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HomeMy WebLinkAbout0022 WINDSHORE DRIVE - Health r 22 Windshore Drive A = 271 - 15C1 Hyannis t r I o e D No. 9-007 qq Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Migpogal �&p!5tem cow9truction permit Application for a Permit to Construct( ) Repair( r)—Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.A,� �//ndsjwl7 G &L wner's Name,Address,and Tel.No. .Z 7/ Assessor's Map/parcel '17/ 50 �_V~I )-� Installer's Name,Address,and Tel.No. SC& 3 Coal- ro a-3 7 Designer's Name,Address and Tel.No. 1l'fn,Q/W q SG. e, r );'71 ' } :e 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(min.required) 4,4 pipd Design flow provided �3 S l gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank [ Soo Type of S.A.S. Description of Soil See SdS ( LcP Nature of Repairs or Alterations(Answer when applicable) -9-e{ 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 oard of Health. SignedQ , Date 10 _O JL Application Approved by Date 6 Application Disapproved by: Date for the following reasons Permit No. �0� Date Issued 10— 30_0 No., C7�T �� a iw Fee 'lTv THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rppticatiou for �Digo!gat i§pztem Con5tructiofi-Vermit Application for a Permit to Construct( ) Repair( 1—'Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. I ., A-,Pwner's Name,Address,and Tel.No. ?7 &SS f Assessor's Map/Parcel a 7/ - ISO C&- ��. G a 3 � Installer's Name,Address,and Tel.No. s 3 Designer's Name,Address and Tel.No. S4.�-r1~S er Type of Building: ae r,` / .• p Dwelling' No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons m Showers( ) Cafeteria Other Fixtures Design Flow(min.required) pd• Design flow provided S ' gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank I SOO Type of S.A.S. m Description of Soil Se P Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenancesdf the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the`system in operation until a Certificate of Compliance has been issued by this Board of Health. _ w..: k } Signed � - ` ~ Date /iJ,30 -0 App lication Approved by C Date /6-30 -U7 Application Disapproved by: U Date for the following reasons Permit No. d DO Date Issued �d- 3 D _C - THE COMMONWEALTH OF MASSACHUSETTS ,BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded e, Abandoned( )by at a �/ �u S h y�� 1)� H,-I,n J has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. O� dated /0_3�'-v j Installer f 1.S re r r cc", S Designer S w-e--, —a- _/ #bedrooms Approved design flow W At gpd -- The issuance of this permitss�halVnot be opst uJed as a guarantee that the system will£un,t�ion�as/ gned. / � �ff Inspector ! c,!�� �� J . / V f ✓ 1 1 - --------------------------------'1--�-- — ---- i No. �k� -1 / Fee THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS t I=i!5po!5at,*p$tem Cold.5truction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at off- �ti, nr S ti C,r`? 9 J P » and as described in the above Application for Disposal System Construction Permit.The applicant reco zi a his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. ' Date �� 3U r Approved by �Je iS 210 Picyaration off fans and Jpenncanui,� n u•• , r •. •—,r< �•--� c. .• - r I — The plans and speci5cations,.for every on-site system shall be prepared as follows:• (1) -1�vcry system shall be designed by a Massachusetts Registered Professional Engineer or a Massach-trsetu Registered Sanitarian provided that such Sanitarian shall not design a. system designed to discharge morn than 2,000 gallons per day pu.