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HomeMy WebLinkAbout0098 PINE STREET - Health 98 Pine Street Hyannis A= 249= 041 -'002 4 ` if 1 TOWN OF BARNSTABLE Lk CATION ��� �T�"��-� SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL C7 QOa INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size). ��' A 0� NO.OF BEDROOMS nn� OWNER PERMIT DATE: COMPLIANCE DATE: "7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > 6 Feet Private Water Supply Welland Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BYZ� �Q},� Jp��J�' /V„ n 11 61 CJ s ` O 6� No. I, j p201lf�— �l� a Fee 0O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitatlon for -MIBposal *pstrm ConstCUttlon VPrmit Application for a Permit to Construct( ) Repair( ) Upgrade(,/jAbandon( ) ❑Complete System Individual Components Location Address or Lot No. F t��_ j- \ Owner's Name,Address,and Tel.No. CsLI1r,.3T`�— Assessor's Map/Parcel L DGl _ (Dp hyyt �� Sys Installer's Name Address,and Tel.No. S®cd— G 55 Designer's Name,Address,and Tel.No. ISa836©j3Jf Type of Building: Dwelling No.of Bedrooms Lot Size `d.,CFt �5_ sq.ft. Garbage Grinder( ) Other Type of Building ��S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided a,, cl S gpd Plan Date Number of sheets Q Revision Date Title Size of Septic Tank <0=!� " Type of S.A.S.Cp Description of Soil Nature of Repairs or Alterations(Answer when apphcable)—_7,jLN�,_ Vqk—aC"I �) C�, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. SigaciL, Date 12 Application Approved by Date ���— Application Disapproved by Date for the following reasons Permit No. O� �V Date Issued c NO. € Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OFBARNSTABLE, MASSACHUSETTS Yes Zipplication for Bisposal 6pstem (Construction permit Application for a Permit to Construct( ) Repair Upgrade(Abandon( ) [:]Complete System [I dividual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �. Installer's Name,Address,and Tel.No. Sn` 6 5 Designer's Name,Address,and Tel.No. 5'©a 360 ;jr/f `Type of Building: Dwelling No.of Bedrooms Lot Size Chi C?=c 5 sq.ft. Garbage Grinder( ) Other Type of Building s-Z-, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided )y a, ,(j1 gpd Plan Date '� (0 Number of sheets Q Revision Date Title Size of Septic Tank k OC_' C� Type of S.A.S. Description of Soil - Nature of Repairs or Alterations(Answer when applicable)_�n..5 __A Date last inspected: i Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been,issued by this Board of Health. / Si Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2 —' 'y Date Issued Y 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 C [1rvt ,Ue�� J� .�yd� �{ at ��� ` ' v� �.� � has been const�ryucc;dd' c/clordance with the provisions of Title 5 and the for Disposal System Construction Permit No.cz, T� 'V dated Installer��.nr�,,� -i ����„� Designer #bedrooms Approved d i flo+ v gpd The issuance of this perm shall not be construed as a guarantee that the system wl fun lion as desi ed. Date 1 7'b Inspector t/ N t ----- ----------------------------------------------------------------- ----------- ------------- = Fee --//=�� No. - a016_ 3(0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade(,� Abandon( ) System located at 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 must be completed within three years of the date of this permit. Date ' Approved by I 'I r Town of Barnstable �WE'Owtio Regulatory Services Richard V. Scali, Interim Director * EARNSPABLE, ; 9�AMASS. Public Health Division rFv �a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 1 Installer & Designer Certification Form Date: 1� ��O Sewage Permit# `C:A( fit C--> Assessor's Map\Parcel �`f f 00 Designer: D S N Installer: Address: S Address: 38k �2�t 3-7 On Q 3® lac +" at issued a permit to install a (date) Qp Q (installer)/ septic system at �O f i WL ST- NYAWIV15 based on a design drawn by �(- (address) 1'K�Y� L• dated (desi I certify that e septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructe e with the terms of the IAA approval letters (if applicable) RR (Installer's Signature) ! 