply with Title 5 and the following local provisions or special conditions.
'. Provided:ConstT/CT
ust be completed within three years of the d to of this pe '
Date:_. l/D T Approved b
TOWN
�OF�9BARNSTABLE f c.
LOCATION f (C� IAI� SEWAGE # — �k;�P
VILLAGE �f C.`�—t✓�v� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO..
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) C c (size)
NO.OF BEDROOMS
BUILDER OR OWNER L 30f
PERMTTDATE: Oqjl) COMPLIANCE DATE: A&' D
Separation Distance Betweapthe:
d Maximum Adjuste Groundw�attdr 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
f I
L3
cle�a�cx�' i
Town of Barnstable
Ft►+e"D'y�� Regulatory Services
Thomas F. Geiler, Director
• BARNSrABM
MASS.9 Public Health Division
ArFDAAA�A Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date:
Designer: Q— hCLk _ �tn �1Q` Installer:
Address: O , ox (Q,11 Fc Address: S-\-
OnD was issued a permit to install a
date (installer)
septic system at 1:S based on a design drawn by
(address)
dated_�� 11 04
ner
g
deli )
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 MqS
!!- N".
nstaller s S;ignature) o? CARMEN- yc
No. 11-81
(Designer's ignature) (Affix D "TAere)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH D 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
; ep - 20-01 13 : 62 BARNSTABLE HEALTH DEPT 50879063U4
sru;ot
NOTICE: This Form Is To Be .Used For tde Repair Of Failed
Septic Systems Only.
PERCOL,s TI.ON TEST AND SOIL EVALUATION EXEMPTION
FORM
rnFs3 �lt�� hereby certify that the engineered pian signed by me
6 tec CA11 C34- _, concerning the property located at
mefs all of the e.
— �3 --
i^I'ow,n, �ntetza. .
• This failed system•is connected to a residential dwelling only. There are no
orvnercia! or business uses associated with the dwelling,
• T? e soil is class:.:ed as CLASS l and the percolation rate is less than or equa to �
-n:n ,tes per inch. The applicant may use historical data to conclude this f3c: or may.
:zmduc:t ?rc!irn :ary tests at the site without a health agent present
• There :s no increase to flow and/or change in use proposed
Therie are ;to variances requested or needed.
• The bottom. of the proposed leaching facility will not be located less than fourteen
aoove the rnaxirnum adjusted groundwater table elevation. (Adiust the
ouln(:water table using the Frimptor method when applicable.f
Please complete the following:
�. lfnp .)i Ground Surface Elevation (using GIS infor-mauon) _
61 G.W - 1— ' 2d;ustment for 'nigh G.W.. �32 '::
ITT-T.R F N C F 0, ETWEE1\4 A and B ,�21
I"S:(�'rIED _ 2tr�t DATE. II C`
3asec jraR the allove !r.for-macion, a raotut permit wil! be issued for 'oedmorns
T.a .,r •u r:. :`<^ ;ddttionat bedrooms :ue authorized to the future without en,tncerec
: E syae^� plans. _ --- —
gain!r,;0u poccamP
Permit Number: Date:
Completed by:
HIGH GROUND-W TER E A LEVEL COMPUTATION
Site Location: r , � U' ', lbpc, Lot No, v.
Owner: ;-�t �?• �, C'j i c;, ,c,;� Address: '
Contractor: ��e�+ � t1J1;ors �rl c>� Address:- '7o. Z[" Q A j C�• VTIA"-)c 0 �' ,
\ t (6
Notes: F � -
h. 2%(
STEP 1 Measure depth to water table
tonearest 1/10 ft. .............................................................................. .Date 11
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
AO Appropriate index well....................................................
0 Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
mine current depth to
Ovate
deter level for index well ........................... 53ti
onth/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 26)
determine water-level adjustment ..............................................:........................................... �J
STEP 5 Estimate depth to high water
by subtracting the water•
level adjustment (STEP 4)
fromjmeasured depth to water
levelat site (STEP 1) ............................................ .... ..........................
