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Home My WebLink About0023 CALVIN HAMBLIN ROAD - Health 23 Calvin Hamblin IR-OA-P 101-025 Marstons Mills I No. 4210 1/3 YEL i ESSELTE 10% i v° Mq ,5'w�'w '�• 7�-�z� YOU WISH TO OPEN A BUSINESS? 4 , For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1 FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) DATE: 44 / Fill in please: APPLICANT'S YOUR NAME: -11 ,, BUSINESS YOUR HOME ADDRESS: Sv5 - 9-a3 iy `77y-3�i� ivi3� ' TELEPHONE # Home Telephone Number NAME OF NEW BUSINESS /� L TYPE OF BUSINESS IS THIS A HOME OCCUPATION. YES NO , Have you been given approval from the building division? YES ed"NO ADDRESS OF BUSINESSo�'3 lam, 1., / MAP/PARCEL NUMBER !� When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMM ISSIO R'S OFFICE MUST COMPLY WITH HOME OCCUPATION This individual h b imfar e "ye t requirements that pertain to this type of business. MULES AND REGULATIONS. FAILURE TO A th rize i nat a** COMPLY MAY RESULT IN FINES. OMMENTP: U F )i 0Si , 2. BO D OF HEALTH This individual has bee i Pn*d-ofthej3@vzQjt requirements that pertain to this type of business. MUST COMPLY WITH ALL i' .HAZARDOUS MATERIALS REGULATIONS uth d nature* COMMENTS: 1 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: -'owe Copv� /off-bay Commonwealth of Massachusetts 1 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (fit u 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every ' page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms 1jp 1 5q63 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Q Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 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 > 12-18-18 Inspector's S lure 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. t5insp.doc•rev.7/25/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 c Commonwealth of Massachusetts ° - Title 5 Official Inspection Form ?" ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- 23 Calvin Hamblin Road u� Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every 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: FE] 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: The system was in working order at the time of inspection. A portion of the driveway was blocked with ties prevent vehicle traffic over the H-10 septic tank. The dwelling is allowed to have 3 bedrooms per discussion with Tom Mullen (12-18-18). See attached 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 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,rnot leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old isavailable. ❑ Y ❑ N ❑ ND (Explain below): t0 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I � Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road v Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 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 ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 1 c� Commonwealth of Massachusetts �a I? Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 23 Calvin Hamblin Road u Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town 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 ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a 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. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every 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 all inspections: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ F-1 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? El ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ E] Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ 0 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ O 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 331/gpd Description: Permit shows 2 bedrooms but approved for 3 per Board of Health (12-18-18) 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes Q No Does residence have a water treatment unit? ❑ Yes rol No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes F!] No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: "'2016-64,000gallons 2017-63,000gallons"' Sump pump? ❑ Yes ❑Q No Last date of occupancy: 2 month ago Date t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road u Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: Owner- last pumped 3 years ago , 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts �o Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. S Type of stem: Y Y n Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: A new SAS was added to the existing 1000 gallon tank in 2004 Were sewage odors detected when arriving at the site? ❑ Yes N No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ❑Q 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: 0 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 1 Dimensions: 000 gallon 10if Sludge depth: 2611 Distance from top of sludge to bottom of outlet tee or baffle 811 Scum thickness 311 Distance from top of scum to top of outlet tee or baffle 11" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . u 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l u 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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): offDepth 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes 0 No* Alarms in working order: ❑ Yes R No* Comments condition notef( o pump chamber, condition of pumps and appurtenances, etc.): NA * 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: ❑ leaching galleries number: El leaching trenches number, length: 5 infiltrators ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 10 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip 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.): The leachingwas in working order and was d with no high staining at time of inspection. 9 dry 9 9 P 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �d ,ip Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments g p y ry V% 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owners Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owners Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/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: ❑E hand-sketch in the area below ❑ drawing attached separately s i q f r 4 p. kyi YYCN T"IF ,e y TSVry4 tt i e f � i �4 _6i ,c a r �� ix M � .ate' cw' �,.r- ,�"'• �� Nn t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Cispcsal SYs1em•Page 16:of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 9 P Y rY ` 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope All Surface water ❑■ Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @ 144" feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record 5-5-04 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form k-"P1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 12-18-18 required for every page. City/Town 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. 0 B. Certification: Signed & Dated and 1, 2, 3, or 4 checked 0 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Sewn& Floor o n Bcdruc,ti, 3 ' �ed�aom 2, 5+..►� 3 Ca)v;.l 1[So��-ht'voc-� O�Rcct, Door c't n+ov4br Qe c Con. W t BOW Aoffti Ctostk- G1os..F 3a° Door ""� C1ou1 L�Utno�foa� i b4-• s !i yi f j• ,_ ! r ` f3 4 JI I��I cs y3ti.. 3 J { { 4 I � Y8, � J dip k; F t s Door bo f r�4 u26}- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road U Property Address a� Jessica Caprio t ,e. Owner Owner's Name s information is Marstons Mills ✓ Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection r Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information 4, l 3q filling out forms on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 ad Company Address Sandwich Ma 02563 City/Town State Zip Code rxco (508)477-0653 S113747 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 Brett Hickey 10-31-18 �o-.:mia+.m io-as:a-0evo Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every 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 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. The dwelling had 4 actual bedrooms but the system has a design flow for 3 bedrooms and is deed restricted to 2 bedrooms per information provided by the Board of Health. Also the septic tank is H-10 and under a driveway. It is recommended the tank be blocked off from traffic or replaced with an H-20 tank. 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 exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 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 ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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: t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ilk gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road u Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 all inspections: Yes No ❑ Q Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary g p yAssessments �� 23 Calvin Hamblin Road �v Property Address Jessica Caprio Owner Owners Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts +� Title 5 Official Inspection_ Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every 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 all inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ E 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? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ a 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: n ❑ Existing information. For example, a plan at the Board of Health. El 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 2 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 331/gpd Description: The dwelling had 4 actual bedrooms but the system has a design flow for 3 bedrooms and is deed restricted to 2 bedrooms per information provided by the Board of Health. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes E No Does residence have a water treatment unit? ❑ Yes ral No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes El No . Seasonaluse? ❑ Yes [E No See below Water meter readings, if available (last 2 years usage(gpd)): Detail: "'2016-64,000gallons 2017-63,000gallons— Sump pump? ❑ Yes ❑■ No Last date of occupancy: 1 month agoDate l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts s, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M � 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: Owner- last pumped 3 years ago Source of information: Was system pumped as part of the inspection? ❑ Yes K No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank,.distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: A new SAS was added to the existing 1000 gallon tank in 2004 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road V� Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1' Depth below grade: 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 1 Dimensions: 000 gallon 10if Sludge depth: 2611 Distance from top of sludge to bottom of outlet tee or baffle 811 Scum thickness 311 Distance from top of scum to top of outlet tee or baffle 11" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �e I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road u Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �n 1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l; u 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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): o„ 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form r' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owners Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town 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 9 No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * 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: El leaching galleries number: 9 5 infiltrators El leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip 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.): The leaching was in working order and was dry with no high staining at time of inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owners Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-'8 required for every page. City/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 publGc watersupp'ly enters the building. Check one of the boxes below: W hand-sketch in the area below ❑ drawing attached separately - i*'w._ss UZ �3Q -.s ^,CSF i ' M Y3Da ��q f �r �rs t r 3t4a x't s. a� x � �'3kba9 fDb3?,wxaz�➢ '�l?'�3 �'�'� � �r� �v��:^ �s✓r .t yfi&.a , 4 - t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage DispoEal System•Page 16 of 1E c Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Calvin Hamblin Road v Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ❑WE Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 144"feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record 5-5-04 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form I� p i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY „ 23 Calvin Hamblin Road Property Address Jessica Caprio Owner Owner's Name information is Marstons Mills Ma 02648 10-31-18 required for every page. City/Town 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 W 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ,= TOWN OF BARNSTABLE L LOCATION Gpll� cc�',J t d—J ��'"`I SEWAGE # VILILAGE � IASSESSOFAMAP & SLOT INSTALLER'S NAME&PHONE NO SEPTIC TANK CAPACITY LEACHING FACILITY: (ty ) �Cz o (size) ` NO.OF BEDROOMS edi o-n l y f r �y� �� a C��,��e ``-, BUILDER OR OWNER PERMITDATE: S d 7 COMPLIANCE DATE: i 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 �r d Q e� 22 TOWN OF BARNS`TABLEEc TION �CJ �\3`l ; , V�y`-� SEWAGE # LOCA f� VIL LAGS `� ��'� ASSESSOPA MAP & LOT lel INS TALLER'S NAME&PHONE NO-72 V-06e;�EF SEPTIC TANK CAPACITY LEACHING FACILITY: (type) t �(size) NO.OF BEDROOMS ,,l o,,/Y �I er BUILDER OR OWNER a�J 4 ?'�p PERMIT DATE: t! COMPLIANCE DATE: Shth y 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 ye _. G/`s .. j AcIz No. FEE COMMONWEALTH OF MASSAC14US ETTS VLL � • Board of Health, APPLICATION FOR ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - ❑Complete System°k?ndividual Components Location -* �,. 1J aM // ,,'42A Owner's Name 'TAMS 1 a r-&A Map/Parcel# Address a M E Lot# Telephone# Installer's Namea Designer's Name Address # s' •TC s N Address Telephone# .S 3 O Telephone# Type of Building �s�l Lot Size ,P?� `SO�f• sq.ft. Dwelling-No.of Bedrooms t _ � -7S f, Garbage grinder Other-Type of Building Nbt�e.. No.of persons Showers (i!Gafeteria (1 Other Fixtures Lo^ n 44 Design Flow (min.required) gpd Calculated design flow Design flow provided i O gpd Plan: Date- �`E� Number of sheets Revision Date S 1-110 4. Title � 1100 261:2 Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluato dAA Date of Evaluation } DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furthe o .not r! c e the t ' operation until a Certificate of Compliance has been issued by the Board of Health. Signed C . Date � m VV 77/7 FEE COMMOA,WW"" Of MASSACHUSETTS Board ofealth, MA. ` APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT / . Application for a Kermit to Construct( Repai® Upgrade( Abandon( - ❑Complete Systemfndividual Components ;Location 4 Owner's Name r�k••\l IN �'��1M(�1,_4n1 M�11 -7r-)M s 1 r4 1 S°'AW Map/Parcel# l ® Address A M E Lot# Telephone# Installer's Name b1 c#a � is cvir� Designer's Name hurt �a•Qn�� !3V<'S Address T` �� Ic 1 Address7. JL Telephone# Co �'C Telephone# Type of Building ( Id�' > a. i Lot Size sq.ft. Dwelling-No.of Bedrooms 1 t urn (A cnr-)M S Garbage grinder (J� Other-Type of Building d fl 1 No.of persons Showers ( 1),Cafeteria ( l Other Fixtures L-.C)UA'1 a2 y k, 4rk2^ Sir I)k L_r✓Ur'7 fC c, , Design Flow(min.required) gpd Calculated design flow Design flow provided , . , gpd Plan: Date �L4 4t•- Number of sheets ' Revision Date S /j-4 1 U 1.