HomeMy WebLinkAbout0711 PITCHER'S WAY - Health 711 Pitcher's Way,Hyannis
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`• THL-C&VN_KWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
............ .........................OF..........................................................................................
Appli Pathan for Dispvii al Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Ipdivi a Disposal
System at: Yl
Location- dress r t No p
a ....... ......................... -----'� .........
......._ ...... ................ Address �j ---- .
Installer Address /��C J
Type of Buildin Size Lot..... v .Sq. feet
U Dwellin —No. of Bedrooms _ ,M�__Expansion Attic ( ) Garbage Grinder 0�
p, Other—Type of Building 's e-••••• No. of persons......A................ Showers ( ) — Cafeteria ( )
a
Other xtes :- ---•-•••--•-•••••••••••••••-•-•-•.••••---•--••-•---•------•---•-••--••••••••••••••••••••••••••-•-•••--••-.....•••-••••-•-•-••-•--
W
Design Flow________.Js_�__ •........ ________gallons per person per day. Total daily flow..__ Q••: ._____._.__...__.___gallons.
WSeptic Tank—Liquid'capaciVy Ogallons 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...o2gl:...sq. ft.
Z Other Distribution box ( ) Dosing ) -/,/
'� Percolation Test Result Performed by....!0.___T...R .. . ...I-_ ...................... Date•••.J/!_. °�.......•--.
Test Pit No. 1___ __________minutes per inch Depth of Test Pit.................... Depth to ground wat .._._..____._._________.
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------- ....... ••••-•----••-•--....--••--••--•--•---•_--•---••._......_..•••-•-••••-••••••••••-•---•-•---
o A -----�.._.._�v � v Asa/L -
Description of Soil.. ... =......................................................
.._..._..••••••••••-•••--•-••••••••-�:12:!.-••••••••_../I7W ..••-••=S...A , .�-----------------------------------------------------------------------------------------
W
...••-••--••-•-
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-------------------------------------------------------------•-•-------•-••••••••-••..............•••••-•--•-••-••----•-------•-•-••••--•••••••••••--•-•---•-••••••••••••••••••-•••••••....._•••---•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in '
operation until a Certificate of Compliance has bee issued by t oar f health.
// 7� '
Signed..-. ..... •_ -'� .:_...... -•-•-_. ! ._._. .. -----•••-
/� Dat
Application Approved By------]�`"""G -------------•----------------------- -! z �Zd� -
Date
Application Disapproved for the following reasons--------------------------------•--------------------•-------....................................................
.........................................-.....................•-••--------......._..------....•.••••-••••---••=•••-•-••••-••---•-•••---••••••••••••---•-••----•••••••••••••--•••-•••--•••-••••-
Date
�,� ��
Permit No. Issue._. cL li ---• ------ ---=-----
Date
No .....t.. Fps........' ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... ----- ---- ------------------OF-.........--....--.:.....------.........-----------------------..........--------......._.
Applira#ion for Disposal Works Tonstrurtion "anti#
Application,is hereby made for a Permit to Construct ( ) or Repair ( ` ) an Individual Sewage Disposal
Sy at
lw/✓ k fr lc.r Locatio IJ� f' 60 aI1t4itMP
a L e ----------------------------------------------------------
�62G G W'yC r Address 1!}
' •--•- ........-
... --------
Installer Address
d Type of Buildi Size Lot__:_� :..............Sq. fe t
DwellinfNNo. of Bedroom ,_ Expansio Attic ( ) Garbage Grinder (/ {
p°I Other—Type of,Building _:_ 414 ______ No° of persons___.._1A___................. Showers ( ) — Cafeteria ( )
a
d Other res - -------------------------•-------•-----•------------------------------------- - ---------•-•-----------••----•-____
W Design Flow........ __.._ J. .......gallons per person per day. Total daily flow � ...�....................gallons.
W Septic Tank—Li uid capacity
P 9 P -- _gLength
-_g. Total Length ---._ Diameter-______ ___ Depth................
Disposal Trench. No .................... Width._ ___________ g _.......... Total leaching area_:___ sq. ft.
a ons en t ___ __________ Wldth.
Seepage Pit No..________!.______. Diameter._.__.__, Depth below inlet..... !__________ Total leaching area__ _:_sq. ft.
z Other Distribution box ( ) Dosing
aPercolation Test Resul Performed by '...___.. . ....................................... Date •-------
Test Pit No. L__ _._.____minutes per inch Depth of Test Pit____________________ Depth to ground wat ............
Test Pit No.,2................minutes-per inch Depth of Test Pit.................... Depth to ground water........................
