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0970 FALMOUTH ROAD/RTE 28 - Health
970 FALMOUTH RD., HYANNIS J TOWN OF BARNSTABLE LOCATION q 1Q ����pV �l Clc�'4 u18�� SEWAGE#,Qoo6—SY3 Yla',AGE_ ASSESSOR'S MAP&PARCEL o25-0 033 INSTALLERS NAME&PHONE NO SEPTIC TANK CAPACITY /,000 G m CFact s � G� LEACHING FACILITY:(type)Soo Gstl Cff 2-#-620 (size) 16,5 X /3 NO.OF BEDROOMS oZ OWNER (.JR�� Innenl PERMIT DATE:3eC_ I I a006 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 " w 9� TOWN OF BARNSTABLE y LOCATION 7 I`�L�le�/�Y oP�j SEWAGE # VILLAGE / �/4/r/�'�S ASSESSOR'S MAP LOTSa"®33 N$�f eT® c S ! NAME PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY FvT c /ti sl�l C//sue - LEACHING FACILITY:(type) (size) I, NO.OF BEDROOMS. PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER iC17e /llo /1 DATE D: /A-/ r- ®/ DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No , {A �', i Y �� a � ° .,� S R f TOWN OF BARNSTABLE LOCATIbN `I f=�.L 2 SEWAGE # VILLAGE # ASSESSOR'S MAP & LOT NAME Sz PHONE NO. A & B CAIM 775-6264 "SEPTIC TANK CAPACITY /O-Pr -1,0yk .1 P'7'S LEACHING FACILITY:(type) (size) NO..OF BEDROOMS `* P ATE WELL OR PUBL C WATER BUILDER OR OWNER G DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: S r,67c S 1A.- arc /oA., VARIANCE GRANTED: Yes No � ©, M A R .. [_ v (� /s�T` M1 _ ® @ � � �_. `�. No. , 3'�G(!� U�`-s�����/��� Fee jYe / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION.-TOWN OF BARNSTABLEs MASSACHUSETTS 2pplication for Oigpont *pgtem Con!5trurtion Permit Application for a Permit to Construct( )Repair(p j Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. q h O FAQ rA.IQA. Owner's Name,Address and Tel.No. Assessor's Map/Parcel �' q Fp�a✓►• �Ol $��$" Oa`�/ o?sd/o3 tic, Installer's time,Address,and Tel o Dq n 's Name,Address and Tel.No. Y5a.�cc tlac.c.l r-,e►-r /a h er S-pg-36a-4gaa sob-v�g-s1aF o-9t—arv'ak SNot,.l�c w. CIA Type of Building: Dwelling No.of Bedrooms cZ Lot Size /6 cl" sq.ft. Garbage Grinder(av� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow a Q C> gallons per day. Calculated daily flow gallons. Plan Date //-/ 3-0 6 Number of sheets / Revision Date.' Title Size of Septic Tank 4. 66 E'14 'a/6 Type of S.A.S. 6*00 ct+R?A-8 Ck Description of Soil AS fv- 106 Nature of Repairs or Alterations(Answer when applicable) JA'c m .75 Ln swwl .17,-&X — TO /A// S o0 6Rl, cWg1-1d,0A 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 Certifi Cate of Compliance has be d by this B of t . Sign Date No as o6 Application Approved by Date Application'Disapproved for t e following reaso Permit No. Date issued 4.7 No. a ,'- 7 Fee_' /�/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: •y €n _ Yes PUBLIC HEALTH DIVISION -TOWN OF BARN,STABLES'MASSACHUSETTS pplication for 0 5poot by.5tem Contructton Permit Application fora Perm tao Construct( )Repair( Vjtpgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Al.'te Owner's Name Address and Tel.No. Assessor's Map/Parcel O i A n Scot f Installer's N e,Address,and Tel No. Designer's Name,Address and Tel... No. b �vct. �1�� �1`I ��� �.. -y {i' 5' � D�ae <�. `-1G_ye'� Juu 36 � � CIS CsUle�v,yt ,J C•Si i�aG'.oC Type of Building: H F_ "Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( 10 Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow,, gallons per day. Calculated daily flow : gallons. k Plan Date b YV 3—U 6 Number of sheets i Revision Date Title _ } Size of Se tic Tank / c%uGGj?� Fy,-5T,�16 S �?G�(: tyn� r g" k P Type of S.A.S. H (C t f. Description of Soil As jo n ' p. yR Nature of Repairs or Alterations(Answer when applicable) f��d� � T=/f z"X��e%x/6 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 Certifi- cate of Compliance has bee iss ed by this Board of Health I j Signe . ' 06 XICY ,�tn I% Date .�ifo ,f'�' .20 a6 Application Approved by Application'Disapproved for the following reason Permit No. 2 Date Issued [ t ^P THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired( k)<pgraded( ) Abandoned( ).by S He ed,�,N c at, P�11\I t J_ • has eg ;.constructed in accordance with the provision`:of Title 5 and the for Disposal System Construction Permit No. ated Installer Zrvc.e .hC_cc J75 Designer %rc The issuance of this permit shall not e,co st ed as a guazantee that t e system it u. do as designed. Date 4 Inspecto. r� No. � . /7�� �,,..:!. Fee--11/fl,Z2 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS =tgpo '16p51" Cori5truction Permit } Permission is.'hereby granted to Construct( )Repair( V)Upgrade( )Abandon( ) System located at G 1"rat oA and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. f Provided:Construction m st he completed within three years of the date of this pe Date: Approved by 1 Bk 21548 P59166 -&78014 1 1-24-2i_ 06 a'l 09 2 12a. NOTICE OF DEED RESTRICTION RESIDENTIAL Notice is hereby given of the applicability of the Town of Barnstable Health Department for a deed restriction,to 970 Falmouth Road , shown in Town Assessors Book dated 2006 . Map 250 , parcel 033 . As Deed is recorded at the Barnstable County Registry of Deeds,on the Deed B/ok- 19791 ,Page 14 . As plan of land is recorded at the Barnstable County Registry of Deeds on plan of land entitled "Subdivision Plan of Land in Hyannis—Barnstable—Mass. Belonging to Anna E. Ellis, Scale 1 in. =50 ft. March a 14, 1975 Nelson Bearse-Richard Law, Surveyors Centerville, MA", which plan is duly recorded in Plan Book 293 Page 27 with the Barnstable County Registry of Deeds. a\ r` The engineered plan prepared by Darren M.Meyer R.S. dated November 13,2006 approved by the Health o Department on ,requires a maximum,not to exceed: 0 pq a� (1) the number of bedrooms not to exceed Two (2)- per design restrictions,Title V, Section 15.214,Nitrogen Loading Limitations, Zone 11 Areas of Wellhead Contribution. Wade S.Behlman,Owner Date 970 Falmouth Road,Hyannis,MA 02601 n COMMONWEALTH OF MASSACHUSETTS County On this thoday of i� ,2006,before me the undersigned Notary Public,personally appeared � & tome through satisfacto evidence identity, was/were to be the person(s)whose nameF�) signed on this preceding or attached document,and acknowledged to me that he/she signed it;,vQ� P its stated purpose(s). u °s. ,,� !