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HomeMy WebLinkAbout0012 FROST LANE - Health 12 Frost Lane, Hyannis A -10 I I Commonwealth of Massachusetts . eq - oa�o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 12 Frost Lane r�.l Property Address ` 4., Estate of Brian O'Connell Owner Owner's Name i information.is required for every Hyannis ✓ Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection 3 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information .F Itl on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane to r9 Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/9/2020 Inspector's Signature( Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name .information is required for every Hyannis Ma 02601 9/9/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The property located at 12 Frost Ln Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and a 1000 gallon precast leach pit. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I.� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and.the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No the system is within 400 feet of a surface drinking water supply ❑ ❑ Y 9 PP Y ❑ ❑ 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 t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is re Hyannis Ma 02601 9/9/2020 wired for eve y 4 every Ci /Town State Zip Code Date of Inspection page. tY p p C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue El approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owners Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I.- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis. Ma 02601 9/9/2020 page. City/town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is Hyannis Ma 02601 9/9/2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: original system 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: .5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5„ Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: g gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts i� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: 1x1000 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form fo Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was dry at time of inspection with a stain line 1'from bottom. Cover is on a riser 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Z. O ,A-( 27 Lf Gi 27 A,z BZ- eW31 1+3 -3(, [33 3 S Ay 70 jay 50 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Frost Lane Property Address Estate of Brian O'Connell Owner Owner's Name information is required for every Hyannis Ma 02601 9/9/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 V i Commonwealth of Massachusetts Executive of Environmental AffairsAlic C` i DEP Department of � ' - Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 12 Frost Lane. Hyannis, Ma. Address of Owner: Klaus Ullmann (if different) 310 Farm Lane.Westwood, Ma Date of Inspection: 08/13/96 Name of Inspector: Michael D eD ecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420 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 )�V Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fails Inspector ' s Signature. D ate: 08/14/96 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. I f 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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Frost Lane. Hyannis, Ma. Owners : Klaus Ullmann D ate of Inspection : 08/13/96 INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: - I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B) SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no, or not determinate (Y,N, or ND). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank 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 pass inspection if (with approval of the Board of Health). ----- 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 wiU pass inspection if (with approval of the Board of Health): ----- broken pipe(s) are replaced ----- obstruction is removed SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 12 Frost Lane. Hyannis, M a. Owner : Klaus Ullmann Date of I nspeckian . 08/13/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if.the system is failing to protect the public health , safety and the environ- ment. 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 of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and 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 is within a Zone I of a public water supply well --- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: -- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM R 15.303. T he basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. --- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Frost Lane. Hyannis, Ma Owner: (Claus Ullmann Date of Inspection : 08/13/96 D)SYS T E M FAI LS (continued) -- 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 over- loaded or clogged SAS or cesspool --- Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary 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 ana- lysis. 