Description of
Ra
w ............................................Nature of Repairs o -------- r------ ...........................................................---•------•--•--•-------•-----•---••----• ..._..
r'Alterations—Answer
'when- ,when applicable.--------------------------------------------------------------------------.....................
....................................... ••------••-••--•••-••---•----------••••--••-----••-•........--•-•....--------•---------------•--•----------•-•---------•-•----.................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee(issued by th" oar Hof health.
/- • � ' a-
Si ed --- -_..-...'t-... " .. _ ........
Da
Application Approved By------ ......... ....................................... ............................
/�* x
Date
Application Disapproved for the following reasons_........................................._........................................................_:.............
.............................................-......................--.......-------...---•--------•-------. =----------------------------------------------------
jV
f 1 //�`3 d ,9
Permit No..
••---•-----•----------•-_. Issued---•-- ...-• ---------Date--_...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
:......OF..... . ..... �, ................ ..:.:............
Trrtifiratr of TontpliFanrt,'
LOOO-
TM3 IS CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by.. G.-� --• # ------ •---•-
-- I a r �C�_
has been installed in accordance with the provisions of 5 f The State unitary Code as descr}b d m the
application for Disposal Works Construction Permit No �� ------------------
THE dated-. -.___' �- ............................"
ISSUANCE OF THIS, CERTIFICATE SHALL NOT BE,CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................. Inspector-_______------------------•---------------
THE COMMONWEALTH OF MASSACHUSETTS
7 BOARD QF HEALTH
�, ....... ..... ............OF...... �""' i..............:... c
No.................... ... -FEE
�i��o� ,�•�� � i:�n �ernti�
Permission ,hereby granted_. :---- s '
to Constru ') or `d 1 diew al ystem
age
�h
at ��-
" ---- ..............
Street
as shown on the application for Disposal Works Construction Per • No. Dated_.. �- �:---.--•-_.
.
Board ov®H alth
DATE.......
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FORM 1255 HOBBS & WARREN, INC, PUBLISHERS �£`-
St�.1GL� �Mnt �! - 3 '�meoowi A
1..10 C• Ai-LFs/.�� G-'R11.fC��1Z '�/ .
2aat��( FIAw - 11b x 3 t 33b G.ptD ,..g.._ II //��A/2e��� ` •
5t...�nc TANK = 330.E ►5c % �i5 6.P�.- ^ tC./,q.
y sue- t o0o s,6.1. � Y�,�
SPDSAL PIT - Lisa loco GAL. {.
ALL A0_GA = l50 S F. k
lSo SF ,c 2.S S'!S 6 RID
-
ToT1&L. �ESIGIJ = 425
TOTAL 'D'dl Lam{. V=L.ow = 33D c�W
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TOWN OF BARNSTABLE •C,•
LOCATION 2// SEWAGE # 99- e7lEX
LAGE i ASSESSOR'S MAP & LOT,2 7/-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /Doo G,o,/.
LEACHING FACILITY: (type)$,.Savo G.a./, D. w csiigllr (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE: 9-g-Qy COMPLIANCE DATE: ;.c.o PP'
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
-- � �.
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a � �.
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
- Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Miq;poml 6potem Con!5truction Permit
Application for a Permit to Construct(pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 5711 t're_4_c r5 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
7 /8'4
Installer's Name,Address,and Tel.No. y 7 1-!13 4 4? Designer's Name,Address and Tel. o.
/o/ /0/, s .�
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Q,-4e
�lAge"ci,S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date
Application Approved by l3► Date
Application Disapproved for the following reasons
Permit No. Date Issued
No. /- Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE. MASSACHUSETTS
.f 01ppYication"for Migooar *potem Conttruction j3ermit
Application for a Permit to Construct(pair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 7// j'rc4_&r W1490' Owner's Name,Address and Tel.No.
�ty�anrliS /�,fJT�iOh/ /ZiCLi
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. 4/77-Oy 4(9 Designer's Name,Address and Tel. o.
t/os,c��i Oti aweA-vS
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan,Date Number of sheets Revision Date
Title
" Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) _v:5),14 � �,-420 6 ga1 0/u ze-11
[ �.ov►96trt u/7` �/' S'Tn�� s9�°o+y`i�� � "�.�.t� .frot�..� ✓ ,:
i
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of'H alth.