- Title _ 1 Description of Soil(s) CA crC Soil Evaluator Form No. Name of Soil Evaluatotcr Q c A Date of Evaluation ,4 1 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5'and furthe�gaeesto not to�ace the'�'system' ^opera tion until a Certificate of Compliance has been issued by the Board of Health. Signed 01r Date (G' pMrMrrse. �VV. `.. { No. FEE �4 N� COMMONWEALTH Of MASSACHUSETTS 5 7/0Board of Health, 4�'ct�;��("`r�� , MA. � 1 _ P, y Description of Work: Individual Component(s) ❑Complete System X. \f^+d! n j -7qa O� "o I f r 1 / The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired Y Upgraded ( ),Abandoned ( ) has been installed in accordance with the provij�ions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. b0%4- f , dated 51-71 / . Approved Design Flow (gpd) t Installer r, _ r _ �- r 1 i �r. _ Designer: 1("Y�a �i��]�Cb(�l�,=n�c� Inspector: ai.,/ A--). .� Date: C ll/b The issuance of this per i 't shall not be construed as a guarant that the system will function as designed. No. FEE COMMONWEALTH OF MASSAC14USETTS Board of Health, . , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair>< Upgrade( ) Abandon( ) an individual sewage disposal system at -V\ 9--> (In�,:1If-, k—\C�r%,Nc ,n M M as described in the application for Disposal System Construction Permit No. -- ,dated Provided: Construction shall be completed nikhirythree years of the date of is errn t.,,All local co ditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date% 07111V Board of Health l" l V TOWN OF BARN TABLE 2 E LOCATION V��`l °� "..3 SEWAGE # VILLAGE V �� -�-� ASSESSOFA MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �. L LEACHING FACILITY: (ty ) p a -A (si�zel) s,7` �`�' ` NO.OF BEDROOMS "ul° Jy pr..74 W J� BUILDER OR OWNER CJ PERMTTDATE: S" (! COMPLIANCE DATE: =tO Separation Distance Between the: Maximum Adjusted Groundwater Tabl�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 �i G 141 , f o �° Town of Barnstable FtHE'O`'' Regulatory Services "o Thomas F. Geiler,Director * BARNSrgBLE, 9 MASS. Public Health Division 163q. ATFD ;�A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: Installer: t� & SgCUTC-P,_ Address: { ,�( (�2� Address: 5 On C) was issued a permit to install a (date) (installer) septic system at (5� ?D (_G\0 In ��1 based on a design drawn by &u�gRLC,�n��dated (address) &signer) 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. 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. -�N OF MgSs� 0 CARMEN staller's Signature) �� E• SHAY No. 1181 `cGISTI�t i6�a„ S \P� (Designer's Signature) (Affix Desigifd 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. THANK YOU. Q:Health/Septic/Designer Certification Form Sep - 20-01 13 : 52 BARNSTABLE HEALTH OEPT 5087906304 S12S�01 NOTICE: This Form Is To Be Used For dae Repair Of Failed • .Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM MShAeff, hereby certify that the engineered pian signed by me Aztec concerning the property located at meets all of the A fct ow;n; c m!eria: • This failed system.is connected to a residential dwelling only. There are no _ommerzia.! or business uses associated with the dwelling, • TP.e soil is ciass;;:ed as CLASS I and the percolation rave is less than or equa !o -n:nut:s -er inch. The applicant may use historical data to conclude this fsc: or may :onduct :>re!trnw.ary tests at the site without a health agent present • There :s no increase to Flow and/or change in use proposed • There at-e no variances requested or needed. i • The bottom of the proposed leachin; facility will not be located less than Fourteen above the maximum adjusted groundwater table elevation. (Adjust the �1. undwater table using the Fcimptor method when applicable) Please complete the following: of Ground Surface Elevation (using GIS informalton) _ 0 QC-) 8; LL' Eievat:on. ad;ustmen( for high G.W. F�=�RFt�t F BETWEEN and B SiO' S.G.VE D _ D ATE. N ...--- -------•---- -- OTICE 3asec �,e�n !ne above r.farmauon, a rroair permit wil! be issued for oedr^oms T.a,IMUM :\:o addiw)nal bedrooms ate authorized to t�e future without .ncincerec :opt.: system plans. __—.