940 - k lk(o esigner's Signature) (Affix Designer _ amp Here) PLEASE RETURN TO BARL ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc low* Town of Balrnsta:W_ s.. .P# /5/ZIl Department of Regulatory Services -exar+ar�er�, � Public•Health-Division, �? . , Date MASS , 1 200 Main Street,Hyannis MA 02601 4 C � Date Scheduled U` - a r _Tim «+ ed N�1 Fee��Pd. Soil Suitability Assessment for Se. _ ge Pisposa w Performed Witnessear P LOCATION&�'GENERAL'.INFORiV1A;TION` Location Address gJ j .Offer s Name � aQ,. Address Assessor's Map/Parcel: Engineer's Name NEW CONSTRUCIYON REPAIR!. \• �.�y. J s�wTelephone#p,,_' c�c�. Q-(S ct---6�?o Land Use - p ( )� a'Surface.Stonesr - �� y ., r Distances from: Open Water Bod7;�i � + ` pe -y Possfl l' Vet Area, 8 ..Drinking Water Well .: �-ft ' Drainage Way T ft Property Line ft Other - ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&,pare tests,locate wetlands-{n proximity to holes) A t , t Parent material(geologic) Depth to Bedrock Depth to Groundwater St ding Water in Hole: ^' Weeping from Pit Face r Estimated Seasonal High Oroundwatec- DETERMINATION FOR SEASONAL-HIGH WATEXTABLE Method Used: Depth Observed standing in obs.hole: In. Depth to Soil mottles Depth to weeping from side of obs.hole: In,;,.Oroundwater Adjj i men t Index Well# Reading Date: Index Well level AdJ,factor, ,,_� Adl,Groundwater Level ,,e PERCOLATIONIEST ' Date Tltne;.__, Observation Hole# • N Depth of Pere _ a Time`at 6 ' 71 Start Pre-soak Time® �� - : '' ;► End Pre-soak ! � Min./Inch 42& Rate Mi Site Suitability Assessment: Site Passed ; t Site Falled: '.'i"'Additional sting Te Needed(Y/N)., t I j .fir j } Original: Public Health Division 1 t Observation•Hole Data•-To Be Completed o'dBack---------- ***If percolation test is to be conducted within 100'�,6f wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\.SEPrIC1PERCFORM.DOC �S . DEEROBSERVATIOMHOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. orljjj ncy %Oravel) r• r u DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. //,, Consistency.% M t/n� l�'1 .� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil . , Other Surface(in.) (USDA) (Munsell) Mottling (Structure;Stones,Boulders. Consistency. Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surf Ice(in.) (USDA)' (Munsell) Mottling (Structure,Stones;Boulders. Consistency. s Flood Insurance Rate Mae: w. Above 500 year flood boundary, No— ' Yes - . Within 500 year boundary No Y' Yes Within 100 year flood boundary No, Yes ' Depth of NaturaIlvy.o,ccurrina Pervious Material Doe's at least four feet of naturally occurring per i us material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pe vious material? Ce d ification I ce> ify that on (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed by me consistent with . the requir in exper6 a d ex erience described in 310 CMR::1.5.0 7. Signature .Date Q:\SFPTICVERCFORM.DOC 'LOCATION LOT NO.'= VILLAGE H ( t-4 W 'I S - DATE .. .rf ,, r APPLICANT OGEArIJ W 1`I:DIKje.` co FEE. o�: 6 ADDRESS -Jy/°rNNiS TELEPHONEf 'NO: �"11 -4400(Non-refundable t 1 ENGINEER ELD afE Q&15 F�s-�I�.SL E-�!4,f'� 'TELEPHO NO. . 15-n# . F` DA►TE SCHEDULED' � . .. ( t pplicant'.s signature f. r SOIL DO SUB -DIVISION NAME DATE Cal.,►7.f+� : .TIME. ' ` EXPANSION AREA: YES ✓NO `LLD ;, UWL 9t�' ENGINEER ' TOWN.WATER .�+ � � . ✓PRIVATE.-WELL � �' BOARD OP HEALTH � '- EXCAVATOR : SKETCH: (Street name,etc. ,dimensions 'o ai f lot,` exact location .of test`.holes' and- percolation tests, locate` wetlands in proximity to test oTes) j I NOTES: ' e. 39�'g \ . 01 ® 00 3 , `PERCOLATION -RATE:- c .►0 will ►A ;' TEST HOLE NO: 0 :ELEVATION: TEST BOLE. ELEVATION. 3 2 p�aZ LAND 1 ► 1— 2•• 3 3 . ' 4 '' . 4 5 5 5 6 I �d i� 6 s e s g �. 9 : . .. 10 . 10 < 12 12 13 13 14 14 ; . 