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0179 MOORING DRIVE - Health
179 Mooring Drive, Cotuit oz4 - its -I 'r I II O i i x f* No. V Fee e ho rf THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS s application for "� o�aY p5tem (Congtr ctt n permit Application for a Permit to Construcf( ) Rep r(L Upgrade O A on ) l�Complete System ❑Individual Components Location Address or Lot No. / / 7 /1� ��� 1Cl Owner's Name,Address,and Tel.No. rV Assessor's Map/Parcel �_,Tl t�� ,/ ,,- 54;-n e Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /COoe. k",-"qve � c &/W 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) 40 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 applicable) C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued this Board alth. Sign by Date Application Approved by ® Date Application Disapproved by: Date for the following reasons Permit No. Date Issuedtuu No. Fee —..,,,,,,, - _ � \ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I - Vs PUBLIC HEALTH DIVISION.- TOWN OF BARNSTABLE, MASSACHUSETTS .� 01pprication for Dioogal *pgtem Congtruction permit Application for a Permit to Construct O RepaSr O Upgrade O Abon�) LJ/Complete Systt�ems❑Individual Components `+ Location Address or Lot No. / / J�? �9 I(/r Owner's Name,Address,and Tel.No. Assessor's Map/Parcel I Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /I O 5" 16-(14 LIE-l C ( /*I r1 Cc 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 of Repairs or Alterations(Answer when applicable) e 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 f` Compliance has been issued by this Board f-H alth. Sign Date Application Approved by o Date j F Application Disapproved by: v Date for the following reasons f Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS - Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by ,-e-q,iG at ���� Garr�iq eq/� has been constructed i acc rdance with the provisions of Tit�}5 and the for Disposal System Construction Permit No. "' dated Installer Designer #bedrooms .3 Approved design flow gpd The issuance of this permits 11 of be con trued as a guarantee that the sy I I,v I I III n a de'gned. Date (p to Inspect No �2U Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS X'gpo5al *pgtem Congtruction permit Permission is hereby granted to Construct ( ) Repair ( �) Upgrade Abandon ( ) System located at GG/�/g Jar. `/� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: C nstru i 1711 be completed within three years of the date of this pe 't. Date Approved by 1 t TRANS. NO.: CITY/TOWN: Ccc1S �p� APPLICANT: \�c�2�•�Ir,`,, �2�C�c�Q� ADDRESS: 1 -�-9 Mccc-\"!��, Xx\ve . DESIGN FLOW: `u30 gpd REVIEWED BY: DATE: N/A OK NO Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 l CMR 15.220(4)(u)]. �/ Locus Provided [310 CMR 15.2204(t)] t/ Plan proper scale? (1"=40' for plot plans, 1"= 20' or fewer for / components) [310 CMR 15.220(4)] V Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways, parking areas etc.) / [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(0] daily flow ,/ septic tank bapacity(required and provided) t/ soil absorption system (required and provided) whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] Existing and proposed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] Location and date of percolation tests (performed at proper / elevation?) [310 CMR 15.220(4)(1)] V Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator [310 CMR 15.220(4)(j)] Observed and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] Address CA-3 1\n8i —Xm � - ��u1,- Sheet 1 of N/A OK NO Location of every water supply, public and private, [310.CMR 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply within 250 feet of the proposed system location in the case vll within 150 feet of the proposed system location in the case of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system / components and the bottom of the SAS [310 CMR15.220(4)(o)] ✓ Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor (required if construction ✓ activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(q)] Materials specifications noted? [various sections of 310 CMR / 15.000] V Sys em components not> 36" deep (unle Local Upgrade Approval r LUA requested) [310 CMR 15. Address 39- ov Sheet 2 of 7 N/A OK NO Nk' �. ..P ✓ `„� " tdfl a,R.,- -d.>d.54 Size OK? [310 CMR 15.223(1)] V , I4 Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR ✓ =' 15.228(1)] Separation between inlet and outlet tees (no less than liquid / depth) [310 CMR 15.227(2)] �/ Inlet/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for V/ upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two for systems >1000 gpd [310 CMR 15.228(2)] All. at-grade covers secured to unauthorized access? [3.1.0.CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.211] VIn1hCompa rtnentTapks...1411111 Required when other than single-family dwelling or flow>1000 gpd [310 CMR 15.223(1)(b)] t/ First compartment 200% daily flow; Second compartment 100% </ daily flow [310 CMR 15.224(2) and (3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address tIC1C ('�� — Cp- -"j i Sheet 3 of 7 N/A OK NO BUIID°INGS Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.211(1)[1]) Cleanouts required/provided ? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches / and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] V Siphon problem/(leachfield below pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller / than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) v M,3Y Stable compacted base [310 CMR 15.221(2) and 3.10 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 ✓ CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(01 Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(e)] Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] MW Capacity(emergency storage above working=design flow)? [310 CMR 231(2)] l/ Proper setbacks [310 CMR 15.211 (same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? ✓ Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and (8)] Stable Compacted Base [310 CMR 15.221(2)] 1/ Buoyancy calculations needed ? Provided? [310 CMR 15.221(8)] Address '1 �1(1Q.�5�� — Cj Sheet 4 of 7 f N/A OK NO Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] ✓ Aggregate specified as double washed [310 CMR 15.247(2)] t/ System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] .... r.:,v�x:.,-...«.� ..».c c,.N...,�:u. ,:.,a te+�..:7a.,.�:�r��,._.., s >..ex.,»„3:r.�s«raw,s� .... ,.,, ...::..�..:a.,:w•a��.•a,3.�5�;:z&' x_.,..,.��i '.,..,r„+?i.� rYw ,.,. .z w�u Chambers and Gal. in trench configuration supplied with inlet ✓ v every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole (if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate P minimum- 4' maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR ].5.253(6)] _ Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)] 100 feet - maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document] t/ BED SAS (Maxmunize of'bed orsfield 5000gpd) 2: .w . minimum 2 distribution lines [310 CMR 15.252(2)(a)] l/ Maximum separation between lines 6' [310 CM RI5.252(2)(d)] , Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)] Separation between beds 10' minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only [310 CMR 15.252(2)(i)] Address Sheet 5 of 7 N/A OK NO DIDTEPhAANN�OE�,,�. g IXra���� . Pressure Dosed System. ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] Construction in fill - Did the plan specify that the fill shall meet . ✓ the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document] f/ Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] �� Check DEP Approval letters for credits and design conditions ✓ If used with pressure dosing do not allow pressure discharge (/ to scour soil interface OM Was zx�,a:' 4 x�xr � k. psi sX, ;max s z as x'. e ax S"1f'ffi` .,✓ ,r y ,�ltern�°ata�ve Sep�ic� Was DEP Approval Letter provided and/or have you V,_ reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? . Is there a note.on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance v manual? Has applicant submitted a copy of a maintenance Variances y .x6 . — ,.meµ Are the variances listed on the plan? [310 CMR 15.220 / (4)(q)] RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.4141 Address "1�_ p t C"��_—Gj)U t"1 Sheet 6 of 7 N/A OK NO Is the system in a Designated Nitrogen Sensitive Area (Zone H for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR / 15.216(1)] � � � Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] r- r Address M O ff S �(\C ��'i� � Cd I� �� Sheet 7 of 7 Town of Barnstable IME Tph� Regulatory Services Thomas F. Geiler, Director BARNSTABLE, Public Health Division - 9 MASS. `bArF03 Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 6 Sewage Permit# Assessor's Map/Parcel Installer & Designer Certification Form Designer: ccc"rle-n Ish Installer: S acC °� Address: 11 t cosh ��- Address: Ec\n e, z(z\ On (S off,L- -_VC© ��5 �XC A��b�� was issued a permit to install a (date) (installer) septic system at '�`��t t4C�CC k<-, !:�)Q Ccrju 17 based on a design drawn by (addr )CC'KI)CQC) dated _ (designer) ZXI certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State &Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if requius� inspected and the soils were found satisfactory. �' t a .a rJ? CA ' a ; (Installer's Signature) ' LCr's (D �g tune) (Affix np Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification forn.doc DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency,% ravel o- o .o'P23 in All v DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% el a- L'o Ci KCA scrok •6� DEEP OBSERVATION HOLE(LOG Hole# Depth from. Soil Horizon Soil Texture Soil Color Soil Other Surface(in.).. (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten Flood Insurance Rate Man: Above 500 year flood boundary No— Yes ` Within 500 year boundary No t' Yes Within 100 year flood boundary No,_, Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio s material exist in all areas observed throughout the area proposed for the soil absorption.system? If not,what is the depth of naturally occurring pervious material?,,_,,,. Certification I certify that on Q (date)I have passed the soil evaluator,examination approved by the Department of En 'ron 1 Protection and that the above analysis was performed by me consistent with the required tr nip exp rti a experience described in 310 CMR 15.017. Signature Date ac3—i b Q.WEF 0PERCFORM.DOC P Town of Barnstable P# 113017 Department of Regulatory Services Public,Health Division Date -? 