=suant to 310 CMR IS.103. Any other agent of the owner.may prepare-plans for the repair of a systerrt.designed to /discharge not morn than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided they are reviewed by:a Massachusetts Registered Sanitarian and•approJcd by the.apprdving �/ authotit};• • ). .Every,plaa submitted for approval must be dated and bear the stamp and signature of the designer, (3J Every plan for a new system or plan for the uparade or expansion of an a isting:system-'-•`_ Which requires a variance to a property line setback.distance;must.also referencc'-a plan which bears the stamp and signature of_a Ivtassachasctts- Licensed Land Surveyor in I- - accordance with M.Q.L. c: 112, § 810; /) Every plan for a tystcun shall be of suitable scale'(one inch=40 feet or fewer for plot plans and one-inch—20 feet or fewer for details of,system.eomponents). fgd shall include. : ttdep' tine of: (a the the legal boundaries of the facility to be served; : the holder and location of any easements appurtenant to or which could impact the • (c the location of the1 dwdling(s)or buildings)existing and graposcd on he fac0ity - d.idenufieatia of those,to-be served by the system; the'iuearion of ekistuiil of proposed irnpertious areas, including:driveways and v p g areas) th e} location and-dimcrsions of e systcrn (including reserve are: -• f)• sys4^m design calculations, including design daily sewage flow, septic rank capacity (re 'cd and provided); soil absorption system capacity (required and provided); and ether system is designed for garbage grinder. - North arrow and existing and proposed contours; (h _.location'and'log of deep'ob'scrvation hole tests including the date of test, existing a elevations marked on each test, and he names of the representative of the ✓✓✓ proving authorty and soil evaluator, - (i) location and results of percolation•tests including th6 gate-of test and tha names of 'the representative of the approving authority and soil evaluator. . name and ecrtiiicafionnumbcr-of the Sod-Evaluator of record; (k) location of every'water supply,public and'private, . 1. within 400 feet of the proposed system location in the .tiro of surface water supplies'and gravel packed public water supply wells, 2. wihin 250 fact of the proposed system location in the case;of tubular public water supply wells, and 3, within150 feet of L proposed'systcm location in: he case of private water supply on , 1) 3ocaon of-any surface waters of the Commonwealth;.ravers, bordering••vegemted wetlands, salt marshes, inland or coastal banks. regulatory floodway, velocity zone, : surface water supplies, tribute.?es to surf ace water supplies,certified vernal pools,private water supplies or-suction lines, ,graycl packed-or tubular public water supply wells, substzface drains, leaching catch basins, or dry wells; and The location of any nitrogen sensitive area identified'in 310 CNLR 15.215 wiriuin which poitions of the proposed / " tern ate located. (m location of water lines and-other subsurface utilities on the facility; observed and adjusted ground=water elcvadon in the vicinity of the system; o) a campletr,profile of the system; -an ote on the plan listing all variances to fate provisions of 310 CMR 15.000 sought W anjunction wih the piar.; (q) , the location and elevation of one berchmark.within 50 to 75 feet of the facility which is not s.ubjcct to dislocation or losi.dt=ring construction nit'the fac'iL'ry; (r) when dosing is-proposed, 'complete desig:i-in specification tsf the,dosing system proposed including.but aoi limited to d6sing.charnber capacity (required and:provided),' urnp curves and specifications, number.o1.d'oSLza cy"1es and depc.�t per cycle; s) whets a Recirculating Sand Filter or equivalent alternative technology is required or posed, a complete plan and specification for the syste ,including a hydraulic profile; a locus plan,to show the location of the facility including the nearest existing weer, ( the strect au"Mber and lot num. if any, of he facility-, and the materials of coast vctio"'d L'le specifications of the system. SWEETSER ENGINEERING P.O. BOX 713 —SOUTH DENNIS —MASSACHUSETTS 02660 TEL (508) 398-3922 FAX(508)398-3063 LAND SURVEYING — ENGINEERING—TITLE 5 SEPTIC SYSTEMS SEPTIC DESIGN PROPOSAL PAGE 2 PROPERTY SURVEY AND FLOOR PLAN SKETCH Please fill out this form,including the floor plan sketch,and return to us with the signed proposal and retainer. This information is necessary to properly prepare your Septic System Design. IF YOU ARE PLANNING AN ADDITION PLEASE INCLUDE THAT INFORMATION