Signed Date - -
Application Approved by cr ' Date
Application Disapproved for the following reasons
� 1
Permit NO. Date Issued
------ ---r----------------j-- --------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(e—).Repaired( )Upgraded( )
Abandoned( )by & /3,�,H,•rs
at delw w has been constructed in accordance
with the provisions of Title 5 and the for isposaI System Construction Permit No. dated
Installer c1tX5r.,2k1 17,e Designer Jo
The issuance of this permit shall t =e cot, e as a guarantee that the syS m ill unction a desLgd. /
Date !. '! Inspector �1
— ---- '/ , ------------------------
Fee l
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwi!6pomf 6potem Cou5tructiou Vermit
Permission is hereby granted to Construct(impair( )Upgrade( )Abandon( )
System located at Z// &1, eve.S c,4-,w y
Ny�hh�s
and as described in the above Application for Disposal System Congtruction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constructio mustfbeTpleted within three years of the date of this e t. j °
/41
Date: `mil l Approved by1 ( v L�
i0
1/tila9
NOTICE: 'This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. ,I
CERTIFIC6J 10N OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CC!rj'STRUCTION PERMIT(WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated $-?-gy , concerning the
property located at meets all of the
following criteria:
,-The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
G,,'—The soil is,Aissifled as CLASS I and the percolation rate is Iws than or equal to 5 minutes per inch.
-There are nowetlands within 100 feet of the proposed septic system
Z✓ There are no private.wells within 150 feet of the proposed septic system
ere is no increase in flow and/or change in use proposed
ere are no variances requested or needed
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. M11 be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching faciEl will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of"Ground Surface ovation(using GIS irtforma pon)
B) G.W. I?levatio
+the MAX. High G.W. Adjustmen =
DLFFERI.rICE BETWEEN A and B ---
SIGNED :
an of syst
(Sketch proposes' I DATE:
p
q:health folder:cent em on back).
00
049
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� �.""'e""'IC L �. -"��'.�` .: ,+ �-,r.. .'..'' Sw _ �e+' � 'Y'F�`a.r��„"ylx�'r;.r a�"ETa",,.. z' -*. � -T' '�- _'«•"^-. 'G i^,.•�s`^�„�""�-�+s�- "'�
_ TOWN OF BARNSTABLE
LOCATION 1/, 4 SEWAGE # Q9-
VILLAGE ASSESSOR'S MAP & LOT2'7/- /94-
INSTALLER'S NAME&PHONE N0. 4 77-a1 y �s�.d _II c .�rr�o�
s;
SEPTIC TANK CAPACITY /000 Ga/,
LEACHING FACILITY: (type).L,.ryo 6&1,, D„w wi=//r (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMITDATE:$—1—9 Z COMPLIANCE DATE: P
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
M
.:
g .
t
�-.ea"C,,� ..c, ` .., s '�-.-9ry.,,,, : .. e t rt' "t� j � .,��i r-si w •r>,—
tt" /
�Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ON+FOR 1
PART A
�p ��
CERTIFICATION s j9 w
Property Address: 711 PitcheA Way Address of Owner 25 Afit l"yn Rd:`
Hyannis,MA 02601 (if different): Milton,MA 02186
Property Owner: Henry Rich
Date of Inspection: November 21, 1997 r
Name of Inspector: Paul C. Jenner
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name,Address and Telephone Number: PA UL G. JENNER ASSOCIA TES
31 RILEY A VENUE
EAST WEYMOUTH, MA 02189
(617) 337-8617 Fax (617) 3374802
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on-site
sewage disposal systems. The system:
X Passes
Conditionally passes
Needs Further Evalu ion B the Lo roving Authority
Fails
Inspector's Signature: Date: November 22, 1997
The System, Inspector shall submit a ropy7othis inspection report to the Approving Authority within
thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office,of the Department of Environmental Protection.
The original should:be sent to the system owner and copies sent to the buyer, if applicable_and ,the a
approving authority..,' ,
_
P'AU LG. J ENNEI$ ASSOCIATES � (Revised 04/25/97)„-Page I .�.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 711 Pitchers Way
Hyannis,MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
INSPECTION SUMMARY:
Check A,B,C,or D
A], SYSTEM PASSES: YES
X I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any criteria not evaluated are below.
B] SYSTEM CONDITIONALLY PASSES: N/A
_ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health;will pass.
Indicate yes,no,or not detennined(Y,N,or ND). Describe basis of determination in all instances.If'not determined"explain why not)
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a
Certificate of Compliance(attached)indicating that the tank was installed twenty(20)years prior to the date of the
inspection; or the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration
or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced
with a conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in.the distribution box is due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with
approval of the Board of Health).Describe observations:
broken pipe(s)are replaced
_ obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced ,
r � —
obstruction is removed
PAUL G. JEi1NER ASSOCIATES (Revised 04/25/97) '-Page 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 711 Pitchers Way
Hyannis,MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NO
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing
to protect the public health, safety and the environment.
