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3620 MAIN ST./RTE 6A(BARN.) - Health
3620 MainStr&t Barnstable A= 317 — 019 I orTME�, Town of Barnstable P# ' Department of Regulatory Services _., �n , s p.Qu.; e i Public Health D �sion Hate 200 Main StreeHyannis{MA 02601 a r Date Scheduled /' s: Tune L� / Fee Pd. ' ` f Soil ►Suitabi>lty Assessment for Se_ age Ds osal P Performed.By: ; - � �-?-� p Witnessed By: LOCATION& GENERALINFORMATION Location Address 3c�76 6��1��► �y� Owner's Name < e� 1 Address C1`ehac l 3o n GS 1 4n. Assessor's Map/Parcel. I /Q F q Engineer's Name NEW CONSTRUCTION REPAIR: Telephone# (am) 4 77—:5'3� Land'Use �5 � Slopes(%) .Z Co Surface Stones N h n.. I Distances'from: Open Water Body; ft . Possible Wet Area�_T-- ft Drinking Water We11ft , Drainage Way A)%�- ft t,Property lane ( � ft Other SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands t`n proximity to d.es)' ,w lJ r Parent material(geologic) Depth to Bedrock. Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face F -�C Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs hole: -- __1n, Depth to soil mottles ' lrr- - Ddoth`to weeping friim side of obi.tiole: - 7-in;_Groutidwatpr Adjustment F= < n '- Index,Well#._ Readiig Date:! index Well level Adj,faetor Adj.Groundwater Level PERCOLATION TEST ngte Ttine..� Observation Hole# �0 / tf ( Time'at V, . .... � Depthof•Perc -36/Lfe, & ` Time.L4t, 1,C) �0 Start Pre-soak Time® ® tJ ,Time(9"WO) ') r End Pre-soak Rate Min./Incli e. . Site Suitability Assessment: Site Passed_� Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division ;:, Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be.conducted within 100' of wetland,you must first notify the, Barnstable Conservation Division at least one (1)week prior to beginning. Q:%SEP 10PERCFORM.DOC , DEEP.OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture .Soil Color Soil that Surface(in.) (USDA) (Mansell) Mottling (Stricture,Stones,Boulders. i v1 16ltylz DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.:. . Consistency i b:.- 1 c pso DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stones,Boulders. + Consistency. - e ATIO HOLE LOG Hole# DEEP OB SERVATION DEE Depth`from Soil Horizon. Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stoties,Boulders, o s' Flood Insurance:Rate Map: Above SOU`year Hood boundary No_ Yes Within'SOU°year'boundary No .Yes x. Within.LOO year flood boundary No Yes DeDdi OfNaturally Occurrina.Perviomi Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout;the area proposed for the soil absorption system? If not,what.is the depth of naturally occurring pervious material? h Cerhf"ication . I certify that on. l> (date)L,have passed the soil evaluator examination approved by,the Department of Environmental Protection and that the above analysis was performed by me consistent with the requied trai expertise and experience.described in 310 CMR 15.0.17:' �.. Signature Date y . Q\S,EpM MBRCFORM:DOC TOWN�OF BARNSTABLE LOCATION. 3��� � �;�, SEWAGE# 24 5 VILLAGE:Z,,c,)S Jr e ASSESSOR'S MAP&PARCEL 3J'7T INSTALLER'S NAME&PHONE NO.�(' A SEPTIC TANK CAPACITY I'5-00 NeL.J LEACHING FACILITY:(type) A.rC. 3G (size) 117 2D NO.OF BEDROOMS ` OWNER � PERMIT DATE: 'z- COMPLIANCE DATE: -b0 Separation Distance Between the: NCh ' ccu� e� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. f iF 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 ( (J `1 An .3, 3 3�% 3' n 0 T aa, Y .. No. �. J S iA Fee d /oV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Mie-posal *pstem Construction VPrttiit'-, Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No. 3(0 2® Ct<N � C� Owner's Name,Address,and Tel.No. � s Assessor's Map/Parcel 3 9 ? "- I cl Installer's Name,Address,and Tel.No. - Designer's Name,Address,and Tel.No. _0`vS k" At Type of Building: Dwelling No.of Bedrooms 2 Lot Size 7 i2 Ce sq.ft. Garbage Grinder( ) Other Type of Building dt No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) aj '5,® gpd Design flow provided 3 'S—. gpd Plan Date �/ !!/�-Z_ Number of sheets Revision Date Title Size of Septic Tank 5 po h/r—cJ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) lN51 e /l AJ fe S�✓l i C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sigzed Date 7 G Application Approved by Date Application Disapproved be Date for the following reasons Permit No.2-p Date Issued Z. ` No. Z -- 2 S THE COMMONWEALTH OFIMASSACHUSETTS Entered in computer: } Yes PUBLIC HEALTH DIVISION - TOWN DFAAR'NSTABLE, MASSAC KS ETTS 2pplication for Mispo'sal *pstr'm Construction 30ermit �. Application for a Permit to Construct( ) Repair(t/f Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3&20 ti(t<<ri St-�Z}GAl Owner's Name,Address,and Tel.No. Jor s Assessor's Map/Parcel 3 { '7 cl ✓ Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 1�, a c. -I:njc S0$-`100-7/t_jj Type of Building: Dwelling No.of Bedrooms 2. Lot Size 7 S 2 4 sq.ft. Garbage Grinder( ) Other Type of Building l Gd5 -e- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 '>C gpd Design flow provided 3r 0 4—. C gpd Plan Date 611///Z Number of sheets Revision Date Title Size of Septic Tank /5 oo Nt^tJ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /N S*4 i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. S' ed Date 7 2 / Application Approved by Date. 2 7p Z Application Disapproved Date for the following reasons ~ Permit No2 c) a — Z/ S Date Issued Z Zd / Z THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by L 5 A 7 ry w r%a T_N C at 3 G 2 0 AA c. .ti S t IZ t- G f{ has been constructed in accordance 70(1 -Z,1^ -' with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 77 Z Z.o/Z Installer ej a g /� �i �o...+ry 'C C Designer E,�,7 I ej,e ,`�, U) �c #bedrooms ';? r7 t°5+C Approved design flow �-/f�S gpd The issuance of this permit shall not be construed as a guarantee that the syste will fimc as Date --------------------------------1-�-, - � ------------ ---------------------------------------------------------------------------------------- No. © — 7- /( Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoBal *pstem Construction permit Permission is hereby granted to Construct( ) Repair(t-� Upgrade( ) Abandon( ) System located at G 2 O AA :,j cj a- fi - and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Ponsrction must be completed within three years of the date of this pe t. Date 2 12 Approved by 07/10/2012 15:25 5084775313 ENGINEERING WORKS PAGE 01 Town of Barnstable Regulatory Services Thomas F.Geiler,Director t Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 503-862-4644 Fax: 5W790-6304 Date: Z c d'f t Z Sewage Permit#20L Z-Z)15 Asses:sor's Map/Parcel 31 —a at Instal er&Desilsmer Ce cation Form Designer: Gnb:nt,!-n', War)As+ Inn. Installer: �til .: rzye+.rvti I C Address: )z W. Cry :r e let 'U, Address: F d X 14 _ On � 'D A was issued a permit to install a d ) (installer) septic system at ; 67 d. PL°V''L- S f- k based on a designs drawn by (address) dated 0121 Z- (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. (F-,, td ra�, L,,d q Q - Z�6 1 1. 3 awrw 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)wa cted and the soils were found satisfactory. `+ OF PETER T. WEN EE to er's Signature) CIVIL Ro.36109 9tEQ�4i4' ( igner's Signature) (Affix Design mod' ) PLEASE, RN TO B TABLE PUBLIC UaTH DIVISION, CERTMCATE F CONWLIAMCE WILL NOT BE ISSUED UNTIL, BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY TIA BARNSTABLE PUBLIC HEALTH D SI N. THANK YOU. q:loffice fbnw\desiSmmerdfica6on formAx AsBuilt Page 1 of 1 TOWN-OF BARNSTABLE' LOCATION tG J' ., SEWAGE# b 2 7 L 6 VIL4AGE oce03 l V -ASSESSOR'S°MAP&.PARCEL : 17-/`s INSTALLER'S NAME&PHONE NO.�1i�� / , (n..DrJ SEPTIC TANK CAPACITY J yb0 IUz°c J LEACHING FACILITY:(type) A('C 3 el 4 r -g.b (size) 17 K 2-n NO.OF BEDROOMS OWNER Trxye PERMIT DATE: 22£ COMPLIANCE DATE: 7 I ' Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom.of Leaching Facility Q*QC, oe6L 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� � C L • i. ti F tc;"-r 4 l,3 3' 3�% 3 via� http:Hissgl2/ir tranet/propdata/prebuilt.aspx?mappar=317019&seq=i 8/23/2012 � r ._• • ".,t��� a u'�'��s�� ��,.��"�'�$�1e p�Nv` a't_. G . •. • . . ` ru f`- IUI ru UI $t postage PPP -h/1 O rl Certified Fee ark ®j E3 ReReturnReceipt Fee Postm O (Endorsement Required) 0 ResMoted Delivery Fee r (Endorsement Required) E / CJ ID Total Postage fl Fees $ (j$� r. & Mrs. KeitfU-ones r r c/o Michael Jones WFJ Realty Trust P O Box 521 T4vannic Port MA 0?047 Certified Mail Provides: o A mailing receipt n A unique identifier for your mailpiece o,A record of delivery kept by the Postal Service for two years ; Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. a Certified Mail is notavailable for any class of international mail. . a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return i Receipt(PS Form 3811)to the article and add applicable postage to cover the' fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for dupluired s to return receipt,a LISPS®postmark on your Certified Mail receipt,i o For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted-Delivery° o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail' receipt is not needed,detach and affix label with postage and mail. a IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530.02-000-9047 I PLETE'THIS SE TI N COMPLETE THIS SECTION ON DELIVERY; Is Complete items 1,2,and 3.Also complete A. ignatu item 4 if Restricted Delivery is desired. `_ ,. . X ❑Agent ■ Print your name and address on the reverse ed ❑Addressee so that we can return the