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 Frost Lane. Hyannis, M a. Owner: Klaus Ullmann Date of Inspection : 08/13/96 E) LARGE SYSTEM FAILS: The followingcriteria apply to large systems in addition to the criteria above : PPy 9 The design flow of system is 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 : --- 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 - IPA) or a mapped Zane I I of a public water supply well. facility into full compli- ance operator of an such system shall bring the system and fa y The owner a p y y 9 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 12 Frost Lane. Hyannis, M a. Owner: Klaus Ullmann Date of Inspection: 08/13/96 Check if the following have been done : -x Pumping information was requested of the owner , occupant and 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 the 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, excluding the Soil Absorption System, have been located on the site. ---x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 Frost Lane. Hyannis, Ma. Owner: Klaus Ullmann Date of Inspection: 08/13/96 RESIDENTIAL: Design flow : 3 30 gallons Number of bedrooms : 03 Number of current residents: O 2 Garbage grinder (yes or no) : Vzi© Laundry connected to system(yes or no): Seasonal use (yes or no) : No Water meter readings, if available: 13 lA . Last date of occupancy : ejc v� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow : gallons/day 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 i ormation -,,�.....WSA�....�!!c . Sy lem pumped as part of inspection(yes or no):....... . if yes, volume pomped : .................... gallons Reasonfor pumping:............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 12 Frost Lane. Hyannis, Ma. Owner: Klaus Ullmann Date of inspection: 08/13196 TYPE OF SYSTEM \Septic tank/distribution boxlsoil absorption system --- Single cesspool --- Overflow cesspool --- Privy --- Shared system(yes or no) (if yes, attach previous inspection records, if any) --- Other (explain) ........................................... APPROXIMATE AGE of all components, date installed (if known) and source of information � �o ......m'c .. y .s............................................................................................. ................................................................................................................................................ ................................ Sewage odors detected when arriving at the site: (yes or no)......1Q SEPTIC TANK: (locate on site plan) r Depth below grade: .Material of construction: ...K concrete ......... metal ........ FR P ........ other (explain) ................................................................................................................................................ Dimensions:5. .x��.L,r 5 Sludge depth:..p,,....... Distance from top of sludge to bottom of outlet tee or baffle:.......34................ Scum thickness :....0............... Distance from top of scum to top of outlet tee or baffle: ...........1.6........ . ............ Distance from bottom of scum to bottom of outlet tee or baffle:......(.�a i�......... Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in relati n tp outlet inve"structurall..inte r'ty, evidence of leakage, etc.)...................... .. .. .. . . V4- ........... . .�..... ..U..Sll40. . . . ..... . SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION (continued) Property Address: 12 Frost Lane. Hyannis, Ma. Owner: Klaus Ullmann Date of inspection: 08113/96 GREASE TRAP : .........NZ.. (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... .......................................................................................................................................... Dimensions:............................... Scum thickness:........................ . Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................ TIGHT OR HOLDING TANKS:.... .. (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................................ Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 12 Frost Lane. Hyannis, Ma. Owner: Klaus Ullmann bate of inspection: 08/13/96 DISTRIBUTION BOX:. . (locate on site plan) Depth of liquid level above outlet invert:.��............ Comment: (note if level and distribute n equal ev ence9�said�arryover, evidence of leaks intro or out of box, ek .). �- ?� � ...` i. . ...ter. . f..( ......t...f..n.... ... .''`�..... 5. p.�.1. C' JE'..1�L..i. ... )......... C ,.... .. .............................................................................................................�................ PUMP CHAMBER:....N.�.. (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ .................................................................................:.............................................................. SOIL ABSORPTION SYSTEM (SAS):....