15 15 16 16 :. SUITABLE FOR SUB-SURFACE SEWAGE: 'LEA'CHING ELELD.. LEAC ING PITSage . w LEACHING, TRENCHES . UNSUITABLE FOR SUB-SURFACE7SEWAGE_. REASONS: 441 NOTE. ENGINEERING' PLANS. MUST:' SHOW NUMBER'ASSIGNED ON PERC TEST`APPLICATION : ORIGINAL: COMPLETED IN ENTIRETY BY P . E. AND RETURNED TO ' BOARD' OF HEALTH rnpv. RRTAINED BY APPLICANT TOWN OF BARNSTABLE L,�)CATION stJt E7- Lo'r SEWAGE # Rb -(967 VILLAGE %1)/5 ASSESSOR'S MAP & LO, 'INSTALLER'S NAME & PHONE NOjJ� USA/ELIJ ,� ` �0 0 SEPTIC TANK CAPACITY /Obo qrg t LEACHING FACILITY:(type) /% (size) loo R NO. OF BEDROOMS 3 PRIVATE WELL OR FJJ03�IQN�AT �� BUILDER OR OWNER ,,DATE PERMIT ISSUED: DATE . COMPLIANCE ISSUED: 12I'2-'l LVARIAN' CE GRANTED: Yes �No � Aq9-w�-002- --_.. �, �� �6� f o �/� '�� �. _ .-,.. • ASSESSORS MAP NO. �� 01. PARCEL NO.: 64_13 • No.�:T.lGl.�� Fps THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................7� --...............OF........�.�.r.. .................�.- n...---•--.....--.._._......-- , pplira#iun for Disposal Works Cnunstrur#inn Frrutit Application is hereby made for a Permit to Construct (>() or Repair ( ) an Individual Sewage Disposal System at: Location.Add' s _ or.Lot N . l e. r'1.�_I�a?.__(!�? .�X - f �_e,_... �cs���.._.t'V_l. .... Owner Add ess ............................ ........ ..-_ . Installer Address Q Type of Building Size Lot.._._ ..tl.9 ....Sq. feet Dwelling—No. of Bedrooms...................-......._.....___.___Expansion Attic ( ) Garbage Grinder ( 6�°� Other—T e of Building ............................ No. of persons.,_,....................... Showers — Cafeteria d O er ur ------10.0m;e-------. = ...--------------------------••--------------------- ....lip.1lons. R; Septic Tank—Liquid capacity.A00®.gallons Length.........b.... Width...... '...... Diameter____ __:_____-_ Depth_. .__.._.. Disposal Trench—No...'.J......_.._.. Width.IAP.......... Total Length__AY........... Total leaching area./ .........sq. ft. Seepage Pit No-----_-------------- Diameter-------------------- Depth below inlet..................... Total leaching area.__`..............sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 3a Percolation Test Results Performed by._._;!. _L�ftt��_.... �__._�-'__•••••-•---•----•_•----.••_ Date..... �_'_ __._. .' Test Pit No. I_�_1M..minutes per inch Depth of Test Pit-----J. ............ Depth to ground water-----ANV .-- (�, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ��/ -------------------------•---......................---.....------.......................................................... O Description of Soill !:Sl9l+�d_ __�31. W -------------------•------------------------------- W ........................•------------------•--------------------•••-•--•••-•-•---------•----......---•-...........---IES1 It" 4 �. x --------------------------------------------------••--•••-•---------•---------.....-••••-•-------••----••••....... . CERTIFY N---- =- U Nature of Repairs or Alterations—Answer when ap ,__ __ ________________ ____________________________RITI.__r.. I IWSTALLED IN STFit: �'' --------- -- --...................................... Agreement: The undersigned agrees to install the afo edescribe Indi idual Sewage Disposal System in accordance with the provisions of iT=. ; of the State Sanitar The n rsigned further agrees not to place the system in operation a Certificate of Compliance ha, e iss y and of health. •. .... to App cation Approved By-•-•-•--------- .:......... ............................................. � cl---------------- --- -- ........ =---- Date 6 Application Disapproved for the following reasons:................... ---•------••---•--------------------------•---------------------------------------•-------- ..•-••••--••--••--•-••-•-•--•----•-•-••--...-•-••-••------•-•--•---••••••.....----•-----••-•-•-------••---••-•-••----•---•-•-•--------- -••------•--•-----•------•----•-••----•---------••------------ Date PermitNo.. - �-•--------_. Issued-....................................................... Date E. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --.-------_-...oF....:. .V..L ......----- .A............................... Appliration for Dt pakil Lkol Tomitrudilan Prrutif Application is hereby made for a Permit to Construct 0(.) or Repair ( ) an Individual Sewage Disposal System at: , P e �-, Location Add* s; or Lot To4 ice s.s. .PJ:. Owner tad4ress Installer ; Address UType of Building Size Lot----� �. Q3 .__..Sq. feet Dwelling—No. of Bedrooms...................:.....................Expansion Attic ( ) Garbage Grinder ( ,AV '. aOther—Type of Building ................... No of persons............................. Showers ( ) — Cafeteria ( ) O aertures -------------------4.6 A---- . .Design Flow.... gallons per person per day. Total daily flow.......... �....._ _.....gallons. W .. - W Septic Tank—Liquid capacity/Vp.:gallons Length....`.:_ ..... Width.. Diameter---- ------------ Depth x Disposal Trench—NTo.__J............. Width_/jV............ Total Length.?.'r'............ Total leaching area// sq. ft Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area__ Z Other Distribution box ( ) Dosing tank '-' Percolation Test Results Performed by..... jrjla : .....__ _ Date_._L-A _ ...... " Test Pit No. if-1w0_-l.mtnutes per inch Depth of Test Pit---1. .......... Depth to ground water....Wla (� Test Pit No. 2:...............minutes per inch. Depth of Test Pit.................... Depth to ground water---------............... W --------------- ------------------- ••---------------- ....------- --------------- •------ -•--------------------- ODescription of Soiyydl_�l ?..c 4 ......-•-----------------•----•----------------------------------•-----------------£:-----------------------..........._._ W UNature of Repairs or Alterations—Answer when ap e.•.__________•-__-.-. _ Agreement: The undersigned agrees to install the of edescrib In ' idual Sewage Disposal System in accordanceYwith the provisions of i= of the State Sanita e Th ersigned further agrees not to place the system in, operation unkil a Certificate of Compliance h iss t b and of health. Siged ............... :...--------------------••--......•. --/ � ate £ APp ation Approved BY - "' ....d� - . ... . ........ Date Application Disapproved for the following reasons---------------•--------..._..........---------------•---------•------------ -------------•••---•------••-•---....-•--..._.__...:-•-------.....--------------..._..---..._...-•----------------------•---•--••----•-•-----•-----•------•-•---•---------•-•-••--------------•••-•..... -Date Permit No. ... ... Issued . ---•- - -•--•-. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. Qwrrfifiratr of faompliaurr THIS 15TO) C TIFY, That the Ina victual Sewage Disposal System constructed (—j57 paired ( ) b V"- lnstaller at --.T tsr �9:. ....... +1�*t'' ----------•------------------•---------------•------------------------------•---------------•-------------------- has been installed in accordance with the provisions of T I i tE 7 of The State Sanitary Code a described in the application for Disposal Works Construction P rmit No. :.�ct.__.��?'- : -.._._. dated_...____'? _4.Y1 _�+............... THE ISSUANCE OF THIS CERTIFICA ,.SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION CTI SATISFACTORY. DATE....................... ..............=1 ..................................... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS v1�Pi V11CC i BOARD OF HEALTH Y ��N'± ..............OF..: A "gip LC ......................................... .. FEE.... ................. Rapplial a �o r than leroti Permission,is;hereby granted.-�_�._. :_:-- _-------`-�:=----------- to Construct or Repair, ) an Individual Sewage Disposal System at \To. --•--- - �. ......