Ir
Figure 13.—Reproducible computation form.
15
FAILED INSPECTION
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
Z w
DEPARTMENT OF ENVIRONMENTAL PROTE CEIVED
MAP � f� � O-
a JUN 2 12004
PARCE
W L I
c'O+M SyO�, LOT TOWN OF BARN:,i»tiLE '
HEALTH DEPT.
TITLE S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 118 WALTON AVE.HYANNIS,MA 02601 310 L-139
Owner's Name: CHARLES ELIASSON
Owner's Address: 118 WALTON AVE.HYANNIS,MA 02601
Date of Inspection: 6/3/04 CO,F j"(
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 56-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_ Passes
_ Conditionally 1'a es
_ Needs Further[; luation by the Local Approving Authority
X Fails
i
Inspector's Signature: Date: 6/3/04
I
The system inspector shall submit a cope of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If°he system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN LEACH PIT IS FULL-PIT IS PAST THE EFFECTIVE
DEPTH OF LEACHING.
****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.
Title 5 tncna.ntinn Fnrm 6/1 5/?000 1
Page 2 of 11
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04
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:
SYSTEM FAILED TITLE V INSPECTION. LIQUID LEVEL IN LEACH PIT IS FULL-PIT IS PAST THE
EFFECTIVE DEPTH OF LEACHING.
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.
n/a 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: n/a
n/a 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: n/a
n/a 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: n/a
Page 3 of 1 I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04
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.
_ 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 n/a
"This system passes if the well water analysis,perfonned 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:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04
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 cesspool 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 nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
YES (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04
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 normal flows in the previous two week period ?
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 different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
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)]
5 .
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 427
Number of current residents:2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use:(yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):fthx- 0�,
Sump pump(yes or no):NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped detennined?n/a
Reason for pumping: n/a
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 a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1979 PER AGENT
Were sewage odors detected when arriving at the site(yes or no):NO
Page Tof 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Ownery CHARLES ELIASSON
Date of Inspection: 6/3/04
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: L 8' 6" H 5' 7"W 4' 1011"
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle:32"
Scum thickness: l"
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: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP,:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
'Page 8ofII
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
n/a
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 WALTON AVE. HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04 r
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LIQUID LEVEL IN LEACH PIT IS FULL-THE PIT IS PAS THE EFFECTIVE DEPTH OF LEACHING AND IS IN
HYDRAULIC FAILURE. BOTTOM IS AT 8FT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a,
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a '
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
4
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04
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.
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10
Page I 1 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 WALTON AVE.HYANNIS,MA 02601
Owner: CHARLES ELIASSON
Date of Inspection: 6/3/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
11
SECTION A -A orsnrmn�Aztx
[house
0 min. from NOTE: ALL PIPES ARE TO BE 4 SCHEDULE 40 P.V.C. AIL OUTLET PEES FROM THEVENT PIPE (® Least 24 Inches tart) PROFILE. VIEW OF ADDITION TO LEACHING SYSTEM DISTRIBUTION Box SHALL BE Existing Foundafion to septic tank Schedule 4d PVC w Choreal Odor Eater t2' CONCRETE COvER r +. ltj
SET LEVEL FOR AT LEAST 2 FT. ' 9
TOP OF FOUNDATION = ELEV.'"'100.00'(Assumed) seams ers tank cov must tro 3" of 1/e` - 1j2` Washed Peaston
within 6 in. of finished grade <�
S/4" to 1 1/2 " Washed Crushed Stone
„. Grade over Sepik Top* - 99.00 Grade over D-Box 99.00 over SAS- 89.00 .KNOOKOUTS
r r�
5.5' OUILET ' 12, INLET vn F
" o d
S . 0.02 3 HOLE H-10 3• Maxkt+em Cover Top Load - Elev. -96 25 C _ AO
DIST. BOX
L 14' EXIST. S.0.01 or Greater y. = 2 Yyp,a / y7 1'1=HAIR Ain prsms, st
- 4' - SCH. 40 Te
NEW PIPE ` ' 1,000 GAL S- 0.01" per foot • '
x d'Effective Depth 1J5" 4 la 1
N'RDN EXIST..FDl1tmATIW w �' SEPTIC..TANK $
co s units a s.2s' = 30'- PLAN -SECTION CROSS--SECTION
/ A 1 H.10 0..
