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HomeMy WebLinkAbout0047 WEST HYANNISPORT CIRCLE - Health (2) 47 Vest HyannisPor°t Hyanni s = ? 4�; rC2 Commonwealth of Massachusetts -. Title 5 Official Inspection Forme jo Subsurface Sewage Disposal System Form - Not for Voluntary Assessmentse l /4- 1/'G/ = J Property Address C,-1 Owner Owner's Name - information is ✓ ,[� �y�! iL0 required for every o1✓1✓1 .. __ /7 Q v of �G �/�; VX page. City/Town State Zip Code Date o�lnspectlbn Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Irar4e_ ationon the computer,use only the tabS / key to move your Name of Inspector cursor-do not '/y V/o., — ! e G/� use the return key. Company Name o m Company Address Cj riY�i o� 70� City/Town State �v �� Zip Code (Sa)Ao , 771oTelephone ,ber License Number B. Certification i certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of.Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the sys m: 1_ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 foram should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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.doc•rev.712612018 live 5 otSoai'inspection porn Subsurace Sewage Dsposal System•?age I of 18 I Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r / /,(,� / rlNiS r'T Cie Property Address T II✓�� S ' Owner Owner's Name e, information is �J v�660 G required for every N N/ /� /b, page. City/Town State Zip Code Date o Inspecti n C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P ses: I have not found an information which indicates that an of the failure criteria Y y e c terra described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SQ L 4 CA✓y og Ih ��GO�N'1ev►G'Gc' . 2) 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): (5insp.00c-rev.7262018 _ Tme 5 otfioai mnspecaon=orm:suosurace sewage Disposai Sys.em-?age 2 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a L/ A✓Ih�S C 1 r Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of nspec on C. Inspection Summary (cons.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 official;rspecuon rom Sucsur6aae Sewage Disposal System•?age 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �/1✓/Ct Owner Owner's Name information is A N„`f iJ OM-0 � -O required for every /`�T (O 1� page. CityfTown State Zip Code Date Inspecti n C. Inspection Summary (cont.) ❑ 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 b. 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- 7 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ckup 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 Sinsp.tloc•rev.72620�8 _ `ye 5 o-mciai tns?ecuon Poem:suosurface sewage Disposal System•?age 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary g p y o unta Assessments ry ^� ci✓01 wof Ct f Property Address 641;of Owner Owner's Name information is required for every page. Cityfrown State Zip Code Date of nspecti n C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 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 5" below invert or available volume is less than 1/2 day flow ❑ Required pumping more than 4 times in the last year HOT 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. ❑ L—VJ/ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion P privy ortion of a cesspool or riv 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 d chain of custody must be attached to this form.] ❑ //he system is a cesspool serving a facility with a design flow of 2000 gpd- 000 gpd. 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. 5) 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 `non to each of the following, in addition to the questions in Section C.4. Ykes 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 t5insp.doc•rey.7f282018 Title 5 01foaj Inspection=om:Subsu`ace Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Al A&4 ti tj jf Ct V^ Property Address Pj" l ✓►g Owner Qwner's Name F ��O 42 /a information is 64 n &' l required for every - page. CitylTown State Zip Code Date Inspectfon C.'Inspection Summary (cost.