ALONG WITH THE FOUNDATION DIMENSIONS AND LOCATION FOR THE NEW ADDITION. �jotal#of Rooms Year Round Home Seasonal Home Owner Occupied Rental 3 #Bedrooms Family Room/Den Living Room Dining Room 1 y #Bathrooms Washer/Dryer Dishwasher Garbage Disposal Gas Service ✓ Town Water In-ground Electric Wires* In-Ground Oil Tank* In-ground Sprinkler* In-ground Gas Pipes* * Please note on.sketch where located. Sweetser Engineering assumes no responsibility if in-ground components are damaged during Soil'Testings, Inspections,Locations of and/or Installation of New Septic System. Cellar: ✓*'' Full Partial(Crawl) Slab Wells: Main Use Irrigation Only (please provide location of all ivells) PLEASE USE THE SPACE BELOW AND THE BACK OF THIS SHEET TO PROVIDE US WITH A ROUGH SKETCH OF THE EXISTING FLOOR PLAN(ALL FLOORS). Also include any items that should be avoided,IF FEASIBLE,i.e.shrubs, trees,patios,electric lines,tanks,etc. IF YOUARE PLANNING ANADDITION, PLEASE PROVIDE THE LOCATIONAND FOUNDATION DIMENSIONS. SO ` e�rst9. `7epk:C S� D.� {tied 7�i �i;oe9uw t ) e e� olo� GU at d s v �� s 0 Town of Barnstable Regulatory Services Thomas F. Geiler,Director S iaaxsTAau. MAS& Public Health Division • � i639 �� '°rEo r m Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: l 0'�-13—0-?Sewage Permit# a Oa7 " 419 J Assessor's Map\Parcel o1 71 ISO Designer: Installer: r 1 I &Al P-erj CGh4J\. Address: 6ne9d-- l"rptG� Address: a3 011drlr`nr,�e �(Z A o 7-A On 10130j07 was issued a permit to install a (date) (installer) septic system at a a- lyihc skp" /��, �c.( _ based on a design drawn by (address) s t",4 y a-e-r- I7 hi'/)'► !222 dated O d, Go 7 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. aAA7 NYA 'c ( nstaller's Signature) U CAr01NcAU'..i (I'll" e s Signature (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. r, THANK YOU. Q:\Septic\Designer Certification Form Rev 03-09-06.doc COMMONWEALTH OF MASSACHUSETTS MEOW EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 22 Windshore Drive,Hyannis,MA Owner's Name: Estate of John T.Broussard ' :2711 -\S 6 r •; Owner's Address: Same . ; c Date of Inspection: 08/29/2007' :7 Name of Inspector:Reid C.Ellis Company Name:Eft Brothers Const.Co. Mailing Address:23 Enterprise Road Yarmouth Port,MA 02675 Telephone Number:508-362-6237 CERTIFICATION STATEMENT CO I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority m ails b ®� Inspector's Signature: Date: ds 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 Co '� ' "`' ' ' " d o k -Rvk ge-( �VW �Xl ****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. 1 � Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:22 Windshore Drive,Hyannis.MA Owner: Estate of John T.Broussard Date of Inspection:08/29t2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15. 03 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in th "Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement r repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the fa r the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or tt,a septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or 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 tatic water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven dist'bution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are repl wed obstruction is removed distribution box is leve led or replaced ND explain: The system required pumping more than 4 times a y due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are repla ed obstruction is removed I ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 Windshore Drive,Hyannis,MA Owner: Estate of John T.Broussard Date of Inspection:08/29t2007 I C. Further Evaluation is Required by the Board C Health: Conditions exist which require further eval n by the Board of Health in order to determine if the system is failing to protect public health,safety or the enviror ment. 1. System will pass unless Board of Health det rmines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner whict will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a si rface