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HomeMy WebLinkAbout0041 WAYLAND ROAD - Health 41 WAYLAND ROAD Hyannis E A = 271 - 231 t 0 No. / — Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitation for bisposal *pstrm Construction permit Application for a Permit to Construct( ) Repair( Upgrade( ) ` bandon( ) ❑Complete System Individual Components Location Address or Lot No. ?21�y�i�� (A Owner's Name,Address,and Tel.No. Cc�✓q`.r� Assessor's Map/Parcel e// 6m e e✓G, Installer's Name,Address,and Tel.No. /4% C e/ I f—P7 Designer's Name,Address,and Tel.No. 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(min.required) 73 gpd Design flow providedlylt­ gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ✓�` e 1`S a'!o'b��i-✓'�.. }�c 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 o place in operation until a Certificate of Compliance has been issued by this Board of Health G/ Si oeDate /'Z//�� Application Approved by Date (9 Application Disapproved by Date for the following reasons Permit No. Date Issued } M. t ( ( _ Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatlon for'Mi�posar *pstem Constructions Permit A ) Application for a Permit to Construct( ) Repair( Upgrade( ')'Abandon( ) ❑Complete System Individual Components t Location Address or Lot No.7�7/ Z 3r ; U wner's Name,Address,and Tel.No. ff fit,.► Assessor's Map/Parcel ri/� li✓ T"/c�r.,,� �� 6.ko L ev-e, f Ins'taalller's Name,Address,and Tel.No./3'Q 3 G C/ $1- 7 Designer's Name,Address,and Tel.No. Type of Building: %± Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) i . Other Fixtures Design Flow(min.required) no gpd. Design flow provided / ' gpd Plan Date Number of sheets w Revision Date Title Size of Septic Tank Type of S.A.S. " Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1--le.ft,-&- Date last inspected: --� --/5 Agreement:, The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5-of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date (� /Z Application Approved by Date Application Disapproved by Date for the following reasons Permit No. f Date Issued 6 ---------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( a/ Upgraded( ) Abandoned( )by D-%g L^a// o �Z-•�--c/ G� �/ A k at 1-/l 1,J e- Ir �`7 rY\ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.Q� I dated Installer, /Ie, e, z^ v A. -� Designer #bedrooms Approved design flow gpd The issuance of 's permit shall not be construed as a guarantee that the system wi+1'fun ti J design Date p / Q► Inspector J y ---- -r.----------------J----------.--------------------------_-------------------------------------------- - ----------- No of Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Mis oral stem Construction Vermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date /� ( �''( Approved by i y Town of Barnstable kz3Barnstable3d Inspectional Services AN-AmedcaC ft MC2Nt3YASLE, 6 9 ,$' Public Health Division °tea 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 9064 January.,3 0, 2019 HEWITT, HENRY & KELLY 41 WAYLAND RD HYANNIS, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 41 Wayland Road,Hyannis, MA was inspected on 01/18/2019 by Frank Nunes III, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • The distribution box needs to be replaced. You are ordered to repair or replace the-septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future , enforcement action. PER ORDER OF THE B RD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\41 Wayland Road Hyannis.doc t Town of Barnstable i sARAT81'ABL.E, i .19 _Regulatory Services Department Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA o Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single Cesspool y"conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc r Commonwealth of Massachusetts o`t�l_ a3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2> �s M y 41 Wayland Rd. ' Property Address Omeara Owner information Owner's Name is required for MA 02601 1/18/19 every page. HyannlS =-, Cityrrown State Zip Code Date of Inspection s C' 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. A. General Information 67# 135(a d 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 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 441116f r' 1/18/19 Inspec r' ig atu 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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth.of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M , 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. Hyannis MA 02601 1/18/19 Cityrrown 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: 13) 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.doc•rev.6r16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. Hyannis