HomeMy WebLinkAbout0061 OLD SCHOOL HOUSE RD - Health -- 61 Old School House Road
-- -- -- — — -- - - -� Hyannis
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A=268-269
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E.
TOWN OF BARNSTABLE
LOCATION 0CA 5 '(_J,.(,f F SEWAGE#
VILLAGE J+—t•4-#�Iti l Q ASSESSOR'S MAP&PARCEL ,
INSTALLER'S NAME&PHONE NO. -C- i- 5'6'-17
SEPTIC TANK CAPACITY tL<L( "j g6 gncq 4 A4— /o
LEACHING FACILITY: (type) (size)c°o, X P1-T-T GCS-s
NO.OF BEDROOMS
OWNER -U - L 5
PERMIT DATE: -' COMPLIANCE DATE:
Separation Distance Between the:
I Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4--�—Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Nbef= Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) 6= Feet
FURNISHED BY / s/' � �lr«•�••f,ns
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No. (lJ L Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y
RppYitation for 33isposal *pstrm Construction J)frmit
Application for a Permit to Construct( ) Rdpair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ( /0/ 'S'h wner's Name,Address,and Tel.No. 610V ?711 '?D-5$
Assessor's Map/Parcel �jh/�e.0o$-ao �nl 1�" D���oo/ham�
Installgr's Name,Address,and Tel No. g 06-'�7/ - g$7,, Desi er's Name,Address,and Tel.No. " 36 A "y
C� Jodt;-Corns fu 4�o ;zm <,/S�= vS a bum y�e iq r'rr� ��S`rl4ir�Sf
5 k i 15
Type of Building:
Dwelling No.of Bedrooms Lot Size lyi sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) U gpd Design flow provided 3V9 gpd
Plan Date &jn e /gym, �OJ(o Number of sheets / Revision Date
Title - 1 �S S� fir, _i sue. 14
Size of Septic Tank e.)S� m j(app Type of S.A.S. of
Description of Soil �� � 1�
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code--- d to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Date Cd 3011
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. C / Date Issued (0
-- ------ -----___
No. Fee / y
THE COMMONWEALTH�OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y
2pplicatiou for -Misposal *pstem Construction Permit
Application for a Permit to Construct( ) •ki�pPr-(--)-Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 6/0lc/ �hUO� GC(1QQ Awner's Name,Address,and Tel.No. :0f--9� �- 5$
�6�-�(c t}ni� / U- L/,O/q��oo//i"4,w/lc/
Assessor's Map/Parcel /� �n�,5 ! 4L U,;1e_6Z
Ins,t�aller's Name,Address,and Tell.No. 5 pi -77/ - g3�/y' Desi ner's Name,Address,and'Tef No. 8 36 a 'yS'/
,9 X��(G� 00 (cx+!vY�, 1r�c `/SL vS�ie !off } io ns S, /(rai.,s�
S A4//(5 6aG v a u r~ d 7 '
Type of Building: t
Dwelling No.of Bedrooms Lot Size �u� / sq.ft. Garbage Grinder( )
Other Type of Building w� No.of Persons Showers( ) Cafeteria( )
Other Fixtures 1�
Design Flow(min.required) 3 3a N_ gpd Design flow provided V 9 gpd
Plan Date Lmo /(,, C�0/(1 Numberiof sheets / Revision Date r
Title i�i 5 S,
/ I
Size of Septic Tank Type of S.A.S
Description of Soil
a
Nature of Repairs or Alterations(Answer when applicable)
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 ode and to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
j Si a Date 111/1
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �w v� Date Issued V
------------------------------------------------- -------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by _ r Fn� 1 ���!x_ ran \ ir,e
at a a has been constructed in accordance
with the provisions of Title 5 and the for Disposal System tonstruction Permit Ni dated )36 �p
Installer &r nIdti Co n.s+:y Designer Q-xfN . a �a Z 1lC �noe
#bedrooms Approved design flow (3 gpd
The issuance of this permit all t b construed as a guarantee that the syste wu ion designed.