_-4-�nA •-------------------••----------------------------•--•---••-••-- - � Street _ as shown on the application for Disposal Works Construction Permit N6 ?._ ?. a Dated.. ............................................................. --- / Board of Health DATE •----------—---------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Alp 332Uk/-45i5jo T�� G./?� /G` d /U/ L z s,RD T 00 ,:015 S� 9 9•._ -�.._. � /ter •a � � TO7-4L. JLy- . -6k<1 0 E� %'.v S,13, .: 171 CL772C�laC-' ' En/le✓�/EE,e;t�/V; ' u /xA/ IAIV- DESIGNING ENGINEER MUST SUPERVISE o MARTIN C INSTALLATION AND CERTIFY IN WRITING o THE SYSTEM WAS INSTALLED IN STRICT 17 : ACCORDANCE TO PLAN. SSIpNAt �r.��L/�•l.�r-- �,�c�,/ fie`!" ' 1, ri'. RE .^ •. f J d s "e, v 3ti': > , i d {k t, :�``• {'7R.l�V+S .for ! � .. r.. .1 ,. • �; 'may Town of Barnstable Board of Health Dear Board: . I certify that the sanitary system that was designed for Lot B Pine Streets Hyannis was installed according to the plan design for the Jamun Corp. dated 6-27-86. c 1• - : Sincerely /7 1 4 44 a i ' { i , 0`!/. 00 lit a Commonwealth of Massachusetts Executive Office of Environmental Affairs REMOVED Department of Environmental Protection OCT S. 1 1T HE t,�MA®p�E��P,T � William F.Weld i! TOW,' QF&�1SIABLE Governor Trudy(;oxe t, 8eeret.,y ECEA David B.Struhs Commissioner 6- �cn l"cL�S�nO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �S sC�TI FICATION �n Property Address: A/1113tl'7/6 R j Address of Owner: Date of Inspection: l O 3`"'9 v (If different) Name of Inspector: W.E. Robinson Sr. Company Name, Address and Telephone Number: W.E. Robinson 'Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT Z�7 77��77 I certify that I have personally inspected the sewage disposl s�sCertt�t 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: _Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: G`�e%� i Date: /6 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30)days of completing thin inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY ASSES: One or more system corn vents need to be replaced or repaired. The system, upon completion of the replacement or fir, passes inspection. Indicate yes, no, or not determined , N, or ND). Describe basis of determination in all instances. If"not determined", explain wiry riot) The septic tank i metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The ystem will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by th Board of Health. W (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292'55N { 1 Printed on Recycled Paper 1 V' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: cf 9, jo,n S ` �/9 t7 n 1 S Owner: Date of Inspection: B)SYSTEM CONDITIONA PASSES (continued) Sewage back or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due 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 requir pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which equire further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety an the environment. 1) SYSTEM WILL PASS UNL SS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WH ICH WILL PROTECT E PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy i within 50 feet of a surface water Cesspool or privy i within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS HE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTION11 IG IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a se tic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water suppl . _ The sv tem has a s ptic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a ptic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systen, Fas a eptic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unl ss.a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollu on from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the s tem violates"one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is ident ied below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage i to facility or system component due to an overloaded or dogged SAS or cesspool Discharge or po ing