-- Faun!r,Aa Pcicc.im2 i 1•. Permit Number: Date: • Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: c23 l of si n TAC+M ,c,%'\�A. �t. t. `ks Lot No, Owner: Address: Contractor: MSOQL" Address:_ - 1 i Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date `fit 4 morph/d_aay/yeearr STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: SOLO OAppropriate index well.................................................... OWater level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well `s ........................... mo h/Year STEP 4 Using Table of Water-level Adjustments for index weGl (STEP 2A), current depth to water level for index well (STEP 3), and water level zone (STEP 28) determine water-level adjustment •8 .......................................................................................... STEP 5 Estimate depth to high water by subtracting the water' level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ................................................. ' 8 ,............................. . I; Figure 13.--Reproducible computation form, 15 'LOCATION SEWAGE PERMIT W VILLAGE I N ST ALLER'S NAME A ADDRESS �Tc 0 U I L D E R OR OWNER. DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � � 5 No.......... =,> Fx$.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. .. ..... -.....oF ...... .a w .re.-------------------------------"...........----- Appliratiun for KbVuual Warkii Tunitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: lob- �" 6 ..................................................f -- Location-Ad ess �.�r ................ ... ...r-..-IkQ[...------•-------.......--•---..... Owner Address a ......................................... ................"----•--.....................--•--••--•-•--•-•-................................... Installer Address UType of Building Size Lot...94.°`.- -Y-------Sq. feet �., Dwelling—No. of Bedrooms..........a..............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building i9�...__..... No. of persons .............. Showers W� YP g ------ ---•--- P --- ( ) — Cafeteria ( ) dOther fixtures --""---------------------"----"--"-•---•--------•--"--...---------•---"----------------------"--..............----------.....----........•--------•--- W Design Flow.....7S.1.9t..........................gallons per person per day. Total daily flow----- .3_®.........................gallons. W. Septic Tank—Liquid capacity/ gallons ` Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width_. _ ..._._._._ Total Length_.--_...... Total leaching ar6,-......sq. ft. Seepage Pit No......__ ----------- Diameter.... .......... Depth below i et...___ ... Total leachin area.. ,._...s ft. Z Other Distribution box ( Dosing tank ( ) e ~�C ��-`�` '7 - �� q ~' Percolation Test Results Performed by............... tea _:..-_,X: '':_:_ ... Date../.A..'_ 7 ............ a Test Pit No. 1,...1..Q_..minutes per inch Depth of Test Pit-•:f!.............. Depth to ground water....................... 44 Test Pit No. 2................minutes per inch Depth,of Test Pit.y................. Depth to ground water........................ Description of Soil .. -----�ot?-H±_.. �' �.. --------�-- .e' ��- V7................................. W x ------------------------•--•--•---•-•-••-•-----•--•- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... 4Lc9IN..t., -------------"----------._....--•----------------•---"--....---•-•--------------........---......------•----•---------------------.......--------------"---............--------•-••--•----------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L I:'�.;;:. 5 of the State Sanitary Code—Th01th. rther agrees not to place the system in operation until a Certificate of Compliance has been ' s d Sied----- .-• 4 -- --- --------------------------•--- ---------- •------------ Date Application Approved By.... 1t!1�1 _ 'f�_ '-7 C/ Date Application Disapproved for the following reasons:........................................... ...................................................._._...___.._. ---•--••---......---••----••......................•-----•--••--------......------..............-----•----------•----•....--•-•--------••-----••-----•••-----•••-----------------------••-•••----•-..----- Date PermitNo...................................................... Issued....................................................... Date C � � No q .� + . w F�s...z`... ....... THE-'COMMONWEALTH OF MASSACHUSETTS BOARD OF .HEALTH . l�r �irttt laa� fug A tt1 o k `C>z at r�tt#inn a attic ApplicafionEJs hereby ;made for a Permrt to Const.uct ( )� or Repair ( ) an ;Individual Sewage.Disposal Sy tem at Aso- Locton- Ad ress t No tt J y - i .--• ---- ............... ............... ... y� y ' Owner X Addr`ess' -....... ... ...... .._ __. ... :`'ta_. _ . F�1 v _...... .. ....... f In' taller Address - ,� T e of;Buildin YP g Size Lot _..-- ---Sq. feet E) Dwellin No. of'Bedrooms.... _ _ ............................... g— Expans>on Attic: ( ) t•< Garbage,Grinder Other.-=•T e of $uildin .._ ?... . No..' of persons ' Showers a YP. gP . ( Cafeteria a r Other fixtures --- y ............................................. , ,Design Flow.:.. ................... -__gallons per person per day. Total daily flow ......................................