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Home My WebLink About0006 WHIP-O-WILL DRIVE - Health 6 Whip-O-Will Drive Hyannis A=289-153 r TOWN OF BARNSTABLE i L LOCATION W� D 0 E I ' 1 . SEWAGE# do 19" ,`i aJ VILLAGE `H[A l!)"`] ASSESSOR'S MAP&PARCEL �/� INSTALLER'S NAME&PHONE NO. �� - ILj � 1 Iq IL4 SEPTIC TANK CAPACITY LEACHING FACILITY.(type)' (size)`7 1-1 z a ,Po NO.OF BEDROOMS OWNERIIf f ( PERMIT DATE: I /S �9 'COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Feet Private Water Supply Well and Leaching Facility(If any wells exist on / site or within 200 feet of leaching facility) N<A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within / 300 feet of leaching facility), 100 Feet FURNISHED BY iE � - 61.-CA CIA CCN� � 0 �p v No.O' THE GOMMONWEALTH'®le M,ASSAEHUSETTS FEE BOAR D .O,F' HEALTH TOWN OF -568'1t S T; Btu APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct ( ) R�cp.:ir ( ; Upgrade (yl Abandon ( ) - NfIc"omplete System ❑'Individual Components 6VH1P-aaWitL V CTBR .Sl1TERN Add JNq I SCE EkRI. ' Inylallmr'sNanw it u 7 T Or- 1.-ill 1kgrc" 19 ei— �J��1 J��1 Add Telephone U Telephone M' Type of Building: Sl119LE r- A M I L`f Lot Size k3p17rj Sq.feet Dwelling--No.of Bedrooms Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required) gpd Calculated design flow d14 9gpd Design flow provided 3g gpd Plan: Date ! Number of sheets Revision Date 19 a it -A, Title D E.5 I ji1�L Description of Soil(s) 3`5' L •5 3"�'�a" L ��3�` i�.�p CrC1f 5E SK Ll] Soil Evaluator Form No. - Name of Soil Evaluator ill W D M AMR Date of Evaluation l 1'11 12 DESCRIPTION OF REPAIRS OR ALTERATIONS :3P� x-:yr,� tom— " I ='* A(1W CdVAPLE TE W IT I5OCJ G A2 5'T. t,9-ZQ ryWX E The undersigned agrees to,install .., a e described indmduol;pWpge Disposal System in accordance vyith the previsbrts of r TRLE S and fu agree:not top a stem in ap-moon unfil a Geri ficcifs of Ccmplian�e has been issued by thq.Board of Hsolth. Sin g Date ICA Ai / In ections 4,2 _ I FORM 1 - APPLICATION FOR DSCP DEP APP ,OVED FORM 5/96 T NO THE;GCMD¢1dWEATH � SACHUSETTSi FEE��I_J B O XR.p„ 0 H A LT H i TOWN OF ' - RM RTKBLE 1 AIPPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) 12 p: (w.4 0pgr.ide-(y1 0h tndon ( ) - 51,complete System []'Individual Components 6WH1(?-n -W(LL, INM V ICTUR Sl-1TERN Um BRIMKLIWE LQ 1 �j Map/f�iri ,qb 1� 0 AJJrr18�T M I KE S of EF-Nt1 EARL LIT 1 Lid. 7 0Tc hNAV T-\s M f\513 " Inxtaller+Nnmc p p Q��q IQ (� _1 T Telephone If Telephone q Type of Building: S 11V16 L E 11Al t��I" Lot Size I`i t� Sq.feet Dwelling--No. Bedrooms Clarbage Grinder Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures - 1; Design Flow(min.required) 's3Z1 gpd Calculated design flow 3'A algpd Design flow provided gpd Plan: Date: 1 Z' t-? 1 1 Num ber of shee ts I Revision Date Title ACvE S,157E) Description of Soil(s) a 3 C 5, '�{' �8". L i`�'` l-�0° CMRSE SA>,LB" Soil Evaluator Form No. Name of Soil Evaluator DAY1 n M ASM Date of Evaluation !l'1-l2 DESCRIPTION Of REPAIRS OR ALTERATIONS �3'_�-�-z'4"--�5� i-a=i'E$=FB §C sj"&(B NtW Ct MPLE TL kg1TA 1��C3J GAL'ST. J-i-lc L.-C _ \A! 4' ) _FS�llih W�Sh11;D 3l4-r., 1t/�irr 5T®I�1L The underslgned agrees to Installt�eabove�eseribed indrvldual Sewage Disposal System in accordance with.the provisions of TITLE 5 and fu agrees not tai plccs the stem m operation unf+l a Cerlifieolp of Compliance has been issued by ths:Board of.NsaNh. ` n y Sign Date4Ii ' 1 a �1 Ins ections t rA / l F i FORM t APPLICATION FOR DSCP ~ DEP APP)fOYED FORM 5/96 --------- -------- No. D L D �S THE COMMONWEALTH OF MASSACHUSETTS FEE 8 �iIL� BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑iIndividual,Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System,Constructed( ),Repaired('),Upgraded( Abandoned( ) by: tA t 1-\ E SUS'E-t!N E \1 at E WK 112"13-W\L L BR)VL 4 NAN Ntt has been installed in accordance with the provisions of 310 CMIt 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow 3 4'q (gpd) Installer PA KC S1-fL IV AI EV Designer: CAaKLLAX7E Y D &IIDNJUpIcink7 Ins e or p- ate The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 - No. �t - �5 THE COMMONWEALTH OF MASSACHUSETTS FEES BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTI N PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( Abandon ( ),an individual sewage disposal system at 6 W I•l1RU W I Lt .