Date Inspecto
No. �C�(Q �� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposai 6pstrm Construction Permit
Permission is hereby granted to
Construct( ) Repair( Upgrade( ) Abandon( )
System located at �Q / / 4 ,Z
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction T
beccomplee ed within three years of the date of this pe rmit. �t �Date /J, / Approved Ry
`6 16je Town of Barnstable P#
�ptpar mentsof Health,Safety,and�Env�ronm qt S ry eesA=l �U
P;ublie,H�ealth on Date,Date,
,�6T'
367 ain`�Stwot,Hyeanis MA'02601'
S wexarnarE.
tadaq l��f,
16 9 J Wr
rEo rug+" Date Scheduled Time� Pee Pd. _
Broil Suitabi�lit`y Assessment fog° Sewage Disposal
�Qf\ G Witnessed B :, �+ Kf
Performed By: rt
1-
xx
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;.::::::::::::::::::::::.::::::;;;;>;:::.;:;::::::::::::.;:.:..:::::::::::::::.....:..:........................................
...............:......... ........
Location Address / D� lJ /1G�pljn,,l a Owner's Name Ur�
Aaa,ress j s X A4
Assessor'sMap/Parcel: p2,W14 Engineer's:Name
NEW CONSTRUCTION REPAIR f _. Telephone#
I /
Land Use 1 Slopes(%) Surface-Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well f Z60 ft --
Drainage Way Co ft Property Line ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,.loc to wetlands in proximity to holes)
V
z
Parent material(geologic) Depth.to Bedrock z '6't'
Depth to Grounae Standing Water in Hole: P g
- -dwt—r: anng /-��4r,�t=:'- -- Wee in -from Pit Face r: -
Estimated Seasonal.High Groundwater_
- ..... ............`..: "" ".. ..................................
.. ....:..:: ..........:.:...:...........::..:.:~ ';; .:.:,......_.::"::::;
...........:.................. .
Method Used: L.
Depth.Observed standing in obs.hole: in. Depth.to:soilgmottles: ; in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well#___ -Reading Date:_..__ Index Well level:.,_ " Adj'tfactor '""' "Adj:,Grouhdwater Level_
Y.
................................................................................................................
Observation �J
Hole#' 1 ,.. Time,al:Y',a -
•`
Depth of Percqe
Time at`6 "}'
---Start-Pre-soak Time®
a
End Pre-soak
Rate Min./Inch
_ Fr,. t�.; �..t, .a, =s:r 'Y:ftt' S'►,oij ,$.tF �.I~
Site,-Suitability-Assessment Site'Passed• ' s o n. +Site,Faded. s:c. .•• AdditkenaaUTesting.Needed(Y/N) -r+
Original: Public Health Division Observation Hole Data To Be rvompleted on Back
Copy: Applicant v. W
t
Ai! Piilp
:: .$ 1 ::::::.......:.::.:.::::.::.:::::::::.::::::..:....::::::::::::::.:::::::::::::.::......
Depth from Soil Horizon Sbil'ToctUret 1 Tl'SoiI:C01or' t.' Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulderes.
Consistenc o
Graveh
0
{* !
:.;>:::.>;:::.;:::o-s:c:•;:a>:>:i::;; >: .: > ; '::':i`ta:::: .';k
:.:< : ER'VAT:I�?�;.H:�?:.L...EL!D:�:.;•.;:.;:;::;:::;>:;.;:.:;.:;I�.::::::.;:<.;:.;:.. .,,,y,,.;:<;.>:::.;:.;;:.;:.>:.>:.;:<:;:<.;::;>:.:.::
EEP ::>�;:>;;::.::::::::.:::..:::: •.:.�:.;:............:..:..:.:::.....:....
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (U
SDA)�r (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,°oGravel)
p
�0•ZO � LS �` �8'
.............
