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HomeMy WebLinkAbout0171 WINDSHORE DRIVE - Health 171 Windshore Drive - Hyannis 'A = 270 - 221 1 1y 1 ,I i 1 1 e I t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. CitylTown State Zip Code 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 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return Name of Inspector key. B & B Excavation, Inc. Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 Telephone Number License Number i 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 inspect on was performed based on my training and experience in the proper function and maintenance ofkbn situ sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of-'-�, Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local,Approving Authority 6/14/10 Inspector's 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 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. [ b11 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage isposal System;Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. City/Town 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): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 < Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water _supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 '/2 day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 1 f I Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. Cityfrown 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? f Was the facility owner(and occupants if different from owner) provided with El ® information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. Cityrrown 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: i Sump pump? ❑ Yes ® No Last date of occupancy: June 2009 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 65' feet Comments (on condition of joints, venting, evidence of leakage, etc.): At,time of inspection building sewer appears to be in good shape- no signs of leakage or blockage Septic Tank(locate on site plan): 2' Depth below grade: 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: 8'6"X 62"X 52" Sludge depth: no sludge t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appears to be in good condition -tees are present- no signs of backup Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene, ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM z 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons � Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears to be in good condition - no sign of backup Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments nM 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in good condition - no damp soils or hydraulic failure 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•09/08 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 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis _ MA 02601 6/14/10 page. Cityrrown 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 a 0 3 O i31= 30' A 3= 2�l� u 3=34•� t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: > 12 feet Please indicate all methods used to determine the high ground water elevation: J ❑ 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: P ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: hand augered hole Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 171 Windshore Drive Property Address Janise Mendes Owner Owner's Name information is required for every Hyannis MA 02601 6/14/10 page. CityTTown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION 17/ GtJr`ly4a'�— SEWAGE # 2oO ,f,5 O 2, VILLAGE ASSESSOR'S MAP & LOT a'STALLER'S NAME&PHONE N0. J-e SEPTIC TANK CAPACITY 10 Dy' / LEACHING FACILITY: (type) —�� ���+f!(O�GS (size), NO.OF BEDROOMS ..3 BUILDER OR OWNER PERMIT'DATE: 9 -0 7 COMPLIANCE DATE: 49 Separation Distance Between the: ry 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 facility) Feet Furnished by S , T b h 9)i ?. No. .2W� R Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplicatiou for �Di5po5al 6p5tem Con,5truction permit Application for a Permit to Construct(ell—Repair(k-)-1U'pgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No. t'�� G(��H Jl�/OP/% ���� Owner's Name,Address; d Tel.No. � ,�� Assessor'sMap/Pazcel D^22 ,Instp�ller's Name Address and Tel No. U�" y7`1' rV 3 S Designdr's Name,Address and Tel.No..