CONCRETE n1LL FOUNOrIT,ON-� v ^ P
>
> A 0,83' (10 inches) 3'
3,
31.25 bt
� e In 3/4--, ,/2• � A A �- 37:25' 3 HOLE H-10 DISTRIBUTION BOX � �• ,�
SYSTEM PROFILE compacted stone v .�
c > u u 0/ � m Effettive ter,gth NOT TO SCALE
Not to Scale c - ei
C °' 4' 4' A SOIL ABSORPTION SYSTEM (SAS) 912g44ltmdliclECeq„p ,,,/ t
> _ 2.5 i
t0' INF'ILTATROR HIGH CAPACITY (H=20 LOADING)/ GEORGE O'BRIEN GENERAL NOTES
compacted stone Effective width (OR EQUIVALENT) Not to Scale
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE � 0 1. Contractor is responsible for Digsafe notification ,
w Bottom of Tact Ode i d 0 138.00 m NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18' /EFFECTIVE HEIGHT IS 10" and protection OF all underground utilities and pipes.
No Groundwater Observed O 132" -/" P g P•P
--- -��"-'-"---"_--- 2, The septic tank and distribution box shall be set
level on 6 of 3/4"-1 1/2"_stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size,
4. This system is subject to inspection during installation
by Carmen E. Shay Environmental Services, inc.
5. The contractor shall install this system in accordance
PERCOLATION ��c� with Title V of the Massachusetts state code, the approved plan
J and Local Regulations.
6. If, during'installation the contractor encounters any
Date of Percolation Test: JUNE 10, 2004 sail conditions or site conditions that are different
Test Performed By. °CARMEN E. SHAY, R.S., C.S.E. from those shown on the soil log or, in our design
Results Witnessed By. WAIVER ( per Barnstable B.O.H.)T LOT #24 installation must host & immediate notification be
Percolation Rate: Less Than 2
SHAY ENVIRONMENTAL' Than 2 INC.MPI � 4O" LOT #25 mode to Carmen` --E. Shay Environmental Services, Inc.
7. No vehicle or 'heavy machinery shall 'drive over the
PROJECT BENCH MARK septic,system unless noted as H-20 'septic components,
TOP OF FOUNDATION 8. 'Install Tuf--rite gas baffles or equals on all outlet tee ends.
9. All Distribution Lines shall be '4" diameter Schedule 40 NSF PVC pipes.
ELEV. = 100.00 (Assumed) rn
Test Hole rn 10. All solid piping, tees & fittings shall be 4" diameter
No. 1 Failed 1 Schedule 40 NSF PVC pipes with water tight joints.
Leach Pit
DEPTH SOILS ELEV. i 11. Municipal Water is Connected to ALL OF The Residence and Abutting
0 99.00 125.00, , i Properties Within 150 Feet
SandyEXIST. 1000 gal. 1
Loom Septic Tank i THE PROPERTY 'LINES ARE APPROXIMATE'AND
to T 3/2 :err:=.` NQRMANDGROQSMAN THE
OFUYA MpUTLAHN, MANERATED BY
0"-12" A 98.00
j `r 1 ENTITLED ",Subdivision Plan of Land in Barnstable, MA,
Sandy LOT #26
Lam„ ~_ j °, DATED November 4, 1978, & PLAN 'NOS. 17201J
IG rR s/s t g i AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
12" 40" B. 95.75 DECK 1 iT SHOULD BE USED FOR NO PURPOSE 'OTHER THAN
Med. r' 37. THE SEPTIC SYSTEM INSTALLATION.
