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Home My WebLink About0089 WINDSHORE DRIVE - Health 89 WINDSHORE DRIVE, HYANNIS A= 271 140 r i TOWN OF BARNSTABLE if'!-,-_Anor4 SEWAGE # _')006 iL AGE < ASSESSOR'S MAP &LOT V4STALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 12OD / LEACHING FACIL=: (type)- e4wi�Fo''S' (size) NO.OF BEDROOMS BUILDER OR OWNER Lr9�vrFhe S��s PERMITDATE: . S"^ 3,OG COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching faccili�y�') - Feet Furnished by �l,r � C�/ .�• ... .�9 ..�s i, � c` � � � `, r �,. 69 � -. r ® tvl _;4;'. t9N �. .f1, � �i �� ►— a o , -44 CZ IN moo, I ti C w t �3 c f f� a �, a7/ C'Mmonwealth of Massachusetts H -tie Official i® FormT Subsurface Sewage I?Is osal System Form-Not7-se- Voluntary Assessments W� 9 Property Address ` �Oe-'c ri Owner information is Owner's Name / 1' �q / required for every ct 0 415 �� lJ V®� page. City/Town 1 State Zip Code Date of Inspe tion Inspection results must be submitted on this form. Inspection forms may not be altered in any Wray. Please see completeness checklist at the end of the form. fillinngg out 8:forms Important:When �o �e9`eral Information ut on the computer, /a11 93 use only the tab key to move your 1 Inspector: cursor-do not use the return key. Name of Inspector — / ra! Comp e " /D Comp ss ), Citylrown / 0 d— 6 0) ) ��_ �A State L Zip Code Telepho berr O� % _ License Number � Certiflcatl®n I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 C R 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority 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 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. 6ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 lqoae. VS C I C®MMonwealth of Massachusetts Title 5 Official Inspection ��Subsurface Sewage Disposal System Form _Not for Voluntary Assessments Property Address Owner Owner's Name �� s information is required for every q&4 14 l� _ / page. CitylTown 04 6 0/ .Ll (v� B. Certification / State Zip Code Date of inspection 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. ❑ YEl N ❑ ND(Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 r COMMonvvealth Of Massachusetts Title 5 Official Inspection F®a Subsurface Sewage Disposal System Form-Not for Voluntary rsessments Property Address Owner J 1 ✓^I 45 information is Owners Name / , required for every Cy 4� ®ol 6 page. CitylTown /J J I State Zip Code �Da:tel ntt on B. Certification (con t.) t.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health a Pumps/alarms are repaired. approval if 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 ❑ ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required quired 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. I. system will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and.the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form kA Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 9 k9 Property Address �— 0� Owner Owners Name f information is required for every ! page. City/Town State Zip Code Date of I spectio B- Cerfif Cation (cont.) 2. System will fail unless the Board of Health (and Public!!dater 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 supply. within a Zone 1 of a pu blic water p er 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 ❑ 19�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 e 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'/2 day flow t5ins.doc-rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 COMMonwealth of Massachusetts M Tstle 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 299 / / Property Address Owner Owners Name lM�$ information is required for every C.ki 41s ®�6 ve page. City/Town / State Zip Code Date Inspe ion 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 y is below high ground water elevation. [l 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. ❑ Lam" Any portion of a cesspool or privy is less than 100 feet but greater than 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 2000 d- /10,000gpd. 9p ❑ ,�,/ 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 If of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 COMMonwealth of Massachusetts h = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments Property Address �f Owner Owners Name information is required for every ::-t v1 47 Bf page. City/Town State Zip Code Date of I specti Co Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes ❑ 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? ❑ s 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 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)] De System Information Residential Flow Conditions: 7F Number of bedrooms(design): — Number of bedrooms(actual DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins.doc-rev.6/16 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Ri Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '4M YO99 Property Address �t all Owner LJWer s Name information is /'t 1 required for every page. IF CitylT own State Zip Code Date of Inspection D. System Information Description: / ��®o � I/v� d - `r ( �r� �' moo �. 6 L s� C), Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundrysystem ❑ Yes No information in this report.) Y tem Inspection ❑ Yes No Laundry system inspected? ❑ Yes 'Co Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? — ❑ Yes No Last date of occupancy: C 1,1 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name—W7 �l � �j information is required for every c:i AA,e page. City/I own State / al Zip Code Date of Ins ction D. System Information (cons.