• - :` 3i>; otary Pub c .:�. .•I 0 My Commission expires 'My CommissionExpir�p��oh BARNSTABLE REGISTRY OF DEEDS Town of Barnstable • Re ulatory Services WAM _ wpernns.- Thomas F. Geder,Di;e for Mm" Pub&Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:508-862-4644 Fax:508-790-6304 Installer cat Designer Certification'Form Date:3c-c• 13.06 Sewage Permit#a,006-S/S Assessor's MaplParcelJSO/033 Designer: �D AIM?_Ea MOY ER Installer: Address: ©'max q8( �Arbc.�c� Address: `$".?orw 2b� On Te c- t ,aoo6 was issued a permit to install a (date) (installer) septic system at '-"t d Fv,l,,.c2 �'ash c n� based on a design drawn by (address) �DRri'cn me-4 r-f dated 1 a- o i-0 6 (designer)_ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank_. I certify that the septic system referenced above was installed with major changes (i.e.greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but.in accordance with State& ocal Regulations. Plan revision or certified as-built o f ow. �N o ,!!,� , R (Installer's Signature) p o ER No. 1140 ,o aISTE��� �W r S�1'MITARI�`� (Designer's Signature) (Affix Designer's Stamp Here) pLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION.CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.THANK YOU. Q:Health/septic/Desiper certification Form 3-26-04.doc 1 Town of Barnstable P# °F Department of Regulatory Services Public Health Division Date KAft I 16 tee$ 200 Main Street,Hyannis MA 02601 ,� l 31 ime Fee Pd, Date Scheduled / ' • =t--- • `oil Suitability Assessyiieat fors _ age Di osal ; Performed By I ' l �"��1 << Witnessed By i LOCATION & GENERAL INFORMATION Location Address'.970 r-Rt Al v U7-H koA-0 owner's Name D&UA ~ 6 / - ! Address 170 a rA-Lp"" �v go ' I Assessor's Map/P�tcel: M'• LS- ' �- ` U 31.3 � \ I t Engineer's Name D Al� -Meye e i 'NEW CONSTRUt'!oN REPAIR X j Telephone# zw, a-`I oxDL D Land Use /1 �� oe/v�A'y "Slopes(%) ! Surface Stones -,All �St�U > ODftY Drinking Water Well >ZSO ft Distances from: Open Water Body, ft Possible Wee Area g r r% Drainage Way �� 'ft Property Line _? 0- it Other /A' ft .SKETCH:($treet name,dimcnsiods of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I C a) ! k A Ln i . . 1 eo Parent material(geologic) t G rn[/ti�(/li I r 1 I Depth to Bedrock I Weeping from PIt.FACe LA— Depth to GroundwaWr.-Standing Water in Hole:' i eep 13 Estimated Seasonal j"igh Groundwater DtT—F. N�`TION FOR SEASONAL HIG]E�WATT R T'A�tiE Method Used: ' ' ln, �'ea►_�to Sall motors;- Jn. Depth (Ibperved standing;in obs.hole: tt, Depth toiweeping from side of obs.hole ! in. Groundwater Adjustment. ! , factor AdJ.�routidwntee];ev!sl.,,,m Index Well# Reading Date index Well level ! Data l3 Thnit _. PERCOLATIOON TEST' Observation / L Timm at910`I. _ .. ....._..� Hole# -�-- S�<< Time at b": "...-----• Depth of Pere Fes-- - Time(9"-6") Start Pre-soak Time.@ End Pre-soak. Rate Min!Inch Site Faileds Additional Testing Needed MN) Site Suitability Assessment: Site Passed .yXe — Original:.Public Heh(th Division Observation Hole Data To Be Completed on Back=--------- of wetland,,yo>i t first notify the ***If percola ion test is to be conducted within 100' n>� Barnstable C . servation Division at least one(1)weik prior to beg g 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 b„ R Low+ $a4 DEtA NIA '_.'4 DEEP OBSERVATION HOLE LOG Hole#Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) LO 20 u .2 l4 V •G. DEEP OBSERVATION HOLE LOG Hole#. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling' (Structure,Stones,Boulders.` nsistenc Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, Flood Insurance Rate Map: Above S00 year flood boundary No— Yes Within 500 year boundary No_X Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring:Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pe ious material? Certification I certify that on l b (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the requited tra ,expertise and experience described in 3:10 CMR 15.017. Signature ' "/ Date Q.-\SEPTIC\PERCFORM.DOC COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 970 Falmouth Road(Route 28) _ G� uaJle MA 02632 �J7-0 _--03_3-�� Owner's Name: Lisa Delia Owner's,Address: Date of Inspection: September 28 2006 Name of Inspector: (Please Print) James M.Ford " Company Name: James M. Ford Mailing Address: .RO.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION.STATEMENT c 'Ca I certify that I have personally inspected the sewage disposal system at this address and that the infon ation relm.yted below is true, accurate and complete as of the time of the inspection. The inspection was perfor ned�b ised on i -. training and experience in the proper function and maintenance of on site sewage disposal systems am a DE-P approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste Passes Conditionally PassesCIO &? ' Needs Further Evaluation by the Local Approving Au'th ity ' Fails Inspector's Signature: Date: October 2, 2006 The system inspector shall subm' 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. Notes and Comments This report only describes conditions at the time of inspection and.under the conditions of use at that time. This inspection does not address haw the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/1 k000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 970 Falmouth Road(Route 28) Centerville MA - Owner: Lisa Delia Date of Inspection: _September 28 2006 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. 