�d g— dpseplFQ/� rHy, 2 �i, /�/� /2 C'�vs3G/zl�/2 , 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 Type of S.A.S. Description of Soil Nature ooff/Repairs or Alterations(Answer w n applicable) mil, �Q � 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 U7" Application Disapproved by: Date for the following reasons Permit No.C2 00 — �QZ —Date Issued ——————————————————————— ——— ———————————- J - .-.-.ter-r�r'�•�.-.q.... ,.-+,..n.�w._� . .,w . .. . . ..,,.�w_ }-.'Sit,..,,,.r �j•-. _ ..,. . � . . - . � _ . . , . :`+•- ` V No. +IN -4 Fee AV I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for �hgpoal 6pgtem Cou5tructtou Permit Application for a Permit to Construct(Repair(grade( ) Abandon( ❑.Complete System ❑Individual Components Location Address or Lot No./7� wm /!�� Owner's Name,Address, d Tel.No. f } ffy�`I7iIs610/Y� t/AhrS.1-- >Assessor's Map/Pamel17 Installer's Name,Address,and Tel.No. SOg 2g�.7y Designdr's Name,Address and Tel.jig. ,cq, uN,�q 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 Type of S.A.S. 1 Description of Soil Nature of/Repairs or Alterations(Answer w n applicable) D Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ac ordance with the provisions of Title 5 of the Environmental Code apd�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 j Application Disapproved by: i Date for the following reasons Permit No.ac Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed (4 Repaired (La—Upgraded ( ) Abandoned( )by JGdi �J,ly'p S at ��/ ��/;yl� t�l'i: l'/1([% &N,!!f/!r has been constructed //iin accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. .� `7�G� dated 0 ' Installer /o�&,W.4 Designeror � 1y �^/s�� #bedrooms Approved design flow � � gpd The issuance of this permit sha In be construed as a guarantee that the system wl fun il t' n as�dess nod. Date ` a/ . � / Inspector _ L�., —7 No. Fee 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migos;ar �&p!gtem Congtructiou Permit Permission is hereby granted to Construct Repair (/�---Upgrade ( ) Abandon ( ) System located at 47/ u1'**&2A rh,, -- a-,y& and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. (""�} ! ;i Provided- C nstruction must be completed within three years of the date of this peg!!!}t. Date Pp` A roved b 1 1 O� Y 10/16/2007 06:55 5084775313 ENGINEERING WORKS PAGE 01 iA t Town of Barnstable Regulatory Service Thomas F.+GeHer,Dire for PubNc Hem DMdon "comas McKean,D&ector M Maw SU04 DMWs,MA OW WOW sw-ma.4644 Fax: "&790.6304 IBstaUer&Deslaner CertTi _&fie__ a Form Date: rd 4 07 sewage Penaw 2 00?- Y e,Anesnrts Mapftreo S?a mAc� LAJ, Inealler. 12:t T Adt : Z'-Z- W I Gr`t!S S l'Q ok C ee: Z\, w�0-W-At On—_-- -) ` )4 c. was ismud a PCMdt to instal]a (date} (installer) septid system at f?l %Lo�S�tar� ! r1...I.� based on a design drawn by _( ) dated q .` I certify that tie septic system referenced above was installed sub to the deli p%which may include minor approved changes such as��the di 'b on boat and/or septic tank. I that the septic system referenced above was installed with major changes (ie. greater them 10'lateral relocation of the SAS or any vertical relocation of any camgonemt of the septic system)but in acc�dance with State dt Local Regulations. Puss rer►isioa or reed as built by designer to follow. �OF pETER T. (Installer's Signature) McEMCEE CIVfI. p1o,3Si09 q (Designer's Signature) (Affix tamp Hero) VRAU •BLUM TOE, 't'A= M" ISION. CiLR"UZIC I36.,OF COMPLIANCE WILL NOT BB RUED UNTIL a= THIS FORM AND AS-B MT CUR ABA AFAMJM BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK M. Q:H=W4qdDW VW a"fiCOUM Foam 3-26.04AOc P F , COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information s 1. Property Information MAP 2=PARC � 171 WINDSHORE DRIVE - HYANNIS MA 02601 `���� Property Address 't " MENDES, ANISE Owner's Name 11 LELAND FARM ROAD Owner's Address ASHLAND MA 01721 City/Town State Zip Code JULY 19, 2007 Date - 2. Inspector: ' JAMES D. SEARS ' Name of Inspector ` r. A & B CANCO ;a Company Name 350 MAIN STREET