7 ° MASS.10q. h�e� 200 Main'Street,Hyannis MA 026d1 Date Scheduled D r/ Time Fee Pd. w So Suitabili . Assessment for Sewage isposal Performed By: Witnessed By: A VI �/• G� LOCATION& GENERAL INFORMATION Location Address I,ii' ,»�� Owner's Name TIMO �Tv% Address 'Sc1Y)e Assessor's Map/Parcel: A/ I f& Engineer's Name \ '�9l1',14Vw�Y NEW CONSTRUCTION REPAIR Telephone# -qq A— `Eq Land Use 0,9,i AcrA a-\ Slopes(4'0) 07c Surface Stones Distances from: Open Water Body 1 ft Possible Wet Area_*:i—ft Drinking Water Well _4A—ft Drainage Way tJ ` ft Property Line Q 5_ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlandRn proximity toaholes) M, (p''. " Z Parent material(geologic) NA-i_J� Depth to Bedrock Depth to Groundwater. Standing Water in Hole:Nbr-le— 15bS• Weeping from Pit Face Estimated Seasonal High Groundwater �� "t." CIS494S DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed handing in obs.hole: __— in, Depth to soil mottles: In, Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level , Adl.factor _ Adj.Groundwater Level ,,o PERCOLATION TEST Date.8 1_) Thne 11..�-D� Observation .v�y Hole# Time at h" ' Depth of Perc Time at 6" � Start Pre-soak Time @ �o _ Time(V-61 End Pre-soak1 ;O 4°•fin _ . Rate Min./InchM r Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) 7 Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC TOWN OF BARNS'T'ABLE LOCATION /7f C ll-;,4� d r SEWAGE# 2-010 3 o ✓VILLAGE e grew ASSESSOR'S MAP&PARCEL 02 - t/g INSTALLER'S NAME&PHONE NO. �0,1Y j6e'a� ,� fl'74,1� SEPTIC TANK CAPACITY % LEACHING FACILITY:(type) sG® r,"&1 (size) / 07 3 NO.OF BEDROOMS ! OWNER PERMIT DATE: t( 0 COMPLIANCE DATE: a 0 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- 6�r4� e d 0 0 0 . e� to ILA CID CA ,t � COMMONWEALTH OF MASSACHUSETT� CO S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI DEPARTMENT OF ENVIRONMENTAL FOR OI C N �4 A ONE WINTER STREET. BOSTON. MA 02108 617-292 . 3 41V WILLIAM F.WELD Governor TpWy 6 199 TRUDY COXE yFpFBgA 8 '�/ Secretan ARGEO PAUL CELLUCCI (TypN�TgB 0 Lt.Governor DjkVID B.STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F FP if Commissioner PART A ` CERTIFICATION 9 Property Address: 179 Mooring Dr. Cotuit, MA Address of Owner: Suzanne L. Hatch Date of Inspection: 11/17/9 7 (If different) Name of Inspector: � 880 Washington St. uie1y Holliston MA 01746 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Environmental Rec1am3tirn, Inc_. Mailing Address: gr,X 5 h Wat n i t , IvW (�5 Telephone Number: CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X,NPasses _ Conditionally Passes — Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: 11/2 7/9 7 The System Inspector shall submit a copy of i inspection report to the Approving Authoritywithin thi ) days of inspection. If the system is a shred system or has a design flow of 10,000 gpd or greater, the inspector and rty Othe systemc owner tshallhis submit a the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent.to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: + X I have not found any information which indicates that the system violates any of the failure criteria as defined in 314)CMR 15.303. Any failure criteria not evaluated are indicated below, COMMENTS: BI 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:iealth, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, Unless the owner or operator has provided the system inspector %with a copy of a Certificate of Compliance (attached) indicating !hat the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally t:rsa;nd, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass iospecnon if the existing ;critic tank is replaced with a conforming septic tank as approved by the Board of Health. (revimed 04/25/97) Page 1 0! 10 DEP on the World Wide Web: htt wwww.magnet.state.ma.UWdep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 179 Mooring Dr. Owner: Hatch Date of Inspection: 11/17/9 7 B] SYSTEM CONDITIONALLY PASSES (continued) T Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) oir due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 CJ 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply wedl. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Ct' CERTIFICATION (continued) Property Address: 179 mooring Dr. Owner: Hatch Date of Inspection: 11/17/97 D] SYSTEM FAILS: N/A You must indicate ear-er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). \!„mber of times pumped _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: N/A You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ,w Property Address: 179 Mowing D r. Owner: Hatch Date of Inspection: 11/17/9 7 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No - Pumping information was provided by the owner, occupant, or Board of Health. X _ 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. X _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. J, _ The site was inspected for signs of breakout. _1L _ All system components, excluding the Soil Absorption System, have been located on the site. X _ 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. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. X _ Existing information. Ex. Plan at B.O.H. —A Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 179 Mooring Dr. Owner: Hatch Date of Inspection: 11/17/9 7 RESIDENTIAL: FLOW CONDITIONS Design flow:—QEQ—g,p,d./bedroom for S.A.S. Number of bedrooms:_ Number of current residents: ? Garbage grinder (yes or no): n Laundry connected to system (yes or no): V Seasonal use (yes or no):,, Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):n Last date of occupancy:1,,,�,f COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow: gallons/dav Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no) —' Water meter readings, if available.- — Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)— If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Yyr 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 11/05/79 BOH Sewage odors detected when arriving at the site: (yes or no) NO (rwisad 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 179 Mooring D t:. Owner: Hat C h Date of Insp ection: p ction: 11 17 97 BUILDING SEWER: N/A (Locate on site plan) �- Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: 2 feet Material of construction: X concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance —(Yes/No) Dimensions: 1, 000 gal . Sludge depth Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: n�_ — inches 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 dimensions were determined: m mJra8 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to integrity, evidence of leakage, etc.) outlet invert, structural GREASE TRAP: N/A (locate on site plan) _ Depth below grade: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation integrity, evidence of leakage, etc.) to outlet invert, structural (revised 04/25/97) Page 6 o1 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ( 77 SYSTEM INFORMATION (continued) Property Address: 179 Mooring Dr. Owner: Hatch • Date of Inspection: 11/17/9 7 TIGHT OR HOLDING TANK:N/A (Tank must be pumped prior to, or 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/day Alarm level:__Alarm in working order Yes; No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryov r, ev(den a of leakage into or out of box, etc.) Tkel) The box has no sigm o solid`s PUMP CHAMBER:�A. (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION (continued) Property Address: 179 NOOring Dr. Owner: Hatch Date of Inspection: 11/1.7/9 7 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: Type: leaching pits, number: 1 leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length:�_ leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: _NSA (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, etc.) PRIVY:— A (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page B of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) �Roi �� (rwisad 04/25/97) - Paqu 9 of 10 ,1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) v Property Address: 179 Mooring Dr. Owner: Hatch Date of Inspection: 11/17/9 7 Depth to Groundwater 20feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from loc31 conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers X Use USGS Data Desalbc in your awn words how you established the High Groundwater Elevation. (Must be completed) USGS data shoes the property to be ih the 20 foot elevation. (rwisod 04/25/97) Page 10-o!_10 I Town of Barnstable Health Department 367 Main Street, Hyannis, MA 02601 Office 508-790-6265 Thomas A. McKean FAX 508-775-3344 O o18f D4gc Health rg Suzanne Hatch 880 Washington Street Holliston, MA 01746 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE U, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 179 Mooring Road, Cotuit was inspected on March 18, 1996 by Christina Kuchinski, Health Inspector for the Town of Barnstable because of a complaint. The following violations of the Town of Barnstable Rental Ordinance Article 51 and the Sanitary Code H were observed: 410.354: Cross metering of electricity from basement apartment to meter#22639583 (3 001 583). You are directed to correct the remaining above listed violations within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, this violation must be corrected regardless of any request for a hearing.. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF TH BOARD OF HEALTH Thomas A. McKean Director of Public Health cc: Jeannette Redding 1 k Mr./Mrs: g�-v NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE,ARTICLE 51 The property owned by you located at 1-)4 r"` 7 was inspected on 3/W- 06 t"4 by CJM W I fU Health Agent for the Town of Barnstable because of a complaint. The following violations of the Town of Barnstable Rental Ordinance Article 51 and the Sanitary Code II were observed: 910. 3 5V h� as G 39 You are directed to correct the violation of within 24 hours of receipt of this notice by You are also directed to correct the remaining above listed violations within seven (7) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. Enclosed are citation numbers due to violations observed on PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health Town of Barnstable 4y.