of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 10-X3 D)SYSTEM FAIL (continued): St tic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liq 'd depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Requi ed pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Num r of times pumped Any po ion of the Soil Absorption System, cesspool or privy it below the high groundwater elevation. Any_po ion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any po on of a cesspool or privy is within a Zone I of.a public well. Any port on of a cesspool or privy is within 50 feet of a private water supply well. _ Any po ion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no accepts le water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for colifor bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS. .I The following crite)isithin ply to large systems in addition to the criteria above: The design flow of is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environmeause one or more of the following conditions exist. the syste 400 feet of a surface drinking water supply the systeithin 200 feet of a tributary to a surface drinking water supply the system is ocated in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water upply well) The owner or operator of any uch system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.0 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: n le Owner: F- Date of Inspection: )0--;.-3-9 Check if the following have been done: .. information was requested of the owner, occupant, and Board of Health. V None of the system components have been pumped for at least two weeks and the system has been receiving nominal flow rates 2d ' that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _As built plans have been obtained and examined. Note if they are not available with N/A. _1,/The facility or dwelling was inspected for signs of sewage back-up. system does not receive non-sanitary or industrial waste flow Vhe site was inspected for signs of breakout. II.system components, excluding the Soil Absorption System, have been located on the site. je'fhe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Ve size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. 2/The facility-owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION a� 1�p Property Address: %,0<' Sy- JI y An N/S Owner: 0/e n lq-ls fro r 0 Date of Inspection: /U—a-3"'21 FLOW CONDITIONS RESIDENTIAL: Design flow:33 fl Qallons Number of bedrooms:3 Number of current residents: Garbage grinder (yes or no): Al' Laundry connected to system (yes or no):—Y— Seasonal use (yes or no):_ZZ Water meter readings, if available: 75 D0 G l.Z. �r gU�� 4 Last date of occupancy: COMMERCIAUIND STRIAL: Type of establish nt: Design florteHolding allons/day Grease trayes or no)_ Industrial Tank present: (yes or no)_ Non-sanitaischarged to the Title 5 system: (yes or no)_ Water metel,readings, if available: Last date of occupancy. 1 _�3 5 OTHER: (Describe) Last date of occupancy: - - GENERAL INFORMATION PUMPING RECORDS and source of information: [.4--* System pumped as pan of inspection: (yes or no) If yes, volume pumped. gallons Reason for pumping: ' I TYPE OYSTEM ✓ 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known)and source of information: ✓�2 S �— g gZ Sewage odors detected when arriving at the site: (yes or no)ZL/ (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Y- j nniz_� Owner: o l e/1 �ulS O Date of Inspection: /0 SEPTIC TANK:_ (locate on site plan) Depth below grade:1.1- Material of construction: _✓concrete _metal _FRP—other(explain) Dimensions: a 5` Z 6. L a"47 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:.j •_ Distance from top of scum to top of outlet tee or baffle:2r t Distance from bottom of 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 inv}rt, structural integrity, evidence of leakage, etc.) u j /t- L i ID I /i A J-- e„ GREASE TRA (locate on site Ian) Depth below ade: Material of con truction: _concrete _metal _FRP—other(explain) Dimensions: Scum thicknes Distance from op of scum to top of outlet-tee or baffle: Distance from onom of 5rum M honom of outlet tee or baffle' Comments: (recommend ion for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evi ence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C " SYSTEM INFORMATION (continued) Property Address: Owner: �jle» Date of Inspection: TIGHT OR HOLD G TANK:_ (locate on site plan Depth below grade: Material of constru ion: _concrete _metal _FRP—other(explain) Dimensions: Capacity: __gallons Design flowTinletee, allons/day Alarm level: Comments: (condition ondition of alarm and float switches, etc.) DISTRIBUTION BOX:'t/ ' (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distributiur, is equal, evidence of solids carr,-ovc , evidence of leakage into or out of box, etc.) PUMP CHAMBER:. (locate on site plan) Pumps in working ord c(yes or no) Comments: (note condition of pu p chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 , a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. g Owner: �r� j94,C,,1 r Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level ofyonding, condition of veggtation,etc.) r; o � 4.10 <l� v-0 3ddn ��' �bc1'i.-�I CESSPOOLS: (locate on site plan) Number and config ation: Depth-top of liquid t inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cessp ol: Materials of constru ion: Indication of ground ater: inflow Ice spool must be pumped as part of inspection) Comments: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of constr ction: Dimensions: Depth of solids: Comments: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Ireviaed 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION (continued) Property Address: % �n Owner: Date.of Inspection: eve qs-' SKETCH OF SEWAGE DISPOSAL SYSTEM:, include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ) l � DEPTH TO GROUNDWATER Depth to groundwater: X O h feet method of determination or approximation: 1 0 o l-1 Iplb.f-S (revised 8/15/95) 9 i i -r� JJ � 7 1 1 ^v LEGEND HYANNIS PROPOSED CONTOUR ® PROPOSED SPOT GRADE `t,, _ J —— 98 —— EXISTING CONTOUR _ + 96.52 EXISTING SPOT GRADE 54, W-- EXISTING WATER SERVICE BENCH MARK WST� TEST PIT i PAINT SPOT ON �� BULKHEAD CORNER � S� SCALE: 1 =20' \ 5 4. 2 3 LOT B USGS DATUM ASSUMED \� AREA = 100615 sf+- _ a W sit ; PLAN Boor. 361 gaGE 58 ASSP MAP249;`PCE 41 —2 N,� PINE ST. LOCUS ,, O)o ,� - LOCUS MAP M S4 . ,I LOCUS INFORMATION PLAN REF: 361/58 TITLE REF: 12439/094 53 DECK f PARCEL ID: MAP 249 PAR. 041/002 IN STATE ZONE II i EXIST. 1,000G �� +: \ I SEPTIC TANK 1 ' 3 1 53 SEPTIC SYSTEM i � EXISTING Io f' q� REPAIR PLAN I G DWELLING LOCATED AT: � I TOP o� FND 98 PINE STREET � I N � ' - � 'EL 54.9G HYANNIS, MA. \ = -F — 14`; I ` ft PREPARED FOR FREDERICK WHITE/ PAVED DRIVEWAY -W READY ROOTER EXC. Tp-z AUGUST 26, 2016 52 UOZ i ,,\\ OF ------- — o DA ReNM. y EnR 31.16' - -- -- 88.75' -- 52— -- U WpC�� O. G ' 1 P G EDGE OF PAVEMENT - NITAVt PINE STREET PLAN fi MEYER & SONS, INC. a; P.O. BOX 981 SCALE: 1 in = 20 ft 0 20 40 EAST SANDWICH, MA. 02537 PH: (508)360-3311 0 10 20 40 FAX: (774)413-9468 meyerandsonstitle50gm ail.com SHEET 1 OF 2 J 1808 ELEV. TOP FOUNDATION NOTE: PLACE MAGNETIC MARKING TAPE OVER ALL COVERS �- (Existing) BRING ALL COVERS TO WITHIN 3" OF FINISH GRADE FINISHED GRADE (53.5) 54.96 F.G.EL 54.2 F.G.EL: 53.9 F.G. EL- 53.5 A MAINTAIN 2% MIN SLOPE OVER LEACHING AREA .i " F.G.EL: 52.79 ;, 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2" • STONE OR FILTER FABRIC DOUBLE WASHED STONE 6" ~ 4" SCH 40 PVC 1. 1o"I 14 6 ®jN 1 MI9F. ®®®®®E3lE31 a' TEE'S ARE TO BE INV.50.,75 ( ' ®®®®®E3E31 4" SCH 40 PVC 2 DEPTH ®®®®®E3E31 I NV.51 .45 I V.50.55 4' 2 X 8.5' 4' GAS PROPOSED DB-3 EXISTING OUTLET BAFFLE INV. 51 .7 DISTRIBUTION BOX EFFECTIVE LENGTH = 25' AM AM A (H20) INV. ELEV.