1) System will pass unless Board of Health determines that the system is NOT functioning in a manner which will protect the public
health and safety and the environment.:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) System will fail unless the Board of Health(and the Pubic Water Supplier,if appropriate)determines that the system is functioning in a
manner that protect the public health and safety and the environment.
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or
tributary to a surface water supply
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_.The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and
Nitrate nitrogen is equal to or less than 5 ppm.Method used to determine distance (approximation
not valid).
3) OTHER:
PAUL G. JENNER ASSOCIATES 3
(Revised 04/25/97} -Page ,_
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 711 Pitchers Way
Hyannis,MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
D] SYSTEM FAILS: NO
_ I have determined that the system violates one or more,of the following failure criteria as defined in 310 CMR 15.303.
The.basis for this determination is identified below. The Board of Health should be contacted to determine what will be
necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground 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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped:
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well. .
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: N/A
The following criteria apply to large systems in addition to the above criteria:
Yes No
The system serves a facility with a design flow of system is 10,000 gpd or greater(Large System)and the
system is a significant threat to public health and safety and the environment because one or more of the
following conditions exist:
The system is within 400 feet of a surface drinking water supply
The system is within 200 feet of a tributary to a surface drinking water supply
_ The system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone
II of a public water supply well
The owner or operator of any such system shall bring the system and facility into full compliance with the ground-water -
treatment program requirements of 314 CMR 5.00 and 6.00. ,Please consult the local regional office of the Department for
further information.
PAUL G. JENNEIi ASSOCIATES (Revised 04/25/97) -Page 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 711 Pitchers Way
Hyannis, MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
Check if the following have been done:
Yes No
Y _ Pumping information was requested of the owner, occupant, and Board of Health.
Y _ None of the system components have been pumped for at least two weeks and the
system has been receiving normal flow rates during that period. Large volumes
of water have not been introduced into the system recently or as part of this inspection.
N/A As built plans have been obtained and examined. Note if they are not available with N/A.
Y _ The facility or dwelling was inspected for signs of sewage back-up.
Y _ The system does not receive non-sanitary or industrial waste flow.
Y _ The site was inspected for signs of breakout.
Y _ All system components, excluding the Soil Absorption System, have been located on
the site.
Y. _ The septic tank manholes were uncovered, opened, and the interior of the tank was inspected for
condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of
sludge, depth of scorn_
The size and location of the Soil Absorption System on the site has been determined based on:
Y _ The facility owner(and occupants, if different from owner)were provided with information on the
proper maintenance of Sub-Surface Disposal System.
Y — Existing information. Ex. Plan at B.O.H.
N Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of
distance is unacceptable) [15.302(3)(b)]
PAUL G. JEll NER ASSOCIATES (Revised 04/25/97) -Page 5-
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 711 Pitchers Way
Hyannis, MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
FLOW CONDITIONS
RESIDENTIAL: YES
Design flow 220 g.p.d./bedroom for S.A.S.
Number of bedrooms 2
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available(last two(2)year usage(gpd): N/A
Sump Pump(yes of no): No
Last date of occupancy: Current
COMMERCIAL/INDUSTRIAL: N/A
Type of establishment:
Design flow: gallons/day
Grease trap present(yes or no)
Industrial Waste Holding Tank present(yes or no):
Non-sanitary waste discharged to the Title 5 System(yes or no):
Water meter readings,if available:
Last date of occupancy:
OTHER(Describe):
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS(and source of information) 4/95/Owner
System pumped as part of inspection(yes or no): YES If yes,volume pumped 1000 gallons
Reason for pumping: Check Structural IntegrityBaffles&Tees/Measurements
TYPE OF SYSTEM:
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system(yes or no). If yes, attach previous inspection records,if any.
UA Technology etc. Copy of up to date contract?