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes'to any question in Section C.4 above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ 00, mping 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 LLL+++ 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 plarl at the Board of Health. goo/00"❑ 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)] Tile 5 Of`dai inspec�on Porn:suoscdace sewage Disposal System•Page 5 of 18 t5insp.doc•rev.7/25/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name n� 9 information is A K��S oa 46 Q v� 7 required for every State Zip Code Date f spect' n page City/Town D. System Information Plow aN1 pv4 .1. Residential Flow Conditions: S Number of bedrooms (design): dumber of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). Description: /,� 1.500 Ga+��on /O�gS7�'jG .SepT�c /�►'"�/ 6 3050s `f 7 X lI X d, D Number of current residents: �/ Does residence have a garbage grinder? ❑ Yes 2 No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes No information in this report.) ❑Laundry system inspected? Yes No ❑ Yes No Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: ❑ es ❑ No Sump pump? Last date of occupancy. Dace ?Ite 5 nspecoon=c, Sewage Disposal system•Page 7 0'18 t5insp.doc•rev.7126/2018 1 Commonwealth of Massachusetts i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I ✓1 h t f o,r� �l V- Property Address .. Owner ' •` q S Owner's Name information is �b!60 required for every C�rl✓1t �—�—/L,q�. page. City/Town State Zip Code Date of section D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5imsp.00c•rev.7/262018 Title 5 offidai mscecton=orm:Suos::rface sewage Disposal system•?age 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments O ,A / LZ Property Address Owner Owners Name /� L47- 00 information is h�f required for every State Zip Code Dat o Inspe 'on page CitylTown D. System nformation (cont.) 4. Type of S em: 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 k� o5 wn) and source of information: 00 /l ; -God, Were sewage odors detected when arriving at the site? ❑ Yes ' No �5. Building Sewer({ovate on site plan): '/ Depth below grade: feet Material of construction: ❑cast iron 40 PVC ❑ other(explain): r Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 'i a iai inspection Fo-.�u sUrtace sewage Disposal system•Page g e is t5insp.doc•rev.7/26/201 a Commonwealth of Massachusetts CL Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not foi Voluntary Assessments Ll7 W r Property Address Owner O . wner's Name information is required for every (>i ���.t A4 �� !D �( page. City7own State Zip Code Date of I 's ction D. System Information (cont.) 6. Septic Tank(locate on site plan): ! Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass po! eth lene y y ❑ 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: /SO O 4. Sludge depth. Distance from top of sludge to bottom of outlet tee or baffle Scum thickness ? Distance from top of scum to top of outlet tee or baffle CJ // Distance from bottom of scum to bottom of outlet tee or baffle — A How were dimensions determined? 9 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 100 1h wo&*lrjj*,P4 . aH `v 44"cl t5insp.doc•rev.726=18 n me 5 vOf`aai I ispecac.i=o gin.suosurtace Sewage oisposai System•Page 10 o`1d Commonwealth of Massachusetts Title 5 Official Inspection Form P J m -Not for Voluntary Assessments Subsurface Sewage Disposal System For n 7 / Cr r Property Address 6: ell/ll?G Owner Owner's Name ! information is required for every A//I page. City/Town State Zip Code Date of inipection D. System Information (cost.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 'izie 5 Cffioa'.inspec—=0c:scosu^ace sewage disposal System•Page 1 t of 18 t5insp.doc•rev.7/2512018 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,.�� � w �1 IS o�� Cal ✓' Property Address h sr Owner owner's Name information is Qa 6� 41 required for every State Zip Code Date of nspe 'on page CitylTown D. System Information (cons.