ZD-�2 1t CS � � alb
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA.) (Munsell) Mottling (Structure;Stones,Boulderes.
o i nc °o cl
::; :::..D�EP;<OBS: RATxap ,E.;:::::.::::::::.:..;:.;:.::.:;::.;::.:<.::«.::.>:.:::.:;.::;
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
onsistency,%Gravel)
------------
..
r*
:1a•Io'od Insura iM-Ahte 1Vlari; r
M Above 500 year flood:boundary. •No_ Yes
Within 500,year,boundary No Yes
Within l00 year flaod'boundary No, ,—Yes, .
to" lati . {tj,*'
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious terial exist in all areas observed throughout the
area proposed for the soil absorption system? V—
Ifnot,what,is the depth of naturally occurring pervious material?
Certification
I certify that on It.2 (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
41e required.training,expertise and experience described in 310 CMR 15.017.
Signature Date V l�
JUL-14-2016 02:5e From: To:150e7906304 Pa9e:1-�1
FROM FAX htQ. Jul. 13 2016 01:42PM P1
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Ilexith Division
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p2 e: 506-?42-4644
based ou a diavmbp
�,.xefCic�+lcBcl s cree rt9�3µ ll� `nb3b=,Ually sc to
T.aestsiytw th R,-?fL am lateral rt;lacaLio t
"^ design,wLich may 3n�;lu+ e mizior a'7oved cha gu
dLtjb+xb.mbms,ta&c sc ir-t�1k
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t IiY la#.a2al.relac riaa of Jo xA•S M a11. •veilin�1 relaaaiiuu��y �
hest ft b;
o septic s , }but in ancuTclauaettt Local�Le ,llariox►;,. lfj�►, i; a�cr
c � deslR�Ps t�,�oTLaQv.
�K OF MWA,q c�
DANIELA,
OJALA
4
U CIVIL
No.46602
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nj
Im ,
r'- Certified Mail Fee
nJru $
Extra Services&Fees(check box,add fee as appropriate)
❑Return Receipt(hardcoP» $
�I � ❑Return Receipt(electronic) $ `A`�Q
I C ❑Certified Mail Restricted Delivery $ \' F{g
I U ❑AduR Signature Required $ �+P
❑Adult Signature Restricted Delivery$ (71
C3 Postage nj 'IN -7 0
r�l Total Postage and Fees 1U)g i
�{ Anita Bourque —� - Spy s� -
r- 61 Old School House Road
Hyannis, MA 02664
l
Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®-postmarked Certified Mail receipt to the
■A record of delivery(including the recipient's retail associate.
signature)that is retained by the Postal Service- .; Restricted delivery service,which provides
for a specified period. delivery to the addressee specified by name,or
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Important Reminders. Adult signature service,which requires the
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or Priority WHO service. Adult signature restricted delivery service,which
■Certified Mail service is notavailable for requires the signee to be at least 21 years of age
international mail. and provides delivery to the addressee specified
■Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is
Insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
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endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for
the following services: postmarking.if you don't need a postmark on this
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of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece. .