C� ram, Company Address WEST YARMOUTH MA 02673 City/Town State Zip Code 508-775-2800 Telephone Number B. Certification :Y. I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The System: ® Passes ® Conditionally Passes ® Fails ® eds Further Evaluation by the Local Approving Authority s ctor's Signature: Date: 1z 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 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Certification (cont.) 171 WINDSHORE DRIVE Owner's Address HYANNIS s MA 02601 City/Town State Zip Code MENDES, ANISE Owner's Name J U LY 19, 2007 Date of inspection Inspection Summary: Check A, B, C, D or E/always complete all of Section D A) System Passes: N/A ® 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: N/A- one or more system components as described in the"Conditional Pass"section need to be replaced or Repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the ❑ for the following statements. If"not determined," please explain. ® The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of compliance indicating that the tank is less than 20 years old is available. ND Explain: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 171 WINDSHORE DRIVE Owners Address HYANNIS MA 02601 Cityrrown State Zip Code MENDES, ANISE Owners Name J U LY 19, 2007 Date of inspection B) System Conditionally Passes (cont.): N/A Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: N/A ® 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 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 171 WINDSHORE DRIVE Owner's Address HYAN N I S MA 02601 Cityrrown State Zip Code MENDES, ANISE Owner's Name J U LY 19, 2007 Date of inspection . C) Further evaluation is required by the Board of Health (cont.): N/A 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3.Other Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 4\1- COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments a �e Subsurface Sewage Disposal System Form B. Certification (cont.) 171 WINDSHORE DRIVE Owner's Address HYANNIS MA 02601 Cityrrown State Zip Code MENDES, ANISE Owner's Name JULY 19, 2007 Date of inspection 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 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓® Liquid depth in pit is less than 6"below invert or available volume is less than '/day flow ✓� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 0 Any portion of the SAS,cesspool or privy is below high ground surface water elevation. N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. 4 N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A 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.] YES No The system is a cesspool serving a facility with a design flow of 2000 gpd—10,000 gpd. Yes No ✓� The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 1 COMMONWEALTH OF MASSACHUSETTS 6 d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 171 WINDSHORE DRIVE Property Address HYANNIS MA 02601 City/Town State Zip Code MENDES, JANISE Owner's Name J U LY 19, 2007 Date of inspection E) NIA-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. x Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 171 WINDSHORE DRIVE Property Address HYANNIS MA 02601 Cityrrown State Zip Code MENDES, ANISE Owner's Name J U LY 19, 2007 Date of inspection Check if the following,have been done. You must indicate"yes"or"no" as to each of the following: Yes No 0 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? 0 0 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? 0 ® Was the site inspected for signs of break out? 0 Q Were all system components, including 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? 0 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: 0 Existing information. For example,a plan at the Board of Health. 0 ® 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)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information 171 WINDSHORE DRIVE Property Address HYAN N IS MA 02601 City/Town State Zip Code MENDES, ANISE Owner's Name JULY 19, 2007 Date of inspection Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder? ® Yes ® No Is laundry on a separate sewage system?