water _ Cesspool or privy is within 50 feet of a bi irdering 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 abs rption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface i vater supply. _ The system has a septic tank and SAS aE d the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS ar d the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS ar d the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to etermine distance "This system passes if the well water analys s,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 an flysis must be attached to this form. 3. Other: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 22 Windshore Drive,Hyannis,MA Owner: Estate of John T.Broussard Date of Inspection: 08/29/2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Y N ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool A— quid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow fired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ZAy es pumped ortion of the SAS,cesspool or privy is below high ground water elevation. ortion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface r supply. _ portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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 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.] (Yes/No)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 o y y caner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: SS14 To be considered a large system the system a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of t ie following: (The following criteria apply to large systems in ac dition to the criteria above) yes no the system is within 400 feet of a surface drinldng water supply the system is within 200 feet of a trib to a surface drinldng water supply the system is located in a nitrogen sensiti ve area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in S n E the system is considered a significant threat,or answered "Yes"in Section D above the large system has fail .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. 4 L Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 22 Windshore Drive,Hyannis,MA Owner:Estate of John T.Broussard Date of Inspection: 08/29/2007 Check if the following have been done.You must indicate es"or"no"as to each of the following: Y 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? 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? A,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,*Kcluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of 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: nYes no/ 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 22 Windshore Drive,Hyannis,MA Owner: Estate of John T.Broussard Date of Inspection: 08/29/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMK45.203(for example: 110 gpd x#of drooms): Number of current residents: Does residence have a garbage grinder(yes or no):!� Is laundry on a separate sewa a system es or no): [if yes separate inspection required] Laundry system inspected(yor no): O Seasonal use:(yes or no):�- Water meter readings,if avpyable(last 2 years usage(gpd)): ?✓ Sump pump(yes or no): IV Last date of occupancy: i�y P.MA COMMERCIAL/INDUSTRIAL /v A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): 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): dA GENERAL INFORMATION Pumping Records Source of information: /Pv,,_a l `T Was system pumped as part of the inspection(yes d no):�7 If yes;volume pumped: /eallons—How was�uantity pumped determined? Reason for pumping: �" ��sx, Tq OF SYSTEM V 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) _hmovative/Altemative 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 kno d source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Windshore Drive,Hyannis,MA Owner: Estate of John T.Broussard Date of Inspection:08/29/2007 BUILDING SEWER(locate on site plan) ��r Depth below grade: Materials of construction:_cast iron 40 PVC_other(expIain): Distance from private water supply well or suction line: Comments,(on condition of"oints,v nting,evidence of I ,etc.): r ` V IS SEPTIC TANK: locate on site plan) i tr Depth below grade: ' Material of construction r/ concrete_metal_fiberglass_polyethylene is/!/tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) r Dimensions: )G 5 v Sludge depth: 67111 Distance from top of sludge to bottom of outlet tee or baffle: � ;Scum thickness:_ 4bae­:-.;M— HowDistance from top of scum to top of outlet tee or baffle:Distance from bottom of scum to bottom of outl tee or were dimensions determined: 'j—)jk­0 Comments(on pumping recommendati ns,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet iqveM.evidence of leakage,etc.): , J �,� r GREASE TRAP:_(locate on site plan) 11�114- Depth below grade:_ Material of construction:_concrete_metal fi erglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba Distance from bottom of scum to bottom of outlet tee.or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and utlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Windshore Drive,Hyannis,MA Owner:Estate of John T.Broussard Date of Inspection:08/29/2007 SOIL ABSORPTION SYSTEM(SAS):V (locate on site plan,excavation not required) If SAS not located explain why: T/Ye eaching pits,number: leaching chambers,number: - ILs��-s► �^ leaching galleries,number. leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): c CESSPOOLS: (cesspool must be pumped as part of spection)(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 or no): Comments(note condition of soil,signs of hydraulic failur ,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) A14 Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failui e,level of ponding,condition of vegetation,etc.): 9 I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Windshore Drive,Hyannis,MA Owner: Estate of John T.Broussard Date of Inspection:08/29/2007 / v SKETCH OF SEWAGE DISPOSAL SYSTEM All f Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 eet Locate where public water supply enters the building. VV 1 _ k d-1 � r 10 13 i v 10 Title 5 Inspection Form 6/IS/2000`-- l Page 11 of 11 e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Windshore Drive,Hyannis,MA. Owner: Estate of John T.Broussard Date of Inspection: 08/29/2007 SITE EXAM Slope Surface water o " -- Check cellar Shallow wells 04 . ` Estimated depth to ground water t 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: Observed site(abutting property/observation hole within 150 feet of SAS) . __JChecked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation Accessed USGS database explain:_ �✓„p,,�,rl C -� You must describe how you established the high ground water elevation: 14 176 11 g LO i�4�T ION SEW E PERMIT NO. VILLAGE 4 IN.STA LLER'S NAME ADDRESS B U I'L D E R OR OWNER DATE PERMIT ISSUED � 2 : 77 DATE COMPLIANCE . ISSUED � ' `q n� �� C1 f t ¢� �� �} 1 :� �,,' .�/�Y ..� ..Y� V� No.. F�� �..... .... t ..�..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l - c v.......0F.... /Cf,%J/,T... ........................................ Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at r� !3................ ------------------ ................................................. Lopn•Add re // or Lot No. ory_�. -� .Q/.t/�I'-----------------------------------------------•---- ner -•--- Address W _ 1. . ... • -•-----•----•-•---------•----•- --•---•---------' --••-•----------•----'-----•---•-•-••---•-- nstalle Address UType of Building Size Lot--- .......Sq. feet .-� Dwelling—No. of Bedrooms---------3..............................Expansion Attic ( ) Garbage Grinder (�4 4.4.4 Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) - Cafeteria ( ) a' Other fixtures _------A"a V ------------- - - W Design Flow---------- .......................gallons per person per day. Total daily flow......... Q-__-_---.-----...gallons. MSeptic Tank—Liquid capacity------------gallons Length................ Width.........------- Diameter______.-.-._--_ Depth--------------- xDisposal Trench—No. .................... Width-----------.