MA 02601 1/18/19 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 distribution box is excessively corroded and needs to be replaced ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. Hyannis MA 02601 1/18/19 City1rown 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 ❑ ® 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 1/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. Hyannis MA 02601 1/18/19 Cityrrown 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. ❑ ® 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- 1 0,000g pd. ❑ ® 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. t5ins.doc•rev.6/16 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 s 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for Hyannis MA 02601 1/18/19 every page. y 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): 3 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Wayland Rd. Property Address Omeara Owner information Owner's Name e reqevery page. Hyannis MA 02601 1/18/19 every page. y Cityrrown State Zip Code Date of Inspection D. System Information Description: System was permitted as a 3 bedroom. Permit on file at Health Dept. Per owner there are 4 bedrooms Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available'(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: 12/31/18Date 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.doc•rev.6/16 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 ,a 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. Hyannis MA 02601 1/18/19 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: No pump history given 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) El 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. Hyannis MA 02601 1/18/19 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Original septic tank, new d-box and leach chambers in 2000 per BOH record 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): >10' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) H-10 tank appears to be structurally sound, it is reccommended that the covers be raised for inspection and maintenance If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 12" t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for Hyannis MA 02601 1/18/19 every page. y 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 >12" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle >2° >2" Distance from bottom of scum to bottom of outlet tee or baffle 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.): Pumping suggested at this time 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.doc•rev.6/16 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 SVB' 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for Hyannis MA 02601 1/18/19 every page. y Cityrrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. Hyannis MA 02601 1/18/19 Cityrrown 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.): H-10 D-box is 3' below grade, it is severely corroded and needs to be replaced at this time Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 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 M 41 Wayland Rd. Property Address Omeara Owner information Owner's Name everyage.ed r Hyannis MA 02601 1/18/19 every page. y City/Town 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.): The chambers are 3' below grade, they were video inspected and are damp at this time, no indication of past hydraulic failure, probing gives no indication of raised covers 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. y H annis MA 02601 1/18/19 Cityrrown 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.): Soils are compact and dry 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , a 41 Wayland Rd. Property Address Omeara Owner information Owner's Name everyage.ed r Hyannis MA 02601 1/18/19 every page. y Citylrown 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 C� (L 1 © 0 t5ins.doc-rev.6/16 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 4 M 41 Wayland Rd. Property Address Omeara Owner information Owners Name is required for every page. Hyannis MA 02601 1/18/19 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 round water: >25 P 9 9 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: per permit on file Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: >5' seperation per compliance on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 60'msl and nearby surface water is 30'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 41 Wayland Rd. Property Address Omeara Owner information Owner's Name is required for every page. Hyannis MA 02601 1/18/19 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Z41 TOWN OF BARNSTABLE LOCATION �d`�1��� �` SEWAGE # awl/ VILLAG ASSESSOR'S MAP & LOT Z 7I-2- i�- -•INSTALLER'S NAME&PHONE NO. A®r&Zolll CAVA,, 7��—�. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) " ✓OO W/ (size) NO.OF BEDROOMS l BUILDER OR OWNER PERMITDATE: 2 COMPLIANCE DATE: Separation Distance Between the a ' 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 ' fy Edge&'Wetland and Leaching Facility(If any wetlands exist .within 300 feet of leaching facility) Feet Furnished by i e W A r �:' ` ry D►GL a7 k.• +� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Oiopogo.f 6peum Cow6truction Permit Application for a Permit to Construct( )Repair(Y)Upgrade( )Abandon( ) ❑Complete System MIndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. �f dqJ�✓���,� Assessor's Map/Parcel r /�,tlJ �5 _ Installer's Name, ddress,and Tel.No. Designer's Name,Address and Tel.No. Aerfn 65910� -� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(116y� Other Type of Building I�f?S�/� gfecC No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ,/�!� gallons per day. Calculated daily flow 3J!J gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank IMO 45W5�l/t9 Type of S.A.S. 2- �'i�O© 4�1lyw 9p•���'/`S Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued thi d f Health. SigneJFDate Z 11 O Application Approved b e Date% l� PP PP Y Application Disapproved or the following reason( Permit No. — Date Issued LI Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for �Dtgooar *pztem Comaruction Permit =Application for a Permit to Construct( )Repair( tf)Upgrade( )Abandon( ) El Complete System L�Irtdividual Components Location Address or Lot No. / jp� �,. Owner's Name,Address and Tel`.No. Assessor's Map/Parcel 6 . ' Ro ief z Installer's Name, ddress,and el.No., Designer's Name,Address and Tel.No. r� �o�too / CoJ�` w 3 Type of Building: Dwelling No.of Bedrooms /.j,T.Lot Size sq.ft. Garbage Grinder( �0 Other Type f Building" No.of Persons Showers Cafeteria ) YP o J � g ( ) ( Other Fixtures F Design Flow 1/05�1 gallons per day. 'Calculated daily flow �;Jo gallons. Plan Date . Number of sheets Revision'Date Title / Size of Septic Tank I /Doo .cif%57`%/1� Type of S.A.S. 2- Description of Soil 1 a 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 in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this B d f Health. Signe Date Application Approved by d4o r Date C/ Application Disapproved or the following reason i? rmit No./ Date Issued --=------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS Z 3 BARNSTABLE, MASSACHUSETTS Certificate of Compfiance THIS IS TO CERTIFY,that Oe On-site Sewage Disposal System Constructed( )Repaired( _10upgraded( ) Abandoned( )by at / Gt/er has bee constructed in accordance with the provisions of itle 5 and the for Disposal System Construction Permit No dated Installer Designer n The issuance of this permit sh 1 not be construed as a guarantee that the s will function as,;ig�� r Date Inspector ' i� UUJVVv,T 1 ' �t! -------- -------------------------- No. Z 7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mizpoof *pztem Conotruction Vermit Permission is hereby granted to Cons ct( ) epair )Upgrade( )Abandon( ) t. System located at W�' /' 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 m st be c9fripleted within three years of the date of s ermit Date: Approved by l cJ �� TA -Rcr-�Ar pUj I S7 ��U� w U6J99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at G✓��`�`ji"D�G. 1p�1�1/ `�J meets all of the following criteria: +, The failed system is connected to a residential Swelling only. There are no commercial or business uses associated with the dwelling. Y The soil is classined as CLASS i and the ercoiation rate is less than ore . p goal to� minutes-� -.ncae. . Y There are no wetlands within 100 feet of the urorosed septic system v There are no private wells within 140 feet of the proposed septic system 1/ 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 not be located less than five feet above the maximum adjusted groundwater table eieration. [Adjust the groundwater table using the rrimptor ethod when applicable] V - If the S.A.S. will be located with_00 feet of any vegetated wetlands, the bottom of the proposer leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: i A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W. Adjustment.3 y = 2 DIFFERENCE BETWEEN A and B SIGNED : DATE: 2—` ,?-3`et7 (Sketch proposed plan of system on back]. q:health folder pert TOWN OF BARNSTABLE LOCATION �a�11a y �'e !`i".�[p. SEWAGE -�. ! VILLAGE lVl�/111I5 ASSESSOR'S MAP &LOT G —L✓`� INSTALLER'S NAME&PHONE NO..