*:5...... (locate on site plan,if passible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ ................................................................................................................................................ Type: leaching pits, number: .`... leaching chambers,number:........ j leaching galleries, number:........... leaching trenches,number ,length:..................... leaching fields, number, dimensions:................... overflow cesspool,number:.......... Comments: (note condition of sail , signs f h fia lic failure, lei el of pondin ,condition o vegetation ?� . ,. .0 ran SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 12 Frost Lane. Hyannis, Ma. Owner: Klaus Ullmann Date of inspection: 08/13/96 CESSPOOLS:....... (locate on site plan) Number and configuration: .................................... Depth-top of liquid to inlet invert: ............................ Depth of solids layer: ............................................... Depth of scum layer: ...... ayer: ........:............................. Dimensions of cesspool: ...................... Materials of construction: ..................... Indicator of ground water: .................... 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 : ..... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . ................................................................................................................................................ I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 12 Frost Lane. Hyannis, M a. Owner: Klaus Ullmann Date of inspection: 08/13/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. r$ \Z A ab Pik - �b A2 32. 6Z- 5 ` �}3 3b Z y -70y _ 3� � 3 U DEPTH TO GROUNDWATER: Depth to groundwater: .- 20.feet Method of deteimin ti r approximative: ,.. !oS�.� ......� , .. ........................................................................................ ....................................................�j......................................................................................... ................................................................................................................................................ ASSESSOR'S MAP N0. /s-l- PARCEL Via L01-CATION SEWAGE PERMIT NO. Z07 -0/ Oa4 V111LAGE Ile-' /� INSTALLER'S A M E i ADDRESS 9, UILDE R OR OW R C ® 's DATE PERMIT ISSUED7i DATE COMPLIANCE ISSUED i G,4-C W � c6 b ASSESSORS MAP NO: , c�� PARCEL NO.: c THE COMMONWEALTH OF MASSACHUSETTS POARD OF HEALTH ......................OF....... ✓ ..... ................ Appliratiun for UiupuuFal Workii Tonstrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --- =- -. ......l 1-- ! 5 �il2f �1 ,+/l!!� `G ......................................... o t Add.. on• res 0 o. L,�11t Owner Ad es (/ �-------•---.f--:-�:✓.Ie.c._........ C J Installer Address Type of Building Size Lot_I _V.6._Q------Sq. feet U Dwelling—No. of Bedrooms.........3............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............... No. of persons....•................_..___. Showers — Cafeteria a+ Other fixtures .....................................•••_-••• W Design Flow................. ..................gallons per person Cpe�rd ay. Total d�ily�flow........_ ....................gallons. WSeptic Tank—Liquid capacity_a__.__..gallons Length_____ _______ Width.._&_.._ Diameter-----------_.... Depth.S__-,T... x Disposal Trench—No. .................... Width_._._._ ._..__._... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No.........I.......... Diameter-------/U....... Depth below inlet.....(a.......... Total leaching area.!�.!;Q....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results, Performed by__ ��.. ?!L'.. _:............................ Date... .-_�v_"�. . ..... aTest Pit No. I................minutes per inch Depth of Test Pit_....,1 ________ Depth to ground water........................ Test Pit No. 2......PL.....minutes per inch Depth of Test Pit----Z..3......... Depth to ground water........................ , - 4-- ............. f'd!y---•• --•_.... ............V � -� "�---. ..escrponoo . . � x W ---•••••--------------------••-•-••-••••-••-•---------••••--------••-•••......------••-•------.-----DESIGNING_ENGINEER MUST SUPERVI E U Nature of Repairs or Alterations—Answer when applicat��.STALLATION AND CERTIFY IN 1Ni�l°f(11fCa THE SYSTEM WAS INSTALL.�O "STRICT................. -----------------•--------------...•-------------------...••••••••-••••---•--- - ---------------- Agreement: ACCORDANCE TO : 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 ntil C ifica of Compliance has been ' sued the board ea h. Date APpation r ed BY... ............................. • . -----•-•-• . .. ...................... ........ Z` ° Date Application Disapproved for the following reasons__________________ •----......--•---------------------------•-•••........................--.. ---.......... ..........................-•-••-------••-••---•--•••••••••-•--•--•-•••......-•••----•--•••--•••---•---...-•-•---•-----•---••.........--•-•--••-•-••-•••-•-•••............