-------- Total Length---------------_.... Total leaching area....................Sq. ft. Seepage Pit No./OV©.OW Diameter-g��-ue_h4-CWpth below inlet...............y.....,Total leaching area...�� _--=-sq. ft. Z Other Distribution box ( ) Dosing ta ) G/A`40/A > A 3 — : W Percolation Test Results Performed by------------- ... ,�lL.�rfe_-_-__-_-___ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ L14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.------_---.----_----. P4 -------------------- •• r - !- . a ... . ---------- Descrition of Soil.------- ------- r W UNature 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 Article NI of the State Sanitary Code— The undersigned farther agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health.. f/ Date Application Approved BY �G'�efi - ----------- Date Application Disapproved for the following reasons_____________________________________________................................................ ............•- --------------------------------------•----•---------------•------------------------------------------------------------------------•-• --•------------------ ----------------------------------------- Date PermitNo......................................................... Issued........................................................ Date No. ............ , �. Fs�..... `. ......:.:..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratinn -fur Miipoiitt1 Workii C owitrurtion Vrnu t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at '{ ............C/4r�1!_•' f. ,JC 4" r�t e --- 1 .............. ...... .J�''`a�-V_r 9 f Locat-t n Addre or Lot No. s er Address ,W1 _---••-----.._._.11.. ----•-----•--------------•------------••••••-------------••-----------------------•----•---•------ C,aller Address Q Type of Building r Size Lot.... ------Sq. feet U Dwelling—No. of Bedrooms._-__ ._. -___Expansion Attic ( ) Garbage Grinder (,W 114 Other—Type of Building ............................ No. of persons. _-.,____ -_-_ Showers ( ) — Cafeteria ( ) QOtller{fixtures .. ' •------------------------- ---- ----------------------------- w Design Flow_..._..__.± .... ........ .. ........gallons per person per day. Total daily flow..._._.._. _` .........._.. gallon~. WSeptic T.uik—Liquid capacity------------gallons Length-------------­- Width-.............. Diameter_--.-....__. -- Depth..._----_.-_--- x Disposal Trench No -------------------- Width.................... Total Length_---______________ Total leaching area--------------------sq. ft. Seepage Pit below inlet......_ Total leachin ire.l__ _ sc ft. Z Other Distribution box ( ) Dosing to ) a Percolation Test Results Performed by............ � --.------ Date Test Pit No. 1................minutes per inch Depth of Pest Prt...�___---__--. Depth to,around water...----..------.-..--... fZq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..------__-_-.----_-. - ._ Descr ton of Soil____ _ «�•_ _____.__ w ------ --------------------------------------------------------------------------------------------------------------------------------------------==---------=------------------------------------------------ U Nature of Repairs or Alterations=Answer when applicable...___- .:..:.........._-r:___--______..._____.ti..____-- _..__....__.____.__.___---____. ---------- ----------------------- - -------------- - - - --- ----------------- Agreement.:. The undersigned agrees to install the aforedescribed -Individual.;Sewage.:Disposal System in accordance with the.provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system:in operation until a"Certificate of Compliance has been issued by the board of health. Si ned -- ----- �s�t � ---`•� -`--- . Date A lication `Approved By..... .._ PP ' --------- D u�• �/ • ate Application Disapproved for the following reasons:---•---•--•----___-----•-•-----•--------------•--•----•-------------------------••--•----•___----•-•----------- •---•----••........................•--...----•------••------------••-------------............................. --••- --•-• ----------- -----••••-------_--•-- Date PermitNo..................