—C tk_- i�IA AOkk 5 as described in the application for Disposal System Construction Permit No. ,dated , Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date ! Board of HealthA ,(J FORM 2- DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W H08Bs8 Wnre+alr"' PUBLISHERS•BOSTON f Town of Barnstable EVE T � Inspectional Services Public Health Division BARNsIABi E � asp Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date:1 .. Z q - 19 Sewage Permit# Assessor's Map\Parcel V6 Designer: (_f L ANTIRN P E Installer: M t k,%7—E 115 W:E Nf_Y Address: l a P�� 6- ik Address: S cncq�C W we)r On 5 q M I K E 'S'W L _1= 4 E\1 was issued a permit to install a (date) (installer) septic system at (D 1'\ F- Q`W 1-L L 07\, based on a design drawn by (address) E1'RL LAN TE tRY dated RCS( 1 Z-`2 L 18 . - V,_ '(designer)I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. I 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. Strip out(if required) was inspected and the soils were found s tisfactory. I certify th system referenced above was constructed in compliance with the to rms of the RA p o I letters (if applicabl HARRY yGo all S f EARL v LANTERY, 1R. .o p No.26575 p /sTt;�`�`��, esigner's Signat re) (Affix DeNA Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Woaldepts\HEALTMEWER connecASEPT(C0esigner Certification Form Rev&14-13.DOC 77. }}, to HIGH GROUND-WATER LEVEL COMPUTATION rT1J y Date: Site Location: �p W H ) ?- U -W t L L D R1VJ-- Permit: 4 - H ,\)A�IN t 0:5 Owner: VICTOR S H t E Phone: Contractor: M A I SW L�_N E 7 Phone: �- Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. (depth is in feet below land surface) Date: p mm/ feet below Is STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: A) Appropriate index well Ww 29 B) Water-level range zone C STEP 3 Using monthly "Current Water Resources Conditions" determine current depth to water level for index well. m m/yy STEP 4 Using Table of Potential Water Level Rise for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level ` adjustment. STEP 5 Estimate depth to high water by subtracting the water-level adjustment (STEP 4) from 0 measured depth to water level at site (STEP 1). NOTE* Tables 1-9 "Potential Water-Level Rise" are attached as worksheets to this file. month) index well data:Y www.capecodcommission.org/wells.html ��. Town of Barnstable P# I �� ^' Department of Regulatory Services It I MWMUMatst i Public Health Division .Date 4' MASS. tm3v 200 Main Street,Hyannis MA 02601 Date Scheduled / Time Fee Pd._ / a:b Soil Suitability Assessment for S e Disposal ;4 Perfbrmcd.By: 1 6,yz Witnessed By: ' LOCATION&.GENERAL INI'ORMATION Location Address (a 1 �'Ii�j� + Owner's rName V( R ySGPI_ERN 1+��1 V 1 V�� /� —�—•�'�Addrassf�� t]CI.J�l,,JY �'�� ( 'f3 o� )K- 1 M Z M A Assessor's Map/Parcel: ` 2$� � � 5 �� Engineer's Name-DAV rvt A J 0 MN NEW CONSTRUCTION REPAIR Telephone# y V\. Land Use• Slopes('%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Dralhage Way I ft Property Line - ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands-in proximity, to holes) Parent material(geologic) Depth to Bedrock Depth to Oroundwater. Standing Water in Hole: Weeping from Pit Pike Estimated Seasonal High Oroundwater etnoa used: DETERMINATION FOR SEAASONALUIGH WATER TABLE � Depth Observed standing in obs.hole: In. Depth to soil mottles: in" . DejIth to weeping from side of ohs.hole: In. Groundwater Ad)uattnent tt. dex Weil lr Roading Date: index Well lmYdl Adj,.factors„_.,-,,,_Ac1J:dtnundwatnr•Level, _ PERCOLATION TEST We- 'rime bservation ' Hale n rime at 9" Depth of Pero Time at 6" �� - - • Start Pro-soak Time @ Tim(911 •611 ) 8nd Pro-soak • Rate Min./Inch Site Suitability Assessment: Sltd Passed Sitc Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on B ack------ ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conseirvation Division at least one(1)week prior to beginning. Q:\SBPTlLAPERCFORM.DOC DEEP.OBSERVt>,TION HOLE LOG Hole# Depth from Soli Horizon Soil Texture Shcl Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucturc,Stones;Boulders. V, o tsistency.