•••........................... ' Date Permit No. ��...._.. Issued....................................................... Date FIms ............ «. C� THE COMMONWEALTH OF MASSACHUSETTS OARD OF HEALTH -..Yv..................OF.......11y.A..)_.10`'. ................ Appliratiun for Disposal Works Tonstrurtion Prrutit Application is hereby made.for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst �a�---- ................... ' ----... ....... o lion-Addres ..iF —©S No. I. .r««............ ......._ .�_J.':� --.�--1�'!;.. == - f �l 'Glc - JNNI« .... .... W r ^� ;caner re Ad ess I teC�& �/✓ ..f.:.:....:...: 1Yli` j�% 'Installer Address Type of Building Size Lot-/.j._o4e C).-...Z feet U Dwelling—No. of Bedrooms.......... ............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of persons............................ Showers a YP g ---------------•------------ P ( ) — Cafeteria ( ) OtherfixturesM....................................................................................................... W Design Flow................. .:_.____ .gallons per personUpgr d g. Total d4ilyAow..........3-.:...........................galjons. WSeptic Tank—Liquid'capacity/.I...._..gallons Length_._.`.__._.. Width.5. .... Diameter_............. Depth.._..-.:...-. x Disposal Trench—No/..................... Width.......�...._.___._ Total Length................... Total leaching area___.. _ sq. ft. 3 Seepage Pit No.........(.......... Diameter......./ ...... Depth below inlet.....42.......... Total leaching area." .... ..._sq. ft.' Z Other Distribution box ( ) Dosing nk ( ) Percolation Test Result Performed by.. _...j�. ._ �'��'�................ ...................... Date.... U ' W -- ---•--•---- ----------- Test Pit No. I................minutes per inch Depth of Test Pit..... _ . Depth to ground water........................... (x, Test Pit No. 2....... .....minutes per inch Depth of Test Pit.....i.A........ Depth to ground water........................ 1x 1 V. - - --f....-.t.. Description of Soil------. t l�� 1�.. - Y ... �'..... j Uor ------------------ -------- ---•---•----------.--------•---------------- ........ ......_... W ? V Nature of Repairs or Alterations—Answer when applicable............................................................................................... .----••---------------------------------------------•--------...----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of T I T LE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Cerdficate of Compliance has bee ued the board h. l fA_I , _ «.... APPl ct�tion/Approved BY v _ ......... ram° M:L. ' ". Date Application Disapproved for the following reasons--------------------------•-•-•--•-------------------•--------.......----...---------....._......--•-•-••---«« ....................•---•.---.............------..........--...._._.....---------•--------••-----------..----....----------.....---....---••----•--------......--•-•------------... ......•-------- Date PermitNo...... «.... Issued...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH 4r Trrtifiratr of Zoutplittnrr THI IS T CERTIFY, Tflat the.-Individual Sewage Disposal System constructed ( ) or Repaired ( ) /Z -/� by.......... 1 . ...... ........ .....0...:............................................................- =-• ....................... - .... ---...« ` ej �-�. Installer ....!�. ...............I............::d --•---------------------------------------•--------•-•••-•-•--••--- has been installed In accordance with the provisions of TITI1 5 of le to Sanitary Co . sf ib in the ap lication for Dis osal Works Construction Permit l�o.-_- ___......................... dated............. I........... ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUXCTION SATISFACTORY. 10 DATE......................... �.G��_. ........................... Inspector ........_... .... .------.......... THE COMMONWEALTH OF MASSACHUSETTS JAM e BOARD OF HEALTH "�l No.-•--•-••••••..... .......... Faz........................ Dispnstt,, urk �unofrnr#ionrrmit Permission Is hereby granted....--- .....«««.. to Construct ( or.4epair (�) an Individual Swage-Diosal System at No..........U!:?c -------------------- ..... Street as shown on the application for Disposal Works Constructiop-ftmit NIo.- - . !Dated........ [..��.:4. ......... ==tea •�l�'1'�� .�...,,�.,., ----•..................•---------------------.-:......................................---'--...........« t �� Board of Health DATE...... -1 ---vv .............................................. FORM 1255 A. M. SULKIN, INC., BOSTON = Xoz 2 .,Pot f� i 1-6 6 'Piti ' 4p.o G8, •. I Soo io�494 W12 4XArte ..... .. .Coz 3 !-6 lx 6 /�,it I S00 ` 1'ot S qs9 9� -_�ti�:- ". GJ/2 atone t i 4V -� pcowe a PR-0 aos f 0' $ 46.3 No 5�-� 4 N . ` I IZo' 1.4 Xo-t 4 132' 11060'-,S.9: I I S00 4A9 . I Q I G.5.9.. j as.00 47.5 i 91toat .eane _ _. .:... ! .... ...... (d iitt J '40 , wide 47•..it a�. RL1 Cape C� plan 5cate I" 30 47.0 49 Ua o t 1Z6ad t7ate 3-1.1.-86� V, R yatrun., ..Ma.. 02601.. Sketch pLa.i of .('and tin Idya�vLi.