card to you. eceivby(Printed Name) C. Date of Delivery e Attach this card to the back of the mailpiece, or on-the front if space permits. D. Is delivery address different from item 1? ❑Yes 1. Article Addressed to: 1r1 O A � If YES,enter delivery address below: ❑ No 1V1rsKe 1 , o:es •W/ . y; y f1 sco Michael Jo es,,• +WFJ`�Realty T st g �tj2 !TP O.Box 521 3. . Type r Cert�ed Mail O Express Mail Hyannis Port, MA. 7 Registered ❑Return Receipt for Merchandise j Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes I 2. Article Number � (transfer from sery HI ,ice l b'el) E i t i i t i 1 i 7 i t- i t W 4 7 0 ('O I]01 4 5 2 5 6 7 8 2 PS Form 3811,February 2004 Domestic Return Receipt f `: 492595-02 M*:f� o 7, UNITED STAT P ,�E I . :; .; ,,'.,dk : Paid I R I er • Sender: Please print your name, address, and 4 in this box'`---- I � I Town of Barnstable ,_., I p { Public Health Division 200 Main Streety Hyannis, MA 02601 i I i IFl�r�rairl�li��lf�iairslf:lt�ili2o f�tl�s�lt;�liftiillit��l�71 �� I � I .. j , • Barnstable Town of Barnstable OF SHE Tp Regulatory Services Department ; 19.A MASSBLE,o! public Health Division - MASS. 0 �A �6gq. �e 2 reo M �° 200 Main Street, Hyannis MA 02601 e07 Office: 508-862-4644 Thomas F:Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO - CERTIFIED MAIL #7011 0470 0001 4525 6782 April 30, 2012 Mr. &Mrs. Keith Jones c/o Michael Jones WFJ Realty Trust P.O. Box 521 Hyannis Port, MA 02647 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at 3620 Main Street, Barnstable,MA, was last inspected on 4/03/2012 by Sean M. Jones, a certified septic inspector for the State of Massachusetts. .The inspection of the septic system showed that the system"Fails"under the guidelines } of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • System is in hydraulic failure. You are ordered to repair or replace the septic system within sixty.(60) days from the date you receive this notification. Failure to repair/replace the septic system with in the deadline period will result in future enforcement action. PE 2TE BQAFBOAR OF HEALTH Thomas McKean, R.S'. CHO Agent of the Board of Health iT Dozumentl r1 RI fU Lf) Postage $ rl Certified Fee f� ��` postmark O Retum Receipt Fee / .a k p (Endorsement Required) 0? Here, ;� p Restricted lalivery Fee (Endorsement Required) O Totai,Postage&Fees $ ��a� 'Q_�nn. ,4 Michael Jones 3620 Main Street Barnstable, MA 02668 Certified Mail Provides: a A mailing receipt ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. ■ Certified Mail is not available fur any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the: fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the . `` endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this.receipt and present it when making an inquiry. PS Fonn 3800,August 2006(Reverse)PSN 7530-02-000-9047 U.S.POSTAGE>>PITNEY BOWES f'"E'�w Town of Barnstable , �' � '� 1 '• Public Health Division aLE200 Main Street !' , ZIP 02601 .� , s�0'Founn+° Hyannis,MA 02601 02 1V4 $ 005.750 l 0001361475 APR. 19. 2012, 7011 0470 0001 4525 6737� -- -- - w_ Michael Jones ` Y '"y 620 Main Street ., Barnstable, MA ( 6 ' RETURN TO SENDER ATTEMPTED - NOT KNOWN � UNADLE_ TO PORWARD -�, .,�.v-Wx .•..�-� ���y�.��•-- I11,,,,;),I,III,I1,,,,,�11,:I,�111,,,11;,,,,1,111.,,:,11„„I,1>I � n_SEN• OMPLETE THIS SECTION • • ON ■ Complete items 1,2,and 3.Also complete A Signature " item 4 if Restricted Delivery is desired. ❑Agent X o Print your name and address on the reverse ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery I ■ Attach this card to the back of the mailpiece, or on the front if space permits. I D. Is delivery address different from item 1? O Yes I 1. Article Addressed to: If YES,enter delivery address below: ❑ No I I I I I f Michael Jones 3620 Main Street Barri`stable, MA 02668 3. Service Type I I ❑Certified Mail ❑Express Mail ❑ Registered ❑ Return Receipt for Merchandise �- - - - — - -- ❑ Insured Mail ❑ C.O.D. I 4. Restricted Delivery?(Extra Fee) ❑Yes I 2. Article Number i 7011 0470 0001 `4525- .6737' " (Transfer from service label) I .k Via= 1 5-02-M-1 0259 540 Town of Barnstable Barnstable P °� Regulatory Services Department w-umaicaci►y �9nAR_MASS..LE.r Public Health Division I Dm r1 �A 039. �0 '" 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A. McKean,CHO CERTIFIED MAIL #7011 04 70 0001 4525 6737 April 19, 2012 - Michael Jones 3620 Main Street Barnstable, MA 02668 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5. The septic system located at 3620 Main Street, Barnstable, MA, was last inspected on 4/3/2012 by Sean M. Jones, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Fails" under the guidelines of the1995 TITLE 5 (310 CMR 15.00) due to the following: • System is in Hydraulic Failure You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. .Failure