� 1 r •,-.'VMt+..i+--•. a. - •r�.r -u. ..n 'n- •i �- K• •..�r . MY �' •s r. . ...c. w • r -•. ... - 'I,V - •. FoRM3o Hosas&WARREN,INC.NOV.1979-1983 THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH CITYITOWN r DEPARTMENT 26 ) ADDRESS (' TELEPHONE b Address 4�/f�-� I)VI t 00 cupant . - � (h Floor Apartment No: No,of Occupants—Al, (� No.of Habitable Rooms No.Sleeping Rooms ,a.._ No.dwelling or rooming units No.Stories Name and address of owner h! /°f /�, 0 J�a�A I �In � t f IU 11-1 r Uh Remarks Reg. Vlo. YARD Out Bld s.:CFences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: 1No _ 'k-&�( 4 "oo-,6',i*Yi ❑ 110 ❑ 220 Fusing,Grnd.: n n G�.t Via,q r AMP: Gen.Cond. Distrib. Box: , , ,s•lt�f / Gen. Basement Wiring: DWELLING UNIT�' //)0/ VentiL L to . Outlets Walls Ceils. Wind. I Doors Floors Locks Kitchen Bathroom Pantry Den V Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks,Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facll. Vent.,Plumb.,Sanit'n.: Wash Basin Shower or Tub: Infestation Rats, Mice,Roaches or Other: E ress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY_" INSPECTOR � •f� / ' TITLE r fi 0I)DATE -3 /Q TIME / P•M� A.M. I THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this. category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to -meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required •by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition.as required by 105 CMR 410.150(A)(1) and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 4110.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 which results in any accumulation of garbage', rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or - spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or dafety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical, wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions:_ (1) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating,, gas-fitting, or electrical wiring standards that do not create an immediate hazard. .(4)_ failure to maintain a safe handrail or .protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board of health. I 9 wComplete SENDER: ems 1 and/or 2 for additional services. 1 also wish to receive the w ■Complete items 3,4a,and 4b. following services(for an y ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. a; > •Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address 2 0 permit. d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery fn ■The Return Receipt will show to whom the article was delivered and the date o delivered. Consult postmaster for fee. 0 0 3:iArticle ddressed to: 4a.Article Number J m E `J���UV 4b.Service Type 0 ' / ❑ Registered ® Certified ¢ �y // Im W O ❑ Express Mail ❑ Insured S N C ❑ Retum Receipt for Merchandise ❑ COD a �� J �-,• 7.Date of Deliveryw � � Z > 2- �� m, 5.Received By:(Pent Name) 8.A 'ijressee's Address(Only if requested Lu S and fee is paid) t 6.Signatur (Addressee or Agent) ~ 0 iiii lfifti i X IIIiii flil fitlif if it l PS Form 3811, December 1994 Domestic Return Receipt ' I UNITED STATES POSTAL SERVICE First-Class MailPostage&Fees Paid USPS Permit No.G-10 • Print your name, address, and ZIP Code in this box • I Health Department >, Town of Ba P0.Box 534rnstable Hyannis,Massachmb am Fax(508)775-3344 Phone(508)790-6265 a 1; z -548. .651 061 Receipt for Certified Mail No Insurance Coverage Provided WIRED STATES Do not use for International Mail VOSTAL SERVICE (Spa Reverse) M Sen;to o) o) Z Stre t and No. 2 � .,Sate IP o a O U Go ostage � ^ ECertified Fee V-! O LL Special Delivery Fee a I We"!rti ict`e`d`DIe`I lver'y"Fee• 1A4ttuinn Rece`ip`1t St%WIhd' to Whom&Date Delivered Return Receipt Sh to Date,and Addre - TOTAL Postag &Fees Q Postmark or ((�� �)7Y USpc' STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address Sri leaving the.receipt,attached and present the article at a post office service window or hand it to youprural carner,.�lndextra charge). Q) I 2 ,you do not wafit thin eceipt postmarked,stick the gummed stub to the right of the return tadddresnfAbee artit�clleeldate detach and retain the receipt,and mail the article. rn 3•f Y�wanT eZurn receipt,write the certified mail number and your name and address on a 2 return receipt card,FoIgn A1,and attach it to the front of the article by means of the gummed Co ends if space permitsPQfh rAse,affix to back of article.Endorse front of article RETURN RECEIPT FEE U¢ EST, b`a-q'ja-cen4 to the number. O 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee, 00 endorse RESTRICTED DELIVERY on the front of the article. + E 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If. t10 return receipt is requested,check the applicable blocks in item 1 of Form 3811. to 0 6. Sa.e this receipt and yr�sgw it-if you make inquiry. 