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: 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: 2 . } Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 970 Fahnouth Road(Route 28) Centerville MA Owner: Lisa Delia Date of Inspection: September 28 2006 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 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 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 970 Falmouth Road(Route 28) Centerville MA Owner: Lisa Delia Date of Inspection: September 28 2006 D. System Failure Criteria applicable to all systems: ' You must indicate either"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 ✓ 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 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes (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. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the.following: (The following criteria apply to large systems in addition to the criteria above) 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 an p y 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: - 970 Falmouth Road(Route 28) 'Centerville. MA Owner: Lisa Delia Date of Inspection: September 28 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined.?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 970 Fabnouth Road(Route 28) Centerville MA Owner: Lisa Delia Date of Inspection: _September 28 2096 RESIDENTIAL FLOW CONDITIONS . , Number of bedrooms(design): n1a Number of bedrooms(actual): - 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 3 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewage system(yes or no): n1a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL.INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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 systein owner) Tight Tank Attach a copy of the DEP approval 4 Other(describe): Approximate age of all components, date installed(if known)and source of infonnation: Date of installation unknown Were sewage odors detected.when arriving at the site(yes or no): No 6 e Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 Fabnouth Road(Route 28) Centerville MA Owner: Lisa Delia Date of Inspection: _September 28 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 32" Material of construction: ✓ concrete _metal fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no certificate) ) (attach a copy of Dimensions: 1000 gal. Sludge depth:. 4" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 1011+ Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 101, How were dimensions determined: Measuring stick Conunents(on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tees were vresent. The liquid level was even with the outlet invert. 'There'did not appear to be anv Si gns o leakage. The inlet cover was 10"below rade. GREASE TRAP: None (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: Continents(on pumping reconnnendations, inlet and outlet tee or baffle condition, structural integrity,.liquid levels as related to outlet invert,evidence of leakage,.etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 Falmouth Road(Route 28) Centerville MA Owner: Lisa Delia Date of Inspection: _September 28 2006 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarn level: Alarn in working order(yes or no): Date of last pumping: Commments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (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.): F 8 ~ Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS AL SYSTEM INSPEC TION FORM PART C SYSTEM INFORMATION (continued) Property Address: 970 Falmouth Road(Route 28) r Centerville MA Owner: Lisa Delia Date of Inspection: September 28 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2- 6'x 6'(1000 gal) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: ° Innovative/alternative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): One pit 022 was full. Li uid was up into the riser. The cover was to gLede. The other it 03 had S'S"of li uid on the bottom. The scum line was uv to the inlet Pipe. The bottom to grade was.10'. The cover was 18"below grade. Both pits were in failure. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: `None (locate on site plan) Materials of construction; Dimensions: Depth of solids: r Commments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 Fahnouth Road(Route 28) Centerville MA Owner: Lisa Delia Date of Inspection: September 28 2006 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 w—here public water supply enters the building. -------------------- A _ g n a p��k yo1 33 a (o g3 10 z-F Page I I of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 Fabnouth Road(Route 28) Centerville MA Owner: Lisa Delia Date of Inspection: September 28 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/ feet Please indicate(check)all methods used to determine the high ground water elevation.- Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: TonoYranhic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: -Usin-z Barnstable to o ra hic and water contours rtta s the mays were showing'a roximatel 30'+/-to roundwater at this site. This report has.been prepared only for 4he septic system and components described herein. This septic system has.been inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future: There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS � r DEPARTMENT OF ENVIRONMENTAL PROTECTION b�• 350 MAIN STREET WEST YARMOUTH,MA �0 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 250 PAR 033 Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Ox%mer's Name: RICHARD,AMY Owner's Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 FRECE7WED Date of Inspection OCTOBER 18,2001 Name of Inspector:(please print) .TAMES D.SEARS Company Name: A&B CancoMailing Address: 350 Main Street ?1. BWest Yarmouth,MA 02673eTq t3Ef T Telephone Number: 508-775-2800 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 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(3101 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: /D A/ a/ 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****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 Inspection Form 6/15/2000 1 Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: 970 FALMOUTH ROAD, HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 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: , 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: .,f Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 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(l)(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 salt marsh 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 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 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. . Other: Title 5 Inspection Form 6/15/2000 ' .3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 D. System Failure Criteria applicable to all systems: N/A, You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in leaching is less than 6"below invert or available volume is less than'/,day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS;cesspool or privy is below high ground 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 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 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CUR 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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes" or"no'to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the systeru 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—1WPA)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 ves"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bates or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X Detennined 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(3Xb)] Title t e 5Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 3 Does residence have a garbage grinder(yes or no): NO_ Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2000 1886 CU.FT./2001 2064 CUTT. Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIIALANDUSTRIAL Type of establishment Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records T Source of information: 1999 Was system pumped as part of the inspection(yes or no): NO 'If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: a TYPE OF SYSTEM X 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 a 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1. PART C SYSTEM INFORMATION(continued) Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 BUILDING SEWER(locate on site plan): X Depth below grade: 3 Materials of construction: Cast iron X 40 PVC other(explain) Distance from private water supply well or suction line: Continents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 45" Material of construction: X concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: F, 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: Continents(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.OUTLET COVER 16"BELOW GRADE. TWO OUTLETS,ONE BAFFLE,ONE TEE.NO SIGN IN TANK OF OVERLOADING. GREASE TRAP(located on site plan) N/A 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(on pumping recontinendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no) Alarn level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): PUMP CHAMBER: N/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.): Title 5 Inspection Form 6/1 i/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 2 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Continents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) TWO(2) 1,000 GALLON PRE CAST PITS.BOTH PITS HAVE 3' WATER.PIT#1 45"BELOW GRADE,COVER 32"AT 18"BELOW GRADE. PIT(2)COVER AT GRADE.NO HIGH STAIN LINE. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionXIocate 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): �c PRIVY: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Conmrents(note condition of soil,signs of hydraulic failure,level of ponding,condition'of vegetation,etc.) Title 5 Ins ection Form 6/1_/2000 9 P - Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benclunarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �fc k w�R 3? 0 LO s� ys P'T 1 0 1r i Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 FALMOUTH ROAD HYANNIS,MA 02601 Owner: RICHARD,AMY Date of Inspection: OCTOBER 18,2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 28 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation site(abutting property/observation;hole within 150 feet of SAS) X Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation Accessed USGS database-explain: You must describe how you established the high groundwater elevation: G.I.S. AT BARNSTABLE BOARD OF HEALTH. 28'TO GROUND WATER. 