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HomeMy WebLinkAbout0058 STERLING ROAD - Health 500 STERLING,STREET,HYAiri'4_ P � r { a I I G j o 8 i i TOWN OF BARNSTABLE rr, LOCATIONS! 62 SEWAGE # �.LAGE' flue" // ASSESSOR'S MAP & LOTAI,Y If/ INSTA.T LER'S NAME&PHONE NO. fNOA1 SEPTIC TANK CAPACITY ize) LEACHING FACILITY: (type) (s/ NO.OF BEDROOMS `7 1 BUILDER OR OWNER PERMITDATE: DRIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater """" to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist I 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 / OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WMRMATION . Prup..,Add� r I 0—. D.tr et[mp.clm.s i SMEXAM 35.3 to B•�aa.pmm�a,..mrfQs.� -�}4'" � 0 Pk..ma.m(&.k).0 memom yam em. 5.-a�w Obmb.dft—y PE—�am .em m e`°°`t°4 for MAS) i . anem..,B—da M.M..W,.m d igs USOS dub.....wa-b0mt(•�`e Yau 0.Y my anblith°d tmt y1(y w.tp sb %aP ":,-- o ms1C90 �9 JY �TOWN OF BARNSTABLE LOCATION "'� '1 _ SEWAGE # ;%LLAGE � ASSESSOR'S MAP& LOT�3"�1 INSTA:iLLER'S NAME&PHONE NO. f SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by F .� n n '1� / �-' � �� z+'" 9 9s _ � 11 � No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes applitation for Disposal *pstem Construrtion Permit Application for a Permit to Construct( ) Repair(k) Upgrade( ) Abandon( ) ❑Complete System °Individual Components Location Address or Lot No. �-,r � � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel �-,11 Gg E� t. & -rg Installer's Name Address and Tel No. 570'��`477 71 Designer's Name,Address,and Tel.No. CAvOLOCD�§ 'i^EY�/.L45 f 1 15.3 cr/ 15 ' tJ A Type of Building: Dwelling No.of Bedrooms 1 v Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) S E-A L- 6 "n-=s-r -.!5�—'l C- mkt f K. 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 H th. . . _ Signed Date X •ZS 2.0 Cl Application Approved by C , Date T Application Disapproved by Date for the following reasons Permit No. l I 0 Date Issued a o b�� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for Voposal bpstem Construction Permit Application for a Permit to Construct( ) Repair(k) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 5 5-rgka�.& -P Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a(pg t F"RAJ�Je. RCk'i Ev Installer's Name,Address,and Tel.No. spas-477-8&�'7 Designer's Name,Address,and Tel.No. CAPGCO(Dc to N Type.of Building: Dwelling No.of.Bedrooms !V � Lot Size sq.ft. Garbage Grinder( ) Other _ Type of Building No.of Persons Showers,(, ) Cafeteria( _ Other Fixtures Design Flow(min.required) gpd Design flow provided a gpd Plan . Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answerwhen applicable) SE C. 7rA' -K�, t 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 begin issued by this Board of H lth. R Signed'_. - Date - XS K 011, Application Approved by Y: c Date . .� g Application Disapproved by Date for the following reasons. Permit No. Ad ICI 0 �� Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system -Constructed( ) Repaired( X) Upgraded( ) Abandoned( )by GAPa�A Dr= di i at (� � �/ � has been constructed in accordance p� with the provisions of Title 5 and the for Disposal System Construction Permit No. 2o(9 -610 dated Installer(�AAC(A)lb6 - '�, Designer #bedrooms ' J•!- Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the s stem will fun on as�esg e Date / InsPec o't r � �?/ � - - -_- — )- ---------------�. - - -----------.----- ------------ -.----- _ -, -.- -- --.,-.------------------- No. �ot� G Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 30isposal 6pstem Construction PPrnut Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at�� �'7 IN jig h4--N 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. n 1 Provided:Construction must be completed within three years of the date of this permit. J� Date 0 2 7 Approved by Mar 12, 2019 23:05 HP Fax page 1 a&g- c `0 Commonwealth of Massachusetts g Title 5 Official Inspection Form ; le} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Sterling Road A,,a Property Address Frank Romeo ' Owner Owner's Name / 4 information is required for every Hyannis annis V/ MA 02601 3-8-19 `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 and of the form. 111tU 111)I Hglp OF Important:When A. Inspector Information )� ���� s9o' filling out forms P ��# �a(FJ� �?;' on the computer, James D.Sea rs = JA M E S use only the tab _ key to move your Name of Inspector cursor-do not Capewide Enterprises ��•.