to repair/replace.the septic system with in the deadline period will result in future enforcement action. PER ORDER OF T E BOARD OF HEALTH Thomas McKean,R.S. CHO Agent of the Board of Health i i ) et» , Q P P :\SEPTIC\Letters Se tic Inspection Failures or Future Eval\3620 Main St.Barn.doc fi Town of Barnstable Barnstable °p THE Regulatory services Department tMer;cact�: 1 I I P 4. BA SABLE,)MASS public Health Division 9Q �1 0p . v i639' �0 M"`a 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director . FAX: 508-790-6304 Thomas A.McKean,CHO _ F i CERTIFIED MAIL #7011 0470 0001 4525'6737 April 19, 2012 Michael Jones 3620 Main Street Barnstable, MA 02668 ORDER TO COMPLY WITH STATE_ ENVIRONMENTAL CODE, Title 5: • r . The se tic system located at 3626 Main Street, Barnstable, MA,was last.inspected on P Y p 4/3/2012 by Sean M. Jones, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the1995 TITLE 5 (310 CMR 15.00) due to the following: • . System is in'Hydraulic Failure You are ordered to repair or replace the septic system_ within sixty (60) days from the_ date you receive this notification. Failure to repair/replace the septic system with in the deadline period will result in future enforcement action. PER ORDER OF TIE BOARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\3620 Main St.Barn.doc Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °< 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for every Barnstable Ma 02668 4/3/2012 page. Cityrrown 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 filling out forms A. General Information " on the computer„ use only the tab 1. Inspector: I key move your our . cursor-do not Sean M. Jones use the return Name of Inspector key. Capewide Enterprises !t Company Name 153 Commercial St. Company Address Mashpee Ma. 02649 Cityrrown State Zip Code 508-477-8877 SI 4522 Telephone Number License Number B. Certification 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 ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/3/2012 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 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 of Fe ofzthe: EP. The original should be sent to the system owner and copies sent to the buyer,if appllce,¢ the approving authority. ****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 differenl<con itions of,use.- v= t5ins•11/10 Title 5 Official Inspection Form:S w ge Disposal System• age 1 of 17 a Commonwealth of Massachusetts k Title 5 Official Inspection form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 15.303.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 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): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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): C) 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feef6f a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 v ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 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. 3. Other: D) 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 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 '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form al Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ® ❑ 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. 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 If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should"contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3620 Main St Property Address Michael Jones Owner Owners Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ElYes ElNo Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts H - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 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 Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 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.): Septic tank was not located Grease Trap (locate on site plan): 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 3620 Main St Property Address Michael Jones Owner Owners Name information is required for Barnstable Ma 02668 4/3/2012 i every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 't5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 3620 Main St i Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityrrown State Zip Code Date of Inspection I D. System Information (cont.) Type: ® leaching pits number: 1 6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection the leach pit had approx 1' of standing water. The pit walls had dark staining/slime all the way to the top. The inlet pipe had dried scum builup on top indicating that it has been hydraulically overloaded in the past resulting in a failing inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments rt 3620 Main St Property Address i Michael Jones Owner Owners Name information is Barnstable Ma 02668 4/3/2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet._ Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately gb 1r, o f N� o ` v t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3620 Main St Property Address Michael Jones Owner Owners Name information is required for Barnstable Ma 02668 4/3/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Groundwater elevation was not established Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 L r r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 3620 Main St Property Address Michael Jones Owner Owner's Name information is required for Barnstable Ma 02668 4/3/2012 � every page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION, b h &+` St Ri SEWAGE # q 0- `H b VILLAGE 1LS1Cd Ic. ASSESSOR'S MAP Q LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 1 c-4 0 \ ��\ LEACHING FACILITY:(type) 1 _ r (size) .boo tiu) NO. OF BEDROOMS , D— PRIVATE WELL OR PUBLIC WATER 1. 1ti r BUILDER OR OWNER DATE PERMIT ISSUED: �1 V DATE COMPLIANCE ISSUED: aA �O VARIANCE GRANTED: Yes No 6 (A 6-k pv S No..{1 .:`..`... FiEs....C1�!.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH - TOWN OF BARNSTABLE Applira#iun for DiupuuFal Works Tonstr inn "truth Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys .... .... . - Q,_ bl .. ........................... ............ {j{...---....... __..----------------------- .......--- � `v I of I�q��� 5 .... ....f. ..__. Owne O 2� � A dress / �,MJ J. /� Q .. ......-.. / ............................ ----�f:... �✓........... �._... .._..... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........... ... .... .. .......:....Expansion ttic ( ) Garbage Grinder ( ) ~ Other—Type T e of Building No. of persons................•_--_______ Showers — Cafeteria a yP g ------•----- P ( ) ( ) Q' Other fixtures --------------- ------••------- . W Design Flow------- ...................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/CVirgallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit NJEV-0........ Diameter....... ......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ' ) Dosing tank ( ) Percolation Test Results Performed by.....................................------------------------------•----- Date....................................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................_. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-----------------•---........ --------------.----- /J° O Description of Soil y`'I/���1 ....��f y _. a ��_�Q.C�h - �c L ---------------------- 0....................... U ------------------ •----------------------- --------------------------------------------------------------- --------------•----------•-------------- •-------------- -------------------------------------- W --•-----•------------------------•-•--••-----------••---------------- -------- ---------------•---......----•-•... -----------•---------- ------------------- ----------- UN jt�re of epairs or Al rations—Answer when appli ble._� --- __G G / __. x�sl !!�? _._..�_ ....... Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental C e—The undersigned further agrees not to place the system in operation until a Certifica of Compliance h en issued b t Ord health. Signed ....... - ------------------- "----- -------- ------- --- ----- ----- ------------- ......r J'� ----ram to ApplicationApproved By --- ........ . . ..... .................................------------------------------------- --- 06; te Application Disapproved for the following reasons- ---------------------------_-..... ...............................-------------------------- /_ ---------- ... - - .........-----......................................-...-.................................... Date Permit No. /G� Issued Date Jb, + �'A No.��._• .......... F�$..............-�............... f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF'-"-HEALTH . - t TOWN OF BARNSTABLE App iratiun for Disposal Works Tonstrud, ion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal 8y! -P 1_ � �*........ ...................(�,qri)��.4 --.............................................. �d�C ^ N ' �{--�— /ff�//' `!r.. tY_�l1_C' .1.. .L�ocati�.. v L ......--•--^^__..........•.... ..................................� 1l2/V 5.L_.._.�t "`�/42•w/�:u, .. /I ^--- at V�l.`! (-'�!.(1. �n1% Gl�.d. J. � I J�� A dre<s ...1r.3.c S• CUhp ��0 14 Installer VO_� Address d Type of Building r �'� Size Lot...........................Sq. feet aDwelling—No. of Bedrooms----------- -_--------_--___-___Expansion ttic ( ) Garbage Grinder ( ) p, Other—Type of Building ................:...-__.... No. of persons............_.