electronic version.For a hardcopy return receipt,
complete PS Form 3811.Domestic Return
Receipt;attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
{ PS Form 3800r April 2015(Reverse)PSN 7530-02-000.9047
o Complete items 1,2,and 3. A. Signature
® Print your name and address on the reverse X ' ❑Ag
so that we can return the card to you. ddressee
® Attach this card to the back of the mailpiece, B. ived by(Printed Na e) C.� Delivery
or on the front if space permits. T
1. Arti,'--AAA D. Is delivery address different from item 1? ❑Yes
Anita Bourque If YES,enter delivery address below: ❑No
61 Old School House Road
Hyannis, MA 02664 I
I
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II IIIIII IIII III I I I I II I III I II II II I I'I I I II III 3. Service Type Priority Mail Express®0 i
❑Adult Signature Registered MailTM
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9590 9403 0521 5173 2827 84 ❑Certified Mail® Delivery i
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Collect on Delivery Merchandise
2. Article Number(transfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationT"
ed Mail ❑Signature Confirmation
7 015 1520 0001 2273 26133 ed Mail Restricted Delivery Restricted Delivery
1$500)
PS Form 3811,April 2015 PSN 7530-02-000-9053 Domestic Return Receipt
I - _
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Postage&Fees Paid
LISPS
Permit No.G-10
I
6
I • SF— �' nrir,t vour_name, address, and ZIP+4®in this box•
Town of Barnstable ~'
I 1 Public Health Division
I r.,
200 Main Street
I =; Hyannis, MA 02601
I USPS TRACKING#
I
9590 9403 0521 5173 2827 84
R F,
- Town of Barnstable Barnstable
OF ZHE Tp�
Regulatory Services Department ANUrtedmCft
BARNSTABLE * Public Health Division
y . 2007
`bA i63939' 200 Main Street H annis MA 02601
rFD MP'I a � Y �
Office: 508-862-4644 Richard V. Scali,Director
Fax: 508-790-6304 Thomas A.McKean, CHO
CERTIFIED MAIL# 7015 1520 0001 2273 3333
May 10, 2016
Anita Bourque
61 Old School House Road
Hyannis, MA 02664
ORDER TO COMPLY WITH STATE ENVIROMENTAL CODE, TITLE 5
The septic system located at 61 Old School House Road, Hyannis, MA was last inspected on
April 27,20169 by a certified septic inspector for the State of Massachusetts.
• The inspection of the septic system showed that the system"Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Leaching pit or cesspool with high liquid level,<12" below inlet (per,Town
Code 360-9.1).
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action
You may request a hearing before the Board of Health if written petition requesting
same is received within 10 days.
If there are any questions about this reminder,please feel free to contact the Barnstable
Health Department.
PER(?*DER OF THE BOARD OF,
• Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\61 Old School House Rd Hy May 2016.doc
R ,
' Cf ZF1E fQy, '
Town of Barnstable
' ; a►uvsrAsc�,
a Regulatory Services Department
i639• A,bB
pTED MA't '
Public Health Division
200 Main Street;Hyannis MA 02601
Office: 508-8624644 Richard Scali,Director
FAX: 508-790-6304 Thomas A McKean,CHO
Feb 6,•2007 •
Rev. 7/6/15
DEADLINES TO REPAIR-FAMED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or.cesspool
❑Any portion of the SAS, cesspool, or privy,below high groundwater elevation
❑Aty portion of the cesspool within'a Zone l to a public well
❑Any.portion of a cesspool within 50 feet of a private water supply well with no
acceptable water.quality analysis. (This-system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool ,
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components; etc)
XLeaching pit or cesspool with high liquid level,<12"below inlet(per Town Code
§360-9.1)
OTHER
A04 CGn A aI
Repair deadline:
WSEPTIMIDEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessment
61 Old School House Road
Property Address
Anita Burgue
Owner Owner's Name/
information is H annis ✓ MA 02664 April 27, 2016
required for every y P
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer, Q
use only the tab 1. Inspector:
key to move your
cursor-do not David B. Mason
use the return Name of Inspector
key.
David Mason
Company
Name
4 Glacier Path
Company Address
East Sandwich MA 02537
City/Town State Zip Code
508-367-1617 S1287
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
i
May 2, 2016
Inspector's Signature • Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 61 Old School House Road
Property Address
Anita Burgue
Owner Owner's Name
information is Hyannis MA 02664
` required for every-- Y April 27, 2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664 required for every y April 27, 2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static'water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664 required for every Y April 27, 2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
® ❑ 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 'h day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664 required for every y April 27, 2016
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 1.5.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664
required for every y April 27, 2016
page. CityrFown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
` ® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the.condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ 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.