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: cq, O />"— _��+5 Was system pumped as part of the inspection? ❑ Yes fVo If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy rn: 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 CoMMonwealth of Massachusetts F Title 5 official Inspection For ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner s Name information is required for every Oki If page. Ugly,I own State Zp Code — Date of In pectio D. System Information (cont.) Approximate age of all components, date installed (if Dom✓ known) and source of information- Were sewage odors detected when arriving at the site? ❑ Yes o Building Sewer(locate on site plan): Depth below grade: IG 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: (� feet � Materia construction: concrete El 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: __5 Sludge depth: �— t5ins.dx•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 �i Commonwealth of Massachusetts Title Official Inspection ®r a Subsurface Sewage Disposal System Form Voluntary Assessments Pro- �® p rty Address----' I,� Owner Ow�rl'sN �e ,� I V ' �� information is - required for every page. CitylTown / ®oZ 6®I D. State Zip Code Date of spe�ct�n /yStem Information (cont.) Septic Tank(cont.) 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 // How were dimensions determined? 0 -e Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): off'/ f k1 - � ) a I J c✓ d/-//® ter . Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass g El polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle — - Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not f r Voluntary Assessments Property Address Owner Owner's Name �I t1 information is j required for every �lO�PJ page. CitY/Town 69GO/I State D. System Information (cont.) ZIP Code Date o In ection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural inte liquid levels as related to outlet invert, evidence of leakage, etc.): grlty, 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 9 ❑ 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 Is c(required'.� opy attached. El Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form.Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ®jI*/J �6(�r� Owner information is Owners Name — required for every 1f tZi to �, ,page. City/Town �j(Jl/tate de Date of I sp ction ®a System Information (cont.) I ' Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert /`—Vie 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 ❑ fVo" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 COMmonwealth of Massachusetts r Title 5 Official Inspection a Subsurface Sewage Disposal System Form-Not for lunta®r 92Voluntary Assessments Property Address / �� _ ®v® i _ Owner Owner's Name �l i R S information is � required page page. City/Town State Zip Code Date off specti n D. System Information (cont.) Type. b f(9 h eachm9pits number: ❑ 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.): ® 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsuiace Sewage Disposal System-Page 13 of 17 COMMonwealth of Massachusetts Title 5 Official Inspection a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner c� information is Owner shame / required for every A✓t 15 � (a®/ page. City/Town State Zip Code Date of specti n ®° Systems 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, etc.): level of ponding, condition of vegetation, t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Comanonwaalth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is required for every G)cid�!� / j l/o`D®� page. City/Town State Zip Code Date f Inspect on Do 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 pu water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately 3 Nn FRoAr r - 35 �-1/ - 9 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 COMMonwealth of Massachusetts Title 5 Official Inspection a - Subsurface Sewage Disposal System Form .Not for VoluntarryAssessments Property Address Owner Owner's Name " information is -- required for every page. City/Town State Zip Code Date of In pection Da System ¢formation (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 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 ❑ O ed site(abutting property/observation hole within 150 feet of SAS) Checked with local oard of Health11-explain: _ ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must®(lI-cribehowestablisheedt thehigh ground water elevation: 7-�`- G Vv ----� () o CGS oG/f ca�r �— -e to L"I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Toile 5 ®fficial Inspection For " Subsurface Sewag e Disposal System Form -Not for Voluntary Assessments Owner Property Address v owners Name - ' s information is required for every G+ page. City/Town _ State Zip Code Date of I spe ion E. Report ompleteness CheMiSt Inspection Summary:A, B, C, D, or E checked ;aLLd--1111`nsjpjtion Summary D(System Failure Criteria Applicable to All Systems) y ms)completed nSyste nformation—Estimated depth to high groundwater k-etch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6l16 -rifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. D / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYicatiou for �Digozat *V!5temc Cougtructiou permit Application for a Permit to Construct( ) Repair(r4�pgrade( ) Abandon( ) ❑ Complete System El Individual Components Location Address or Lot I4o. D f W1e -r4e;4a'1',� Lr Owner's Name,Address,and Tel.No. Ny"6kj413 4041 ^--,ve- Ywio-f Assessor's Map/Parcel 2 171 1 y0 3190,P115 Installer's Name,Address,and Tel.No.S08 �20 �73g Designer'sPName,Address and Tel.No. o�� %�'s� J®s,Cp/i 07- 130'ev-vs Type of Building: Dwelling No.of Bedrooms Z I,ot Size sq. ft. Garbage.Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank _Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when plicable) [.' 'falf 2,S"o lyta� �/='We'l '4.0"y l dS cvl r y `Srohr� l.�tyvti, 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. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. �'' Date Issued No. � �! _ Fee • THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplirdtion for Digpogal 4p$tem Cow5truction Permit Application for a Permit to Construct O Repair(C.ly-l'Upgrade( ) Abandon O ❑ Complete System ❑Individual.Components Location Address or LoV q"�� 'fQb��' 1/r Owner's Name,Address,and Tel.No. yat!$ (= Assessor's Map/Parcel Installer's Name,Address,and Tel.No.SDg y20^97�g Designer's=Name,Address and Tel.No. r Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd ' Plan Date Number of sheets Revision Date Title Size of Septic Tank 'N' Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) rfT r,011 9"S"o O 601 [✓=k1Gh c�,�a.� /:!'S 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.. Signed Date _ Application Approved by '`l.:rl ,iAr � 11 ,,oyir!`- � Date . =% Application Disapproved by: ' / Date for the following reasons Permit No. V\ (/, Date Issued (/ S THE COMMONWEALTH OF MASSACHUSETTS 1 BARNSTABLE, MASSACHUSETTS Certificate of Compliance ,.THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( � Upgraded ( ) " Abandoned( )by c/0 e �/�-c ,G� ,VV eG at fr 9 !.�//� S'�io r/� eOII V,- �4,V4,yh/.S ha/ eeenn constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �(/�j� (J dated Installer L4,511014 iA6s 5 Designer #bedrooms 2 Approved design flow gpd The issuance of this permit/s Il/dot be construed as a guarantee that the sy em will n Ko a designed. Date Inspecto ——=No. �� Fee `'i'l./tdi THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 'Di!gpogar �&p.5tem Cott.5truction Permit Permission is hereby granted to Construct ( ) Ree air ( 4 T'-'Upgrade ( ) Abandon ( ) System located at �� 4o eva�''S�soa!_= 12s^i i//= and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Cons ctio ,mu/st be completed within three years of the date of this permit: Date .� /�/.� Approved by � Nodes This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST A" SOIL EVALUATION EXabliMON FORM hMbX CQMfY that the darted.-3"7f G 6 concerning the property located at Vk Meets of the following orite ria: • Thin f6ft0d 1YINtm is c0WWcW to a ra sidentiat dwalling only. Jim an no, P MIRM hrciad�r- busbwu um hired with dw w dwelling. • The satil is classifed as CLASS i and the percolation rate is less d=or equal to 5 reroute• Pier incle. 7be oWlica nt may use historicsl data to conclude this fact or stem+conduct do Fast MCI and percolatien WU at the site without a hWth ermt premt. • T bare is no ' in flow and/or change in use proposed • Thm are no MiGAM requested or aaoded. • Tlw bottrmn of the proposed leaching facility will,be located no lass am five feet above to nvWnwrn adjusted groundwater table elevation, r djust dw gtomdwstw table wit the Frimptar nnethod wham applicable] LA run"compk a the foikVWlmg: A) Top of Oro nd Surface Elevation(using 01S information) E) ®,W. Elmtion �'7 adjusonent for high 0.W'',-3'-r 't3® -D"ERJEN 5 CE BETWEEN A sod S .._ sM DATE: NOTICIt Based than dw abovt haf tion,&rE*r permit will be issued for bedroom Munnum No additional bedwom are authorised to the tubze evitllout en ' 1 • Pe r. 06/:i0/2006 16:01 5094775313 ENGINEERING WORKS PAGE 01 Town of Barnstable Regulatory Services Tbamas F.GeUer,ibiraetojr Public Health Divisioi �, ' Tttia�mtts Mtl(;eat1,D�irsctar zoo Mara Sovot,Flyaaak,MA 02"1 Offkm 508-862.4644 Fax: �48.7a(1830A Dsae• L0 sewage Permits `� 't S u Asses sor's Mt IPa1.c4pt,°2 7 1— Lk 0 s ^ Install`er; Address )2 w� Ccv s s ~a Imo'--� Addreos: - 404 On to �3 Jo i S �G,� C'A�Fai issued a permit rn i►rO-Al a (date) 1 (insta►1ler) SeptiC system itt based on a design drawn bey (address) �� Pier 6'�G`�'� dated S�o� I certify that the septic system referenced above was installed suhaasnt:all;1y accordi (a the dewier, Wfuch may include minor approved changes such as lateral rei�ocation of the distribunon box and/or septic tank. t oertify that the septic system relerenced above was installed with major changes 6.e• greater than 10' lateral r+elocatior of the SAS or any vertical relocation of Sny component of the septic system)but in accordant with State dk Local Regulations flan revision or certified as-built by designer to follow, �N OF Mq vr� PETER T. elm WENT�E CIVIL �f No.351 oe .t q�0 9FOrBsEP�o�� --- tamp 1�ere) (Designer's�signature) (OX ' 'iA►.��...�i al -19 AAR ?ARL,L....pU UL XF.&LIW wRUAI Q[iW. rRIA foss ANb A&��11Lr CAIt� A 8lrL'IY�iR l!Y Dili. ML U:Me6It~;WDWrW CxroAeuim Pon++I.26.04.4M 017 CERTIFIED SEPTIC SYSTEM REPORT LOCATION 89 WINDSHORE DR. . HYANNIS," -MA MAP 271 PARCEL 140 LOT 9 PREPARED FOR SELLER MRS . CLAIRE RAGUSA 89 WINDSHORE DR. HYANNIS, MA 6ecepp�® BUYER 2 1995 MR. & MRS . LAWRENCE SIMAS, JR. OF 6 BUCKINGHAM DR. SANDWICH, MA PREPARED BI ��•�® HILLIARD HILLER, JR. JUL P .O. BOX 250 HEALTH DEPT CENTERVILLE, MA 02632 OFBARNSTABLE 508-778-1472 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property Owner' s name G L 4141 Date of- Inspection 011s19s PART A CHECKLIST Check if the following have been done: �✓ Pumping information was requested of the .