�,� o ••�. use the return Company Name key. 153 Commercial Street "�F+SrI� SPE` ,�F —Q Company Address Mashpee MA 02649 CitylTown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails a4tL4— d' 3-8-19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform In the future under the same or different conditions of use. 151nsp.doc-rev.71Z612018 Title 5 Offirdal Inspeclion Fonn:SUhsurfsoe Sewage Disposal System•Page 1 of 18 Mar 12, 2019 23:05 HP Fax page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information is required for every Hyannis MA 02601 3-8-19 page, City[Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 16.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal.Tank D Box and two chambers. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiftration 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): t5lnsp.doe•rev,7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 2 of 18 Mar 12, 2019 23:05 HP Fax page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 56 Sterling Road L' Property Address Frank Romeo Owner Owner's Name information is Hyannis MA 02601 3-8-19 required for every page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below)` ❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Nnsp.doc•rev.7/26)2016 Tide 5 Official InspWIon Farm:Subsurface Sewage Disposal Syslem-Page 3 of 18 - - Mar 12; 2019 23:05 HP Fax page 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information is required for every Hyannis MA 02601 3-8-19 Page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS Is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for MLI 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 15insp.doc rev.712612018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 4 of 18 Mar 12, 2019 23:05 HP Fax page 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information is required for every Hyannis MA 02601 3-8-19 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in sommW is less than 6"below invert or available volume is less than 1/2 day flow ,C UeAIAI6 ❑ ® Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) El ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4, 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 Proteciion Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.712612018 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal system•Page 5 of 16 Mar 12, 2019 23:05 HP Fax page 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !" 58 Sterling Road Property Address Frank Romeo Cwner Owners Name information is required for every Hyannis MA 02601 3-8-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered'yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304,The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for al!inspections: Yes No ❑ ® Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7I2&2018 Title 5 Official inspection Forth:Suhsurtace Sewage Disposal System•Page 6 of 18 Mar 12 2019 23:05 HP Fax page 7 c� Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information is Hyannis MA 02601 3-8-19 required for every page. CitylTown State Zip Code Date of inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual); 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: 1000 Gal.Tank D Box and Two Chambers. 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 36Ga1s 8, Water meter readings, if available (last 2 years usage(gpd)): 2018-2017-626237Gals Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5lnsp.doc rev.7126/2018 Tine 5 Official Inspection Form:Subaurface Sewage Disposal System-Page 7 of 18 I Mar 12, 2019 23:06 HP Fax page 8 c Commonwealth of Massachusetts Title 5 Official Inspection Form rd Subsurface Sewage Disposal System Form •Not for Voluntary Assessments F� 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information equiretio re Hyannis MA 02601 3-8-19 required for every page, City/Town State Zip Code Date of Inspection D. System Information (cont) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft, etc,): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7126=18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 18 Mar 1 z 2019 23:06 HP Fax page 9 c Commonwealth of Massachusetts Title 5 official Inspection Form �i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information is required for every Hyannis MA 02601 3-8-19 page. Cityffmn State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner)and a copy of latest inspection of the IfA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed (if known) and source of information: Tank NA 2005 New Leaching Permit # 2005 - 615. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locale on site plan): Depth below grader 21 feet Material of construction: ® cast iron ®40 PVC ❑other(explain): Distance from private water supply well or-suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is cast Iron and PVC. t5insp.doc•rev.71215 2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Mar 12 2019 23:06 HP Fax page 10 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j� 58 Sterling Road Property Address Frank Romeo owner Owners Name information is Hyannis MA 02601 3-8-19 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan); Depth below grade: 11 g feet 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 Gal. Precast H-10 Sludge depth: . 3" Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness - 2" Distance from top of scum to top of outlet tee or baffle 12' Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Plan Jape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, e1c.): Tank and covers at 11" below grade.Inlet baffle wlout let Tee. t5lnsp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Mar 12 2019 23:06 HP Fax page 11 Commonwealth of Massachusetts .. Title 5 Official Inspection Form t. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information is required for every Hyannis MA 02601 3-8-19 page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 7. Grease Trap(locate on site plan): Depth below grader feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow; gallons per day 15insp.doc rev.7=12018 Tlee 5 Official Inspechon Farm:Subsurface Sewage Disposal System-Page 11 of 18 Mar 12 2019 23:07 HP Fax page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information is Hyannis MA 02601 3-8-19 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(conQ Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 70 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.): D Box is 16"x16"-39" below w/cover at 1T'. Box is clean and solid wltwo line's out. No sign of over loading or solid carry over. 15insp.dcc rev,712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 10 Mar 12 2019 23:07 HP Fax page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form .}� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Sterling Road -- Property Add ress Frank Romeo Owner Owners Name information is required for every Hyannis MA 02601 3-8-19 paw. cityfrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: l5insio,doc•rev.TM2018 Title 5 official Inspecticn Form:Subsurface Sewage Disposal System-Page 13 of 18 Mar 12 2019 23:07 HP Fax page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name requinform r on is Hyannis MA 02601 3-8-19 requiredd for every page. City/Town State Zlp Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): Leaching is two 500 Gal. dry well chamber's w/35' stone per plan.Chamber's at 40" below grade w/cover at 15", Chamber's are wet on bottom w/clean like new walls. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): tWsp.doc rev.7/26/2019 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Mar 12 2019 23:07 HP Fax page 15 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information is required for every -Hyannis annis MA 02601 3-8-19 paw. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): 16insp.doo•rev.7/28/2018 Tille 5 Official fnspection Farm Subsurface Sewage Disposal system•Page 15 of is fMar 12 2019 23:07 HP Fax page 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 Sterling Road `J Property Address Frank Romeo Owner Owners Name inforrnationis Hyannis MA 02601 3-8-19 required for every page. Gty/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5lnsp.doc•rev.7/2e/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 16 of 18 Mar 12 2019 23:07 HP Fax page 17 Feb 0619,09:36a Capewide Enterprises 506-477-4977 P.5 FF TOWN OF3ARNSTAbLE �c LOCA71ON '� .