1, x Title 5 Inspection Form 6/15/2000 11 COMMON WEA-1-All OF MASSACI1lJSas'I"1'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS -- DEPAIZ'ItME-NT OF ENVEZONMEW.rAL YRO'ITCTION 4 ONE WINTER ER STREF.,T, ROS'1'0N MA 02109 (617) 292-55 5' ��f� � TRUDY COXF 350,MAIN STREET OC `© 's Secretary ARGEO PAUL CELLUCCI WEST YARMOUTH, A T 1 DAV.P B. STRUHS Governor 508-775-2800 to, l 3 ommissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI ARM o+ PART A CERTIFICATION. MAP 410 PAR 250-032 PROPERTY ADDRESS: 970 FALMOUTH ROAD, HYANNIS '• :' ADDRESS OF OWNER: DATE OF INSPECTION: SEPTEMBER 28, 1999 JOHN CARLSON - NAME OF INSPECTOR : RICHARD K. CANNON' } I am a DEP approved system'inspector pursuant to.Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 , 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. PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTORS SIGNATURE: -. r' '{ ki DATE: The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 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. NOTES AND COMMENTS: W t SITE OVER ALUPASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME OF THE INSPECTION.THERE IS NO GUARANTEE ON.THE_LIFE OF THE SYSTEM. .y x revised -9/2/98 1 w yk e " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 970 FALMOUTH ROAD, HYANNIS Owner: JOHN CARLSON Date of Inspection: SEPTEMBER 28, 1999 INSPECTION SUMMARY: Check�A,B, C,:orD:, A] SYSTEM PASSES: YES' , I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. 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 that 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 unsound,shows substantial infiltration-or exfiltration,or tank is failure is imminent.- The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board.of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed ' distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed y pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced Y "" obstruction is removed " • i - n Sevised 9/2/98 2 _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 970 FALMOUTH ROAD, HYANNIS Owner: JOHN CARLSON Date of Inspection: SEPTEMBER 28, 1999 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b)THT 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 ANY) 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 of 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 1 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 well. 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 and is equal to or less thar 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER ' h+ ,. revised 9/2/98 - 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) F Property Address: 970 FALMOUTH ROAD, HYANNIS Owner: JOHN CARLSON Date of Inspection: SEPTEMBER 28, 1999 D]SYSTEM FAILS: N/A You must indicate either"Yes"or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 16.303. 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 over- loaded 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 Y2 day flow 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of 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 mapped Zone 11 of a public water supply well) F: The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information, revised 9/2/98, 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 970 FALMOUTH ROAD, HYANNIS Owner: JOHN CARLSON Date of Inspection: SEPTEMBER 28,1999 F Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X 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. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow.' X The site was inspected for signs of breakout. X All system components,including 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: X Existing information.Ex.Plan at B.O.H. X 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)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface.Disposal System. i revised 9/2/98 ;;.; .' 5 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 970 FALMOUTH ROAD;HYANNI$ Owner: JOHN CARLSON` Date of Inspection: SEPTEMBER 28, 1999 i FLOW CONDITIONS q RESIDENTIAL: YES AF Design flow: 330 g.p.d./bedroom for S A.S. Number of bedrooms(design) 3 Number of bedrooms(actual) 3 Total DESIGN flow Number of current residents: 2 Garbage grinder(yes or no):. NO Laundry(separate system) , ry( p y ) (yes or no): NO ;If yes,separate inspection required,' Laundry system inspected(yes or no): YES' Seasonal use(yes or no), NO. t Water meter readings,if available(last two(2)year,usage(gpd): ¢ N/A Sump Pump(yes or no): NO ;q r Last date of occupancy: N/A �� '^ • COMMERCIAL/INDUSTRIAL: N/A s Type of establishment: Design flow: Gpd(Based on 15.203) Basis of design flow ?, ;-� 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 Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: W GENERAL INFORMATION PUMPING RECORDS and source of information f 1997 P a> System pumped as part of inspection:(yes or no) ,-" NO �. If yes,;volume pumped: "gallons' Reason for pumping ' p . TYPE OF'SYSTEM , z ". X. Septic tank/soil absorption system's `„;,* w.•,_ y Single cesspool Overflow cesspool s; Privy. Shared system(yes or no)(if yes,attach,previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract. Tight Tank Copy of DEP Approval ..Other - APPROXIMATE AGE`ofall..components, date installed„(if known)and-:source of information: UNKNOWN `Sewage odors detected when.arriving at the site;(yes or no) -b'` ' N0: 4 'revised:9/2/98 , mA, c: i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 970 FALMOUTH ROAD, HYANNIS z Owner: JOHN CARLSON Date of Inspection: SEPTEMBER 28, 1999 BUILDING SEWER: N/A (Locate on site plan) z 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: YES (Locate on site plan) Depth below grade: 46" Material of construction' X concrete _ metal _ Fiberglass ' Polyethylene other(explain) If tank is metal,list age Is age confirmed by Certificate ofCompliance (Yes/No) Dimensions: 1,000-=GALLON PRE CAST f Sludge depth: .2" Distance from top of sludge to bottom of outlet tee or baffle: _ 28". Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 9 2" Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined :TAPE&ASBUILT Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TANK AT WORKING LEVEL,COVER 16"BELOW GRADE OUTLET BAFFLE&TEE GREASE TRAP: NIA (locate on site plan) Depth below grade: i 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: f (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) revised- 9/2/98 .7 t! ' k n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM o PART C SYSTEM INFORMATION (continued) Property Address: 970 FALMOUTH ROAD, HYANNIS Owner: JOHN CARLSON Date of Inspection: SEPTEMBER 28, 1999 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or at time,of inspection) (Locate on site plan) x Depth below grade: Material of construction concrete _ metal _ Fiberglass Polyethylene _ other(explain) Dimensions: Capacity: Gallons Design flow: gallons/day Alarm present 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: N/A (locate on site plan) Depth of liquid level above outlet invert: . Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) PUMP CHAMBER: N/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 9/2/98 8 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 FALMOUTH ROAD;HYANNIS Owner: JOHN CARLSON } Date of Inspection: SEPTEMBER 28, 1999 SOIL ABSORPTION SYSTEM (SAS): YES J (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: T e: YP .. Leaching pits,number: 2 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,damp soil,condition of vegetation,etc.) 1-1,000-GALLON PRECAST PIT,1-1,000-GALLON H2O PIT BOTH PITS HAVE 28"WAATER PIT 1 —45'BELOW GRADE,COVRE 18"BELOW GRADE.PIT 2-COVER AT GRADE CESSPOOLS: N/A (locate on site plan) Number and configuration: , Depth-top of liquid to inlet invert: .. a 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 hydraulicfailure,,level of ponding,condition of vegetation,etc.) PRIVY: N/A (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:),-..; revised 9/2/98 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 970 FALMOUTH ROAD, HYANNIS Owner: JOHN CARLSON - Date of Inspection: SEPTEMBER 28, 1999 - SKETCH OF SEWAGE DISPOSAL SYSTEM: - include ties to at least two permanent references landmarksor benchmarks locate all wells within 100'(locate where public water supply comes into house) R t _ W�Q p .�1 Pit I revised 9/2/98.: 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 970 FALMOUTH ROAD, HYANNiS Owner: JOHN CARLSON Date of Inspection: SEPTEMBER 28, 1999 NRCS. Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Ground water depth: Shallow Moderate Deep SITE EXAM Slope Surface water « Check Cellar Shallow wells Estimated Depth to no groundwater 14 Feet r Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record X Observation of Site(observation hole). Determine it from local conditions Y Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,installers ' Use USGS Data Describe in your own words how you established the High,Groundwater Elevation:(Must be completed) revised 9/2/98 51 �Q S r --r Li CIA ri r 3 Lo 3 A 3 � 4 4 L/ - �" 3 ry �. o t --..-------- { _ V �qp�p v �9 o V � dr— ASS OR'S MAPr NO 410-3 2So.o-ORCEL I A S T A LLER'S RAME ADDRESS 8 U I L D E R OR UWHEnd D A T E PER MIT i S S U E0 ,� � � _� U � ^1 �V I ,' � J \ �� .V ``� s 1 '�� J'' �. V r `�. v A� + ^\. I -� r . , . . - TOWN OF BApRjNSTTAABLE Yo ` LOCATION �� �/a�/y%AAA 1�C,�(�i�o SEWAGE# VILLAGE CC-,Irc,ryj� ASSESSOR'S MAP&PARCEL D a,33 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) P,7--1 (size) G,X,(, NO.OF BEDROOMS a— l OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY "�i1.SDe,�Ti u� 37 FDr2 r io W ,cp w 4SENQIR� MAP N@ PAVE% fM.'; No.. FxB ,o 2 ,- ....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i—,....................0 F... ................................................... Appliration for DW.Vviial Workii Tow3trurtion Frrutit Application is hereby made for a Permit to Construct or Repair (NL) an Individual Sewage Disposal System at: ...... .................................................................................................. Location-Address or N —ad5o, , i .................... .......................................................... .......................... Owner - A 360 Main S _4 j dyes ...oi�. 49.............................................................. .............................. ................ Installer Address Type of Building Size Lot............................Sq. feet U ..............Z.......Expansion Attic 9 Dwelling—No. of Bedrooms.................. Garbage Grinder ( ) P_� P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width__.............. Diameter_______.._______ Depth................ Disposal Trench—NTo. .................... Width.................... Total Length..___............... Total leaching area_------------------sq..ft. Seepage Pit No_____________________ Diameter....._.._..__._..._. Depth below inlet................_._. Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by........................................................................�. Date........................................ Test Pit No. 1----------------minutesperinch Depth of Test Pit..........._.._._.._ Depth to ground water.._.....__.._........-_. Lr4 Test Pit No. 2................minutes per inch Depth of Test Pit..__._......._.._._. Depth to ground water______._._...__.....___. M ............................................................................................................................................................. 