%'t3ravel) • o y ti ' t nn .IL ' DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Sol]Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistency, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color 9011 Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Slopes;Boulders, Co Flood Insurance Rate Map: Above 500 year flood boundary No yes _____ Within 500 year boundary No Yes„:E— Within 100 year flood boundary No.,Yes. �. Death of Naturally Occurring Pervious Material Does at least four feat of naturally occurring pervio terlal exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what is the depth o naturally occurring per I materiall Certification �� q I certify that on ` (date)I have passed the soil evaluator examination approved by the Department of Envir irimental Protection and that the above analysis was perforined by me consistent with . the r it training, pa"land Wxdnce described in 410 CNM 15.017. Signature Dart; Q:WEPTICVERCPORM.DOC L oFt�r� Town of Barnstable Barnstable Regulatory Services Department UWWWcal0fty � BARNSfABI.E. 1 � P 9� b 9 ,�� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4990 6586 May 21, 2018 SHTERN, VICTOR & LUDMILA 65 BABCOCK ST APT 6 BROOKLINE, MA 02146 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 6 Whip-O-Will Drive,Hyannis,MA was inspected on 04/30/2018 by James Ford, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • A portion or all of the SAS is below high groundwater elevation. You are ordered to repair or replace the septic system within one (1) year 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 OARD OF HEALTH Thomas c ean, R.S., Cl Agent of the Board of Health I Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\6 Whip-O-Will Drive Hyannis.doc IKE rj Town of Barnstable 'j;b$ Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 0$cc: 508-862-4644 Richard ScA Dircctor FAX: 508-790-6304 Thomas A McKcaa,CEO Feb 6, 2007 Rev. 5111116 DEADLWES TO*REPAIRFAILED.SYSTEMS (Town Code §3604-4 and Title V: 310 CMR 15.000) _ An`Y'marked in the ❑is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA o 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. :. o Backup of sewage into ouse due to an o rloaded or clogged SAS or cesspool ONE 1 YEAR DEADLINE CRITERIA n. ox above outlet invert due to an overloaded or clogged SAS or cesspool 4.-lny portion of SAS �cesspoolorprivy �elowigh groundwater elevation ❑Any portion of the cesspool wit 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 q" Single'Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) o Leaching pit or cesspool with high liquid level,<12"below inlet(per Town Code §360-9.1) ❑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 0? 9- l53 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 6 Whi -O-Will Drive 'R Property Address �a Victor Shtern Owner Owner's Name information is Z.required for every Hyannis MA 02601 4/30/2018 k' page. City/Town State Zi Code P Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms 13008on the computer, use only the tab 1 Inspector: ` key to move your cursor-do not James Ford use the return key. Name of Inspector Ford Septic Services LLC Q19 Company Name P.O. Box 49 Company Address Osterville MA City/Town 02655 508-862-9400 State Zip Code S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails Needs Further Evaluation by the Local Approving Authority 5/6/2018 Inspec 's Signature Date The s em inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or . has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/3 0/2018 page. 