}��riirIit SEWAGE M•L0K Lw; n.LAGE_-L�L l ASSESSOR'S MAP R LOT o268-17/ DMALLOR'S NA a&P HONE NO. SEnc TANK CAPACnV LEACMC FAC1LrrYr(type) ?-06411 (aim)Z1. x it,- x L: NO.OPBEDROOMS ` � BUMMER OROWNER PSR)NrrDAM IL- COMPt ANa DATE: b— Separation Distance Hetwc4p the 1 4 0 Makittwm AdjuitodGmuodwaierTable to the Bdtom of Leaching Facility Fast Pti��eWaterSupplyWellaodLeaGbingFaci6tY (Ifaa�weIlsc�ist 0o tare or within 200 fat of leaching fm.iliry) Fie Up of Wedand end Leaching PwIry(If any wetlaads exist within 3tb fcct d tcadung facility) Fen Furnished by JL - �, _ � � f - - Mar 12 2019 23:07 HP Fax page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 Sterling Road Property Address Frank Romeo Owner Owner's Name informrequired is Hyannis MA 02601 3-8-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells AX9 12' Estimated depth to high ground water: 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: 1-1-05 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: T.H. on Design plan 1-1-05 12'no G.W.. Bottom of chamber's at 6'below grade. Bottom of chambers at 6'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.71Y6 M8 Title 5 OfWal Inspect on Fonre Subsurtace Sewage Disposal System-Page 17 of 18 Mar 12 2019 23:08 HP Fax page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (S� u 58 Sterling Road Property Address Frank Romeo Owner Owner's Name information Is e. Hyannis MA 02601 3-8-19 reqpage. for every City/Town pa State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included f3 0/!om la c 14A013ZAS � N ' G�w t5insp.doc-rev.7125I2018 Title 5 Official Inspection Form;Subsurface Sewage Olspoeal System-Page 18 of 18 TOWN OF BARNSTABLE £�- SEWAGE # VILLAGE Y`hl� _ ASSESSOR'S MAP & LOT269—/7/ INSTALLER'S NAME&PHONE NO. RAI jrr.,a SEPTIC TANK CAPACIT� 4 f LEACHING FACILITY: (type) �,VL�P►'► "� S (size)Zrs �' 1'Z,s X z� NO.OF BEDROOMS (� BUILDER OR OWNER PERMITDATE; f Z" -0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) < Feet Edge of Wetland and Leaching Facility(If any wetlands exist within'306 feet of leaching facility) - Y Feet Furnished by f', � \ ' ,u � ��' � „/� 1 � �� � � � � � ,� 4 '� 1�" y,�y.' . , a .- N �,/� . � µ � No. Fep O O .0 O / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t�✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mi!6posal *pgtem Con5truction Permit Application for a Permit to Construct( ) Repair()o Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 7 7 5—O 2 41 58 Sterling Rd, Hyannis John Harrington Assessor'sMap/Parcel 268 171 58 Sterling. Rd, Hyannis Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 3 6 4-0 8 9 4 Wm E Robinson Sr Septic Eco-Tech RQ Box 1089 , Centerville 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder (ng Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) Install a new Title 5 leach system to plans of Eco-Tech, #ETE-2242 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 H Ith. t Signed "' Date 1;~�`O, s Application Approved by vv,. Date t2- Application Disapproved by: Date for the following reasons Permit No. �oa.�- 6�� Date Issued —��U FeA100.00 } •' m computer: THE COMMONWEALTH OF MASS C USETTS EnteredYes PUBLIC HEALTH DIVISION "TOWN OF BARNSTABLE, MASSACHUSETTS t ZIpprication for Migpoga1 �pgtem Congtruction Permit Application for a Permit.,to Construct O Repair(X) Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. 7 7 5—0 2 41 58 Sterling- Rd, Hyannis John Harrington Assessor'sMap/Parcel 268_/171, 58 Sterling ®d, Hyannis Installer's Name,Address,and Tel.No. 7 7 5—8 S 7 6 Designer's Name,Address and Tel.No. 3 6 4—0 8 9 4 Wm E Robinson Sr Septic Eco-Tech 8 --*- 0 43 Triangle Cir, Sandwich Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder (nC� r .. Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) Install a new Title 5 leach system to plans of Eco-Tech, #ETE-2242 Date last inspected: r Agreement: 3 g The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in1 ! 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 lth. t Signed Date 1 _'T`02 !