Other(explain):
APPROXIMATE AGE of all components,date installed(if known)and source of information: 1978/Permit#78-169 BOH
Sewage odors detected when arriving at the site: (yes or no NO
PAUL G. JENNER ASSOCIATES (Revised 04/25/97) -Page 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 711 Pitchers Way
Hyannis,MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
BUILDING SEWER
(Locate on site plan)
Depth below grade: 18"
Material of construction:_cast iron X 40 pvc _other(explain)
Distance from private water supply well or suction line: N/A
Diameter: 4"
Comments: (condition of joints, venting,evidence of leakage,etc.)No abnormal signs observed
SEPTIC TANK: YES
(Locate on Site Plan)
Depth below grade: 6"
Material of Construction: X Concrete_Metal _FRP _Polyethylene _Other(explain):
If tank is metal, list age_Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 8'L x 4'W x 4'6"D
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 31
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How dimensions were determined: Before,During and After system pumped
Comments(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structural integrity, evidence of leakage, etc):
Recommend system be pumped every 12-18 months
GREASE TRAP: N/A
(Locate on Site Plan)
Depth below grade: _
Material of Construction: _Concrete _Metal _FRP_Polyethylene _Other(explain): _
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to
outlet invert, structural integrity, evidence of leakage, etc.): _ aI
PAUL G. JENNER ASSOCIATES " (Revised'04/25/97) -Page 7
{
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 711 Pitchers Way
Hyannis,MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
TIGHT OR HOLDING TANK: N/A
(Locate on Site Plan)
Depth below grade:
Material of Construction: _Concrete _Metal _FRP_Polyethylene_Other(explain):
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order: (Yes/No)
Comments(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: YES
(Locate on Site Plan)
Depth of liquid level above outlet invert: 0
Comments(note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc)
D-Box was level with no signs of solids carryover
PUMP CHAMBER: N/A
(Locate on Site Plan)
Pumps in working order(yes or no):
Alarms in working order: (yes or no):
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.)
PAUL G. JENNER ASSOCIATES ' (Revised 04/25/97) -Page 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 711 Pitchers Way
Hyannis,MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
SOIL ABSORPTION SYSTEM(SAS): YES
(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:
X leaching pits and number 1
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields,number, dimensions
overflow cesspool,number
Alternative system:
Name of Technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
No abnormal signs observed at time of inspection
CESSPOOLS: NO
(Locale on Site Plan):
number and configuration
depth-top of liquid to inlet invert
depth of solids layer
depth of scum layer
dimensions of cesspool
materials of construction
indication of groundwater
inflow(cesspool must be pumped as part of inspection)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
PRIVY: N/A
(Locate on Site Plan)
materials of construction
dimensions
depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.),
PAUL G. JENNER ASSOCIATES (Revised 04/25/97) Page 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 711 Pitchers Way
Hyannis, MA 02601
Property Owner: Henry Rich
Date of Inspection: November 22, 1997
SKETCH OF SEWAGE DISPOSAL SYSTEM:
(include ties to at least two permanent references landmarks or benchmarks)
(locate all wells within 100)(Locate where public water supply comes into house)
"SEE ATTACHED AS-BUILT DRAWING"
PAUL G. JEl1NEI$ ASSOCIATES (Revised 04/25/97) -Page 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 711 Pitchers Way
Hyannis,MA.02601
Property Owner: Henry Rich
Date of Inspection: . November 22, 1997
DEPTH TO GROUNDWATER
Depth to groundwater >12 feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump, etc.)
Determine it from local conditions
X Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Conversation with BOH agent and topo maps of area, SAS is determined to be> V above
groundwater.
PAUL G. JEl1NER ASSOCIATES (Revised 04/25/97) Page 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ATTENTION
THIS REPORT DOES NOT CONSTITUTE A
GUARANTEE, WARRANTY OR REPRESENTATION
THAT THE SYSTEM WILL CONTINUE TO OPERATE
AND FUNCTION IN GOOD WORKING ORDER. THIS
REPORT IS SOLELY LIMITED TO REPORTING
WHETHER THE SYSTEM MEETS THE CRITERIA SET
FORTH IN 310 CMR 15.303; THERE MAY BE LOCAL
LAWS OR REGULATIONS APPLICABLE TO THE
SYSTEM WHICH THIS REPORT DOES NOT ADDRESS.
THIS REPORT CONSTITUTES THE ENTIRE REPORT.
THIS REPORT WAS PREPARED ON BEHALF OF THE
PERSON NAMED ON THE FRONT PAGE OF THE
REPORT AND THE ONLY PERSON AUTHORIZED TO
RELY UPON THE CONTENTS OF THIS REPORT IS
SAID PERSON; ANY MA TTERS WHICH SAID PERSON
INTENDS TO RELY UPON MUST BE CONTAINED IN
WRITING IN THIS REPORT AND SAID PERSON
ACKNOWLEDGES THAT THEY ARE NOT RELYING
UPON ANY ORAL COMMUNICATIONS OR
DISCUSSIONS CONCERNING THIS REPORT.
PAUL G. JENNER ASSOCIATES (Revised 04/25/97) -Page 12