` gallons:- R: Septic Tank—'Liquid capacity' .gallons LLength................ Width. Diameter................ Depth` ,..... W x Disposal Trench—No............ ..... Width.. .......... Total Length_._._.�P ...... Total leaching area.4 '___ __sq. ft. 3 J Seepage Pit No __________________ Diameter ................. Depth:below inlet .._ Total leaching area...........:..•._sq. ft. z '.Other Distribution box ( Dying tank ( !�) f E_.f! < t Dat `._:_ %..__. Percolation'Test Results Performed b;-.`.............L ,�' Test Pit No. I.... .4...minutes per inch Depth of •,Test Pit ........ .......Depth to ground water........................... 44 Test Pit No. 2._... ...._:.minutes per inch :Depth`ofrTest, Pit..................... Depth to ground water'.'___.................. O Descri t'on:of Soil .,� 3' ` �' ' - w r x P v Vt4 _____. _,.._ .............................. ..___________.__..__._ - 'Nature of Repairs or 'Alterations—Answer when applicable___________________ .......................................... y ................................................. ........................................ ............,-• - -------------------- ----- .......................... Agreement: r The undersigned agrees to'install•the aforedescribed Individual Sewall e Disposal System.in accordance with the provisions of TITLE 5 of the State Sanitary Cod — T e unde i d'f'urtl:er agrees not,to place the system in OP eration until'a Certificate of Compliance has been "ss a the' iealth. �;. Si ned ......_----- •..... ........... Date - Application Approved B I:lca-�.J.__k__ �__ i o.•J.� Date Application Disapproved for the following reasons: ...........................---------...........................................------------------- ......................•-•-................----•---......-----........-••--•-----•........-----_.... ..................................................... k Date PermitNo............ ........................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF�HEALTH.. .............. ........OF..........::.. ,' /.L.................................. -...._....... Tatifiratr of TompliFaatrr THIS IS TO 7C4?TI Y That the Individual Sewage Disposal System constructedor Repaired.--- ---• -• -------• ----•.............. . _. (, � •/� •-- Inst Iler -------------------- Ile - .., at `".'-'-- ---'-'� /C - �' !1 l r t� Pry , .... Ll /t r ----- has been installed in accordance with the provisions of TY 5 of The State 'Sanitary Code as described in the application for,Disposal Works Construction Permit No.('_..:_._.�__2._.�1...._._.._.;' dated__..A -_-2_7.`:__7_ ________________ THE ISSUANCE OF THIS CERTIFICATE .SHALL NOT BE_CONSTRUED AS A GUARANTEE THAT THE SYSTEMI,WILL'FUNCTION SATISFACTORY. DATE..........................................................4,.... Inspector.............--•---• i•-----•---•.....--- .....-•---•..... . THE'COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALT f/ w 1 ; ..............'...........t' �........0 F.. 7..!Lr. 7/.. ...........................................t �J-1 No...............:. .... FEE........................ Disposal Workii at ttr#i�rat eraatit Permission is hereby granted-- •• 'f ` ===' '''---- -1 a- ........................•-•-•-----•----••------- to Constr(�ct ( or Repair ( ) an!Individual Sewage Dis sal System j ' - at No.. 1 ,�f - - .' .� I i `„ / fir.�_JcI`s. �� `��-r'f IId ' v r Street as shown on the application for Disposal Works Construction Permit No......... Dated.. f__ .___._ ._ ............. ............. ` e.. /_ ._ .. %/'/.....lr!'try!// Board of Health DATE...... 'w°?l� Z FORM 1255 HOBBS & WARREN. 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M/N. - rRAOE, .4 24 ",D/AM E f�ER CO/yC.�F_ TE COIiE.P �._ SJ,IALL eE BRDUGHT 7�;O..GIgADE. �CiN .E�'7"RfA a 4`PVC P/PE CONCRETE i �iE.4Yy CAST //2.ON CO,fYE/? SfL4GL !3E USE.C7 T = i IB PER FT. /F/N DR/VEwA Y t . COVERS q •::o. 4RAOE CC) V_^ R � CLEAN SANO -% �— &AC/CF/L.L d- - —! _ L/QU/O LEVEL - .� •�1�+ y i. 2LAYER 4" CAST D o Jo o OF IRON PIPE i / 6 02 e . " �' QI IN. P/TcN ` GAL. 4 d ° • • o • • • • r / D �4 ryA5HF0 ST2�NE V4"Rem e SEPTIC TANK D157. r • . . . r ° ' , o BOX p G • 1 .B • . • • • lDp p� ... •; . - o n EFFECT/VE • s :S, d o ° • • DEPTH • ° ' m, o WASHED STOiYE —�. � 4 c / • • o • e. o • 1 1 ' °' ° ° r • • . e • • r pip( P — PRECAS T SEEPAG E P/7 DR EQUI•✓. !/VV/eKT ELEVATIDNS �L l y�,U 6 FT PIA M— INVERT AT BUILDING EE TABULATION INLET SEPTIC TANK `.� h• FT _ FT. O/Al+'I. ; C S OUTLET SEPT/C TANK `'• ' FT. INLET DISTR/t9UPDN BOX % `� �' FT. SECT/aN OF" GRO�No W,�1TER 7A�3LE OC/TLETD/STR/BUT/ON BOX FT. $'EWAGE ,D/SROSA L SYSTEM � !/VLE7- LEACM/NG plT FT TA,�QILATIDIV LEACH11V4; PIT DiMEIVSI'ON A DE /G/V CRITERIA scALE : %a _ / o " 'N FT. D/MENS�1O $ D/MENS!ON C FT. WAf85R OF 6EDROOMS GAReACED/SPOSAL UN/'T SOIL LOG +r _ SO/4 TEST TOTAL £ST/!