�. Application Approved by V,. �. Date Application Disapproved by: Date for the following reasons Permit No. �b�" 6/s Date Issued ———————————————————————————————————————————— THE COMMONWEALTH OF MASSACHUSETTS .. BARNSTABLE, MASSACHUSETTS Harrington Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( X) Upgraded ( ) Abandoned( by Wm E Robinson Sr SEptic Service 58 Sterling Road, Hyannis athas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Uo S 6 dated Q4 GI� Installer Designer #bedrooms Approved design flo-\ 3 3 U gpd :- The issuance of this permit shall not be construed as a guarantee that the system-wile ti'on/as designed_ � Date f I Inspectori�J Lam. -------------------------------------------- No. 1100.00 THE COMMONWEALTH OF MASSACHUSETTS Har :rq HEALTH DIVISION —BARNSTABLE, MASSACHUSETTS Migpont *pgtemt Congtruction Permit Permission is hereby granted to Construct ( ) Repair (X ) Upgrade ( ) Abandon ( ) System located at 58 Sterling Road, Hyannis and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructio must be completed within three years of the date of this'pelt. Date � ' U Sr Approved by Town- of Barnstable OpZNE� - o Regulatory Services m _ Thomas F. Geiler,Director `"A Public Health Division. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax:- 508490-6304. Installer& Desianer Certification Form Date: Designer Eco-Tech Installer: Wm E Robinson Sr Septic. Address: _ 43 Triangle Circle Address: PO Box 1089 Sandwich- Centerville On Wm E Robinson Sr Sept Vv8a issued a permit to install a (date) (installer) septic system at S8, Sterling Rd, Hyannis based on a design drawn by (address) Eco-Tech . dated 12-5-05 (designer �U/I certify that the septic system referenced above was installed substantially according to the design, whicp may include minor approved changes such as lateral relocation of the distribution box d/or septic tank. I certify that the ;septic system refe eneed above was installed with major changes (i.e. greater than 10' lateral re �on of the SAS or any vertical relocation of any component of the septic s ut in accordance with State & Local Regulations. Plan revision or certified - t by designer to follow. R OF rypgSsq e' DAVID Ll (Installer's Signature) o D. COUGHANOWR No. 1093 O �FG/STERE S�Ml TARk (Designer's Signa ;re) (Affix Desi er s Stamp Here) PLEASE RETURN T ' BARNSTABLE PUBLIC. HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE-R ECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Cert' cation Form I i 1 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, D, CDVG hWQWk hereby certify that the engineered plan signed by me dated DC c- &Kconcerning the property located at meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the 4 maximum adjusted groundwater table elevation. [Adjust the groundwater table using the ° Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation (b .0 +adjustment for high G.W.3 Z = ( `` 20 DIFFERENCE BETWEEN A and B I G 3 O SIGNED :( :�" Crrr/1�-._._ lC� DATE: DcC w NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASepticlpercexemp.doc Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM f • 1, h y 1 t) D • COV G hW CW hereby certify that the engineered plan signed by me dated c- property located at meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)and two percolation tests shall be conducted. • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will-be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] /Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation (G b +adjustment for high G.W.3 DIFFERENCE BETWEEN A and B 16. 30 SIGNED :(��• 6w1L !�-� DATE: �� S� 2-00S NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. gASeptic\percexemp.doc t OF INE tp Town of Barnstable * STAB . * Regulatory Services 9 MASS. g Y 1639. Thomas F. Geiler, Director rFD MA'S a Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 SECOND NOTICE November 3, 2005 Ms Elizabeth Harrington 58 Sterling Road Hyannis, MA ,_02601 NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V. The septic system owned by you located at 58 Sterling Road, Hyannis, MA was inspected on August 151h 2005, by Mark Polselli, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "FAILED"under guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: Tank f 1, leaking You have 2 years from the date of the sys em failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT COMMONWEALTH