-awner, occupant, and Board of Health. V" 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. i/ As built plans have been obtained and examined. Note if they are not available with N/A. r/ The facility or dwelling was inspected for signs of sewage back-up. r/ The site was inspected for signs of breakout. A11 system components, -a;;;r-luding the SAS, have been located on the site . ✓ The septic tank manholes were uncovered, .opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. t/ The size and location of the SAS on the site has been determined based on 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms / number of current residents No garbage grinder, yes or no YXS laundry connected to system, yes .or no - seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: .cixive� slc�ovvT 7�, 7hy 101Q,st,rXLy Last date of occupancy GENERAL INFORMATION Pumping records and source of information: owl,/ System pumped as part of inspection, yes or no if yes, volume pumped 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) Other (explain) Approximate age of all components. Date installed, i.f known. Source of information: /977 �/ 1,V5T/1GGE1zs ,U4 Sewage odors detected when arriving at the site, yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade: � material of construction: v concrete metal FRP other(explain) dimensions: yiG x 8 sludge depth as" distance from top of sludge to bottom of outlet tee or baffle a " scum thickness B " distance from top of scum to top of outlet tee or baffle /Y" 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, evidence of leakage, recommendations for repairs, etc. ) Ti9,y/� �y� T.�CS Lc�.Pa'.o CsWD DISTRIBUTION BOX: y (locate on site plan) a depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) Re7x e-✓rvs G,e alt"G. ,vo soLios' a2 1�.�l�cs� E T11Z AiT rr�r�S pi.•iE i Hz .di.�.z lfiso s�ii�c.o �9� ��s�,�� s,��✓�,�- PUMP CHAMBER: (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. ) 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: :.S Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs.. of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) (JO S/G!/ of Fi,�/G�2� S'y" G/4�/a Tv GovEl1 , W.)" a� Gilavao cc�.C%. ^5.� o f'vT 4 RISP/1 bt/. L/c1via /S /8' 11r 16 :/I T 16 A.�j4/1G3�r.�r�TCL y CESSPOOLS (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 (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,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, recommendations for maintenance or repairs, etc. ) i -z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: 's-f include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 81lG A t DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: P.�fli�,l/STAi3L �s/S Sh'Ouis T/f,� k L r/AT/y't/ o% T/1,"r S/T Td e6 5� 7 ' Tf/,C O�'srllr/t'� ul"T A T/ 4z J'��L �� O.PfI /,vG s/�ivs 7-&,C dC &Z 8 tf/z r.SGS S4,7 -a8 -c.y ; _aa13' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of deterrrr.ination in all instances. If "not determined", explain why not) 10 Backup of sewage into facility? kO Discharge or ponding of effluent to the -surface of the ground or surface waters? yW- Static liquid level in the distribution box above outlet invert? P//O,r AV% Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? _!tJ Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS , cesspool or privy: (� below the high groundwater elevation? within 50 feet of a surface water? within. 100 feet of a surface water supply or tributary to a surface water supply? AJ 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) ? _IJ within 50 feet of a private water supply well? Al 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.. TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME 1)W5 C'GX'x e XQ 6615'9 PA1;T D. - CERTIFICATION NAME OF INSPECTOR COMPANY NAME COMPANY ADDRESS r°bX a.SZ> Street Town or City State ZIP COMPANY TELEPHONE ( Sod ) 77S= -/1/7,1 FAX 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 time 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 : System 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 °ss.nd the environment in accordance with Title 5 , 310 CMR 15 .303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form. Inspector Signature � � �,,.Y -�// Date 3— One copy of this certification must be provided to the OWNER, the BUYER (where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . ,_ partd.doc (,� TOWN(OF—BARNSTABLE I>-'?GXTION l h1 SY��`L. — SEWAGES^� ��;'•.. VILLAGE w :� S & LOINSTALLER'S NAME&PHONE NO. 6 �ASSESSOR'�MAP -�W � 0-" SEPTIC TANK CAPACITY o LEACHING FACILITY: (type) ` d (size) NO.OF BEDROOMS S BUILDER OR OWNER �-�� E C. PERMIT DATE: (O " cls� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Qe, Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) l� Feet Edge of Wetland and Leaching Facility,(If any wetlands/�ex�xist within 300 feet of le ng facili ) CQ � Feet Furnished by )I e / 5 Lt No.7 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Applirativat for Diti-paii al Work,6 Cnuat,itrur#inn firrutit Application is hereby made for a Permit to Construct ( ) or Repair (�') an Individual Sewage Disposal System at: C,_ , f ..... .. - �' ti`�Q..._..._•----- P 4 �% ..........--•--------•-------- ��^,, ` L cation-Addre r Lot No. `, 1CP� L � -' '�al 1.�-'_•� _.'a u s D a------------------------ rIf\r,(�_0__._.___..-, ...... _____1... _. ... . . � ddress•-_._ _ _ _._ g` • §r Installer Address Type of Building Size Lot---------------------------- q. feet ..� Dwelling— No. of Bedrooms--------_________-_____-______-___-.-----__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures Design --------------------------------------------gallons per person per day. Total daily flow............................................gallons. W n Flow---------------------------------=- WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth-_--________._.. x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No__________ __________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------------------------------------------------------• Date........................................ a Test Pit No. I________________minutes per inch Depth of Test Pit_._-..