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M a,•` 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis, MA 02601 4/30/2018 page. Cltyfrown 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 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•3/13 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 6 Whi -O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town State Zi Code P 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 day flow t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts RAM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M a 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. Cltyfrown 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- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the.system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M A 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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 3 3 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins-3113 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 wM 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 Whi -O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town State Zi Code Date of Inspection P D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: never pumped in 23+ years- per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 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 �A. 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 page. City/Town State Zip Code Date bate 018 of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: installed on unknown date Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12" feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Sludge depth: 12 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. Cityrrown 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 13 Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 8 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Cement baffles were present. The tank has the old small square covers. There was no of leakage. The tank needs to be pumped. Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle { Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: n/a Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 15ins•3/13 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 •'' 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. Cltylfown 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 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.): 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: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit had 1'of clear water on the bottom.The house has been empty for a long time. I dug a test hole, and comfirmed it was groundwater. The bottom of the pit to grade was 8 5' r 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 6 Whi -O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town 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 3 4) I � 0 a Q 26 30 a 30 33 3 0 3 y s" yo !Sins•3113 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 6 Whip-O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 7.5' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water.elevation: Groundwater was observered in the pit and in a test hole and was at 7.5'. This site MIW 29 zone C 3/2018 has no adjustment do to high groundwater Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 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 a 6 Whi -O-Will Drive Property Address Victor Shtern Owner Owner's Name information is required for every Hyannis MA 02601 4/30/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 Lc ' � TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE_ ,6,/��► i_ ASSESSOR'S MAP&PARCEL '9-IL INSTALLERS &PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: 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) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) FURNISHED BY Feet )c -97- L .g :% 4 T OF BARNSTABLE / LOCATION �o L, ,d� SEWAGE# VILLAGE. y ,�/!S' ASSESSOR'S MAP&LOT �9-/S� INSTALLER' - S NAME&PH ONE No. SEPTIC TANK CAPACITY i�'c I+FACHING FACILITY: (type) (size) O.OFBEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: ----------------- Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility on site or within 200 feet 9f leaching facility any wells exist Edge of Wetland and Llbac4j4 FacilityFeet within 300 feet of leaching facility any wetlands exist Furnished by_ f? /fie .Sd Feet • a i '` T\ Y jo PROPERTY ADDRESS:_ 6 r 4y,.aa,.i,>, .l1a.6,3 C> On the above date, i inspected the septic system at the above address. This system consists of the following: Based bn my Instnectlon, I certify the following conditions: 1 „ 7hi,. i.,, a .1.