OF MASSACHUSETTS �8S ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i!i"1 a,P d. 64 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Ovt6v/ i q r f Owner's Name: •E z.. . g,,,•i„ `` Owner's Address: SOp,,• r„' j�0`� Date of Inspection: Name of Inspector: lease print) Company Name: i -4-1G =3;' Mailing Address: c Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system Passes ' Conditionally Passes �Ieed�Further Evaluation by the Local Approving Authority ✓Fails Inspector's Signature: q4i6V1,q 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A llC/ERTIFICATION(continued) Property Address: JAY � �h• / G Owner: ,n n o v� Date of Inspection: / p3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst m Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally passes: A/ e or more system components as described in the"Conditional Pass" repaired.The s st upon completion of the replacement or repair,as ass section need to be replaced or e y . m' p° � ep approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health, A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating-that the tank is less than 20 years old is available. ND explain. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipes).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Title G inanwrtinn Rnrm�./1 iMAAA 7 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4ey- LL// Owner: l7'ti.el-I64.4 H Date of Inspection• ? 0 C.` Further Evaluation is Required by the Board of Health: /V Conditions e°which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the System is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a Private water supply well**.Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: V--,i, GZ� Owner• c— b� Date of Inspection: j D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Y" mockup 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 .plo ged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or 1 d depth in cesspool is less than 6"below invert or available volume is less than'/:day flow — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number �mes pumped _- AY 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 ter supply. �Y e �Any rtion of a cesspool or privy is within a Zone 1 of a public well. rtion of a cesspool or privy is within 50 feet of a private water supply well. — rtion 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,performed at a DEP certified laboratory,for coliform[This system passes if the well water analysis, bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] PL (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described is 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• You must indicate either"yes"or"no"to each of the following; (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply — system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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 15.304.The system owner should contact the appropriate regional office of the Department. Title C i..e.. +:..—D-- r is r-- A Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: A4. Date of Inspection: / O Check if the following have been done.You most indicate"yes"or"no"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health ere any of the system components pumped out in the previous two weeks? t/Has the system received normal flows in the previous two week period? &-, a 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 b or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no ✓Existing information.For example,a plan at the Board of Health. —L/Detem pined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] T46 C incv%"t;^n 1Pnrm 4/1 C/)AnA 5 ' Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �W A-,�1� tk1 Owner: Date of Inspection: p 'FLTOO CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): -� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no): A,10 Is laundry on a separate sewage system(yes or no):&V[if yes separate inspection required] Laundry system inspected(yes or no): GLp Seasonal use:(yes or no} /_I Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): . Last date of occupancy: COMN[ERCIAL/INDUSTRIAL Type of establishment Design flow(based on 310 CMR 15.203): god Basis of design