-________.__- Depth to ground water..................... f? Test Pit No. 2................minutes per inch Depth of Test Pit._.____._-._____---- Depth to ground water........................ P --......--••----------------•-•---.......................--------....-•-•-------•-----------.....---......................................................... 0 Description of Soil-------------------------------------------------------------------- ------••-----------------------------•-•-•-•------------------------...--•--•••.............-•-•- x �p ��. Nature of Repairs or Alteratio s=AnswerT-cle h a h e......... ...... �� ---------------------- UP PP --�... ............... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp ' nce has been issued by the board of health. Signed .... ----- ---------- ............................... .. �,�...^.°j. '...... Date Application.Approved By ...... \� t�-�-�`-- ----�o. �.^.. �' ..................................................................... ......Date Application.Disapproved for the following reasons: ----------....................._..-----------------------------...-.................----------------------------------------- -------------------------------- --------------------------------------------- ---------------------------------------------------------------------------------------- -------------- ------- A a.� PDare Permit No. ..... � -... ��6.. Issued 1�j^_'1...�..'��..5�- .......... Dare /' � .�► .J ><�a :+."� �/jam 'r\� � }', r "; �.;�� '� � 1' ____ �__�__'y Y tw 0.?6 '.Ric THE COMMO'N5WEALTH OF MASSACHUSETTS V t 1� BOXRD OF HEALTH r TOW l OF BARNSTABLE ,{� Avv trattott fur- -spagal Work,6 C owitrurttnn Vrrmit Application is hereby madeN r a Permit to Construct ( ) or Repair (kL) an Individual Sewage Disposal System at: C L cation-Addre / r -- r Lot No. (' p C ............1. �_ � dd+ess 1•Y1 l M Installer ----•-•-•- ....:---•_-••- Address UTypeiof Building Size Lot---------__________..____._..Sq. feet Dwelling— No. of Bedrooms-------- -------------------------------Expansion Attic ( ) .Garbage Grinder ( ) a -' Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ._..._..t"� _ ___.__. . -----------•----------------------------------------------- ------------------------------------------------------------- W Design Flow___________________________/'__�r.......gallons per person per day. Total daily flow.....................................,------gallons. WSeptic Tank—Liquid capacity=_ %_gallonsl Length---------------- Width--.--.-_-_------ Diameter--.............. Depth................ Disposal Trench=No .._. Width Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No---------- �_�.Diameter ' - -.-.- Depth below inlet-------------------- Total leaching area..................sq. ft. Other Distribution box ( ) •+i Dos ng tank ( ) WPercolation Test Results Performed by.,-, -------- y. --•--------•••. ..................................... �te.-'...............•--•••......---•-..... Test Pit No. l� .............minutes,,per`mcii) Depsth� f Test Pit _-----____.__- Depth to ground water_--_-..---___-__-.-_---- (s. Test Pit No 2________________nunutes per inch Dept�h'%�of Test Pit.................... Depth to ground water...................... , , -------------------------------------------------------------------------------------- O D cription of Soil - ...................... •A if i A� ^� -- - -----•--------------- r U .. ............................. ............................ ......___.: -__-_-•--._.__._..r _____.......___.__..__....................._..._..._._ 11 vt j r V~ ---------------------------- U Nature of Re airl or Al'teratio s—Answer whe a h le Corn ��„y,. Agree. e f a$ The undersigned"agrees to install the aforedescribed IndividuaL Sewage Disposal System in accordance with ihe�;provisions of.TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of ComPkince has been issued by the bo d of health. p ..�- Signed .......�` �' tOC�•�... ---------------------------- �^j 15- Application.Approved By ..... - - ------------------------------------------------------------- ----(10:.. --- 1[e: . .,." Date Application Disapproved for the following reasons: ...............------------------------------------------------------- .........................------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------. ----- -------LB -......_ fa it N Permit No ----- .. - . tr � �� Issued -.w �. te' .�,�.,•,�^,~" Dare ......a.. ±�.z+a..�.�...�,�..e�a�,...��.�.�.-�._�_�-��1..�:,e�u++s4.<�.s �sc�a��!��r�.z�..a_arra..a tirr+zr. e�aesw�e.>t ray .y..z�v.•>e.a e_s.�>.tioe �Y z..b��e��es�a�sa�-r+w;ca�.�.-tea i.� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertifi atr, of ILomplianre H 6 IS T ERTIFY, at the ndivid al Sewage Disposal System constructed ( ) or Repaired ( Y ------------------------------------------------------------------ h,t:di�. �� m _ ��. .ate � �.� - ' has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ._ _. 7_-..f, G.�'�.... dated _ -..�.. ---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT—BE CONSTRUED AS A GUARANTEE THAT SYSTEM WILL FUNCTION SATISFACTORY. ... P' _.- Inspect :-, �* ----------------------- DATE � W THE COMMONWEALTH OF MASSACHUSETTS��"?�� MAP i$ y BOARD OF HEALTH 'Puy � r TOWN OF BARNSTABLE No.. ...:5..'. FEE---__.__d'.Co Dispint IV rks butt tr tin , I Permission is hereby ranted .1 1� ......................................................... Yg _ 7 to Construct ( or Repair (�,[r�a Indi idual Sewa e Disposal SX7 -_ - t Street as shown on the application for Disposal Works Construction Permit /-_ Dated___-___ ._... .._.