-ii_Lr �i 6.e.12f. 73' Co�F. c .5- t zm . ':h .L,� :e; ?c2 t,o �.k`n i o zdr:)� c f SIGNATURE: Gil Name: J.P .Mac omber Jr... Company: J. P_Macomber & Son-_Inc . ; Address:- Cente�rvill.eLMass__02.632 Phone:--- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY a" rSEP. MACOMBER & SON, INC. nks-Cesspools-Leachtlelds Pumped & installed own Sewer Connections 6' Centerville, MA 02632-0066 776-3338 775-6412 • � 7 r SE L Dig T)• Sn .. .. _.. .._nP.C.. J_3.'06P.L f1Y5TE2S _.,L_ .. AggEess Of Proper.ty 6 F zo.5.t l a.n.e Ny«.nn.i f, Owner ' s name !zo Date of Inspection • PART A Cli i.'CKLIST Check if the following have been done: -� um was s Pumping information a requested of the owner, occupant, and Board of ealth. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period . Large volumes of water have not been introduced into the system recently or as part of this inspection. �As built plans have been obtained and examined. Note if they are not available with N/A. _ZThe facility or dwelling was inspected for signs of sewage back-up. P . The site was inspected for signs of breakout. All system components, 4cludiny the SAS, have been located on the site. The septic tank manholes were uncovered opened, and the interior o p P f the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based . n existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance '.of SSDS.' 1 , Sept."ir .tank aFowod U.e our",2?d. 2. /1 J::•5Ln 1"2P_ aA u ed g e .in d iacci ion. . 3 . L3.z .,/'e,L to -t_aak -6 2o! -en P,,? .ZQ:T.O:.J.2,1 a d r,ew tze �[L� •( G:. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLAW CONDITIONS: ' If residential number of bedrooms . number of current rg sidents S garbage grinder, yes or no • laundry connected to system, yes or no ' seasonal use, yes or no If nonresidential , calculated flow: Water meter readings,;. if available: Sae- 4r-74CAe,?��,eJA)WA BJ;� Last date of occupancy GENERAL INFORMATION Pumpin recor —and our261-9� of formation: ` System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: , Type f system Septic tank/distribution box/soil absorption system . Single cesspool l►/[7 Overflow cesspool , NC'I Privy _A/0 Shared system (yes or no) (if yes, attach previous inspection records, if any) l Other (explain) Approximate age of all •components. Date installed, if known. Source of informat ' _.. --.._....__......_,...._..._... _................... -------------- Sewage odors detected when arriving at the site, yes or no i C:US1"Oh1ER CONSLtIPTI044 FIISIORY 1CCOl.it►l r•n iME3Eft 89 153 CUSTOM.J.1 NAME_ LEONARD LEVIN SERVIC:E LOCATION b FROST LANE READItJG CATES F=E:ADIMS USA+G= _ PERIOD t r,It-IWYY) t CCF) (CCF) ALLOW NJCF= BALANCE FIRST 07 07 95 544) A SEC!.>r'-JC? O'! 03 95 540 A AVERAGE WATER USE 10 TH'i.RD 01 Ob 95 S4 0 A YEAR TO DA rE WATER USE FCALIP,I"FI 10 07 94 54�1) A 13 F1:F'I F 1 07 07 94 52-1 A 16 tnH EWER U E SI XTI-! 04 05 ^q S 1 1 A 8 z OTHER USE SEVENTH 01 ID 94 50:3 A 5 cr EIGHTH 10 06 9:1 tV713 A 28 0 f41141 •! 07 08 93 470 A 1F TENTH 04 05 93 4513 A af `r" NON SEWER F"IRST READING F`L EVE f 'l H 01 05 93 458 A 4 . cr 3 rION SEWER SECOND READING TWELFTH 10 06 4? n-r34. A 30 J NON SEWER METER NO. TFIIRIEENTHt 07 Oa '?2 e424 A 9 w FOURTEENTH 04 03 9p 41 S A cn z ENTER = FIRST SCREEN PFF:EY 14 = PRINT SCRt Er'J af cr 74 m ' 0 9 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:l/G (�',� � �•v� (locate on site plan) depth below grade material of construction: _zconcrete metal FRP other(explain) dimensions:- if x yr'` 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 distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet. invert, structural integrity, e idence of leakage, recommerldations for repairs, etc. ) ,9 , S G .Q DISTRIBUTION BOX: _z (locate on site plan) depth of liquid level above outlet invert Comments: .(note if level and distribution is equal, evidence of solids carryover, evi*nce of leaka a into-•or o t o€ box, recommendation f r repairs etc. ) k/r T,4t 3 e.v,G 1?