flow(seats/persons/sq%etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL ORMATION Pumping Records Source of information: Was system pumped as part of the inspectio (yes or no):_ If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: ____ TYP F 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) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: ©✓"C-t,P, G- — C-Sf — Were sewage odors detected when arriving at the site(yes or no): /fib Title G r._— i., ..... Ac ` Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address•'✓�in g J Owner: Date of Inspection: / a� BUELDIiNG SEWER(locate on site plan) Depth below grade: Materials of construction:— ast iron 4401V—C_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(�locate on site plan) Depth below grade:l Material of construction: te—metal— fiberglass__polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: a`r Scum thickness: (9 Distance from top of scum to top of outlet tee or baffle: N Distance from bottom of scum to bottonyjooutlet tee or baffle: How were dimensions determined: ff o t QA; C66-1 c-•-- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evi ence of leakage.etc.): 714-n Jr- GREASE TRAP•_locate on site plan) Depth below grade:— Material of construction:—concrete—metal fiberglass_—polyethylene—other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baflIe condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T41a C 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued) Property Address: J 7�r �t�. d Owner: Date of Inspection: 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(expLiin): Dimensions: Capacity: xallons Design Flow: aallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:/y (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: /V(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.): Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rQ Property Address: .7 C� J�P�i< Owner: #C4 in Date of Inspection:/QS SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type eaching pits,number: 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,!!Nos of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): a G 4 .r CESSPOOLS: /( (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:&(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.): Page 10 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: U � '�/�''i• /C h OoZ-,6 O� Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system inchuling ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 32f 10113 �3 r 127 1; , V Tula G inonartinn Form 4/1IMAM 10 t Page 11 of 11 _� t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYST RMATION(continued) M INFO Property Address: Owner: Cote O/ Date of Inspection: SITE EXAM Slope 19 Surface water Check cellar � Shallow wells ( Pf Estimated depth to ground water feet O Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:giserved site(abutting property/observation holeAvithin 150 feet of SAS) ked with local Board of Health-explain: Iwm�tion) Checked with local excavators,installers_(attach do Accessed USGS database-explain: You must descri a how 7ou established the high gro5Vwater elev tIon: ro � f7C...4-10 / r ` / O P off' 6za cf� p0 0m o Q od 9119' l0. PLAN REFERENCE WEST • MAIN STRIRCII,_ PLAN BOOK 213 PAGE 85 36 BENCH MARK' ASSESSOR'S MAP: 268 .4/1 fr c LOT: 171 — 35 PK NAIL IN ROAD ELEVATION - 33.22STERLIBARNSTABLE GIS DATUM J 3/2-0234 N N ` 24 f t x 12.5 f t x 2 f t ! 12 a r, HYAAMS. MA 3 LEACHING GALLERY GAS LINE O v — TP-1 pp - LOCUS MAP NOT TO SCALE ® n G�R -o j'UE 36 TP-2 SLAB ,cN P11 VED DRIV 1 O CONTOURS EWA Y EXISTING - -- - - - - 50 MINIMAL GRADING PROPOSED O o ° ° C) QD o W',TER LEGEND W J pIM EXISTING *12-0 W \ 1000 GALLON o 0 LOT 13 Qj � 1 TER Z SEPTIC TANK AREA - 11217 s f +- �� (GATE D-BOX O a TEST PIT EXISTING O /20.74 i f- — a LEACH PIT 35 ! W ( ^34 UTILITY POLE $ � v J FLOW PR F I ALL PPE ELEVATIONS SPECIFIED ARE INVERT ELEVATIONS TREE 7F O LE -NUMBER REFERS TO DIAMETER p PLAN .1: .