___.._. . •---- . ------ { DATE-........... ---------------`---��-?�--------------------------- Board of Health FORM 36508 HOBBS Er WARREN,INC.,PUBLISHERS TOWN OF BARNSTABLE 11�CATION 5'� Y2-,,1e.[Vle SEWAGE # 77-kd, VILLAGE /IYXI.41/5 ASSESSOR'S MAP& LOT a7/ / o L�1 INSTALLER'S NAME&PHONE NO. 5 SEPTIC TANK CAPACITY fe:e� LEACHING FACILITY: (type) (size.) > NO. OF BEDROOMS oZ OR OWNER VI?5. fCaflleX IL176415,4 PERMITDATE: I,3-or7-77 COMPLIANCE DATE: ✓`''S'- 7� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) r Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet toof/leaching facility) / _ Feet Furnished by l�" , i r a d Cri s_ u� f LOCATION SEWAGE PERMIT O o 7- I W f vv o �'&ilf- � VIlLAGE IINSTA LLER'S NAME & ADDRESS 1��n i T3 o um Co B U K D E R OR OWNER J ` AIV!VIS ' DATE PERMIT I SUED OAT E COMPLIANCE ISSUED y, S'- 7g .a j ;�\ � � � �' � � � r f �, � �%� / � � � � ^� � � �� _ ��.® �-� SItJGL� FNIAIL� = 3 ��M � �� ►AO GAErsaG>C laR1 . radl U4 >`L.ow _ 110 ,c 3 = S3a. O:Pn. 5E-'PT'!G T,�IK.<= 33o.r ISG % • �C.7 lea P.D' �� 1 ; 1.�ii a 1 . � ! i . t � . ' ' t�-f j �ri1 (l` USA- t 000 ( I ' ' � I715POSA,L: PIT USE loco GdL ? ..I :,� � i .� � r ' i f � � � SUr=W4L-L. Av-F-A = 15o ISo SF ,c 2.S + S 7S G.P.L5.' ' ' ' : .. BdTTO,NI ,�QE1� �,fl sr--. c.A S►�. . ,� ► .c� - - 50 C7.PD. E" + , �,`: � ' ( � : � 6,Xg �S:f � I ' ( i ` 3', -rALTO �ESIG P.D. u 4 Ma . ,TOTAL �eilL_�f FLow - 3306.PD �` t s _ n�sr w J - PE.Ir1GGL.&T1oLJ L74- E : ►`�IQ 1-mIw'.. 02 �SFs,7 . : -. /ouo o 1 t C GA1. 3 i T ;� t f { HI ' j f T { t� OF bf 6s /. i . b$i �tAOFr . >'e� � t.� �� $f� 44 WILLIAM ?�" i ALAN•C. r. , c NYE JO V y i No. 19334 0 w•, STE v�j !+'t a T J� , I t j F G.it A.A.) �fU SUX� /a t r•'� ,a , 1 I - t I 1 1 s TOY Fyv o,00.o . nipro �Am �'Ppe Iuv•`�7.0 I 4�p,,�1 plsr Iw. GA6L.r( � } .box , SEvC I o SAtiD y . i 1w V. 0l T'.�N K I w PIT [.", ..-(j SA�p ' wAsuE� t ., ( r •. + E I ,. . , ..< 'j- T� ,a. i ( ' -iZ CCizTIF1EC� PLcb*rl � TF PL./ifr�1 / - - - SAtio' t ' Pczo�-a�� LOCATl oN E1 �(&Q IJIS I' M A55 v ��Z i ►.)o �c AI..Crr I i �L3l.� : iAS NoT�-�ATC� 12�27,?'1 1 GGIZTl1=� , .T&4A-r, TI-1G. PeU�. JELL.5woww V4V-I?E a1-1 c:G0APL VG W I TI••1'. T1-4G 51 D E.LI 1-4E: Qua S�Tt>�cK GquI�EMcNTS 0I= YH(Z. f3 n►2►�sT�,��„� ` I C _ cQ �`. u�lC- ah.XT Iuc. t2EG11;,IR:-t-ano 1- wo 5U2val?01'Z T1415 17 t_A►-I I� LlOT i_' A`:oCr� v1•.1 o� rc:r~vIL�L1-. u A,CAS��. i (4JrCC•?t1Anl W j jU�' /l..y� ;�- '1 AIL: r_�!=�—;f cC/, •',111�W1_l� /1•!�1':,1_1 <A.1- l "1— ' 1•�>r C:1.< lJ•r',(:`.a i'i:, lil:'..1"l:!'_MI ►'Jl_. 1..i;..�. 1_11�1�,:•.: - .�___._....__.__�.--- CAcp� ,�l�E �C^\/, No......... _ Fxs//» ..... THE COMMONWEALTH OF MASSACHUSETTS -BOARD 0 HEALTH O`CV.-.t)........OF......... !..... '3.............................................. Appliration for Disposal Works Toustrnrtiun Prrutit Application is hereby made for a Permit to Construct (G-)"or Repair ( ) an Individual Sewage Disposal system at,* ... . ...................................... ...•------•-•----....... L=.....------------.............----------- Locatio q Address �/f or Lot Leo. s ---------------•---•---•-----•---- ...................... ff.�!,a�1.�. f �y0e"wne Address Installer Address Type of Building Size Lot...Z4.!: O.-9.._..Sq. feet aDwelling—No. of Bedrooms..........�.........................Expansion Attic ( ) Garbage Grinder Oa P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures .. 0Y1.(' --------------•------------------..........._... w Design Flow................ `sl........_._�..�_. ..gallons per person per day. Total daily flow............ ...............gallons. WSeptic Tank eLiquid capacity_6tllgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No....................:Width_...._ _.... ...__ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No%04. Diametek r epth below jnlet................: Total leaching area.#Z'� .....sq. ft. Z Other Distribution box ( ) Dosing to —d .�C a- 2 7- 7 7 '-' Percolation Test Results Performed .._......-.. �..... Date..../ .77:Z�............. a Test Pit No. 1................minutes per inch Depth of Test Pit..____.__.._........ Depth to ground water_-_-_________-__--_-___. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-______-___---______ ---------- ------------------ ------------ ?7•-- - ---;-- 0 Descriptiog of Soil - " 2 �. .• 7 - ''�i'.�-'1 ...._._.._. --- --------- --- - --- w -- ----- --fir-r -- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------------•-•-------•------------•--•----------------.._.....----•-......------------------------------......---------.......................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign 1�.4 ��I,� 1 Date Application Approved By----------- -------C.................... .....-� z ---- ------- Date Application Disapproved for the following reasons_________________________________________________________---•.............................. ..__.___...... ..........................................•--------......----------•---•--••-----------..._._..---------.._................-------------------------•--------------•------------------------------------- � Date Permit No. -•-----. Issued- --- •--••----------------•--- _. Date 6 No 0, THE COMMONWEALTH OF MASSACHUSETTS BOARD O?f HEALTH ----------:;;f .........0 ........ 0 ve &...................................................... Apphration for Uhipaaal Works Tonstrurtion rmuft Application is hereby made for a Permit to Construct.,( cr Repair an Individual Sewage Disposal Sys 'i� - ....... f./ . ..... ............... ... ........... . Locate Address orVWo . r . ............ . ----- ...... ..........