�?r4TED FLO<�SI cz' > �G.hL.1P,4Y .SnIL TEST 14E/ SO/L TESTgd�2 Num8ER OF :=.-ACHING: P/TS _� � �`ELEY. !�'�•� ELF1/ ,DATE OF SOIGr TEST $/rpE LEACHING PEiZ P/T l SQ, FT. ` ) RESULTS `t//TN.1 SSED BY T r'• 'U^l S i '� , v TT L OM EACHING PER PIT-2`� S4. FT G:`r- ( =c PL`RCOLAT/ON RTE /OE I M/NI/NCH TOTAL LEACH/NG AREA SQ.I FT. PE 1�COLfiT/oN R.�TE2 I'71n+.�/NCH ESERI�E LEAG'NlN6 AREf'► -� '' SQ FT. 7 C�l�%�!�•" .�/ �l ';? .:.� L,.J� .`-=• . !.'`f mod'._. �N OF ti1 ROBERT: G GJ:t ;z 5,P. t BurviKis ELOREDGEENG/N,EER/NGGO/NG. 7/2 /4 1,y ST.. . 33 dy MAIN ST. No.22162,O Q r �� •fl HYstNN/3 MASS. SO• YAR/+9f7uTH MASS• G f �Oc�G�STE��`�J ® NO GIeOUND. WATER JENCOU/VTL�REO . .[ Fss'ONA1 G/20 UNO W..ATER AT .-LEY/ _ : ✓O$ /1/D. GAF I?� SHEET�—OF �C. Hazardous Materials Inventory Sheet Checklist 4k"- Date Physical Street Address-Check database to ensure it exists Working Phone Number Actual Amounts -( ie. gas being used to fuel machines,thinner to clean brushes all count as hazardous materials-no blanks) %- Storage Information - location of storage, how long is storage for? If none, note that. Disposal Information -where and who? If none, note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -give a vehicle washing policy and explain it Attach the Business Certificate with your sign off and comments "The inventory form should explain what the business consists of and the procedures thev are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates [cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME In town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. OATS: `D , Fill in please; APPLICANT'S YOUR NAME/S: i''/4� "-.�,; 01 BUSINESS YO RP OME ADDRESS: ` TELEPHONE # Home Telephone Number .;u C") �• —,may 7 y ti NAME OF CORPORATION: NAME OF NEW.BUSINESS :.✓L( 44 ,4o TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YE5 O ADDRESS OF BUSINESS MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and ra-gulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) .to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. q Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual h .an Inf ad of the per equirerrients that pertain to this type of business, Authorize ignature** �t�� f T COMMENTS: pp �1US7 0 �� _ f4�.t.a 1� 00 '1 - .._ , B. CONSUMER AFFAIRS (LICENSING AUTHORITY] This individual has been informed of.the licensing requirements that pertain to this type of Chu',9irlges!J 11G 60 N01 Authorized Signature* COMMENTS: 9_10 SN'M 30 NNA01 r TOWN OF BARNSTABLE Datevylo?y TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: TkH e- BUSINESS LOCATION: C . �� (/�NVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: 77q--qb 7-77 E S__ MSDS ON SITE? TYPE OF BUSINESS: �iO9yyn rCrfM;i INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed 1 Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison"labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes �-- � r Laundry soil &stain removers (including bleach) Spot removers &cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials iiAIUR►M1�lAttt M t t t SECTION A -A " SCHEDULE 40 P.V.C. VENT PIPE (0 Least 24 Inches toll ALL OUTLET WES FROM t 51 E--10' min. from *NOTE: ALL PIPES ARE TO BE 40 PVC w/Chorcool Odor NE PROFILE VIEW OF ADDITION TO LEACHING SYSTEM DrsTRteuTm sox sNALL sE _ 12• , �vER tm Schedule 4 EnlstYnp Foundation house to septic tank SET LEVEL FOR AT LEAST T FT. TOP IT FOUNDATION ELEV. IMM (Assu+ed) Septic tank covers must be I wMNn 6 In. of finhOwd grade -:i 3 - 5•aT�Grose owr Saptk: Tank - 96.00 arade over o-sox - 9s.00 ow sAs - 97.07 to 9&00 3' of 1/8' - 1/2" Washed Poostone ` KNOCKOUTS ~ 3/4' to 1 1/2 - Woshud Crushed Stone % ' `• ss -� 12' eA eT as S - 0.02 4"PVC(CAPPED)04WECTM PORT TO BE OUTLET • 6' , 'hsK,E •� ( �� ' 3 HOLE H-10 op DIST. BOX 3' WYNrnum Cover T Load - Elev. -9s.25 INSTALLED AND TO BE MTHNi 6"OF GRADE _ 10' EXIST. s-o.rn or Great Top of SAS - Elev. -94.75 / ! Cnx w.mtf Fr t5.6 4' - SCH. 40 T t.73' E_YI_cT. PIPE N � 1,000 GAL. s- o.ol' per root or greater . V i FItO�t EXIST. fDUNDAnQI w �' SEPTIC TANK g 2s` °-Ett«t+.. Dip1A Klwf%we LA H-10 PLAN SECTION CROSS-SECTION p w LQ ! CONCRETE Ft><L FM �'` 4) > N 0.83' (10 inches) 5 Units 2 6.25' = 30' ' E'"�r�eu_a fr _6 ' 3' 3' 3 HOLE H-10 DISTRIBUTION BOX SYSTEM PROFILE 6 In.of 3le-1 1/2' $ ;; n 31.25" 1°„ a c compmted eton6 i u o i rn NOT TO SCALE Not to Sole S A 3T25 ®llgl RaiG ltttth ^. T l3493 ^TM�Woprc ' 4' 4 ' Effective length c o 0' o SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES 6 in.of 3/4"-1 1/2' v o compacted stone Effecttve Vida, INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE 1. Contractor is responsible for Digsafe notification 0 Bottom of Teat Hde I Oev.=86.00 _m (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. Obs. Groundwateest Hole 1 Elev.= NONE OBSERVED NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 10- 2. The septic tank and distri ution box shall be set r - T level on 6" of 3/4"-1 12" stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. 