[if yes separate inspection is required] Yes No Laundry system inspected? Yes ❑ No Seasonaluse? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): SEE ATTACHED PAGE Sump pump? Yes No Last date of occupancy: PRESENT Commercial/Industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 31QCMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.) Grease trap present? Yes Ej No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to'the Title 5 system? ❑ Yes ® No Water meter readings if available: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Q. Subsurface Sewage Disposal System Form D. System Information (cont.) 171 WINDSHORE DRIVE Property Address HYANNIS MA 02601 City/Town State Zip Code MENDES, ANISE Owner's Name JULY 19, 2007 Date of inspection General Information Pumping Records: Source of Information: 2006 Was system pumped as part of the inspection? ❑ Yes [21 No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: 0 Septic tank,distribution box,soil absorption system ® Single cesspool Overflow cesspool Privy ® Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank.Attach a copy of the DEP approval. ® Other(describe): Approximate age of all components,date installed (if known)and source of information: AROUND 1980 Were sewage odors detected when arriving at the site? ❑ Yes No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 I COMMONWEALTH OF MASSACHUSETTS o Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 171 WINDSHORE DRIVE Property Address HYANNIS MA 02601 City/Town State Zip Code MENDES, ANISE Owner's Name JULY 19, 2007 Date of inspection Building Sewer(locate on site plan): Depth below grade: 16" feet Material of construction: ❑ cast iron [3 40 PVC other(explain) Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): GOOD Septic Tank(locate on site plan): ✓ Depth below grade: 20" feet _ Material of construction: Elconcrete ❑ 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-GALLON PRE CAST Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 27" Scum Thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? ASBUILT—TAPE&SLUDGE JUDGE. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 171 WINDSHORE DRIVE Property Address HYANNIS MA 02601 Cityrrown State Zip Code MENDES, ANISE Owner's Name J U LY 19, 2007 Date of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): TANK AT WORKING LEVEL, TANK & COVERS AT 20". OUTLET TEE, 18" CENTER COVER. Grease Trap (locate on site plan): N/A Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene other(explain) Dimensions: Scum Thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A Depth below.grade: Material of construction.- concrete ® metal ® fiberglass ® polyethylene ❑ other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 COMMONWEALTH OF MASSACHUSETTS r Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 171 WINDSHORE DRIVE Property Address HYANNIS MA 02601 City/Town State Zip Code MENDES, JANISE Owner's Name J U LY 19, 2007 Date of inspection Tight or Bolding Tank(cont.) N/A 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 a copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): ✓ Depth of liquid level above outlet invert OVER 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.): D-BOX IS 12" X 16" —28" BELOW GRADE, ONE LINE IN — ONE LINE OUT. BOX IS FULL TO COVER, COVER BROKEN, BOX NO GOOD. Pump Chamber(locate on site plan): N/A Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ® No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 r COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 171 WINDSHORE DRIVE Property Address HYANNIS MA 02601 Cityrrown State Zip Code MENDES, ANISE Owners Name J U LY 19, 2007 Date of inspection Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): ✓ If SAS not located,explain why: Type: © leaching pits number: 1 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.): LEACHING IS ONE 1000-GALLON PRE CAST PIT. PIT & COVER AT 30", 4' STONE. PIT IS FULL TO COVER, LEACHING NEEDS TO BE REPLACED. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 I COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) . 