0 Description of Soil........................................................................................................................................................................ U ......................................................................................................................................................................................................... ---------------------------------------------------------------------------------------------------------z;... .. -P-4 U Nature,of Repairs or AlteratioT—Answer when applicable.,LAi.44---------------------------------- ---------X-----91-----V 404;-ft& Ce. PW- r ....4...Jr . . .............................................................................................7.................................................. Agreement;, The undersiL-ned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the proviSi6jjS Of'TTT�� I— .5 ol the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. I - _?'k..............Signed......./72.0. 6.40 0.& .................................. --V- /?. —,?_Pa& 10 ApplicationApproved By.................................A. ................................... ....................... .....--- Date Application Disapproved for the following Uesons:................................................................................................................ ......................................................................................................................................................................................................... Dat PermitNo......................................................... IssuedL....................................................... Date d W r No......................... Fss. � ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7T4wn...... ...........OF..1 Appliratiun for Di"aaal Works Tonutrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair (4,) an Individual Sewage Disposal System at: .- ... ...Eki .. tSGt ,�cr sj3\!S t ------------------- -------------•----••-----••-•----- ......-•--------------•--•------•---.......--------••- Location•Address C t'1�n .,� O h a or Lot No'. -� _?t. ...........................•--•--.....------............ ..........---��..1�, l . f r tl'. P� .....•............. Owner I Address/ W fg .7'n .�Sa 1Sltctr, r 1, at�._�_. Add.................:... ._.......-.--••------•---••-•-•---•--•-----•-- � Installer Address Type of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms..............................« -.......Expansion Attic ( ) Garbage Grinder ( } aOther—Type of Building ............................ No. of persons.......--................... Showers ( ) — Cafeteria ( ) dOther fixtures -----------------•------•--•-•-----••--•--••---•------......•-•------......-----•-•----------°--...---°-•-------------•-------•-•---•-•--.....-------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity........---.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..........--............. GZ, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................--... a' ..................... ------------------------------------------ --------- ------ •-------- ------------- ---------------- ----------------------------------------- ODescription of Soil..................................................................................................................-..................................................... W U --•--------------------•-----------•--••-------•----•--•-•- ----........--•---------•-----.....---........------------...--•---------------•------------••---------......----••----•---...-•------------ ......-•.................. .• ----•-•-•---------••----•--•-•-------•----•--.....--•---...................................r..............-•---•................ U Nature of Repairs or Alterations—Answer when applicableS --- � ------ ---- ---------------- ._.ft� ........ ink4----------------------------------------------- Agreement: 0 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'ITEM ; of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...... n?.Mm'I-` .................................. .......................... a D ApplicationApproved By.............................. 1- - -•--•---•-----•--•-•------------------ ............................---------- Date Application Disapproved for the following r asons:---••-•••-•---••--••-•-•••-•--•--••--•--•--•---•-----•-•----•----•------•------•••-----•- ...................... ---------------------•----•-----------------•---•-••--------.......--•-•-----------------------.......-----...............••-----•••-•---•-•••--------------••-•-•--•--••-------. ---------------------- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF #HEALTH C+ ?1?.......................OF l �cit�». C��tA........, ........................................................................ Trrtif irate of Tomplionrr THIS IS TO CERTIFY, That th Individual Se *age Disposal System constructed ( ) or Repaired by ! - - -- In alley y� 1 has been installed in accordance with the provisions of i�"E j of The State Sanitary Code as scribed in the application for Disposal Works Construction Permit N o.__.1.d.-_�_�L............... dated---.._09.�.�C. ..- . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT YHE SYSTEM WILL FUN�1 N SATISFACTORY. c� "-�'`---------------------DATE............... �.....�_.C�_......_..._....-------.. Inspector.....t---... .............-------------•----•----.........--- (r tl10) THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ....................UW ................OF.......:. ?at1... 4 J .................................................... NO.......... FEE.A�............. �►iu�uu I Turku �onutrnrtion hermit 22 Permission is hereby granted------. I✓...........C Aja.G.o-•--••----•-•----•---•----•--------•-----------•-.......