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert 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.): a4�1�z 7t.e 5 otfQai:nspecuon=0- s Dsu face sewage Disposal System•?age 5 Z of 18 t5insp.doc-rev.7262018 Commonwealth of Massachusetts Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form - Not f r Voluntary Assessments Property Address ern Owner Owner's Name information is a 44 if pad required for every page. Cityfrown State Zip Code Date of I pecti n D. System Information (cont.) 10. 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.): i t If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): if SAS not located, explain why: / J?o s Type: SD ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number. length: ❑ eaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeiaitemative system Type/name of technology: --- ?ice 5 Dffiaai Inspe,.8on=..—:sUDs,_rrace Sewage Disposal System•?age 13 of 18 t5insp.doc-rev.7126/20;8 Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments AaA441od CI✓` Property Address G 1 Owner Owners Name Od—G O1 information is required for every 20411 page City/Town State Zip Code Date of Inspection 4 D. System Information (cost.) 11. Soil Absorption System (SAS) (cont.) f hydraulic failure level of ondin , dam soil, condition of Comments (note condition of soil, signs oP 9 P vegetation, etc.): ON ii n P-e, e- 410-Vi- 00 rat o, L �t 4 s I 12. 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.): Tine 5 omcai inspzcvon For.sucsu;face Sewage Disposal system•Page 14 of 18 t5insp.doc-rev.726/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form 5//I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��� W _ o. Clio- Property Address Owner Owners Name information is /%.,Q Q60/ required for every / b page. City/Town State Zip Code Date of lrhpectiV D. System Information (cont.) 13. 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.): Tiue 5 Cfnaal;nspactOn=orrn.s�osurface sewage Disposal System.Page 15 of 18 tsinsp.doc-rev.7126/2018 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System ,Form -Not for Voluntary Assessments jqQ#14115"'P.11- Cl Property Address �/ l✓1 Owner Owner's Name information is /f] / n required for every /7L�#14IS "" 600 4 6 9- - page. CitylTown State Zip Code Date of i specti D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks enchmarks. Locate all wells within 100 feet. Locate where public water supply enters the bui ng. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately i � I I i /50o 6,11,o-, PlQsfr� Sea��/�c C9N �'77 I 1 O a W 1'- —54.N� i Core,- i ✓IS 2 G4(07 !Je AW /4 /- 3 t6insp.doc•rev.7/26/2018 Title 5.,)ffidy in cti speon c-m:Subsccace Sewage Disposal System•?age 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address rr P�I1�lA Owner ;Own;erl'sameinformation isrequired for every P/page. tate Zip Code Date o I pectin System nformation (cons.) 15. Site Exam: {J Check Slope ❑ Surface water ❑ Check cellar /�, Ja!A &'7 ❑ Shallow wells �� /f-vm Estimated depth to high ground water: 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 ❑ bserved site (abutting property/observation hole within 150 feet of SAS) Checked local Board of Health - xpI _ 71, Checked with local excavators; installers- (attach documentation) Accessed USGS database- explain.- You must des ibe h G u establishe )he high ground water e v tipn: Cs Pe' 0(� 4( ft C c. lteel- 00( Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5insp.00c•rev.7262018 Side 5ca;Ins cn=cr:subsur`ace sewage Disposa system•?age t l of t 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address v►a5 Owner Owners Name - information isna6 o/ J,6 /� required for every page. City/Town State Zip Code Date 5f tnspecti96 E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Inspector Information: Complete all fields in this section. Certification: Signed & Dated and 1,.2, 3, or 4 checked L/ c. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 ailure Criteria) and 6 (Checklist)completed D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 'ne 5 O'fiaai:nsxc on Forth:suDsc6ace Sewage oisposai system•?age 18 of 18 t5insp.tloo•rev.7128/2018 • Town of Barnstable Regulatory Services �. Thomas F.Geiler,Director • Sa►TNSFai�BF:E. s Public Health Division O Aj O MA C Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: Do. 0 7 / Designer: y Pc l� I �Y nstaller: �_,;��1; � ��, Address: . P,®• 90 X 91 Address: z On, 2 d N H 1 was issued a permit to install a (date) (installer) septic system at 4 W - H VO N IS P�T' C I based on a design drawn by (address) M V �S-dated (designer) T 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 anchor 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 r cation of any c ponent of the septic system)but in accordance with State&Lo Pl evision nt certified as-built by designer to follow. �p�� say or pA E yGs M. lelh zlllv��b_ ` o. 1140 N (Ins er' ignature) 0 4siCgne�r�'s Signature) (Affix Designer's Stamp Here) Lr 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. T AN YOU. Q:Health/Septic/Designer Certification Form ASSESSORS NAP: PARCEL: �'L7 26� TEST 1 FLOOD ZONE:NOIA 14AZ/Y9-0 SOIL EVAI REFERENCE: WITNESS: DATE:76 PERCOLATI A-UAL"7T I(�lg9S p° TN-I LL Iq A Lp�M LOCATION MAP(617:-) 21" Sh*14 ft B Sm�o� to 4„ G ° 2 S�+n SE 3-7J&13 -L80dSINNdAH 1S_gM F lIB.gAVd� -MM 1 osZ , oho 3 o pow <N. s 1A zzr N� EXISTING �N u w ZWo m DWELLING IO Ya ws ° ° 0 TOP OF FPDN 5L*8 EL 7043.- EL:13.43 ! DE ac SLAB S E F °lam TOF:E, N (perk) - M g ey »ost r3x3 EKIST►mq C65SP60LS 40►A�Po�Y B��F 0077= 7 61_f5.0 TV 12.0 ! �02 DAI� Nre�1. _ E SR'GTEaN 4NITA0.1� I�I1ell� O G S NOTES: I� I) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH QA{QI1 RS.,CSE S PLAN, M MASSACHUSETTS TITLE V & TOWN OF O STF a BOARD OF HEALTH REGULATIONS. 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, 4.2 I ING SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO . L-rkQ-07y 9Fk�/ry INSTALLATION. TH-2 C+ 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE DETERMINATION. 17 4) ALL PIPING TO BE 4"SCHEDULE 40 Qa I/9-1 FOOT. (UNLESS SPECIFIED OTHERWISE) SD 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A I n GARBAGE DISPOSAL. 1.0 f 6) SEPTIC TANKS AND DISTRIBUTION BOXES(WHEN INSTALLED) MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON S A BASE OF 6"OF CRUSHED STONE, 15 7)EXI5TIT,a5sPmLb iD BE. PuA^PEO,pui1 g, ----- �, PEP,-PTLE V-FE PLRL£W CcERN,ffirzo SRNo. J 8. I ID KNVkIE WFJ L�MJn1 1�Ot.P_+wP. (� 1 Y S T E M DESIGN 9-Io VJOr NQ5*/( 150'ot:epoP:_.LEpvBt nl(� ATE 10)1I'l2R9E[.,Ta PI kc��0_N1_PQI N — A6 S AT IID GAL/DAY/BEDROOM -�SCGAL/DAY S'+IrowN-M Fie - �-�/S,otoEL12_) II)ND S, _ Bn of f•{'EiYLT1��V�p�y�VIR{b• ,Y a 2 DAYS - 11 00 GAL n-�4S F'F2-NDT7( ' ulaFp fp2 F( �E�T• _ GALLON SEPTIC TANK—OEcA)- VS a- P"eT.HyLEN6 TihrJK- IE NGcESSMz��{{ Dvt10SIM C.)AAS7R4VARS 'TION SYSTEM L(jOH !C'PPRDV+h.Rs¢L�IO� INGILT'RA'mP 2DS0 UNITc v/�II ��TUNE >.�•M'SSaNE ON SAGES 1'41'LX II :It)✓<Z;�� _-._. _ AREA I(�F7)�*(.11-)z�x 2 k 0.7y' 171. Gg M AREA: 4+K It _ x 0.74= 382,58 ssN.Is 4 P- YSTEM SECTION F0r�4J 0 grace. 4 1^�+ Bw�.Y INSP I�P.T WlI� J °F 10 f4 � wl(o' 9ra4e Iny}^II IID c a EL IS.o &Sf�,e 6at�tas �^�OX o IISOO GAL tc IT IS. I• 7.13 SEPTIC TANK �4,'j.',IneSS� q.SG 1 1• 12.Z Da-3 f-- 47L.K II 2Y 36 IJasw bl SITE AND SEWAGE PLAN S•M¢. LOCAT ION:-47 V/.4YA-I&SPOPT ORCLE v I " 1�lrtNUIS, MA- 3�4 41 �" .4 _ DDobL- IUD PREPARED FOR: EL/N4,f S'f'Dn2 (I DARREN M.MEYER,R.S. SCALE: "=20 P.O.BOX 981 DATE:I + EAST SANDWICH,MA 02537 DATE HEALTH AGENT (508)362-2922 a No. Fee THE: COMMONWEALT-H OF WASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVI4SION - TOWN OF' BARNSTABLE, MASSACHUSETTS Ye ZIpplication for Migpogal gppgtem Con.5trUction perrait Application for a Permit to Construct( ) Repair 4 Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Lr'') VJ 1,1a ('X' Owner's Name,Address,and Tel.No. �1��oxtXt s,m,a.