==-- ..................................... Issued--=---------------------- -........................ Date THE COMMONWEALTH �OF MASSACHUSETTS s. BOARD OF . HEALTH' 'S<!..d ,j........OF....� !i�!,4,tiff: "....................................... �rrtifira te ofF fN m ii�turr THIS�'TO REIFY, That the Individual Sewage Disposal System constructed ( - or Repaired ( ) by -------•--•-•••-••-=-- Installer ---- has been installed in accordance with the provisions of A icle 'I o Th State Sanitary Code as described in the application for Disposal Works Construction Permit No.-- - - &1------.-_ dated-.-----/--_ ---? .; ' X7.. ThE 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 OF HEALTH No............ .1. - FEE ........ �i��>a�tt � ����tr�trti�Ht rr�tit Permissionis hereby granted...... A----- • -G=----------------------•-----------•-•--...-___. -•---------- ........................................ to Construct (4-) or Rgpa r A Individual Sewage Disposa ystem 3ireet as shown on the application for Disposal Works Construction Re it No. Dated--- 1 ..�_' ----- / '/��'j ar. s Board of Health 1 - 24 �I -- DATE............................................................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS •,y .. 't. St�aGLr--- V:76miL'-4 - 3 'T-�SmeOc7M 44 LAO C-,AtzFsAC.� ''c . f-LOW c t 1 h 0 P n• i Pv � a�YT'1C T�11C = 33os �St% % = 4-95 6. . e cv USC= 10�7C� 6,4t_. �ci 15Po5AL PfT L-)SE (oc� Gaf_. ►^'`' � r �CJ.�.WAf_.!_ Ae� = lso s.F• � owes. �. to - Sty �f'. l .o - SO �.PD. fJ 111 o Pax , TOi,dL �ESiGtJ = 42.5 G.Rr�. � _ z�• ,' Cl" 2MIu. OIZ l.F-s�I. 7 BAXILR i -rr. }2tUiAf�jl �` f l� �L�1 / tQ, �fy.� ,.•� Tor l7►ID = ICO.b p 4`pv� VtST. I W. G".. 2 YL, SUB so 4 r oX qG.4 tWV. JK11C Cou r?S t? 1000 96'7 ttNv, tw. 96.1 Z- $A ND GAL.. 9C jp ` LGAC p "p i GRAYF-t- PIT WASWED Ga�te+5@ SToti� eq,-7 tocATIO�-J H' A RN t t--, Mi - � Vi L 40FT-*PAl j ��iZ� -7 7 Ao f ✓rxTt pF-oP' a P 4t.l TZi_t=c_PcV lcC:: _� � c!y rz�'�t=�•( ���a T T 1�i✓ jam,`�;�,L.r t�, Ca 5 t-lo,,u W+ t-te.P. twr�,,1 Gca�.tn►-�<s Ott fT 4 TO : 51pr t_1►a `' bh1D �iETC�nCI! VC-LJUIQGVt&-k'AT; C)F T►-fC—. '7 ptaTG. tD CC 1 �.cr+.- SA)(T iIQC-- SxtvGtl"L(ZixD 1.A1`t� SUZvC tit L`T "_sue^-,/1 CL7 to" /,�•1 O s t �'V I L l C� c> 1t,C A;�r, - 1fJ;1- ':J!✓LC=W i /iU4�♦/t=`f .7 T4af_ C�Ft: r/� it 1Gl:ll Jt{ t�R_N:C /S.F.� T`�l✓ a 10 E. DLV C t.t`sr clC U CSC) TG l-Jfyt'(=C'_/ t��i= �C�'Y- l_1 t•lt= r.. ._. TOWN OF BARNSTABLE 1x0 ATION � �'�/�h�� -C.. iOrV--Y 1�1—wtiSEWAGE# V�I LAGE �i1la-,a✓�"'� ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. 171 rrJ--r`� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS ,J OWNER PERMIT DATE: 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 ---- --- -- of �OOOVSI/9—d®ICISSW..1 ,i L,h� •� t1 OI n�IOL Imo,U !J bz L'2Rik —� �, �� TOWN OF BARNSTABLE ?LOCATION as Lty hdAar--L b rk SEWAGE 6"' �9J 4 VILLAGE N�yn r►,r ASSESSOR'S MAP&PARCEL71 - /S INSTALLERS NAME&PHONE NO. I=111.5 /8Pc r%0/-1 SEPTIC TANK CAPACITY LEACHING FACILITY: e 44®i-- size .11f x id 'FG&O NO, OF BEDROOMS 3 OWNER 6 6/L0 J 2O PERMIT DATE: 10.20I a7 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 r Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY f t !v�"A rl P• CP co DP M tA ✓j r p .�,_v SOIL. TEST P# 11948 • , OP OF r 0UNDA71ON ( 20 FT, MINIMUM FROV CELLAR OR CRAWL SPACE I ELEV. = 109.00 -� i 10 F-. MINIMUM 'n FT. MINIMUM FROM SLAB DATE Jr SOIL TES �U• OBEP 2CC - CLEAN SAND SC-IL TEST DONE BY 4SSUMED' 1 WITNESSED BY MI f2ANDi____ 1` t \ I CONCRETE �_- ____ it COVERS INSPECTION PORT - - �- - / 4" SCHEDULE 40 PVC PIPE -LOAM AND SEED IvtiN. PITCH 1 8" PER FT. \ 2.. LAYrR OF OBSERVATION HOLE ,t ELEV.=. 98.70 �`T I / --------_- - ` /8 TD 1/2^ -t C Tv�r. PATE _ _;__2-- MIN./INCH A� __.5� ! � - _ w.,HES WASHEP STONE ' '�'"- - „ OR F!L ER FAB IC I DEi'TH I HGidIZ I TEXTURE COLOR MOFT� [OTHER I 4" CAST IRON PIPE �.8 #1AX. VENT T ( ; ._ NOT REQUIRED (OR EQUAL) MINIMUM --1- M� �0-iS" Ap LOAMY SAND 10YR5/3 NO tROr.T' t PITCH 1/4" PER F,. 1 t � I � ` "5-30 8 _ LOAM SANG_..___. !10'rR7/4 R30' � 30-�20" G MEDIUM SAND I _.5 �3/4FLOW ELEV- _ 5_ i �I 1 U," LINE 95.80 MIN. I - 1 L ( I ELEV. _ o� _ _-4. 