Sand
�' 2.5 Y 7/4 :: ��\ EXISTING LEACH PIT TO BE PUMPED OUT AND
36" 132' C, 88.00 EXISTING ; -
2 BEDROOM TEST HOLE #1 w d LOT #28 REMOVED TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION
i Garage ELEV.= 99.00 � _ NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
q�' ROUSE Co FROM THE EXISTING LEACH PIT TO BE DISPOSED
#118 ' OF AS PER BOARD OF HEALTH SPECIFICATIONS.
20'_ 0.5
--- -NO vvtjL N DS ARiE_.PRESF-N -WITHIN 200' OF-THE PROPERTY _
4" PVC ASSESSORS MAP 310, PARCEL 439
LOT #27 T VENT LEGEND
10,000 Square Feet +/- 1 ASPHALT t ��
Perc #1 ',DRIVEWAY
Depth to Perc: 42" to so" _______ 1 , -----__-_�� DENOTES PROPOSED
Perc Rafe= Less Tho 2 MPl i -T-- 104X 1
---------- ---- 1 SPOT GRADE
Groundwater Not Observed It c`
No Observed ESHWT 1125.00FL DENOTES EXISTING
ADJUSTED H2O Elev. = None X 104.46 SPOT GRADE
------------------------------ �,
------- ------------------------------------�--------------------- PL PROPERTY LINE
Wes-L TON A V.L'N UE 96P PROPOSED CONTOUR
(40 FOOT RIGHT OF WAY) •- --- -- -97 EXISTING CONTOUR
TYPICAL 1000 GALLON SEPTIC TANK DEEP TEST HOLE &
N07 TO-SCALE
PERCOLATION TEST LOCATION
2-18' DIAM. ACCESS MANHOLES
6 FOOT STOCKADE FENCE
:cr --
TOi
INLET - P LOT P LAN
OU
TET
THE ACCESS COVERS FOR THE SEPTIC TANK. OF PROP0SED SEPTIC SYSTEM UPGRADE
DISTRIBUTION BOX AND LEACHING COMPONENT
SET DEEPER THAN 6 NCOES BELOW FHSHED PREPARED FOR
GRADE SHALL BE RAISED TO VATHIN 6' OF
STEEL REINF'OR/�CED PRECAST CONCRETE nNISHED GRADEPLAN VIEW NSTALL 1UF-TITE GAS BAFTUS OR EQUALSMR . CHAR ES ELIAS0N
AT
3_24-TAD - # 1 18 WALTON AVENUE
3min. d�aran� HYANNiS MA
INLET 8" mn•I _12 mtWet to outlet"-LWUW lev � T Design CalculationsoF REPARED BY:
15 TLNumber of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Gal./Day Min. per Title V)Eo 4'-W m "' 1. Garbage Grinder: No NC u/� Yu` daeptb Leaching Capacity Proposed: 330 Gai./Day Minimum (Min. Per Title V) 1J111-1 1Septic Tank : - 2x 330 Gal./Day - 660 USEEXIST. 1,000 GAL. Septic Tank. 0 20 40 50 � VIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using`percolation rote of <2 min./inchoa P.O. BOX 027
-1DBottomArea: 0.74 gal/sq, ft. x 370 sq. ft.-= 273.8 gallons.. Sidewall Area: 0.74 gat./sq. ft. x 78 sq. ft, = 58 gallons �fsT��` EAST EALMOUTH, MA02535
CROSS SECTION END-SECTION Providing: = 331.80 gallons SSTIESTEL/FAX 508-�548-�•0796
Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS. HAVING A 0.83' (10 INCHES) EFFECTIVE, DEPTH, SCALE: 1..=20'
BE USED WITH 4.0' OF WASHED.STONE ON THE SIDES, AND 3.5' OF WASHED STONE
SCALE: 1 "=20' DRAWN >BY: CES DATE: JUNE 11, 2004
ON THE ENDS. NO STONE UNDER. PROJEC?#SD584 FILENAME: SD584PP.OWG SHEET :1 OF 1
-