*:CN.ES. LETTER CE.":nrEs Typo TOP OF FOUNDATION RAISE COVERS TO WITHIN O-OAK M-MAPLE P-PINE F j EL - 36.31 +- 6 in OF FINAL GRADE ►ONE INSPECTION RISER FOR f SCALE: l in - 20 ft LEACHING GALLERY I 2- LAYER OF 1/8 DROP D-Box 1/2' ST�E SEWAGE DISPOSAL SYSTEM PLAN FLOW LINE -TO SERVE EXISTING DWELLING 10- = 4- -TL - T ~ RAYMOND & ELIZABETH HARRINGTON r3 -AST BAFFLE 48 ORYWELL 3/STONE4• OFM r;Tr-n Ass 58 STERLING ROAD HYANNIS. MA PRECAST33.21 +- 6 in BOTTOM OF STONE SOIL ABSORPTION o� DAVID ECO-TECH ENVIRONMENTAL EwsTNp E'05T`'"' BASE 31.98 LEACHING t SYSTEM ��. D. EXISTING 32.15 GALLERY 1 o COUGHANOWIR N 43 TRIANGLE CIRCLE SANDWICH MA 0256 EASTINO 31.85 5.00 fl • No. 1093 1000 GALLON (END VIEW) 29 85 IP ��G ��0 508 364-0894 EwsT'N° SEPTIC TANK 26.5 f, o> 5 f, 12.5 f, [' 2 3.�� b � I/TAR\ ETE-2242 DEC 5. 2005 1 It" I/2 14 f' ILS THIS PLAN IS TO BE CONSIDERED A DRAFT PLAN UNLESS IT ADJUSTED 19.20 BEARS THE STAMP AND SIGNATURE OF THE DESIGN ENGINEER 13RO NDW HIGH bee 7 ` Z005 ORIGINAL PLANS INTENDED FOR SUBMITTAL TO THE BOARD GRGUNDWATER OF HEALTH WILL BE SIGNED N BLUE AND STAMPED N RED. TEST L 0 G DATE OF TEST: " DE CEMBER I, 2005 SOIL EVALUATOR: DAVID D. COUGHANOWR. RS DESIGN CALCULATIONS - SOIL WITNESS REQUIREMENT WAIVED - NO VARIANCES SOUGHT NO GROUNDWATER ENCOUNTERED TEST PIT I PR AENT MATERIAL: A ERIA: PROGLACIAL LS L H DESIGN FLOW: 3 BEDROOMS X 110 GPD - 330 GPD ELEVATION - 35.76 +- SEPTIC TANK: 330 GPD X 2 DAYS - 660 GALLONS DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER USE EXISTING 1000 GALLON SEPTIC TANK IF IN SOUND STRUCTURAL (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 35.76 CONDITION. IF NOT. INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) 0-6 0 WOOD LOAM 10 YR 2/I NONE FRIABLE DISTRIBUTION BOX: USE 3 OUTLET D-BOX, 6-8 E LOAMY SAND 10 YR 4/1 NONE FRIABLE SOIL ABSORBTION SYSTEM: A 24 ft x 12.5 ft x 2 ft LEACHING GALLERY CAN LEACH 8-12 A LOAMY SAND 10 YR 3/4 NONE FRIABLE Abot - ( 24 x 12.5 ) - 300 sf 12-45 B LOAMY-SAND 10 YR 4/6 NONE LOOSE Asdw - ( 24 + 24 + 12.5 * 12.5 ) x 2 - 146 sf 32.01 Atot - 446 sf 45-144 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 23.76 Vt 0.74 x 446 - 330.04 GPD NO GROUNDWATER ENCOUNTERED USE A 24 ft x 12.5 ft x 2 ft GALLERY. Vt - 330.04 GPD > 330 GPD,:REQUIRED TEST PIT 2 PARENT MATERIAL: PROGLACIAL OUTWASH ELEVATION - 35.53 +- PERC AT 54 in : 2 MIN/INCH IN C SOILS DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 35.53 0-6 0 WOOD LOAM 10 YR 2/1 NONE FRIABLE 6-9 E LOAMY SAND 10 YR 4/1 NONE FRIABLE LEACHING GALLERY 500 GALLON DRYWELL Dt*-N&OM A/vDTAIL 9-12 A LOAMY SAND 10 YR 4/4 NONE FRIABLE CONSTRUCTION DETAIL use "`'OC taut 12-44 B LOAMY SAND to YR 4/6 NONE LOOSE 31.86 DRYWELL UNIT INSTALL ONE INSPECTION IN 44-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE 8•-6-x 4•-10'x 2'-9- STONE INCHES OF RISER TO FNAL GRADE SIX 24.53 2 ft EFF. DEPTH ® AND INDICATE LOCATION 24.0 f t ON AS-BUILT PLAN O 7 NOTES o 34 7 LA in 1) GARBAGE GRINDER NOT ALLOWED WITH THIS DESIGN C4 p��pp0�ppC:3 cl a�� In 3) ALL COMPONENTS STALLED SHALL MEET THE2) ALL LINES TO BE SCH 40 PVC AND PITCH AT /MIN MUM RE MINIMUM INCH PER FOOT ��p�ppp�ooQo �OO 4" OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15) 3.5 8.5' 8.5' 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES 24 O ft NOT TO 102 in BEFORE EXCAVATING FOR SYSTEM. SCALE 5) EXISTING AND LEACH PIT TO BE PUMPED. COLLAPSED. AND FILLED. OR REMOVED 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE 7) LINES EXITING D-BOX TO RUN LEVEL FOR 2'-0' BEFORE PITCHING DOWN GROUNDWATER ADJUSTMENT SEWAGE DISPOSAL SYSTEM PLAN 8) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES EXISTING GROUNDWATER LEVEL AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK -TO SERVE EXISTING DWELLING BASED ON TOWN OF BARNSTABLE 9) SYSTEM IS NOT DESIGNED TO WITHSTAND .VEHICULAR' LOADING. DO NOT GIS DEPARTMENT RECORDS. RAYMOND ELIZABETH HARRINGTON PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 10) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT MIW- INDEX WELL IW-29 . BEFORE :STARTING WORK. INDICATED GW 58 STERLING ROAD HYANNIS. MA 11) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TOt GRADE ON A LEVEL ZONE C STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH READING DATE DEC. 2004 ECO-TECH ENVIRONMENTAL SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING READING 8.1 12) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED ADJUSTMENT 92 1 43 TRIANGLE CIRCLE SANDWICH MA 02563 FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. ADJUSTED GW .2 ETE-2242 DEC 5. 2005 2/2