N El Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance
pp sta ce Is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is H annis MA 02664 required for every Y April 27, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
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 ears usage d Yes
9 ( Y 9 (gp ))�
Detail:
2014; 16,500 gallons and 2015;17 g ,250 gallons
sump.pump. El Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official -Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664 required for every y April 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Board of Health
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
i
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
II
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 61 Old School House Road
Property Address
Anita Burgue
Owner Owner's Name
information is Hyannis MA 02664 April 27, 2016
required for every y _ p
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
built in 1991
Were sewage odors detected when arriving at the site? El Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
r
Septic Tank(locate on site plan):
Depth below grade: 2feet
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 Typical
Sludge depth:
8"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is April 27, 2016 Hyannis MA_ 02664 A required for every y p
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 36"
Scum thickness 5
Distance from top of scum to top of outlet tee or baffle 3
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Scour Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Effluent level with outlet invert. Tank is 12 inches below grade.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664 April 27, 2016
required for every Y p
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664 April 27, 2016
required for every y p
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Not Applicable.
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.):
Did not expose distribution box after observing leaching pit.
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664
required for every y April 27, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
6 foot pit with 2' stone., Effluent within 2 feet of inlet invert. Evidence of staining above the inlet invert.
Leaching pit is failed on the basis of staining above inlet invert per Barnstable Board of Health policy.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert -
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burgue
Owner Owner's Name
information is Hyannis MA 02664 required for every y April 27, 2016
page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
61 Old School House Road
Property Address
Anita Burgue
Owner Owner's Name
information is Hyannis MA 02664 required for every Y April 27, 2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide.a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
M
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
. , Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments'
61 Old School House Road
Property Address
Anita Burgue
Owner Owner's Name
information is Hyannis MA 02664
required for every y April 27, 2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 18
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:
Groundwater Contour Map
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Groundwater Contour Map
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°wM 61 Old School House Road
Property Address
Anita Burque
Owner Owner's Name
information is Hyannis MA 02664
required for every y April 27, 2016
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE
LOCATION y l -7/' SEWAGE #
VILLAGE «,� ``�=- (.� ASSESSOR'S MAP & LOT
INSTALLER'S NAME& PHONE NO._,`/y✓; 2)
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ATf(size) 6 W z/f4)k
NO.OF BEDROOMS 7 PRIVATE WELL OR PU�WATE
BUILDER OR OWNER __ ,�'('v,��'✓c'
DATE PERMIT ISSUED: 3 1 `T
DATE COMPLIANCE ISSUED: 'Z( o I
VARIANCE GRANTED: Yes No
o
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=268269&seq=1 4/26/2016
TOWN OF BARNSTABLE /
LOCATION SEWAGE #
VILLAGE 15 ASSESSOR'S MAP & LOT J
INSTALLER'S NAME & PHONE NO. ?/ %/ �✓ � 7P"
SEPTIC TANK CAPACITY l j
-LEACHING FACILITY:(type) % j �'r� (size)
NO. OF BEDROOMS PRIVATE WELL OR P �WATE
BUILDER OR OWNER low�
DATE PERMIT ISSUED: 3 2Z %
DATE COMPLIANCE ISSUED: �(
VARIANCE GRANTED: Yes -No
Cay
(� 1
\ ,. ::
•,�x
d '9
No----,1. -.Zd.9 Fss..... ......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Marks Tonstrudion thrutit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
............. _�✓. .L �S .. d............... .... �!.l �`�j 5 �� -.,.... (..d. .....-----•---
'Location-Address or Lot No.
I
............................... j --............ ..........................................................
................. ...............................
w , er d �`�.yr fit` n 5
Installer Address
Q Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
'114 14 6ther—Type of Building .... No. of persons............................ Showers — Cafeteria
Pa 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 ( )
'-� Percolation Test Results Performed bY............................................................................ Date.........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water._.------_--.-------..:-
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--.................--.
P4 •----------•-------------------------------•--......---•--------------...........------------------...............................----------------- --•-----
0 Description of Soil...............................................................................=........................................................................................
x
U
W
UNature of Repairs or Alterations—Answer when applicable......................................._....---.----........--......................._._........