*---------------- Owner Address ................................................................................................. .................................................................................................. Installer . Address �, I., �', Size Lot.. ............Typ,2�of*'h�j-lding,,, .....Sq. feet I ng— droo er.100) U �-�bwell6' No.,oei'Be Bedrooms___.._ ..........Expansion Attic Garbage Grind Other type U Building ............................ No. of persons.............*............... Showers Cafeteria �4P4 Other fLxUwes ------ ...............................----------------------------------------------................................................. Design Flovk........................... W—gallons per person per day. Total daily flow___...... .................gallons. 04 Septic Tank—Liquid*ca -----.......gallons Length................ Width__-............. Diameter:____'--------- Depth................ y Disposal Trench—.No. .................... Width....e..... ...... Total Length_......_...._._..... Total leaching area----- sq f t. 9 , - j, 11 ------------ Seepage Pit NqA0j9#.-W DiameteX-44*10�ept Belo in 7' jpt��- ........ �,otal leachina area.O:-?. .....sq. f t. Dosi t Other Distribution ) L,—%.�-� -77 Percolation Test-Results Performed by............ .....a ........ Wfe. ........................ ' ' ---r................... �/OnAel Test Pit No. 1................minutes per inch Depth of Test Pit_ __..........._.. Depth to ground water. _____._._._......__. Test Pit No. 2...............minutes per inch, Depth of Test Pit....._....._..__._.. Depth to ground water.___....._..._..._._____ tj ------------- .......... .......... -.7- ---- ----- -- - ------- ----------- 0 Description of Soil ---------------- ------------------------ ..... ......................... ------------7 ----------------------- ---------------------------------------------- ................................................................................................................................. U Nature of Repairs or Alterations—Answer when applicable...... ,.7---------------------------------------- ----------------------------------------------- .................................................................................................................................. - -------------------------------------------------------------- Agreement: ' :'sal System in accordance with The undersigned agrees to install he -afoiedescrilA:'Individual Sewage-Disp9 the provisions of TLITILE 5 of the State Sanitary Code The undersigned further,agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. F. Sign ------- ........ 4-r?1424 .. Date Application Approved By. - 77 .......... ....... ...... ............... Date -47 Application Disapproved for the following reasons:.. _...___._ I...... ...................................................... ........................................................................................................................... .................. -,-!7------------------------ ."tDate f. Permit ............................................... r. ... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.................. r.............................................. Trrtifiratr of TontAkturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed 0-1-or Repaired by........................................ . . . ................. - .............. ......---------------------------------------- ----------------- at. ��-------- ............................................................................................ ...................... has been installed in accordance with the provisions of TITLE 5, ,The State Sanitary Code as described in the application for Disposal Works Construction' Permit No........... a. e - -d t d-17....4-1�77................. THE ISSUANCE OF THIS CERTIFICATE SHALL N &C6N-S-?1IJjD AS A GuAiANTEE THAT THE SYSTMMILL FUNCTION SATISFACTORY.,,!-,' ,,�,,,,,., ................................. Inspector ... ............................................. DATE.................... r.. ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD, OF HEALTH ......... ..... PF.. ... ...A-A .................................................. No................. FEE-1.................. Permission is`hereby granted.............................................................................................................................................. a to Cons tf u--ct xp;/ii an.,Individual Sm%-,a Disposal System System ge O .. .... ................at f . . . . .................................................................. Street as shown on the application for�isp 'al Works Construction Pe it N� Dated....1-7.7 f.'16'77 qS ............................ ............................... Board of HeajV DATE............................................................................... . FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS • rA 1 ` I ROUTE 28 K` 1 LEGEND LOCUS ° PROPOSED CONTOUR PROPOSED SPOT GRADE a� EXISTING CONTOUR 7666rA. TEST PIT � UG( ee Sh t 2 — _ -'--'--- +Id'-"-..... EXISTING WATER SERVICE Q N13 34'15"E «ace .,� '---'-,q ' t 0 -- EXISTING GAS SERVICE �:t�cdcc� ferry c; 115.54' L O T 9 r j TP-1" 13.2� APN 271- 140 BENCHMARK . 12,086f S.F. E=I7NG Pr a� TO BE PUMPED c P IT.S. 7^ ua. FILLED WITH SAND N I — - ( ' f �' F_XIST/ G SEP77C TANK ac TOP OF TANK EL: 98,35t Z• INV(OU'I') EL. 97.60:t Tom:..._ 1 RAL NOTES _ BENCHMARK GENE u , � " TOP OF CONCRETE STEP 1, ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL patio BOARDS OF HEALTH AND THE DESIGN ENGINEER. TO BULKHEAD p c 2. ALL WORK AND MATERIALS" SHAL.L CONFORM TO THE REQUIREMENTS tr Nv LEV.