�, Ma; 96,t Sawn 9. Zucke,t l9e i n f tot 4 " aJwwn. on a plan teeou ed..in Barn. to te- 1zeyistty A. 183 Pq�. I9. t6tock 2) Ueva,t i o na- shown ate opt an a aaumed:datum. 1�cr.�e: eta--� Ze data o �ea�-tFi w I geAt Pit AP.-s74 1. __-_ Made 3-10-86 Wit Witel 9. McKean I No e count, wafiet 0"An. p Ai 2 i top to � i ! DESIGNING ENGINEER MUST SUP�RVIS INSTALLATION AND CERTIFY IN.W�ITIN 4c•: THE SYSTEM WAS INSTALLED IN'STRIC co co _ ACCORDANCE TO PLAN. I 9z 2 4z.6 j w r F M�VS� 1 sand 4aild / LIAM { .Wil pP l FAUDIE us i� \ Ne. 8395�Q t1V �� .,,I•.il,!lnt�• , Upper Cape Engineering P.O. BOX 616, EAST SANDWICH, MASSACHUSETTS 02537 (617)362-6281 Nov.:. 14, 1986 Board of Health Town of Barnstable Hyanni s,,. Ma s s, RE: 86-597 Dear Sir: . We have caused to inspect the septic system -located at lot 4 Frost Lane, Hyannis and found that ib has been installed In accordance with the plan submitted by All-Cape Engineering, _ Than.k /l y - J Jacobi .n 4 A e a w •- .r s 7 72 6 LOCATION SEWAGE PERMIT NO. lCos �.A. VILLA E A & B CESSPOOL SERVICE ' 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER CA,�rn DATE PERMIT ISSUED -���'p� O � DATE COMPLIANCE ISSUED Cl i r , - f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................Toren.............OF.................Bams:_able.............................................. Appliration for Bisposal Workii Towitrnrtinn Vprrmit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal ,' ESystem at: 4 u,, ... nQs L_La ne,...Hya nn i,..1A.....j026m ...................... ...•--•--••-••-•-••••--------.........--.----•--•--•-............._......--........-----....••--•- Location-Address or Lot No. S:toast._Zhapasa..-----•------------------------•------------------•--....---.... .4.FrQst.-Zan.Q.,._.1Yanna,s_+__.MA----Q2641.................... Owner Address aA.& des,a Q.QI.�SQxx QQ-+•--Inz.................................. �2 _.his.hogci. Q,=&QQ4...Hyaaa�isx MA _02601- Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building No. of persons ..................... Showers YP g ---•---------•------•--...-•- P ( ) — Cafeteria ( ) Otherfixtures ----------------•----------------------._...----------.•••---..............._..--•-•---- ............................................................. 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........................................ Test Pit No. ,................minutes per inch Depth of Test Pit.................. Depth to ground water........................ fro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ........................-.........................................................:......................................................................... ODescription of Soil............Sand.................................................................................................................................................. x w U Nature of"Repairs or Alterations—Answer when applicable..._ nstallation--- f--a-.1_,000•__gallon,__T—.cast, " stone••.backed•.leach••pit•••(overflow•�_......................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'11S 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of Signer -- .......... Application Approved BY.................................................................................................. 8...1 �"w ---------------------- Date Application Disapproved for the following reasons:..................•••-•••-••••••••••••••••••-•••......•••••-•--••-••-•••-••-•-•••--•........................--- ..•••-••-••••-••••...................•-•••••-••••--•••--••••••-••••-••-••-•---••.....---........••---••--"••••-•-••-••••••••••---••-•---••-•••--••••---•-••••-•-••••-----••• ............................ Date 84 Permit No... .-. ........................... Issued_............Y14/........................ ............ ..... Date ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................Tmn..............O F................A.arnatable--.--......---------------------...---......... Apptiration for Diipoutt1 Workii Tomitrnr#ion untit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: M�►....-A2601....................... .................................................................................................. Location-Address or Lot No. S11 i:..3hapirA...----•- ------------------------------------------------ .4.F=ost__Lane,..Hyannis.,--MA....D26QI..................... Owner Address �n .x 128._'Riehaps_-Tez-rase,...H3a,nnia,..�'tA_._..Q IAI Installer Address Type of Building 4 Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons....6..................... Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------••-•---•••-••-•-••-•--••----•-•----••---•••-••--••--••••-••••--•--••-••--•--••......-•-••-••••. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity..---.......gallons Length................ Width................ Diameter...--.-_.._-_-- Depth................ W 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 ( ) aPercolation Test Results Performed by.................................................................