�or�� � Cok�T 771 SEPTIC TANK CAPACITY LEACHING.FACILITY: (type) CaLV*t� (size) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: 2- -/54r—9-dd0 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 LOCATI'O v" SEWAGE PERMIT NO. VILLAGE INS TA' LLE 'S NAME . ADDRESS ,ADDRESS �. ITO ,rC e;j&? ✓i^ BUILDER OR, OWNER PATE PERMIT fSSVED DATE C0IMPLIANCE ISSUED 02 f JJ91 Y r <iZ No.+ .....s� � � F�s...-"�- ............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................. own.............OF.....Barn.SA"Ie..................................................... ApplirFa#iun-fur Uigpuual Worku Tunitrnrtiun ramit Application is hereby made for a Permit to Construct (g ) or Repair ( ) an Individual Sewage Disposal System at: ....Lot.. ---.ajo----.��.t � . ........ ...... y-a?a11la.,..--Mp.....---•----•---•-----•-----................------......--•- o ation Address or Lot No. Ca.ricorn.Rea y. Trust _. 76S_ Falmouth Road,__Hyannis,_„_„_,,, -. ..... Owner Address WSteve Lebel ................................•-------- ..........................I- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........3.................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ranch.............. No. of persons............................ Showers (2 ) — Cafeteria ( ) W Other fixtures ..-----•----------••----•-......- • . --•. W Design Flow.................5.5......................gallons per person per day. Total daily flow...........3.3.0.........................gallons. WSeptic Tank—Liquid capacity1000.gallons Length_8__`_6...... Width..4 1 Q.'_ Diameter................ Depth..5.'$ __. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... Diameter.... 6_......... Depth below inlet....... ........... Total leaching area....266.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed b Eldredge Engineering- Date._.._11--25_81 aY ...... ........_ .................... ,.l Test Pit No. l 2.o.Q.._minutes per inch Depth of Test Pit.......2...._..... Depth to ground water n0ne...encounter- TestPit No. 2_ A.....m L�I inutes per inch Depth of Test Pit._ ,A......... Depth to ground water----11tlA........... C4 ----•-••--•------- ------------------------•---•---------------•----........__.....---------------- ---•----•- -••-------•••-..._..------------..--...... O Description of Soil--------Q.....- 2 Oa?il..&... 9. Q -------------------•----------------•----•----------------•-•--......--------------- 2' .. 1Q-.......medlua..ye11.oW.. Bard.............................................................................. ------------------------------------- 1-Q. 1-2 med-._-_bIte.--aand/traaas... f---gr&V.L_1/no... rat-er...a.t...12 ' U Nature 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 i i:i:; 5 of the State Sanitary Code—The undersigned furtl.er agrees not to place the system in operation until a Certificate of Compliance has been iss d b the board of health. [' igned ----- -t-& ✓ ...------•--- a. -1. .... ............ ApplicationApproved By. .... ..........•------------------•--.....--------------------........-- ---- . •-- ................ Date ` Application Disapproved for he following reasons-----------------------••-------•----•-----•------------•---•-•--- =.......................................... ........•---•--•-------•------------•--••---------------------------•-••--------------------.._.........-•----•------•-•--•--•---•-----------------••-----•------------•-----•----- ``•c'`~ ..........................Date .....--•-------•--------------••--•---•--------. Issued._....... ........ Date IN /y Fuim............................ � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................Town.------......OF.....Barns*able.---------------------------------------------------- Allp irFation for Bitivaii of.lRorkg Tonitrurtion rrniit Application is hereby made for a Permit to Construct fi) or Repair ( ) an Individual Sewage, Disposal System at � . ..... �t.. .... -. . •: ......... ----•- nn�s....m�.. ................................. ........ Location Address or Lot No. ._Capricorn_Realty Trus�.. 76.E Fad. o> � i...I�Qad.w..Ny. nX��. 4................. •_... Owner Address a ._.$teve.:'I.e el---------------------------------------•--...--•---•--........._ .........---------------._...------...---......-•---...._...------•-----.._........----------••--- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_______.3.................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ra nah_____________ No. of persons............................ Showers (2 ) — Cafeteria ( ). a Other fixtures _________________________________ _ WDesign Flow.................5.5______-____________..gallons per person per day. Total daily flow...........3,�.0................