---•.......................... to Construct ( ) or Repair ( ) an IndividuakSewage Dispos� System at No.----------I--7.®-------------fwm� 0A------.-.------.t- Street I as shown on the application for Disposal Works Construction Permit No_ ..........:.... Dated...... . ... ....................... Board of Health DATE--------=' ------------------ FORM 1255 HOBBS & ARREN, INC., PUBLISHERS Y yy E t LEGEND ou �• a � PROPOSED CONTOUR LA o ® PROPOSED ,SPOT GRADE Bq 00 -- 98 -- EXISTING CONTOUR `� R 7 4 + 96.52 EXISTING SPOT. GRADE t; 28- p00 i PAM 73 00 f d Hyannis 12S ft t W— EXISTING WATER SERVICE �jS Pei p TEST PIT R a�H 9L ,e 6 0 S 58 a' o Barnstable y, S w — 4t�` HS Q �\ �� II LOCUS MAP N.T.S. TH - Z 62 TH '�� z I� II n 7 i i '; GENERAL NOTES: EXIST. LEACH PIT Q 1 I I I F_ I I I 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL I I BOARD OF HEALTH AND THE DESIGN ENGINEER. Z• 7— ' I 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS \ 20 i ft z �� 3 ft I OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE I \\ 1 I LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED: — 310 CMR 15.405 1 (b) 1) A 1.75 ft. variance to allow-4.75 ft. of cover vs required 3 ft. 3 DISPOSAL THE SEWAGE:TQ INSPECTOON AND C KFILLED PRIOR APPROVAL BY THE BOARD OF D HEALTH A HE DESIGN ENGINEER. w \ 4� II 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN I I I L \ I ENGINEER BEFORE CONSTRUCTION CONTINUES. I ` O tT 1 �� I 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 62 AREA = 15226 s f + ;� I 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR HE FAILURE OF J I I HE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF \ I HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. _ l 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 58 I 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED I TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. Of \\\ I \\ j 9. IT SHALL BE THE RESPONSIBILITY'OF THE CONTRACTOR TO VERIFY THE Mq I THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING - EOGE 7 9 �� � � \ I CONSTRUCTION. o D R / O/C. .A S �� �I O 10. EXISTING LEACHING PIT TO BE PUMPED, CRUSHED AND FILLED .11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION N 1140 eMEN I 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY T �\ Z O I AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY 2 / BENCH _MARK PROPOSED SEPTIC SYSTEM UPGRADE PLAN TOP OF DRAIN GRATE 970 FALMOUTH RD. CAPT. ELLIS LANE, HYANNIS, MA ELEVATION BARNSTABLE GIS .DATUM AMP: 250 Prepared for: Wade Behlman SURVEY REFERENCE: LOT.-033 Engineering by: Surveying by: SCALE DRAWN JOB. NO. DEEDBK:19791 DARRENM.MEYER,R.S. Eco—Tech Environments! 1"=20' DMM PLAN OF LAND BY NELSON—BEARSE SURVEYING D Box 981 (508) 364-0894 GATE CHECKED SHEET NO. DATED: MARCH 14, 1975 DEED PG:014 EAST SANDWICH,MA 02537 508362-2922 12/01/06 DMM 1 of 2 f frr ELEV. TOP y FOUNDATION i �Q141 (Existing) ^� �C 61.49 F.G.EL: 61.0 60.0 F.G.EL: 61.0 F.G. EL: 62.0 i FINISH GRADE=62.0 --� _ • MAINTAIN 2% MIN SLOPE OVER LEACHING AREA COVER OVER LEACHING = 4.75 FT. w• .Y COVERS TO WITHIN 6 OF GRADE i 2" OF 3/8" DOUBLE 3/4" _ 1-1/2" DOUBLE L = 25 WASHED STONE WASHED STONE a rT-T6" • ~„• 4" SCH 40 PVC F=-�, i L 5' 4" SCH 40 PVC J 10"1 :INV.56.72 S= 1q MIN. 6 ® ®(MIN.) TEE'S ARE TO BE ( ) © S= 1% (MIN.) ®® ®®®®®4" SCH 40 PVC 2 EFF. DEPTH ®®®®®®®®®®®INV.56.47 INV.56.30 4' 1 X 8.5' 4' EXISTING OUTLET GAS PROPOSED DB-3 BAFFLE EFFECTIVE LENGTH = 16.5' • ••••N •• • ••-• •••• H-10 DISTRIBUTION BOX INV. 56.97 EXISTING 1000 GALLON SEPTIC TANK INV. ELEV.= 56.25 - GAS BAFFLE TO BE INSTALLED ON NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING BREAKOUT OUTLET TEE AS MANUFACTURED BY PIPE INVERTS PRIOR TO CONSTRUCTION ELEV.= 56.75 TUF-TITE, ZABEL, OR EQUAL 2) D-BOX SHALL BE SET LEVEL AND TRUE TO TOP CONC. ELEV.= 57.25 • GRADE ON A MECHANICALL COMPACTED SIX INV, ELEV.=56.25 .®® � ®® INCH CRUSHED STONE BASE, AS SPECIFIED IN ®®® ®®I® 310 CMR 15.221(2) ' ®®®®®®® 3) REPLACE EXISTING 1,000 GALLON SEPTIC ®®®®®®® TANK WITH 1500 GALLON SEPTIC TANK BOTTOM EL.= 54.25 ®®®®®®® IF FAILED, DAMAGED, OR UNDERSIZED. 4' 5 FT. 4' F 4) INSTALL INLET & OUTLET TEES AS REQUIRED SEPARATION'•5.25 FT, EFFECTIVE .WIDTH = 13' SEPTIC, SYSTEM PROFILE i. BOTTOM OF TESTHOLE EL: 49.0 N.T.S. GROUNDWATER EL. = - 31 .0 - SOIL ABSORPTION SYSTEM (SECTION SOIL LOGS (per Barnstable-GIS GW MAP) DESIGN CRITERIA 1 NUMBER OF BEDROOMS: 2 BEDROOM DATE: NOVEMBER 13, 2006/DECEMBER 1, 2006 { SOIL TEXTURAL CLASS: CLASS I - SOIL EVALUATOR: DARREN MEYER, R.S., CSE DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DONALD DESMARAIS DAILY FLOW: 110 G.P.D. HEALTH AGENT s DESIGN FLOW: 220 G.P.D. (2 BR DEED RESTRICTION REQUIRED) GARBAGE GRINDER: NO Elev. TH-1 Depth Elev. TH-2 Depth 62.0 LEACHING AREA REQUIRED: A LOAMY A D 0" 61.9 A LOAMY D O" 61.25 B 9" DE /3 1YR61.23 8^ ��) = 297.29 S.F. r B LOAMY SANG LOAMY SAND USE ONE (1) 500 GALLON PRECAST LEACH CHAMBER 10YR 5/8 10YR 5/8 WITH 4 FT. STONE ON ALL SIDES: 13.0' w x 16.5' I x 2' d. 59.5 Cl 30" 59.23. 32" BOTTOM AREA: 16.5 X 13 = 214.50 SF Ct MED. SAND MED. SAND SIDE AREA: (16.5 + 13) X 2 X 2 = 118 SF 2.5Y 6/4 2.5Y 6/4 TOTAL SQUARE FEET PROVIDED = 332.5 vs 297.29 REQ'D OF dlA,jJ9 PERC 0 50" �DARKEN M. cyt� PROPOSED SEPTIC SYSTEM UPGRADE PLAN c MEYER 970 FALMOUTH RD./CAPT. ELLIS LANE, HYANNIS, MA t No. 1140 Prepared for: Wade Behiman Engineering by: Surveying by: SCALE DRAWN JOB. NO. 49.0 156" 51.9 120" DARRENM.EAST SAN MEYER,R.S. gco-Tech B'nvimnmeatal N.T.S. DMM PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) NITAR�p EO BOX ASTS4NlDWICH.MA 02537 (508) 364-0894 i GATE CHECKED SHEET N0. NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED 1f 508-3s2Z922 12/01/06 DMM 2 Of 2 c