105603-93-B-0218 SEES SEES■MEN ®■■ ■■■I■ ■■ ■■ ■SS■■■ ■■■ M■■■■■ ®■■® ® ■ �■ ®■ SEES■■ ■■ ■■ ME■■■M■ ■■ ■■ ■■■■E■■■■ SEES ■MOM ■■ No OMEN , , , t : , ■ ■ ■■ Ste■ IINS■ NN ■■ ■■ I■■■■■ ■■■ MSS■we� ° ■■ ■■ ■■■ ■■E■■■ ■■■® ■ ®■® ■® SEENo 0 ■S ■ ■ ■ SEES MENEMEMS ■■ ■ ■ONES ■ I® ■ Mil■■I MESS■■ ■ ■■■ ■ ,��. ■ i■ �® ■l11�■■I SEES■■■ SEES ■■ ■ ■ ■Sfl ■! ®■■�■■M ME No ®SEES ■■■ ■ `a' ��■■_ �■■' ,:w.._�� ! ■■■■■ ®SEES ■EFL■■ iI �1l ! ■ ■ ` ■■■■MEMO ME mom MENNEN MEN 2 , ON SE so ES■■■ ■■■ ■ ■■ ■■■ ■M IW■■ ■ ■ � MEIN 1■■ 0 ■■ !■■■■■■■■■■ SEES■■■ ■■■■■l . ■ m A■ ■■■■■■ME WMEREMEMOM ■■ ■■ ■ME ME as EMMONS ME M ■■■ ®■ ■ �■■■■ ■■■■■■■■■ M ■MESS■■ ® SL ■ ■ ■■■ '�E■® ►■ ■®■'■■■■■MEM ■ ■ ■._ ■■ IF, MOONS■■■■■ IN ■ ■■ ■■ iM M■■ SEE■■MMS ® ■■ on ■■ SEES■MOONS ®SEES ■SEEMS No ■■■ ■ ■■so 0 ME so ■■■■ ■ EM MMMEMM■■■■N ■mom■■ ME SEES MMMM■M■M■■ME■EM■■■MM M■ SEES■■■ ®■■■■■ESE■ ME■M■■■■■ ■M ■■■■E■■ ■■MEM■■M■■■ M■MEE ■ No ■MEMO INNESSEEM MEN ommos9ommmmmmomms 0 MENOMONEE mommmonolmimmoomm mom immmmomommsommmmmmimm M m NNE 0 M NNE MMMMMENEEM mmomom ONEEM MOM 0 0 NNE mmmom No MOM No MENOMONN MENOMONEE M MEN M MEN mom MEMNON M ME 0 mommmommmomommmm MMENEMENSEEM mommommommom CC mommoommo0:C'.'.:�'.:C:C'C:'.0 C:' �OC�CC: .C:�EC:C�mmmm�.CC �C C'� ■. C i �e Adm.. i . _ irke t ■��Cmi �MEMEME ii�uSEM�i■�iEENEMii�■iio Page 1 of 1 _ 3Z zo . f 1029 3 a � f http://www.town.bamstable.ma.us/sketchesll/1400_1445.jpg 6/6/2011 L' O CAT ION � SEWAC, E PERMI No. { /A§ VILLAGE o :LIZ z� Q I N S T A LL R'S NAME 6 DDRES f R U I L 0 E R OR OWNS DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 4 d �o 4 - i 's f. No. Yr^�s....�?d..�.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH .............O F... . Appliration for Bhipooal Works Tomitrurtion ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syste%at: nAddre .. . .. Lot No.......................................... Owne l ress a ....................................... .. ............-----•---•--.......................... Installer Address d Type of Building Size Lot�_. ______Sq. feet U Dwelling—No. of Bedrooms._.______ Expansion A tic ( ) Garbage Grinder ( ) pa, Other—Type of Building..._ _ __. ...._ No. of persons.......... ................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------f-/.. _ W Design Flow........ .....................gallons per person per day. Total daily flow---- r GO........................gallons. WSeptic Tank—Liquid capacity/". ..gallons.gallons Length 7.! .AV ... Width..__V_... Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------/----------- Diameter..... .f.__..__. Depth below inlet.7` .._. Total leaching area � _sq. ft. Z Other Distribution box Dosing ( ) ~' Percolation Test Results Performed by..... �•_____ ______ ____ ________________ ate..- �'z _._._..____ ,6i . Test Pit No. l................minutes per>nch Depth of Test Pit.................... Depth to ground Ovate ___.............. f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-A �+ -------------'------------------•--•-----•------.....--•---•--------..._......-•----••-•••......--••.........................................................O Description of Soil................................................... ------- - x V --••------------------------------------•-.----------------------•----------------- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... --'-----•-----------------"--------------------------'-------------------------'-----------.......--'--••----------------------------'----'•--•--------'--"--•---•-••--•-•--•-•----•-•.....--••-.--••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The unde igned further agrees not to place the system in operation until a Certificate of Compliance has been ' ed by the rd health. Signed., - / -------•-----------•- Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons-------------'---'--------------------------------------------'------------------•-'-"--'-'-'--'-------......•-- ...•--...--•-----•---•----•--•---•-----'---•-•-•-•---•--'•-•------•---•-•....-'•-•.....................•---•--•-•-•------•--•--•••-••-•-----•--••••.'--"--•-•- --------"---'---------'---•'------•••- Permit No........... .. Issued_.��-- / _..... .-_ •��---------------------ate...._. Date No )1712 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------....OF... > - !£+'ram ----------- . ,� rl r ti�an for Uiipn,sal Works Towitrnrtinn ramit Application is hereby made for a Permit to Construct X or Repair ( ) an Individual Sewage Disposal System at_._ .._. /1 .... Location Address /. .. .. .......... ..... ..............._ Lo t No ...... ..............._..._.`,........,..... ................= •-••-•-•.._..---•-••-- -•••-.........~.......-•-•-------•-•--......_��....... ........._...... f Owner. /Z�4�::�AKe2L a -'lip.2:✓1 f�L fl�ff � ../�..... .ress............................................... Installer Address Type of Building Size Lot_ /-� �.___._Sq. feet Dwelling—No. of Bedrooms.......... ...........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building,/ ........!�..... No. of persons.........15/............. Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------•--•-•-----•-•-------•--•••••--------••--------•---••-••-•-...------•--•-•-----.._.....-------- W Design Flow________;_'��..._____.I_______________gallons per person per day. Total daily flow__..___<' _/_')__.