-100.00 (ASSUMED) OF THE STATE ENVIRONMENTAL CODE, TITLE, V; AND ANY APPLICABLE `� o g LOCAL RULES AND REGULATIONS. �/ /r 1 cr7otrt i,r7k fer?ce '% 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFiLLEO PRIOR •••-° " TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE Z EXISTING o ; llSE�# ) /� r` �, V I DESIGN ENGINEER. • ,� 89 r' �,"` �` �,_ CO t 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING A V FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES, a. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6, THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 9 -` `w• M1 � i HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 7, WATER SUPPLY PROVIDED 9Y TOWN WATER, STONE `'- ! p! yI 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A,S. D / - PAVE-Ff Q � As�9�, 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED , AV �y�� 'f� TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. ! ca PETER T. CIVIL MIEN E 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY �-gg—. L THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING • __.. ,..� __ _._ _ 4 �, 35109 CONSTRUCTION" 11, WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 115.00' I �fG/SSE`��Q �� IN THE AREA BENEATH AND FOR a FT. ON ALL SIDES OF THE S.A.S. 516�25'S8"W SSIO � AND REPLACE WITH CLEAN FILL AS SPECIFIED IN a10 CMR 2550). O� 12. CONTRACTOR SHALL EVALUATE STUCTURAL INTEGRITY OF EXISTING SEPTIC TANK PRIOR TO CONSTRUCTION. edge [� HhaVerr;�:r7f 1.91> ,5 �2 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY, WINDSHORE DRI VF s : �: TAKEN FROM r RTI�IEa P,n'P FLAN" L�� -� .Ardis �� sA^i ,,a = �./ /6, BY D0.'"N. CAPE f NOiNEERiNG, ROUTE 54A, YARMOUTH NIA, , PROPOSED SEPTIC SYSTEM UPGRADE 89 WINDSHORE DRIVE, HYANNIS, MA Prepared for: Lawrence Simas, 89 Windshore Drive, Hyannis, MA 02601 Engineering by: SCALE DRAWN JOB. NO. Engineering Works 1„-20' P.T.M, 159-06 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET N0. (508) 477-5313 5/19/06 P.T.M. 1 Of 2 r i r NOTE: TO PREVENT BREAKOUT, THE PROPOSED q Y. T.O.F 1 F.G. EL: 98.9t FINISH GRADE SHALL NOT BE < EL:95.9 FOR A DISTANCE OF 1 S' AROUND THE (EXISTING) EXISTING F.G. EL: 99.33t(EXISTING) /- F.G. EL: 99.Ot PERIMETER OF THE S.A.S. .� MAINTAIN 2% MIN SLOPE OVER S.A,S. 4 SCH 40 PVC PERFORATED PIPE WITH SCREW CAP SET TO WITHIN 3" OF FINISH INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER O-BOX TO 2-50Q CALLON LEACHING CH M ERS GRADE TO SERVE AS INSPECTION PORT, TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL. SIDE INSTALL RISER OVER CHAMBER L =34' L=13' SHOWN ON PLAN AND SET COVER ZLIK4' SCH 40 PVC ]WITHIN " OF FINISH GRADE .. 4" SCH 40 PVC ---2" LAYER OF 1/8" TO t/2" f 10 EXISTING r4^ ® S= 1% (MIN,) �' ® Sm 1% (MIN.) � am OOUBLE WASHED STONE *; 1000 GALLON SEPTIC TANK INV. ELEV.=96.17 I INV. ELEV.=96.00 2' EFF. DEPTH 4 g,2 4 3/4"-t t/2" (SEE NOTE 12 —SHEET 1) INV.EL: 97.20t EXISTING A 0 �qg 0-BOX DOUBLE WASHED FLE EFFECTIVE WIDTH 13.2' STONE I NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING l INV. ELEV.=95.40 PIPE INVERTS PRIOR TO CONSTRUCTION. 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE TOP CONC. ELEV.-96.2 --BREAKOUT ELEV.=95,9 ON A MECHANICALLY COMPACTED SIX INCH CRUSHED INV. ELEV.=95.40 STONE BASE, AS SPECIFIED IN 310 CMR 15,221(2). �� ,� 3) INSTALL INLET & OUTLET TEES AS NEEDED. BOTTOM ELEV.=93.40 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 3' 2 x 8,5 17.0 3' AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL, 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23,0 T.P. EXCAVATION OR G.W. SEPTIC SYSTEM PROFILE NO G.W. ENCOUNTERED L HING SYSTEM 5 TION BOTTOM OF TP EL: 88.4 N.T.S. (3) 5„ OIA.OUTLETs @�� Of 04 � {-�--s'S �I Z" PETER T. cENTEE a-- de. . fir+�w --._ M CIVIL 1El �-� stotra DESIGN CRITERIA No, 35109 s v V1 13.2-� NUMBER OF BEDROOMS: 2 BEDROOMS F�S'l0 t � H-10 LOADING 2" 4. ui I SOIL TYPE: CLASS I D-BOXa I SOIL. LOG DESIGN PERCOLATION RATE: 2 MIN./IN, ,12'LI OG ".T.e. DATE: MAY 18, 2006 DAILY FLOW: 220 G.P.D. c N I I ? SOIL EVALUATOR: PETER T. McENTEE C.S.E. DESIGN FLOW: 330 G.P,D d I p INSPECTOR: NOT WITNESSED—CLASS 1 SOILS GARBAGE GRINDER: NO y LEACHING AREA REpUIRED: (330) = 445.9 S.F. TP 1 Depth Elev. .74 Elev. I �h TP—2 pe�th ®®®® Q ®E390i 9.5 „ EXISTING SEPTIC TANK: 1000 GALLON CAPACITY ss° �p c ale. 98.8 A LOAMY SAND D„ 98`9 A LOAMY SAND0®®®®®IE�®®� ,pc7tra 10YR 3/3 1aYR 3/3 „`�� 2-500 GALLn LEACHIN Ch1AM ERS Ir SERIE 98.3 6 98.2 8 E. B LOAMY SAND B LOAMY SAND SIDEWALL AREA: 2 13.2' + 23,0' X 2 = 144,8 S.F. , 10YR s/s 1aYR s/a ( ) Toz" ff ,f� 96.8 24" 96.6 28" BOTTOM AREA: 13.2' x3A' = 303.6.0 S.F. /� .` C1 LOAMY SAND Cl LOAMY SAND �''- EXIST/NG //` 5Y 6/3 5Y 6/3 TOTAL AREA: 448,4 S.F. 4° KNOCKOUT HOUSE'(#89)/,/ .. 20&GRAVEL/c088LEs 20&GRAVEL/COBBLES Zo° OIA. COVER 95.5 40" 95.4 42" DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. 7S' F/, C2 M-C SAND C2 M—C SAND 4." KNOCKOUT /♦" KNOCKOUT 62" /f /`� r 10YR 5/6 10YR 5/6 I O „/ / 93.8 93 20%cRAVEL/cOBBLEs 6Q„ 6 20%GRAVEL/COBBLES 641, / C3 M—C SAND C3 M—C SAND PROPOSED SEPTIC SYSTEM UPGRADE 4" KNOCKOUT 7,5YR 5/8 7.5YR 5/8 _. 5%GRAVEL/COBBLES 5%GRAVEL/008BLE5 8g WINDSHORE DRIVE, MYANNIS, MA 91.6 C4 MED. SAND 86 90.9 C4 MED, SAND 96 500 GALLON CAPACITY, H-10 LOADING 2.5Y 7/3 2.5Y 7/3 Prepared for: Lawrence Simas, 89 Windshore Drive, Hyannis, MA 02601 c5XGRAVEL Engineering b SCALE DRAWN JOB. NO. 88.8 120" 88.4 <SF.GRAVEL 126" g Y'CHAMBERS "Ts S.A.S. LAYOUT 1 NO G.W. ENCOUNTERED ® Engineering Works NTS P.T.M. 159-06 PERC RATES < 2 MIN/IN. ("C2,3,4" HORIZANS) 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. (508) 477-5313 5/19/06 P.T.M. 2 of 2 e r t