171 WINDSHORE DRIVE Property Address HYANNIS MA 02601 City/Town State Zip Code MENDES, ANISE Owners Name J U LY 19, 2007 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow'. Yes ® No Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Privy(locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signssof hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 `' COMMONWEALTH OF MASSACHUSETTS a Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (Cont.) 171 WINDSHORE DRIVE Property Address . HYANNIS MA 02601 City/Town State Zip Code MENDES, ANISE Owner's Name JULY 19, 2007 Date-of inspection Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r c e to -� 43 e ' i Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 TOWN OF BARNSTABLE LOCATION / rr.�d -� j SEWAGE# f VILL 2rE �7 ASSESSOR'S MAP&PARCEL �9 L ' t � � /� F NAME&PHONE NO. SEPTIC TANK CAPACITY —S -,'07f LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER 'PF4=Wr DATE: 9—Z f" c-7 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 t t TOWN OF BARNSTABLE LOC:ATI;ON /'rX 5�we SEWAGE # VILLAGE f����j �° ASSESSOR'S MAP Cz LOT 2-7O'��l INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY 100d LEACHING FACILITY:(type) le.?e4 1,,"size) l®.4 NO. OF BEDROOMS 3 PRIVATE WELL OR UBLICC WATE BUILDER OR OWNER 2&e ,5 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE RAN D• Yes No f ,� N � ;N .� n �� �. a.` O G � � 0 � � � �. aa.._ .. ``, ,. � M e'�� � J .� • �� _ ROUTE 2a AV LEGEND _ 78 PROPOSED CONTOUR �t LOCUS 79 PROPOSED SPOT GRADE j r........... _,..,......_f'` EXISTING CONTOUR �q 11 102.76 x EXISTING SPOT GRADE IRwo 19 TEST PIT vt Q I y 8 yt Otth 5t(eet yg z7 p W EXISTING WATER SERVICE ZG A n ~ 98,75 9, 0I1W S OVERHEAD WIRES wESi awN ST VENT •r 2 3 „ il� BENCHMARK p3tit:D p .:; / o�M #- LOCUS MAP N.T.S. EXISTING S.A.S. _ , TO BE REMOVED AND STRIPOUT SOILS ASSOCIATED WITH THE '� ���f `;� �� 99.43 EXISTING S.A.S. (SEE NOTE 11) TP-1 § a " r� I CO K 96.90 EXISTING SEPTIC TANK TR 1 ® r'' TOP OF TANK, EL.=98.11 , •; m �r GENERAL NOTES: INV(OUT) EL.-96.75t �. 0 ,�`'"� d ` , " �- ep �► 99.57 III N .� 1• O / ��1/ 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL r t BOARD OF HEALTH AND THE DESIGN ENGINEER. C)F�11/I-WAY 2, ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS BENCHMARK: CORNER BULKHEAD OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE ELEVATION - 100.O' ' LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: (A55UMED DATUM) if 1) 310 CMR 15.405(1)(b) CONTENTS OF LOCAL UPGRADE APPROVAL: No. 171 ,,,' 4 4 a' A 1' variance to maximum cover requirement of 3', for 4' of I STY. A rnaximum cover. S,A.S. shall have H-20 units and be vented. i 99.68 WD, ,,, \\ g'9 33 i /�• �� ,, 3. THE SEWAGE DISPOSAL.SYSTEM SHALL NOT BE BACKFILLED PRIOR �� C '• T.O.F. 101 .OT" ,"�`. � 'j' z 97,30 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE IA' DESIGN ENGINEER. `+.1 `x �, Q 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING "' h �' �- FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. x 97.39 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF .,�`.. 99,73 rs THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. x 97.53 7. WATER SUPPLY PROVIDED BY TOWN WATER. 98.65 10,411 APN 2 oy� !4 8. THERE ARE NO ABUTTING WELLS LOCATED WITHIN 150' OF THE S.A.S. x I ±5F±SF 6Qy60g"� � �, 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 61 r� TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 'Z` 5 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING Off- 9.2T x'98.OD CONSTRUCTION. 2s• C 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS . ' © IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. NO OF 4 S AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). -PETER T. McE -� PROPOSED SEPTIC SYSTEM UPGRADE CIVILVIL �� No. 35109 171 WINDSHORE DRIVE, HYANNIS, MA RFGIS�� Prepared for: Janise Mendes, 11 Leland Farm Road, Ashland, MA 01721 Engineering by: Surveying by: SCALE DRAWN JOB. NO. EnglneeringiWorkc HOOD SURVEY CROUP 1"=20' P.T.M. 200-07 9 12 West Crossfield Road 18 Route 6A Forestdole, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET NO. (508) 477-5313 (508) 888-1090 9/8/07 P.T.M. 1 of 2 �y•. 