� ® ve Ali �. PUMP CHAMBER: A10 (locate on site plan) pumps in working order; yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, . recommendations for maintenance or repairs,etc. ) Wove, II 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ) PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan if possible; excavation not required, .but may be approximated by non-intrusive methods) If not determined to be present, explain: leaching pits and number 14'X2 /A&OAST h� Ar` leaching chambers and number leaching galleries and number leaching trenches, number, length O leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil., signs of hydraulic failure, level of ponding, condi ioa of vegetation; recommendations for mainte ance or repairs,etc. ) CESSPOOLS (locate. on site plan) : number and configuration AleNE 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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,, recommendations for maintenance or repairs,ete. ) "AC PRIVY: NDN (locate on site plan) materials of construction iLf1�L>� dimensions depth of solids Comments: (note condition of soil, signs of. hydraulic failure, level of ,ponding, condition of vegetation,• recommendations for maintenance or repairs,etc. ) . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.,FORM .PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE LISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 1001 b YAA4 ,"r Sv W#4Tdw- L � -1v DEPTH TO GROUNDWATER ' I depth to groundwater , method 'o d}etermination or approximation: 12 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) .�Q Backup of sewage into facility? (� Discharge or ponding of effluent to the surface. of the ground or • surface waters? Static liquid level in the distribution box above outlet invert? LzW-A 'fir- C NIX `7 =5 Liquid depth in ee� ' <6" below invert or available volume< 1 2, day flow? / Required pumping 4 times or more in the last year? number of times pumped We:. 9-1-,f'6_ Septic tank its metal? cracked? structurally unsound? substantial infiltration. • substantial exfiltration? tank failure•. imminent? Is any portion of the SAS, cesspool or.privy: .AM below the high groundwater elevation? _1114 within 50 feet of a surface water? within 100 feet of 'a :Surface water supply or tributary to a surface water supply? .0 within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh' (cesspools and .privies only, not the SAS) ? ' ` 4/d.- within 50 feet of a private water supply well? I - less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has 'been analyzed to be acceptable, attach copy of well water anal;,for coliform bacteria,- volatile organic compounds, ammonia nit ro and nitrate nitrogen.. gen :r•ranrn+ Tes•r—.-rr-1r..-r..rrsr..r�:r...r...rr.::r..r_rr,avr�--:rri:tr.-ra:*as-e�a:rrs. _ ...- . - - _ .rsr-rrr�res-srrrr..e-•.F TOWN OF /3a;Zn,1.t�:,P.%o BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION i�••--nR•••;.tr-.::s-..--sr.-+r•r.:+e:—s.-+:ir.--zz-r. z•s.—:--c.-asnr----rrm�rr-a—r..rre*rrs _ ta:stes'rnrrr.resrrrrrr�r.:-:r-rr•r.-ter -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED- STREET ADDRESS _6 ;`:zo is t .!agv_ .H.ur�,2 •�, l'lli, , ASSESSORS MAP, BLOCK AND PARCEL # 289-153 OWNER's NAME Leana-�,71 PART D - CERTIFICATION r NAME OF INSPECTOR COMPANY NAME R Son Inc. COMPANY ADDRESS P.ox r;6 Street Town or City State LIP COMPANY TELEPHONE -'7` 3 '38 FAX (508 ) 790 -15,38 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal, system at this address and that the information reported is true, accurate, and complete as of the. t.ime of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: X, Z XSysteln PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303. Any failure criteria not evaluated are as stated. in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with ,Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature ef j Date 911195 One copy of this certification must be provided to the OWNER, the BUYER (where applicable) and the' I30ARD OF HEALTH. * If the inspection