= 49.50 EXISTING 1,000 GALLON SEPTIC TANK GAS BAFFLE TO BE INSTALLED ON ������ OF �Asfq�ti . BREAKOUT OUTLET TEE AS MANUFACTURED BY o ARREN Gr ELEV.= 50.50 TUF-TITE, ZABEL, OR EQUAL M T �o INV. ELEV.= 49.50 ®® ®®TOP CONC. ELEV.= 50.50 � NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING E3®® PIPE INVERTS PRIOR TO CONSTRUCTION 1 r�stE O ®®®®®®® 2) D-BOX SHALL BE SET LEVEL AND TRUE TO a ®®®®®®® GRADE ON A MECHANICALLY COMPACTED SIX MANT00 BOTTOM EL.= 47.50 INCH CRUSHED STONE BASE, AS SPECIFIED IN I �I�j 3.75' 5 FT. 3,75' 310 CMR 15.221(2) Ip 3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK 1 SEPARATION 6.05 FT. EFFECTIVE WIDTH = 12.5' WITH 1500 GALLON SEPTIC TANK IF FAILED,DAMAGED, NOT H2O LOADING, OR UNDERSIZED. SEPTIC SYSTEM PROFILE 1 SOIL ABSORPTION SYSTEM SECTION 4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 41 .45 _ ) GAS BAFFLE AS REQUIRED (500 GALLON LEACH CHAMBER) GENERAL NOTES: SOIL LOGS P#:15124 DESIGN : CRITERIA ' I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL NUMBER OF BEDROOMS: 3 BEDROOOM BOARD OF HEALTH AND THE DESIGN ENGINEER. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: AUGUST 9, 2016 SOIL TEXTURAL CLASS: CLASS I (0.74 GPD/SF) OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE DESIGN PERCOLATION.RATE: <2 MIN/IN LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: SOIL EVALUATOR: DARREN MEYER, R.S., CSE #1614 - 310 CMR 15.405 (1) (B): WITNESS: DAVE"STANTON, BARNSTABLE HEALTH DAILY FLOW: 110- G.P.D. X 3 BR = DESIGN FLOW: 330, G.P.D. 1) A 6 FT. VARIANCE FROM 310CMRISa11 TO Avow LEACHING GARBAGE GRINDER: NO (not designed for garbage.grinder) TO BE 14 FT (MAX) FROM DWELLING VS. REQUIRED 20 FT. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR Elev, TP-1 D SEPTIC TANK: epth Elev. TP-2 Depth 330 gpd x 200% = 660 gpd, USE EXISTING 1,000 GAL. SEPTIC TANK TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE = DESIGN ENGINEER. 53.10 FILL 0" I 52.95 FILL 0" LEACHING AREA REQUIRED: (330) 445.94 S.F. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 74 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 52.02 A 13" 51.95 12" 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. USE TWO (2) 500 GALLON PRECAST LEACH CHAMBERS W/ 4 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF LOAMY SAND A LOAMY} I s3A/N10 STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL. BOARD OF 51.68 17" HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. B 51.53 B 17" BOTTOM AREA 25 x 12.5= 312.5 SF 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. LOAMY SAND LOAMY SAND 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED IOYR 5/4 10YR 5/4 SIDE AREA: (25 t 12.5) X 2 X 2 = 150 SF A TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 50.18 35" 50.12 34" TOTAL SQUARE FEET PROVIDED = 462 vs. 445.94 REQ'D 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE C FINE C FINE DESIGN FLOW PROVIDED: 0.74(462 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING perk O el. 48.6 MEDIUM- MEDIUM- CONSTRUCTION. D SAND 10. EXISTING LEACH PIT TO BE PUMPED, CRUSHED AND FILLED PER Tins 5. 2.5Y 6/4 I. 2.5YY 6/4 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION 41.60 138" I 41.45 138" 98 PINE STREET, HYANNIS, MA 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY <2MIIN/INCH IN "C` SOILS AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY NO GROUNDWATER OBSERVED Prepared for: White/Re d Rooter Exc. 13. NO PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. Engineering and Survey by: SCALE DRAWN 15. ALL PIPING TO BE 4" SCH 40 ® 1/8-/FT (UNLESS SPECIFIED) • I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 MEYER&SONS,INC. N.T.S. DMM to conduct soil evaluations and that the above analysis has been performed by me consistent With the PO BOX 981 requirements of 310 CMR 15.017. 1 further certify that I.have passed the Soil Eval. Exam in October, 1999. EASTSANDWICH,,MA122537 DATE CHECKED SHEET NO. 508-882-2922 08/26/16 DMM 2 of 2