4. This system is subject to inspection during installation by Carmen E. Shay - Environmental Services, Inc. LOT #15 5. The contractor shall install this system in accordance PERCOLATION TEST 74 0 " W a with Title V of the Massachusetts state code, the approved plan d 16 r� and Local Regulations. CP tP � S _/� 6. If, during installation the contractor encounters any Date of Percolation Test: APRIL 14, 2004 to 301 ___--- soil conditions or site conditions that are different Test Performed By. CARMEN E. SHAY, R.S., C.S.E. ,�'� _ 74 from those shown on the soil log or in our design Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) --- -- Excavated By. SHAY ENVIRONMENTAL SERVICES, INC. ` 125'88 installation must halt do immediate notification be Percolation Rate: Less Than <2 MPI \` --- 76 made to Carmen E. Shay - Environmental Services, Inc. -- 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. Test Hole --- 78 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. \ _ 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. No. 1 `�\ �� '� -DEPTH SOILS ELEV. 10. All solid piping, tees do fittings shall be 4" diameter � � LOT #6 _ - --80 Schedule 40 NSF PVC pipes with water tight joints. 0 98.00 �� \ /�� 11. Municipal Water is Connected to ALL OF The Residence and Abutting Sandy \ \ --- .21,504 Sq,eare Feet /,�' Loom -_ 82 Properties Within 150 Feet. 10 YR 3/2 0 \\�` THE PROPERTY LINES ARE APPROXIMATE AND A, 97.25 �\ ��\ \ �� COMPILED FROM THE SURVEY PLAN GENERATED BY Loamy `90 Sand �� ELDRIDGE ENGINEERING OF S. YARMOUTH, MA 10 YR s/6 (92 � ENTITLED - OF PLOT PLAN OF LOT 5 CALVIN HAMBLIN ROAD, _ --86 MARSTONS MILLS, MA, DATED APRIL 18, 1979, 8-- 24" Be 96.00 �9 ---- ______-- -- LOT #7 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN Med-Coorse �� _ IT SHOULD BE USED FOR NO PURPOSE OTHER THAN Sand 24" 84' 91 W _-- ,� THE SEPTIC SYSTEM INSTALLATION. `� _ EXISTING LEACH PIT TO BE PUMPED OUT AND Sad LOT #5 O �� `� \\\\��\ ��'�' ------ -90 FILLED IN PLACE OR REMOVED TO FACILITATE INSTALLATION OF NEW SAS. 84"_ ,u 2.5 �/4 .00 \`� \`� - �� i NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE ` \\�`� FROM THE EXISTING LEACH PIT TO BE DISPOSED OF AS PER BOARD OF HEALTH SPECIFICATIONS. ROJIFE BENCH MARK TOP OF FOUNDATION NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY to �� ; ELEV. = 100.00 (Assumed) ASSESSORS MAP t01, PARCEL 025 LEGEND rn 4" PVC � ------- -, \ ----� i Perc #tl - _- --'-94 Depth to Perc: 30" to 48" �\ Vent Pipe DECK Perc Rate= Less Than 2 MPI , Observed ESHWTO - NONE OBS.- 144" Assumed \\`� 96 ko 104X 1 o DENOTES PROPOSED ADJUSTED H2O Elev. = NONE OBS. - 144' Assumed �5 HOUSE #F29 SPOT GRADE EXISTING O A X 104.46 DENOTES EXISTING _ Co -� SPOT GRADE TEST HOLE #1 2 BEDROOM �-� -`� � ELEV.= 98.00 HOUSE PL PROPERTY LINE 96P PROPOSED CONTOUR 37. 5'!'*;_ �,--EXIST. 1.00 gal. ,' - - - - - -97 EXISTING CONTOUR i r / Septic Tank I ` �'0 DEEP TEST HOLE & __ PERCOLATION TEST LOCATION 2-18" DIAM. ACCESS MANHOLES - _ 1 O - ___-- . - v, --__ 6 FOOT STOCKADE FENCE Ir aile ,• .4• - - j __�:� 00 ---- _ LeacF 45it/ DRIVEWAY �� / / ��.;:..r.�..�..••, REV.. 5 6 04 Reduced to 2 Bedroom permit and 3 bedroom --- ` Minimum design per BOH and Title V. INLET - 10 '� ,�^�`,_- ;' - �.\ �( ---- -- ---- 100 aU T 32.49 PLOT PLAN _ -_-____ L = 69.0 - I TILE ACCESS COVERS FOR SEPTIC TANK, O F PROPOSED SEPTIC SYSTEM UPGRADE DISTRIBUTION BOX 6 I LEACHING B COMPONENT 102--- + I i \1 st:r DEEPER THAN 6 1Ncrl�s BELow FINISHED = 463.43 ----- GRADE SHALL BE RAISED TO WITHW 6' OF 23.49 _ STEEL REINFORCED PRECAST CONCRETE FINISHED ~\�� PREPARED FOR PLAN VIEW INSTALL nIF-nTE GAS BAFFLES OR EQUALS � ��\ '----------- i DAD TAMSIN B . TROW f3-24- REMOVABLE covExs-� B�IN 'R � AT 4. r.:,.• AL VIN HA11� WAY) # 23 CALVIN HAMBEIN ROAD 3' min. de nonce tr eacr C' RIGHT OF INLET 8=min T-L2•-mh. filet to oufl�t (40 FOOT M A R S T O N S MILLS , MA FT UW9 Ileusl OUTLET 5• -r •= -1� '~ L_ 's -r Design Calculations y OF s PREPARED BY: bg seed.. _ uwb depth Number of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Gal./Day Min. per Title V) CAR�1�'N E. SH�4 Y * Garbage 3 Grinder: No Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) - z. .r; -.-f Septic Tank : - 2 x 330 Gol./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. 0 20 40 50 " N ENVIRONMENTAL SERVICES, INC. -10" SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch 0, $9 CROSS SECTION END-SECTION Bottom Area: 0.74 gol/sq. . x 370 sq. ft. = 273.8 gallons P.O. BOX 627 ft Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. = 58 gallons GIST ago FAST FALMOUTH, MA 02536 TYPICAL 1000 GALLON SEPTIC TANK Providing: = 331.80 gallons SCALE: 1 "=20' SAUI'TAR\01 TEL/FAX : 508-548-0796 NOT TO SCALE Use: (5) INFILTRATOR HIGH CAPACITY H-10 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1 "-20' DRAWN BY: CES DATE: MAY 5, 2004 TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE ON THE ENDS. NO STONE UNDER. PROJECT#SD568 FILENAME: SD568PP.DWG SHEET 1 OF 1 _