----------------------------•---•--......--•-------•-------•-----------------------............---------•-------------------------------------....------------------------------•----•---••--:......._..
i -
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of has been issued the board of health.
Signed ---
Compliancy ,
-----------------
re
Application Approved BY -------------------------------
---------1�n-
J Date
Application Disapproved for the following reasons: ...........
-------------------------t----------------------------------- ---------------------------------- ---------- .----------------- --------•---................................... ..-............---------------------------------------
Date
PermitNo. -------- ` %./-------------------- Issued -----.........------------....-- -- --. .....------. .....--
Date
's o ! 41
FEB
THE COMMONWEALTH OF MASSACHUSETTS a
- -- BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirdtion for Disposal Works Tonstrnr#inn "anti#
l Application is hereby made for a Permit to Construct ( ) or Repair (k) an Individual Sewage Disposal
System at:
ev
.. Location-Address or Lot No.
......... - ILLS _G�-IS_5��... .• ... .... .... ^• --' ...-
W owner Adis
----- ------------------ ,�-------------------------------------------------------
Installer Address
Type of Building �/ Size Lot............................Sq. feet
�-t Dwelling—No. of Bedrooms............... ........................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building .............. No. of persons.................._......... Showers — Cafeteria
Otherfixtures f---•-----------•--......•--••---•-•---•-...•-------•---•---•--•----•-----•-------•-----•----•••-------•._...-•..........................:...
W Design Flow................................:...........gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width-__en..._..... Diameter................. Depth`............_.
x Disposal Trench—No.:{................. Width.................... Total Length---------- ....... Total leaching area_...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet---ZZ-"_-.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolationjest Results Performed by.......................................................................... Date........................................
Test-Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
G� TestjPit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
_._.
Descriptionbf Soil......................................................................................... -............`--=------------------------------•--......--•---.............••.
W �.
U -•--•-•-------•-----------------•---•--------------•-•---•------•-•-••-•----•-•---•••----•-•-•---•--•------•----•----•-----------...--•---•-•-----•--•-----••--••••-•--...................--------•-----
W
U _ Nature of Repairs or Alterations—Answer when applicable__._....4____________ ___________// ..
f; =.ter'.. -
.................................................................................................................................................._.........__�........---•.-.....--•---•----•--
Agreement:
The undersigned agrees to install the,aforedescrl�d Individual Sewage Disposal 'S'ystem in accordance with
the provisions of TITLE 5tertificate
f 1t'PeQState En-v4fonmenta4-C*.@.de—The undersigned further agrees not to place the
system in operation until a of Compliance has been issued b the board of health.
=----------- 2 �...Signed ��(s%✓t.-�-� ^{�
r.-d/!'�......................................................� ... �1/....--1Z__/
.... ....
Application Approved By -------------1. -----.t7 _ .�
n --
Application.Disapproved for the followi g reasons- -------------------------------------------------------------------------------------------------------------------------------------
f Date
PermitNo. 9---------------------- Issued ----------..............------------------....--------------------..
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cer#tftrate of (fantyliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( � )
by........`t..i..PP.t .------------------- ---------------------- ---------------------------------------------------------------------------------------------- -------------_---------
Installer
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
w the application for Disposal Works Construction Permit No. ........ �...��..�Cx... dated ....... ......................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE A A GUA ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... - - .�-... Inspector r-- -_
---=
THE COMMONWEALTH OF MASSACHUSETTS I
BOARD OF HEALTH
TOWN OF BARNSTABLE
No. 1..'. � . FEE.. . ?........
Disposal Works -Tons#r Uan meat
Permission is hereby granted.----••�" '• .-->� .X&<....--••--••--•..................................................................•-•---
to Construct ( ) or Repair (A) an Individual Sewage Dip System
at No.. a%? !�'1��... � `'�L! ' *-` 'gw.------------------ �... /�j/ /_.................