•••..... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....•..._--_---.------.. f%4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ••••••--••-.......--•--•-••-••-•-•••••--•-•...••••••-••--••-••-•••-•••..................••--••••............................................................. 0 Description of Soil...........s=dd............................................................................................. ..................................................... x U W --------------------------------------------------------------------•--------------------•----------------------------------.....--------------------------------------------------------------......... U Nature of Repairs or Alterations—Answer when applicable_-installation ofa1.000__,gallon,.__.pre-Cast, stone packed-leach pit _(oyerflow) --------------------------------------------------------•-------------------------------------................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bbeeeen isssued.by the board / Signeo 14/84 ApplicationApproved By.................................................................................................. 8/1v Date Application Disapproved for the following reasons---------------------•---------------------------------------------------------------------------.....••••....._ ---------------------------------------------------•---------------------------...••----•-•-•••----••----•----••--•••.....••-----•--••-•-•---••-...••••••••----•--•••••-••----•••••••---••••-••••-•---•- Date 84 PermitNo._E!.- ��--=�-•-------------------------------• Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1, .................... own...........OF.. . . Barn.stable............................................ .................... CIrrfifiratr of Tompliatta THi� IS TO CERTIFY That the Indivi,� e Dis osal S-ste const ucted ge aired A & B- Cesspool Service, Inc i�i� shops Terrafe, Hynnis, MA( 6 01 p ) by........................------------•-------------..------.-.---.-------.-.---•-----------------------------------•-----•----.-------------•--------.---•------------•-•-----------------------•--- 1. 4 Frost Lane, Hyannis, YA 02001 Install= Stuart Shapira at ...• ......••.... ---••••-•• ......---•--•... •••••• • --•••••----------------------•------------------------------------•----------------------------------- has been installed in accordance with the provisions of T�Lp_ 5 of The State Sanitary C$� � 4escribed in the application for Disposal Works Construction Permit No..._-._.._.��....................... dated.....--........_.-_-....................._...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �J DATE....... 8//_i4-..� KInspector.....`f_ THE COMMONWEALTH OF MASSACHUSETTS C BOARD OF HEALTH - .....................Town............OF......Rarnstable $ 15.00 ... ................. No......................... FEE........................ Biupsa1 Workii 0.1onu#rudion �ernti A & B Cesspool Service, Inc Permission is hereby granted....................................------•--.------•-------•----- ----.-.......------------...-----......--------....------............... to Con r t (( orzRe r an div evta Dis o S tem 1 rod t)Lan e p at No. r...-••-••...a .e MA b i - UAR Sha '�ro Street as shown on the application for Disposal Works Construction Permit No.. ._ .... Dated..8/14�84.......................� � 8/14/84 Board of Health � DATE................................................................................ FORM 1255 A. M. SULKIN. INC.. BOSTON It tiii c THE COMMONWEALTH OF MASSACHUSETTS BOARD )PF HEALTH ..._0F.....��J.;r� ... ...... .. . ................ Apphratiou for Disposal Works Taustrurtivit Prrutit Application is hereby made for a Permit to Construct or Repair ( 0<an Individual Sewage Disposal System at 24M.AM J..... .".-.Y..... . .................................................................................................. Add ........................................or Lot No. . .......... ... ............................................... 0 X��ress . .........................../000 ........... ................................................ ............................... Installer Address U Type of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms......................................:.....Expansion Attic Garbage Grinder 4 P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 44 44 Other fixtures ................................................................................................................................... ................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width.__............_ Diameter..._......_..._. Depth...._...__..._.. Disposal Trench—No. .................... Width_...._......._.......Total Length....._..........._.. Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter..........._.__.____ Depth below inlet_....__............. Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by.......................................................................... Date........................................ 1.4 Test Pit No. I................minutes per inch Depth of Test Pit................_... Depth to ground water.._._.___._._........._. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.._____.........._.. Depth to ground water........__...__..._.____ 04 44--- 0 Description of Soil.........j"a I le-f 4a.: ........................ W U ......................................................................................................................................................................................................... W ............................................... ........................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable----4, F _X ................/:n-/A:A— of ............................................................................... ;P ., ............ ................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TILE A'LE 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 b he b,4rd o I"Ith, V cw Signed. . Z.... . Date Application Approved By............................. . ....... ....................................................... ........................................ Compliance'A has b issued b h, Date Signed- .......... ....................... -n . . ................ Application Disapproved for the followi re ons:............................................................................................................. ........................................................................ ...............................I............................................................................................... Daft PermitNo....................................................... Issued-...................................................... Date ----------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH- d41 A) Appliration for Disposal Works Tonstrurtilan truti# Application is hereby made for a Permit to Construct or Repair �an Individual Sewage Disposal System at �t® L c yn Ad ess - or Lot No. 11.i�. K................ .....................•-------..._......----- '---•-••--•-..............----•---..._..... Address Installer Address Type of Buildinge Size Lot............................Sq. feet aDwelling JZ No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p,I Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QI Other 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 ( ) 0-4 Percolation Test Results Performed by------------------------------------------------------------------••••. Date......................................... E� Test Pit No. 1----------------minutes.per inch Depth of Test Pit____________________ Depth to ground water........................ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O --- -- _ Description of Soil........ ���&'- :-•_ -.. _... '-'•���-`-•'-�`-�--•-•-----------------------•---------------.............................................. W Nature of Repairs or Alterations—Answer when applicable--- - ...........14----------- ..-----•----•--•-••-•-----•-•••---------- --- -- --- --- ---------•-••--- ._._...... ----- ...................................... 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 the Wrd 1 alth. Signedr y1/AgV f Date Application Approved BY --•------=------ Date Application Disapproved for the following reasons------------------------------------------------------=---------------------------•------•--••--•------••--•-••-- ----------------------------------=---------•------•-----------•----........--------------•-•-------...------------------------------------•----...------•--------------------•----•----•-•-------_...._ Date PermitNo......................................................... Issued---------------------................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HEALTH • ...........OF... !�' ........................... CIrrtifiratr of. Toutpfiattrr TuIS^ S,T CERTI& That the dividual ge Disposal System constructed ( ) or Repaired --------------------------------------•--------••---•-----•- ------•-- Instal has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-_............................................ THE ISSIJ NC OF THIS CERTIFICATE SHALT. NOT BE�CONSAS A GUARANTEE THAT THE SYSTEM WI F CTION SATISFACTORY. DATE.... � _._.. Ins r P THE COMMONWEALTH OF MASSACHUSETTS BOARD, QF HEALTH, L � �.. � .....-....OF....:�-�A ���o�..✓e��l�'_1'%° �_'.�-�e 7a b No�_................... FEEL Permission is hereby granted__`: ,�a t 4r �r�l <.:; ------------- to Construct ) or .;pair (d/f`an IndividualSew, ge Disp� System atNo....... r _a.. .... Q ' ......................................................... treet as shown on the application for Disposal Works Construction Permit _ __________________ Dated.......................................... ................ .... --•-•------------------------------------------•-----------.................. Board of Health DATE--/, FORM 1255 A. M. SULKIN,-INC., BOSTON -