• C7e,. �1 �w Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms S Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures !+ Design Flow(min.required) S 5 O gpd Design flow provided !j 5`t gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank S`�Q Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (OAT{ �p S l ( 150 0DIC 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 Certificate of Compliance has been issued by this B eal Sign o Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired Upgraded ( ) Abandoned( )by at �1 1 ? . E F I (l 11X1 !` i:� + ���is— I` L�Z)Ir, V7 °' has been constructed in accordance with the provisions of Titlee 5 and the for Disposal System Construction Permit No. l � (�/O dated �Installer �c. .(•)E Tck l 1 l I Designer Do.'rf- #bedrooms 5 Approved design flow gpd The issuance of this permit shall nol be cpnstrued as a guarantee that the system will-f unction-. est ned. Date Z` Inspector 4_.. ———————————————————————————————————————————— No. r OC Fee �ri7L+ d-n1%41% f1XTXX7U A T T'LT f LI A4 A CC A f'T7TTQ TTC TOWN OF BA.RNSTABLE LOCATION S e,091C 1, c L e SEWAGE # AW 6 VILLAGE 11)1.4 A4&is ASSESSOR'S MAP & LOT - 7 INSTALLER'S NAME& PHONE NO. J- MAC CA HeA - Soil SEPTIC TANK CAPACITY _ /, S-y o - o G 1i LEACHING FACILITY: (type)6— /A,'f IL yR d PeKf"s (size) 's NO.OF BEDROOMS. BUILDER OR OWNER PERMITDATE: —COMPLIANCE DATE: �. / I _ 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 Ou o °Y\ O � 1 No. Fee v THE,.COMMONWEALE I OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIV,E'SION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye 2pprtcatiou for Migogal �§pztem Con5tructton Vertu Application for a Permit to Construct'( ) Repair 4 Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/parcel L{-] W,r[;qQM,l'ti1 V0V4 Q—V-. Q IcJ� So�b��1'7S_333 � 7a a� Installer's Name,Address,and Tel.No. �� Designer's Name,y�A�dd�ress and Tel.No. �o aox to 0 (AAkYU �,. a tiYYA Type of Building: Dwelling No.of Bedrooms S Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) S 50 gpd Design flow provided �j5'1 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank t SoQ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (I TT c� S Lo_i l` iSOO�oo � %� 9 r) Ra X — 0 l ,Q X-9 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 Certificate of Compliance has been issued by this B d eal . / Sign o Date I ( �S Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued 147. 0. TH'E'COMMONWEALTWOFMASSACHUSETTS Entered in computer: PUBLIC HEALTH,DIV6ION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplicati0n f 6� Miq;poaY 4p.tem Con!gtruction Permit t Application for a Permit to Construct( )" Repair(A) Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. /. ►'V����(1��1jPQr ! C�r Owner's Name,Address,and Tel.No. ( / La1:�,C�,, .:t (� t Assessor's'Map/parcel,,: LO W,►�'yc�w!S voc l Q). 1�0t 16 f"l Installer's Name,Address,and Tel.No Designer's Name,Addre s and Tel.No. P. yyLk �o Yn.�o en o x� vc e.rtrl`L¢y 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) gpd Design flow provided `1 gpd Plan Date Number of sheets Revision Date Title Size of-Septic,Tank 11�`JQ Type of S.A.S. Description of Soil a Nature of Repairsor Alterations(Answer when applicable) r-- •_ OO cdj ToI� 1� 15 J ,n lc, 11.a�x ri ,)A( !Pko-5-0 l 1APAV)�6-Q)r!g ..k..� 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.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:- / S'igne (, ' o Date t1 Application Approved by '' 4 Date Application Disapproved by:`: V Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS _ Certificate Of Compliance 1 Upgraded THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( X) Upgr ( ) Abandoned( )by j.1 . Ol R r n nY b D_x �1,� S-�Q n . _ at 141 /A)nf)1"� 0,0 r� 0ll0 Ul�1i,--) M o\ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ((/!