Street
as shown on the application for Disposal `'forks Construction Permit IZTo.���� Dated..........................................
...........................3.`-_.T.._ _.�..........................................................
U Board of Health
DATE-- �....._;_I...... .............
FORM 36508 HOBBS h WARREN.INC..PUBLISHERS -
ALL SYSTEM
OMPONENTS SHALL
SYSTEM PROFILE MARKED WITH CMAGNETIC TAPE OR BE
NOTES
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS NAVD 88
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE 2. MUNICIPAL WATER IS EXISTING m Mai
2' PEAST❑NE OR GEOTEXTILE West Main St. St.
\ TOP FOUND. EL. 34.6 FILTER FABRIC OVER STONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. end e
31.6' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 31.0 P
WATERTEST D'BOX FOR LEVELNESS BLOCKS OR 4. DESIGN LOADING FOR ALL PROPOSED PRECAST T '�
PREC7E..
MIN. 2' WALL THICKNESS PRECAST RISERS UNITS TO BE AASHO H-]Q
RISER � - Locus
4'0SCH40 PVC MORTAR ALL
30.3' PIPES LEVEL 1ST 2 COMPONENTS INVERT IN 27.5' 5. PIPE JOINTS TO BE MADE WATERTIGHT. to ey o
4 CTYPJ
ENDS SIDES 28.33'
EXISTING 14>� _ 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE
° ° ° ° ®®®® ®®®® ®®®®- ®®® WITH 310 CMR 15.000 (TITLE 5.)
TEE SEPTIC TANK TEE °
\28.9±1* °°°°°°°° ®®®®®®®®®®® ®®®®L�®®®�®® °°o°°° ° Sinifh
°"0.,0.
° ° ° ° ° ° °
° o >°°°°°°°°
'°° ° ®® ° ° ° 7. THIS PLAN IS FOR PROPOSED WORK ONLY ANDGAS BAFFLE:• a 00000°o ®®®®®®®®®®� ®®®®®®®®®®® ;oa000000° ° ° ° . ° ° ° ° NOT TO BE USED FOR LOT LINE STAKING OR ANY° ° ° °° °°°°°°
27.7727.6 ° ° ° ° 25.5 OTHER PURPOSE. a 5 O
LH-20 500 GAL. LEACHING CHAMBERS BY ACME PRECASTOR EQUAL. °
3/4 -1-1/2' DOUBLE WASHED STONE 4' MIN. 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC.
ALL AROUND PRECAST STRUCTURES <2) UNITS REQUIRED
6" CRUSHED STONE OR MECHANICAL aywo
OVERALL DIMENSIONS TO OUTSIDE OF STONE, 25.00' X 12.83' 9. COMPONENTS NOT TO BE BACKFILLED OR
COMPACTION. (15.221 [2]) CONCEALED WITHOUT INSPECTION BY BOARD OF Cb
C HEALTH AND PERMISSION OBTAINED FROM BOARD o
(2°`F% SLOPE) ( % SLOPE) OF HEALTH.
FOUNDATION- EXIST. SEPTIC TANK 47' D' BOX 12' LEACHING 10. CONTRACTOR SHALL BE RESPONSIBLE FOR
FACILITY CALLING DIGSAFE (1-888-344-7233) AND
20.5' BOTTOM TH-2 VERIFYING THE LOCATION OF ALL UNDERGROUND &
**INSTALLER SHALL CONFIRM MINIMUM OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF
*THEINSTALLER
SHALL T VERIFY
AND ALL H SEPTIC TANK SIZE AT 1000 GALLONS NO GROUNDWATER FOUND WORK.