_........gallons. WSeptic Tank—Liquid capacityl_O.04_gallons Length_$___6...... Width._4._1.0_ Diameter________________ Depth_5__$___._. x Disposal Trench—No_ ____________________ Widtli___.�.._.._._._.-_. Total Length.................... Total leaching area___.................sq. ft. � ` Seepage Pit No..................... Diameter___.._.6_.__..__. Depth below inlet___._._..6.._._.____ Total leaching area.....26_6_....sq. ft. Z Other Distribution box ( ) Dosing tank ( '-' Percolation Test Results Performed by...__E�-d@.__ ;e_.Eg �C;<eer .n�g.......... Date.....11- Jr-$1............ Test Pit No. 1 f .0_..minutes per inch Depth of Test Pit-----12 1_.____. Depth to ground water n0nA anco lnte - (i Test Pit No. 2..N/A_____minutes per inch Depth of Test Pit..1\4/A......... Depth to ground water----K/A........... e ------------------------------------------------- ............ •....... •••---------------- •-•------------••--------------- •--•--•-••-------• ••••-- D Description of Soil------_.. '_.."..2-!--•._...10a1.__sk...tQ.�-�Q�.1.--------•---------------------------•---....-•---- cxi ...... Q ......Medi _-yell aW...saxkd---------------------------------------------••_... W 1-Q•--•-"--•12 ------.med.----t�i t-e- sans/traess...of__ vellno...w .ter---at.__12 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 TITTLE 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 b7. the board of health. Signed-- ---------•--•--•...............:.. .............. `_ .................. lJ ate Application Approved By....... --,1--- •- �r s.�! :•:._._.. Application Disapproved for a ollowing reasons----------------•-----------••--------------------------------................................................. ..........................................................-............................................................................................................................................. Date PermitNo.......................................................- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH' .....................Town......_OF...Barnstabl.�................................_................ Tatifiratr of Tontpfittnrr THIS IS TO CEITTIFY That the Individual Sewage Disposal System constructed ( X) or Repaired ( ) SteveLebel --------- ----------------------------------------------------------------------------------------------- ----------- __ Installer MA at Lot...................... .. `�._ .. ::... x ` ? 1 � .............. has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s de rib .__ ed in the application for Disposal Works Construction Permit No �.._�_�_ __............... dated---- -_,�.�lKlk-.._.___._________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS • BOARD OF HEALTH Town OF Barnstable �.................... ..........._.........-• •-•---...--•......._......_.. NOJVI to oottf orkii Ty-onotrurtion rrniit ,// f Steve Lebel Permission is hereby granted________________________________________________ to Con rut NIA V) or Repair�c ( ) an,lndivid al Sewage Disposal System ,U ' ,��r Pc 1" ..__......-•---•- nns, at No. O........................... Street as shown on the application for Disposal Works Construction Permit No.., -i Dated r .................................... w—� 'Bo�r of Health DATE FORM 1255 HOSES & WARREN. INC.. PUBLISHERS l 0,00(o. . F I CU .W t or)-7i OF M�S�q� ice.'• � � • G 0 c `jt H O 30 , �v �1Vt7 SUR��'� f e LO 0 o 0 oe yo N �o SLOT Z.0_> �G j LxPANs. m (V aN /o� ergcN,/a," _ LEGEND EXISTING SPOT ELEVATION 010 ,PLZNOFMgss CERTIFIED PLOT PLAN EXISTING CONTOUR --- 0 ---- 23� , /_v 2 v r .nth ';' �0 A v FINISHED SPOT ELEVATION ALBE fz.A �S -FINISHED CONTOUR 0--- No.10951 O 1 N AWltOVEOs ®GARB OF HEALTH AJIRS tAS.L AS3• P GISTE �a ��FSSIONAI D E 'AGENT SCALE / �- DATE EDQE .E`NG/NEERINQ CQ iN CLIENT ` A'_'vCll I CERTIFY THAT THE PROPOSED EAISTB e REAISTM'ED JOB N0. Fl z BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS DR.BY, Ate,.. Of BARNSTAB E, A3S. 712 M&I N STREET, CN. 8Y� `�R.E ' M YA N N I S,. MASS 05 �2 >�i �1_� ._._ t'. SHEE' —OF Z DATE y 0. LAND SURVEYOR y � y � < � P C NO \3)0pSq tj D � A � D o � 2 � ]► y203 � � "y a wo oN Z u, .- W 0 2 Fy�p �m �� O4Y� D y � y y yti O � A F 0 a o \✓FFR S 1 �� y y ° clz � 3 NI yD V � I� Q3N Q�I.p � n � n � ° i sty � � r � _` � � .` � o► y � .�� � hriC � olb ILI o•. o . � a o :— -- ui p a p ° d y • a0°v % ° � D O 30 -4 T ti O o f� „ a s o.� m M . . . .. N nn� 0 fti C cj •• , p w aim �► IAo � �, g rh y N �1 ti At M H y 2 Z 1� �► Nov\. N � y cn (� OvD y I! A� min y o o •� � � ��r� \ D