7 f I Ev. / % '✓EL I �` ` 10 94.47 s _ t 6" SUMP _ "° �! _L__�Lam. _ 1 ELEV. _ _-' C�S ELEV. _ __95.81 - E1Eb. - _444- ,T 120 88.70 IN- p �NpO�+WrA�_R ENCOUNTERED AT __-•__ ELEV. �__ __ BAFFLE t�ISTRiBp SON ELEV. = Hi H 'APA ITY INFILTRATORSIT ' OBSER 1/ATION Hey E �8-.70- LIQUI,j3 OUTLET 4 G C W H OL.E 2 i TO RE PLACED N FIRM BASE BOX - - STONE 'N AN Z -�-- (' ) DEPTH HORi� 4 F ET 14 INCHES i TO BE WATER TESTED � ,77 __ - E TEXTURE - COLOR i MGT GTHER ! I 5 19 INCHES 11' X 36' X 100 TRENCH FORMATION 500 GALLON IF M``RE THAN ONE OUTLET 0-9" A LOAMY SAND 10YR5/2 NO ROUTS 6 FEET 24 INCHES i - _'--------- ;nNIA 8 FEET 34 INCHES SEPTIC TANK (TO BE PLACED ON FIRM BASE) SOIL ABSORPTION WELi ONE 9-'� -- GAMY SAND 10YR7/4 ROOTS I 3/4 1 U 1 1 1 CLEAN - ( SYSTE1u! (SaS1 ADJUST-DEX "- 30-132" c MEC um SAND - 2.5YS/4 --_ __ 10% f-'086LFS 1 DOUBLE WASHED STONE i / A 1 FREE OF FINES & SILT SEWAGE DISPOS ., STEM PROFILE � UWA FRTABLLE WATER TABLE ELEV. = ____ _ NO WATER ENCOUNTERED AT 1 ELEV. _ _ 87.,'U i NT�t `_ f�i�.�'"�L.G 08SERVEU WATER TABLE ( / / ) ELEV. _ _ _ --- ELEV. R.OTTOM OF TEST HCLE ELF\ = e7 70_ DESIGN CALCULATIONS NOTES' 1 A-- 3 - 1. ALL WORKV NSHIP AN, MATERIALS SHALL CON'FC;rr`M TO D.E.P. � 't' !vIBER OF BEDROOM'✓ TITLE 5 AND THE TOW�v'S RULES AND REGULATIONS FOR j I G;RBAGE DISPOSAL UN!'' NO TvTAi. ESTIMATED FLOW THE SUBSURFACE DISPOSAL OF SEWAGE. 110 GAL,/19R./DAY X .. 3 - SR.) _ Q GAL./DAY 2 ALL COVERS TO SANITARY iJM,S SHALL BE BROUGHT 70 / REQUIRED SEPTIC TANK CAPAC �Y GAL. WITHIN 6" OF FINISHED GRADE. ACTUAL SIZE OF SEPTIC TANK 1 GAL. 3. ALL COMPONENTS OF THE SANI''APY SYSTEM SHALL BE CAPABLE OF SOIL CLASSIFICATION _ - WITHSTANDING H-10 L OADO:; UNLESS THEY ARE UNDER OR WIT'HiN DES/ ( 10 FT. OF DRIVES OR PARKING ARE.43. H--20 LOADING SHALL BE EFFLUENT PERCOLATION RATE 5 MIN./IN. USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 1 / F"LUENT LOADING RA"E Q,74- GAL/DAY/S.F. 4. ANY MA OVARY UN!T5 J QED TO BRING COVERS _'O GRADE SHALL -- i LEACHING AREA 474.33 SO. FT. � >>4 4¢, (11X38)t(47X2X10/12) - BE MOFc TARED IN PLACE. J 98.7 LEACHING CAPACITY (AREA X RATE) L.44 GAL./DAY 5. NO DETERMINATION HAS KEN MADE AS TO COMPLIANCE WITH i 474.0 X 0.74 DEEDED OR ZONING REGU3_AT*NS. OW?iER / APPLICANT 1S TO . gi.6 99.3 OBTAIN 'LUCH DETERMINA11C% FROM APPROPRIATE AUT`iORITY. / OR/ / RESER,;- LEACHING CAPACITY NQt GAL./DA.Y 6. tjTILITIES SHOWN ARE AP OXiMAT ,.E ONLY, EXCAVAII3N ONTRfQTOR v 10 IS ­10 CALL "DIG-SAFE" A r 1-888-!'4-7233 AT LEAST 72 HOURS 99.5 moo' 98.8 98.1 PRIOR TO COMMENCING WORK 01, SITE �- 7. CONTRACTOR IS TO VERIFY GRADES AND Ei_.,/ATIONS AS WELL AS / 98.9 X SITE CONDITIONS PRIOR TO COMMENCING WORK ON ATE. ANY VARIATION I 99.0 LOT 19 .6 ;S TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER MMEDIATF.!- - \ 8. PARCEL IS IN FLOOD ZONE J9. LOT IS SmOwN ON ASSESSOPS MAP _ %7 AS Pr,KQCL / 6 f 1C. EXISTING SEPTIC TANK, C '?OX, AND LEACHING FACILITIES ARE' TO BE g u / PUMPED AND REMOVED A_U +G WITH ANY POLLUTED SOILS ENCOUNTERED. f 0 / 11. THE INSTALLER IS TO GIVE THE. ENGINEER MINIMUM OF 48 HOURS BOX (2 WORKING DAYS) NOTICE FOR THE FINAL INSPECTION (NUMBER BEL(.'N). 9P.7 98.8 1500 GALLON l SEPTIC TANK SOIL I 96.2 t TEST O i I D,R1 VE 1 ZH OF Ays ! r / 9£.4 $ SOIL " .� 17 p0' PEST 2 ::,�` T A I I� DUhfAS n G t I J 98.60 r L' r 1! No 61 i APPROVED BOARD OF HEALTH • 98.71 . r. xf r S Aa.�l� 196.5 1 8' I ` uATE AGENT PROPOSI D SEPTIC DESIGN I �k"IN STATE OF JOHN BROUSSARD JR.) I SER ENG G 235 GREAT WES FERN ROAD Z \ \ I 508- P. 0. BOX 713 ! I LEGEND; +� \ 39S-3922 SOUTH DENNIS, MASS- - 02660 I EXISTING SPOT ELEVATION 001A 0' v� - EXISTING CONTOUR ----M----- I !DATE SCALE s >' - ---j FINAL SPOT ELEVATION fn/�t�r OCT. 1 , 2( 1 20 FINAL CON TOUR- SOIL TEST LOCATION UTILITY POLE -O- -� j TOWN WATER -W- =W REVISED I JOB N0. @Q1 2 0 11 1 CATCH BASIN ®/ REVISED GAS LINE -G '" - r - --- -----� r ---� _ CLEAN OUT c.o. LOCATION MAP I � �F I CESSPOOL C.P. C I _ E [ SHEET �� i O: 1 58 1 PROF 6613-00 ! dw9 'I 6613-sees.DWG C-0 200 SWEETSER ENGINEERING