� dated Installer l tc t^l r l Y)t Designer �GG% t PC #bedrooms _eD � Approved design flow - gpd . The issuance of this permit shall nol be c nstrued as a guarantee that the system wild-function esigned. Date �t-i Inspector --- ------------------------------- ----- _ No. Fee-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS ;Di$po!5al �§p$tem Cow5trUCtion Permit Permission is hereby granted to'Construct ( ) Repair ( X) Upgrade ( ) Abandon ( ) System located at `� l).) , 1 (I 7Q0�� ' I I n t')A l� i� a and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction 4usVbe com leted within three years of the date of this Date �' Approved by c . Town of Barnstable Regulatory Services .. ;. Thomas F.Geiler,Director +: BAWSrABL% qj i639. 10 Public Health Division a�FD ,�a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer &Designer Certification Form Date: (A_ 00. 0 7�_ (r Designer: & 0 H . Installer: Ci!46 Address: . P.0- BOX 0 Address: 5A7J10VJ iC,�t 02S37 6_om On �_ - 1 was issued a permit to install a (date) (ins faller) septic system at 10 N lS W' C( based on a design drawn by (address) dated (designer) (designer) Y 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 r ocation of any c mponent of the septic system)but in accordance with State&Lo . Plan evision or certified as-built by designer to follow. ��� Sqe DAFa E, 1�Gs nll. V 1 / o. 1140 s a er' i ature gn ) FcrsTE� SANITP, 4esiCgner's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE.BAINSTABLE PUBLIC HEALTH`DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form __ -- ASSESSORS MAP : 26� TEST HOLE LOGS_ NOTES: PARCEL : 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH t 'p0 i Q,r R•.1, CSC SOIL EVALUATOR: HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF 1, ` "�$1 FLOOD ZONE: 14 A7A-",,,, WITNESS: tAm- -(mmo BOARD OF HEALTH REGULATIONS. REFERENCE: e>6 PGZ I DATE 7F.LE Utgt;R., i 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, t PERCOLATION RATE: L 47- 1140 SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO L r, fv V! - i ✓G' `srr ';; ` � i,� �u L' � � t, INSTALLATION. ,h � TH- I E% S � • 1U,� � TH-2 � 3) . THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM .INSTALLATION Siol— ( �'D V(n L`T t"I ` ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE ofP WAY . '' LL. DETERMINATION. OL R n 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS A S JOYS 3/. SPECIFIED OTHERWISE) 11 LOCATION MAPC6T.5) �1 S) . THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A Lopill u fl-4 10V R �g GARBAGE DISPOSAL. 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) - MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON ABASE OF b"OF CRUSHED STONE.` ; 7) EP517nl4 CESSPOOLS _M BE, 'PUMPED, 05ffED -- EPA CS& Cc.EAA)MED�_S Jb SEPT I C SYSTEM DES 1 GN 9 o uiE ►� io' rrFP. I� 3 _73 al� 1 80d31NNVAH .L 33M FLOW ESI I MATE 10,�5T?fiU.E�C..tb �c-k � "'tL_P��. 0aw>J 7U pe-tr.VEr1— $ 't•. E .is.0 -fD 8-L i 2.� — - - - 10a-,S4vd JO �o3 _ BEDROOMS AT GAL/DAY/BEDROOM SC7GAL/DAY 11) r �-� �.lo v��s tu�l -n TLz����� 1i D'SL N SEPTIC WANK I I QU - _11 Rauvf��SU GAL:/DAY x 2 DAYS GAL I�-� NOT?(, ( USE _ {— > on I�)D GALLON SEPTIC TANK )�h.J USE- Pay t-Lf_N E T"l6- 3 / oF 6 D v' To S rFE GINS l /NTS o (r N ft¢ 57 o o N ! ` . SOIL .AB:rORaT i(3N SYSTEM cr 0 i e (1`a� o� l yg t t ToSb t,�N t tS t1�I.I S 5 _per ' � - I EXISTING v :�;Q I � Z LijzW� SIDE AREA-(q-7)2-+ 01 -z�x, 2 k 0.7q 1-7 1 o m _J BCTTOM AREA: K t l x 0,7 4 = 38 Z, o ' DWELLING o WD 55�l. I S p� TOP OF FNDN Sth8 EL " Z093+- E1. t3:a3 SEPTIC, SYSTEM SECT ! ON � s2� � P� SLAB ,/_ . - D DECK Zo.93 77 c LL : -17 "' tns+ctl E�15•° i aoo& 4S �03 OX - - �- i GAL t�46 1-7 I L7� p .� D'SL -�-- 13x3 (-T.t 3 SEPTIC TANK lt. e 1 SS � .SD 12.SO �,,�L o� 5,75 C655,06OLS � P K (:.ey ff G 5s fE6370t,)_ � � I~t CNo7e 7ll (3GTTo�► ©1G T�STt/dZ� ��� G:7S J 1 .o Tv 12. �� 5 SITE AND SEWAGE PLAN N S LOCAT ION : 47` V1 411A-aims PORI 62G1.E �ZH OF IygS DA f ►� a, �� able Ida PREPARED FOR : 6E&1A14,f No. a 4I �° T ,� a - 5-�m �01SSEa� I l DARREN M. MEYE -R.S. SCALE: _ 20' a S'9NITAR��� (h C� W 1 P.O. BOA 981 DATE: G t EAST SANDWICH, MA 02537 DATE HEALTH AGENT (508) 362-2922