______.._______._-_._gallons. WSeptic Tank—Liquid capacity t! gallons Length_ f✓f`. Width_l �/f! Diameter________________ Depth................ x Disposal Trench—No. __..:`?'_____________ Width.................... Total Length_______.._..__�__ Total leaching area....................sq. ft. 3 Seepage Pit No-------/......_____-Diameter___..._......... Depth below inlet_,7_:2_______ Total leaching area... ft. Z Other Distribution box (,/) _ Dosing tank ( ) a Percolation Test Results Performed by-...... .___"' Date_._. a Test Pit No. 1................minutes per inch Depth of Test Pit__________,_________ Depth to ground water .--- (T4 Test Pit No. 2................mmutes_ )er inch..='Depth of Test Pit.................... Depth to ground water_,�:t'./f__._______. W _. ,.r ------------------------------------------------•-•-----------••----------....-•---.......--•-----..__.._..----------.......-------•----•---•---•-----_----- Description of Soil______________________________ x =-------•-- ----- U -------------------------- ----------- •-------- --------------------- .....� .�! - - - - ....--.... W UNature of Repairs or Alterations—Answer when applicable. -•--------------------•--...--•-------------.•..------------•-•--------•--•--•-----._......----------•--•--•------------------------------•-------------------•---------------------._....-•--•-•-----. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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 t-hee`board�of health: Signed..... .7 Date ApplicationApproved By................................................................................ q Date Application Disapproved for the following reasons___________________________________ =--------------- ..... ........................................... ---------------------•-------------•.............................................. f -------••'=2= Date PermitNo......................................................... Issued Date THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH 4 C1 0_�* / 1!.......................OF...... Tntifirate of Toutplittnrr THIS IS TO CERTI r Y, That the Individual Sewage Disposal System constructed or Repaired ( ) :-----•-----------------------------•------.................................................. __^I ff �/ 1 T ! i{� Installer at = =/S R�(r, >l t'-•---...-----•--• ----------------------------- -------------------------- has been installed in accordance with,-de provisions of U_t f The State SanitaryCode as d'escrib d in the application for Disposal Works Construction Permit No __"��____________ dated _:�`-��._�__'__7�____........... THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............1 >.. :.`7. --•--- Irispectoi'..... __ l''( --------------- •...._._....------...............•-•____. THE COMMONWEALTH/OF MASSACHUSETTS � BOARD OF HEALTH I �► !{✓/'�dL�..........:....OF....... Q.//s....................r .__....._._..._....__......-..... �"� FEE:._=3(��.r Disposal, Workiiinn trnrtUan rrutit Permission is hereby granted.-- ...................." ...= to Construct ( ) orrRepait ( ) ari Individual Sewage Disposal System !,,/ at No------- --- ---- -1 ' .Ae =Ti = �' --•---------------- Street `.. 7`��,� as shown on the application for Disposal Works Construction Per ,_____.___ Dat d_ — 7- . _____._.... - Boa ' ... � �:... ;' Board of ealt DATE / --: --•----------- ---------------------------••--- FORM 1255 HOSES &WARREN• INC., PUBLISHERS T Tor 4 rC r E,c�v .vt E ✓a� °e�4t• d c r V IS T C3 o x �, `► " + 1 ` ` : j!! .r » .�--"r•.---w.`.i---- '•,---•A-- 'fir•_a '��'''°'''�''` .. { '7-. „ .� � r r -r .firs Q 4Wr tee+ %$� „ LGrr�Glf�lw} P{T + i►• - .��".�t G/J C.QI TERlr4 4WA*VpV AV T, 7 wry . •', :�,: r�/��'1,1i`�st t C .>��t"'�{'`/c�,'<'�T X•2' `•- --1�7��,L.1 s a� !✓ •.� �• � - k - * f^ r"r.' �7.,5 r..s�s^} •,� ... ♦CL:�� ��� / , f ,r _ ti�1 �-C,w !C: - r �/FrG'SR, f, aw ' a j: �, • a 4 s . /1 ir 5It 5, ��'}ICc�o s�O ��•ks� ��.s`►c+.s�� S ff�T� d , AAS t r /,1 -.- �� �CaTUjTJ 1 /��GC•IGtTE �': __ .� ,�J, �✓ J ,�•' I , /t, l � Si�/'1L•Er � 3G� L��TE.' ,,r,.- :� ^, r ; 4w a�ER: Tif/�O GG�IJb`l�Q. CO,t2� Se Y, �';v► k,orra. r �,., � :p• Lam`L I"� NP'J �i�1 �/ • RSRC- $. yA�Ma vr�� Ada s 3. 12105 ` 3- . ;� 4 orJ 1JO if MA A.) 6,eo SS M4 nl, P E, POINT IZ CjA.0 *NOTE: ALL PIES ARE TO BE 4' SCHEDULE 40 P:V:C. VENT PIPE(O Least 24 Inches tal) 1W min. tom Sche"40 PVC w/charcod Odor Filter � Existing Foundation - [;-11se to septic tankCHAMM tw*coven; rims be cow r he cover awd GRADE TOP OF FOUNDATION - ELEV. 100.00 (A--mea) 6 In.of*ddwd Waft wry 6"OF Few GRADEf Cra&aw Smile To*-95AGI 3 HOLE H-26 Grade am D-8oa-97.Oo over SAS-97.40 SECTION A A _� PROFILE FIEW OF MACHM0 SYSTRIlt `# �s 11 to 21- EXIST. S=Qdti or Aneew 3 tiim�a�m+Corer Tap OF Systa -•'Flew-M-7$ h" i/ Ar—#A-wee"Paofto 0 1,000 GAL +'e.r r aw.�w.a or..ua aae. r € +. ,. .. 5= " �+ ['.iWBr!1?