1, NOTE: TO PREVENT BREAKOUT, THE PROPOSED TOP OF FOUNDATION -,IPROVIDE RISC OVEPA,D-BOX F.G. EL: 99.0(MAX.) FINISH GRADE SHALL NOT BE < EL:95.0 6TO WITHIN .6" OF FINISH GRADE VENT FOR A DISTANCE OF 15' AROUND THE EXISTING F.G. EL: 99.5t F.G. EL: 99.2t PERIMETER OF THE S.A.S. (, MAINTAIN 2% MIN SLOPE OVER S.A.S. I a, 4' SCH 40 PVC PERFORATED PIPE WITH _ SCREW CAP SET TO WITHIN 3" OF FINISH INSTALL RISERS W/COVERS OVER INLET 3-500 GALLON LEACHING CHAMBERS GRADE TO SERVE AS INSPECTION PORT. a' &•OUTLET TO WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL SIDES L-1 t INSTALL RISER OVER CHAMBER SHOWN ON PLAN AND SET COVER " F FINISH GRADE WITHIN 6" O 4" SCH 40 PVC 4" SCH 40 PVC a. 2" LAYER OF 1/8" TO 1/2" A; io^ ya" STONE 0 S= 1% (MIN.) s" 0 S= 1% (MIN.) ®®B�me (ORBLE APPROVED FILTER FABRIC) a EXISTING 48" LIQUID INV.=95.83 2' EFF. DEPTH ®®®e®®i LEVEL INV.=96.00 4' 5,2' 4' 3/4"-1 1/2" DOUBLE WASHED BAFFLE � PROPOSED D-BOX -...r- INV.=96.75t EFFECTIVE WIDTH = 13.2' STONE �� EXISTING 1000 GALLON SEPTIC TANK EXISTING INV.=94.50 NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING TOP CONC. ELEV.=95.6 -BREAKOUT ELEV.=95.0 PIPE INVERTS PRIOR TO CONSTRUCTION. INV. ELEV.=94.50 8®®®a 2) D-BOX SHALL BE SET LEVEL AND TRUE TO ®r��® GRADE ON A MECHANICALLY COMPACTED SIX BOTTOM ELEV.=92.50 INCH CRUSHED STONE BASE, AS SPECIFIED 3' 2 x 8.5' = 17.0' IN 310 CMR 15.221(2). tI�-'-"` 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = 23.0' T.P. EXCAVATION OR G.W. (3) 5" DIA.OUTLETS 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE 16 AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL NO G.W. AT EL.=86.0 (TP-2) LEACHING SYSTEM SECTION 15.5" a" SEPTIC SYSTEM PROFILE 12" 15.5" 1 O r 8„ . N.T.S. 6" A Tjr D-BOX 2" DESIGN CRITERIA wr.a . , ay �ky � NUMBER OF BEDROOMS: 3 BEDROOMS . °° / i ►! SOIL LOG SOIL TYPE: CLASS I / /� DESIGN PERCOLATION RATE: 2 MIN./IN. l/ ' / N . 1 / DATE: SEPTEMBER 6, 2007 (P-1 1902) ' � i f` � I DAILY FLOW: 330 G.P.D. 'NO. 17I / / SOIL EVALUATOR: PETER T. MCENTEE P.E. DESIGN FLOW: 330 G.P.D ®®®® ®®®® � i WITNESS: DONA' MIORANDI-HEALTH AGENT INVERT ''V�• F •�i /, ' , GARBAGE GRINDER: NO ®®®®®®®®E3 37" T.O.F. _ 101 .0T.-' ' /,'`' LEACHING AREA REQUIRED: (330) = 445.9 S.F. ®®®®®®®®®®irk r , , / ; Elev. TP�- 1 _ Depth Elev. TP-2 Depth 24" ®�a®®®®EE�D®®® �L/ ' � 99.1 0" 98.9 0" .74 1oa° - FILL FILL EXISTING SEPTIC TANK: 1000 GALLON CAPACITY SECTION 97.8 15" 97.8 13" A I A SANDY LOAM SANDY LOAM USE 2-500 GALLON LEACHING CHAMBERS IN SERIES 6$a 2,5Y 4/2 2.5Y 4/2� � SIDEWALL AREA: 2(13.2' + 23.0') X 2 = 144.8 S.F. lk 97.E 19" 97.5 17" a° KNocKour o B 13.2' x 23.0 = 303.6.0 S.F. / B I BOTTOM AREA: M SANDY LOAM SANDY LOAM i zo ow: COVER (h' 10YR 5/6 10YR 5/6 TOTAL AREA: 448.4 S.F. a" KNOCKOUT �/4" KNOCKOUT 62" �,y�,' �\\ 95.1 C1 1` 5001, 94.9 C1 48 DESIGN FLOW PROVIDED: 0.74(448.4) = 331.8 G.P.D. ����✓✓ �� F-A' AND PERC F-M SAND • 4" KNOCKOUT �O,p 10YR'5/4 62" 10YR 5/4 >207.GRAVEL & >20%.GRAVEL & q NOBLES GOBBLES pEngineering ROPOSED SEPTIC SYSTEM UPGRADE PLAN 90.1 C2 108" 89.9 C2 108" 71 WINDSHORE DRIVE, HYANNIS, MA 500 GALLON CAPACITY, H-20 LOADING ����' F-M SAND F-M SAND for: Janise Mendes, 11 Leland Form Road, Ashland, MA 01721 2.5Y 6/4 - 2.5Y 6/4 : Surveying by: SCALE DRAWN JOB, NO.CHAMBERS 87.6 138" 87.4 138" Works HOOD SURVEY GROUP N.T.S. PTM 200-07field Road 18 Route 6A NO GROUNDWATER OBSERVED Forestdole, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET NO. S.A.S. LAYOUT PERC RATE. <2 MIN/IN.("C1" & "C2" HORIZONS) (508) 477-5313 (508) 888-1090 g�$�07 P.T.M. 2 of 2 tastl-�� F"LC>%&/. tto x 3 t '3.3b 6.p.T7. �. ��r�rtG T�� = 330,. lSc % • 4-95 6.'t=t�. _ `.� _ '�w_ . .� � �2( t'�j 'o U S,F-- l QC K:j .6AIL • D.,Ba+t lyl f =Po--A,L PiT - LISE !oc� C-�A..L_.. rAP41i o Tor�L vc-�sl�t� = 42S 6..nn. s S Qao \'0 -A- 1. tj �j- dllt/ st. -Box si',.SS fir` I o 4 • INV. Gv,�►? Joao 9G:ca INv. u ' LAN qG to 9G�3 p,T 69AVGL. wire 111 wAsuED ,1 STor�t= AID PLC) r PL./a,ti GOa2SC .S.�Na Plzo -t i_ - — - A4 a l4 m ASS SC L.5, 1"a.J,; bA.TC— CGCZTtl= f Tt-(AT" T14G FoQb, Nlnw-4 '5U�_ _L�►t.! Q l=c tZ C.iG� CCV,lPLI?G � 1 r{-Z TWGl �ID6`_LRt-3 � Aa Jt:� r'SETC;AC-4 G'C-L'4ulQGV&QT, OP 'rt4C. Lo TO VJ Q ct= � T t„ ^. 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