LOCATIONSOF ALL LOCUS MAP
BUILDING SEWER OUTLETS AND AND ITS SUITABILITY FOR RE-USE. 11. ANY UNSUITABLE MATERIAL ENCOUNTERED
REPLACE WITH 1500 GALLON SEPTIC SHALL BE REMOVED 5' BENEATH AND AROUND THE NOT TO SCALE
ELEVATIONS PRIOR TO INSTALLING ANY TANK APPROPRIATE TO SITE PROPOSED LEACHING FACILITY.
PORTION OF SEPTIC SYSTEM CONDITIONS IF NOT SUITABLE
12. EXISTING LEACHING FACILITY SHALL BE PUMPED ASSESSORS MAP 268 PARCEL 269
AND REMOVED OR PUMPED AND FILLED WITH CLEAN SITE IS LOCATED WITHIN A ZONE II
LEGEND SAND.
99- EXISTING CONTOUR
X 991 EXIST. SPOT ELEV.
-[99]- PROPOSED CONTOUR
[98.4] PROPOSED SPOT EL.
CAUTION:
TH 1 GAS LINE IN THIS AREA
{b TEST HOLE SYSTEM DESIGN:
2� SLOPE OF GROUND _ LOT
GARBAGE DISPOSER -IS .NOT ALLOWED
UTILITY POLE 70, 01+
EXISTING 3 BEDROOM DWELLING
FIRE HYDRANT ' �
y _ _ 1 03 _ DESIGN FLOW- 3 BEDROOMS Q 110 GPD = 330 GPD
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING I
S�1°1�1'�a' O USE A 330 GPDD
DESIGN FLOW
�/ \ O ' SEPTIC TANK: 330 GPD (2) = 660
TEST HOLE LOGS SLEEVE SE LINE O LP **RE-USE EXISTING 1000 GAL. SEPTIC TANK
WITHIN 10' TH2
SE #
CRAIG J. FERRARI, 13871 WATER LINE LEACHING:
ENGINEER: / TH1
o SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD
WITNESS: DAVID STANTON, RS
/
DATE: 6/15/16 o, BOTTOM 25 x 12.83 (.74) = 237 GPD
� �
PERC. RATE _ < 2 MIN/INCH / O O TOTAL: 472 S.F. 349 GPD
CLASS I SOILS P# 15071 / / PAVED ��� O N o USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL)
DRIVE u� WITH 4' STONE ALL AROUND
ELEV. O ELEV. ) O1O C:) ao
off 1 31.5' p z 31.5' � / \ EXISTING C)
DWELLING Z
A A y� // ON- DWELLING
= 34.6
LS LS MA
10YR 3/2 10YR 3/2 APPROVED DATE BOARD OF HEALTH
12" 10" BENCHMARK BENCHMARK
MA
B B EL.G=SET 31.4' Y DECK TITLE 5 SITE PLAN
LS LS OF
10YR 5/8 10YR 5/8 O
24„ 29.5 20 29.8 tiQ,° ✓� 61 OLD SCHOOL HOUSE ROAD
HYANNIS, MA
PERC
C C 2 PREPARED FOR
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M/CS M/CS
BORTOLOTTI CONSTRUCTION/BURQUE
DATE: JUNE 16, 2016
1 OYR 7/6 1 OYR 7/6 6-\b `
OF higS cf CN OF -10 0 ��'t M s c F Mg1 . off 508_362-4541
�? , DANIEL_ DANIE yG fax 508 362-9880
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ANIEL
DANIELA. ;®OJALA 9 Yo A. �' � A. N�'. downcape.com
OJALA CIVIL m OJALA I(c OJALA W e CIVI No.40980 n c` 40980 � Qp ell h7eeridg Inc.
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132 20.5' 132" 20.5' No.46502 fi R� 4 OJF� ��� � �� �� o�� civil engineers
Scale: 1'= 20' �F�G�STeR �S srE
NO GROUNDWATER ENCOUNTERED �s ��,�� s� NR� N I r{: ����� land Surveyors
33\^ `- aqa 939 Main Street ( Rte 6A)
LICE # > 6- > 6'S
0 10 20 30 40 50 FEET O DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675
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