FAILED,' th)e owner or operator shall u pgrade ' the system within one year of the date'. of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . II~ partd.doc CC.;,rrcnwearn cr Masscc:':aeris Execunve Cttice cr EnvlfcnmenTc: r.ttc„s Department of Environmental Protection ' Water Pollution Control Tecnnlccl Assocnce and Training Sections WlUlam F.Weid Gw«na Trudy Coxo S+ow y.EOEA Thomas&Powers • i 06/12/95 t ATTN: Joseph P. Macomber, Jr. Joseph Macomber and San PO Box 66 Centerville, MA 02632- j Dear Joseph P. Macomber, Jr. , 1 I am pleased to inform you that you have actended craining, met the experience qualifications, and have passed the Title 5 System Inspector exam, pursuant to 310 CMR. 15 .340 . The passing grade for the exam was 39/52 or 75% . This is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15. 340. You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following i address: Kimball Simpson ! D.E.P. Training Center `.30 Route 20 Millbury, MA 01527 Thank you very much for voar time and consideration in this matter. Sincerely, Kimball 7. Simpson, DEP Training C: .'..er Director (2405) Routs :'0 • Millbury, MA c • FAX 503-755-9259 • ion-;n„ne 508-756-7:R+ r r Water r Coris'er • •° vation SAVE Tips. ; . ME. CHECK FOR LEAKS Water Loss in-Gallons Due to Leaks r 'Leak a ; C *`. this, Loss Per Day Loss Per Month Size w" f' 120 3,600 x'. • � 360 � 1 i 4 lr•LS,N ti 1�� fi+��+. 10,80020.790 693 a v TTTT± 14 • J ti • 1,200 36.000 '1',920 i 57'600 ' i ;3,096 i 92,880 4f .0 4,296 ® 6;640 199,20Q ' 1 '084 20Q,520 252 8A24 ' ,720 s 1 ' . 1888 296,040 ,4 ® 11,324 339,720 N IyY ! F is ✓ 12,720361,600 r= of„•<� ti stAOL 14,052i 448,560 y� - . .. rl,, 1 •''� � r � i.t Y•r ♦ 7, J ji'j YY * t'. • Ir , 1 � �tl� ,D5' r A' Ytl T •i , LP f7 v�-� C' TOWN'OF BARNSTABLE LOCkTION �� 6' "�--%* -- _-__SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INS'yALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: 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."J _. - faC 0/s1,(e r. -:f Sc, /a 1's �� 4� 0 �� d: . -.� r `� I 9 ti .\ �� "a �' w - — � r.T OFrBARNSTABLE LOCATION 4 1- 4 If/ 'I SEWAGE# VMLAGE. !f ` ASSESSOR/'S'MAP/�&LOTgj9 INSTALLER'S NAME&PHONE NO. !o a -D— SEPTIC TANK CAPACITY BLEACHING FACELITY: (type) - (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 2 feet of leaching facility) - Feet Edge of Wetland and Lag Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by t ..0i} L- Tor��=-°�/�*�� A, 1AATE 1:,' NL s;-oaE , _ rr, Q''.i.7�4 ?'pal Ov'�, 0_ . 1_} 1�� .3�x , 1t500 GAL—NE'.. '� CONC. - l -g-- - •��}} �DP.ltt LI 5 I �'�f2U�� 7'�•s� �'��"r'rk t�Cir�)-�_\ 3/9-'rFo1 D�� - A 1),Tu S tL - 'At L IT ' rt_ Il :�15 NOTES: 1. Disposal System to be constructed in strict accordance with F)LE �,d. Y _�u: � � � �` Commonwealth of Mass. Environmental Code -Title V. ' '` A-) 2. This plan is for the sole purpose of construction of a septic system. -- =- 3. Contractor to call Dig-Safe 72 hours prior to beginning of excavation. r j ..-- 4. Pump existing pit, fill with sand and abandon. 5. Pump existing Septic tank, fill with sand and abandon. cc --�--� N 6. Contractor to field check invert at foundation. co E r- > 7. Bench mark is elev. 24.0, top of Foundation. -' ' I o 8. APN is 289 / 153 for Town of Barnstable. �� l GL�- r 9. Sub-division is served by Town water. } r ZZ ti �M" 10. Topography corrected by instrument survey, GIS off by 2+ feet. 11. Remove all soils 5' around SAS to elev. 13.7. —�- � - 12. The plan view is based on plot plan by Ed Kellogg, RLS. and s< , �� i recorded at Barnstable Reg. as plan box 183, Pg 21. da %- 13. Replace existing septic tank with a 1500 gal. septic tank including _ 1- � "`� tee's and gas baffle. � ,.� I FILL PIT 14. Use 2- 5'x8'x2' PCLC with 4' of Y4" to 1 %" double washed stone. - - �-a � �.%�R blG � Cover with filter fabric per town regulations. RF tr �-- --- .ZI' 15. Grade the lot around SAS with a slope of 3 to 1, loam and seed all 140 disturbed areas. (0 RRY I t 6JTl/`l}DE l T.� EA 15,7 WELL . NAL _T P L A _. F;S / n N E a-.1 RE� V 1 a� �FI,�0M� C.A__. 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