{bt tie FtIDlI arst rourtlna6rt o, SEPTIC TANK n t rsGwa 6 d to g►ede Hg ' CONCREIE SAL ! m "Al 9O .., s, SYSTEM PROFILE 6 s/ 4, ,�. C3 - a E3 C3 ca C3 p p! Not to Scare ti a tb+fts a 85'= 17' GENERAL NOTES ' JrI. >t 1. Contractor is responsible for digsofe notification, Verification of Utilities NOTE. ALL COMPONENTS MUST HAVE RIMS TO YATFI�i 6' BELOW GRADE ti 3/rt 9 t/r : and protection of all underground utilities and pipes. Effec#ivwr Ler4rth �atone m 2. lThe evel an septic ton 3onj d'tst 1/2"cation box shall be set r� �-� Dote of PercolationSOIL ARMPTION SYSTEM (SAS>ation Test- AUGUST 11, 2010 3. Backfill should be clean sand or gravel with no ,PEl�C Test Permed By. CARMEN E. SHAY. R.S., C.S.E. Bottom of Test Hole i Lies_= 84 00 500 - C W-20 LEACHING LN41TS ! ACME PRECAST stones over 3" in size. Results Witnessed By. DAVID STANTON (BARNSTABLE B(XI) _ 4. This system is subject to inspection during installation EXCAVATOR- Shay Env. Svcs. Groundwater observed - NONE Not to Scale by Carmen E. Shay - Environmental Services, Inc. Percolation Rate: LESS THAN 2 MPI O 42" 5. The contractor shall install We system in accordance with Title V of the Mossochusett state code, the approved plan Test Hole Test Hole and Local Regulations_ No. 1 No. VARIANCE REQUEST: 6. if, during installation the collitraptor bacounters any DEPTH SOLS a". DEPTH SOILS a". 1. REQUEST TO INSTALL SAS MORE THAN 3 FEET BELOW GRADE soil conditions or site cot soi that are different D 97.00 o 97.00 from those shown on ate soil #+og or in our design A VENT PIPE HAS BEEN PROVIDED installation must halt & immediate notification be made to Carmen E. Shay - Environmental Services. Inc. FILL7. No vehicle ow heavy eery shall drive over the -i 17 ao septic system! unlessas H-20 septic compot ft. Ap y ,g 8- Install Tuf--rAe gas or equals on all outlet ends. Sarrd 10 VR 3/2 9. All Distribution Lines shall be 4" diameter Sched 40 NSF PVC pipes. 10 rR s^io An S.50`- 3Y ee 4.33 12"— is 10. All solid .piping, tees & fittings shall be 4" d'1. afar Schedule 40 NSF PVC pipes with water tightLoonl nts. Mad Y 11. Municipal Water is Connected to ALL OF The'Residence and Abutting Sand 10 IR 6 fs _------ 12 L� Properties Within 150 Feet. 32`-15s' c, 00 18"- 42' Srt 50 -"` - --- _ LOT #100 THE PROPERTY LINES ARE APPROXIMATE AND , Mad. i _ 20,000 Sgtson-e Feet + - COMPILED FROM ME SURVEY PLAN BY NORt W GROSSMAN, ENTITLED SandI'erc Ida �� - FOUNDATION LOCATION PLAN OF LOT #100 SING DRIVE, OMIT, MA _ _ DATED DUNE 30, 1979 Depth at Pere: 42 to 60 J AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN 42"-120: � #33.oD Perc Rate= G'2 MF� � � `��1�i Groundwater Not Observed ! TEST HOLE #1 No Observed ESHWT 0 1S IT SHOULD BE USED FOR NO PURPOSE OTHER THAN ELEV ADJUSTED H2O Elev. None f .= 97.00 THE SEPTIC SYSTEM INSTALLATION. i 11.25 E�STING EXISTING LEACH PIT TO BE PUMPED OUT AND FILLED IN PLACE. ' ALL Wan PIFIES FIRM 1HE I xv' �� NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE DISMOUTION tY ppygq s .-- \. '"�°• "SHALL� � 1 -�•- * � '� ♦ FROM THE LEACH PIT TO BE DISPOSED f> -:rs k�r z, i .E f^=� OF AS PER BOAl?Q OF HEALTH SPECIFICATIONS. KNOCKOUTST ST HOLE #2 D-E3ox t 96 i'' I I ♦♦ i• DUAET , W MET l".= 97-00 ,,-%�``-' ` s ♦` THERE ARE NO D5 ARE PRESENT WITHIN 200' OF THE PROPERTY LOT ,#99 r i � � ♦� ASSESSORS MAP 24, PARCEL 118 -i7s- % Failed ' r t '�� LOT #101 L E G E IN D PLAN SECTION CROSS-SECTION Leach Pit � + • DENOTES PROPOSED 3 HOLE H-20 DISTRIBUTION BOX PROJECT BEN+Ci4 MARK �*�, `. 5 _�' 1� DECK i 15Q i a `,�____ 1�4X1 SPOT GRADE t>i-tttw ItlUiIaES TOP OF FOUNDATION � t `� ELEV. 100.00 (Assumes() -- ' + �� vi- + DENOTES EXISTING g = `- ____'- ♦ a I X 104.46 =: - -. __ _.. tr:-. :�; _... ♦ ` `�♦`� SPOT GLADE DECK EXIST, PL PROPERTY ERNE 1000 gal p Septic funk I 1 T — o .� ik PROPOSED CONTOUR Y 1HE AocEss COVERS FM TIC7tc TANK, i + It # --- --97 EXISTING CONTOUR BOX AM LEACHING COMP Mr EBIS??1YC I I I X SET DMIER THAN 6 ONES SELM FINISHED 7 of w sHAlt trnt�m r 16- 3 BEDROOM I t STEEL_ REINFORCED PRECAST CONCItETE FASSHED MADE. _ -'` HOUSE I � I BEEP TEST HOLE & V1 V11 NAIL nW 7nE GAS tTAFFIES OR Emits -' i ,'� PERCOLATION TEST LOCATION PLANa-sa REIMA8IE COVERS t #179 ,+ � 6 FOOT STOCKADE FENCE T twin.clearance + ♦� I I /r SET 8 awin� r Min.h"to awttlet 0t17IET s Z S—7* L 0 T P LA IN' ' �>,� rY _- f ', r C OPOSE SEPTIC SYSTEM UP ADE � � , e c' ' PREPARED FOR CROSS SECTION END—SECTION ,; T ---- %_` i '-i 98 AT 125.00 # "OORING DrR%IVE 179 M TYPICAL 1000 CALEflI . SEPTIC TANSNEW NOT TO SCALE ! �� QT T, 'Design Calculations i ' I Number of Bedrooms. 3 Bedroom EXISTING i--_ -CB D.H. T ` ♦�. ��H OF PREPARED BY. Garbage Grinder No 2 / T / ,�{7� T 7� �-v lr.C3 �� 1 1' li . tl Leaching Capacity Required: 330L/Day (MIN. PER TITLE a') , FNO 11'l ' C RAC i' `V Cr Vim' 9 �O R E Septic Tank : - 2 x 330 Gal./Day = 660 USE EXIST 1,000 GAL Septic Tank. (40 FOOT RIGHT OF WAY) PIRONYNNTAL SERVICES, INC. SOIL ABSORPTION AREA: using percolation rate of <2 min./inch Bottom Area: 0.70 gat/sq. ft. x 325 sq. ft. = 24s350 gollons © 111 THORNBERRY CIRCLE Sidewalt Area: 0.70 got./sq. ft. x 152 sq. ft. = 112.48 gallons 0 20 40 50 �c ��� f1 ASl'IPEE, MA 02649 Providing: = 3 s298 gallons S to ANITa�0 TEL_/'FAX : 508--539-7966 Use: (2) 500 GALLON H-20 CONCRETE CHAMBERS, WAVING A 2' EFFECTIVE DEPTH, m , (5' W x s.s' L) TO BE USED VATH 4' OF WASHED STONE ON THE SIDES AND SCALE: 1 =20 DRAWN BY: CES DATE: AUGUST 23, 2010 4' OF WASHED STONE ON THE ENDS. SCALE: 1"=20' PROJECT#1187 FILENAME: SD1187PP.DW SHEET 1 OF 1