----........... Showers ( ) — Cafeteria ( ) Q' Otbrr fixtures -----•-••---•... •------•-•--. . W Design Flow---------s.._3--_��......................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacityl llons Length................ Width................ Diameter................ Depth................ x Disposal Trench—/�- No..................... Width...... ............ Total Length..................... Total leaching area....................sq. ft. Seepage Pit NO.(!__:K.-------- Diameter......_�P--__...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( � ) Dosing tank ( ) '-� Percolation Test Results Performed by-----••--•---•••----•-••--•---------------•---•--f••-----•-•-----•-----• Date------------............. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fit Test Pit No. 2................minutes per inch Depth.of Test Pit.................... Depth to ground water------- ................ a --••---------•------- ..............................-../........... ....... /y O Description of Soil•.. t� l'r� a....-.Cl.. ��.... ..c GCS .......... ---.._. .......�`/_1--(..Q- ------------- x U ----------------------- --------------- •-•--------------------------- .----------------------------------- ----------------------------------- ._...---------------------------------------- -•------------ W --------•-------------•••--••------•---•--•---•-------•......---------•-•------.......................... --------J /. U N ure of epairs o} Al rations—Answer when appli ble.----_U i at r' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage.Disposal System in accordance with theiprovisions of TITLE 5 of the State Environmental e—The undersigned further agrees not to place the system in operation until a Certificate of Compliance en issued b t and of health. Signed Application Approved By .j;.....���...,v_o„_1_ �._:,... --^". ��_ ��-.�_ v,�....... . ...........� `,..._.. ........................................ // Date f Application Disapproved Disapproved for the following/reasons: ............ - 1.........-------------------------- -- ` ,,........ ---------------------------------------------------- ------------------------------------------------- ......................................... ................ Date PermitNo. ..L----------------------------------------- Issued ----.............-:.--.._...............----- ------------------. Date _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i TOWN OF BARNSTABLE Ter#ifirate of Toraylianre r THIS TOrCE�RbI�jY, vhaat the Individual Sewage Disposal System constructed ( ) or Repaired ( �r by.................................;;_..------------------ f-..->... 1 taller at ........ ............................................................... ..... .,,-,,.� /1 n iT has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .fit-�...,. r..._ ...� ...�.... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BrE'COWTRU��AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. /� `i' - ... Inspector ......� �,G�/E�.. DATE ......... .-...... .............. p v--------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No��.-� FEE---���'--- Diupusttl Works Tunutrur#iun Vvimi# Permission is hereby granted..s.................••---•-----•......------•--••-...----....--•-------••............................................ ............. to Construct ( ) or Repair (I/) an Individual Sewage Disposal System at No......3—4. '1 -=-�'�•--...� +�.:._t� .14, .............. Street �� // as shown on the application for Disposal Works Construction Permit No.I -Y/W Dated..��` �,. !f-................. �I / �//7 G A4�Board of—Health-7 t DATE...................... _ j ! f FORM 38E08,HOBBS 6 WARREN,INC..PUBLISHERS �``�/'/ �{ If, f - C/ 2 TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE 11: MINIMUM STANDARDS FOR HUMAN HABITATION Date--A 112—.0 U Time: in Out i Owner 1 A!&q—2 J ( )D&&� Tenant Address BZo 6W CIAA 2D 1266C-P—Var�-FtVt,Address 36 Z0 MAitJ 5l Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities Cert JJ ( � 4. Water Supply 5. Hot Water Facilities o �C3 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use ✓ 12. Exits 13. Installation and Maintenance of Structural / Elements v 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal V/ 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowe Number of Persons Allowed (max) Person(s) Interviewed N%,) Inspector y/ If Public Building such as Store or Hotel/Motel specify here - . TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date = — 10 Time: In Out Owner V � ` Tenant Address Address Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8.Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed max) 3 Number of Persons Allowed (max)_ Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here ' LEGEND N Ra ;a o Z` 3 EXISTING CONTOUR 3 d x 100.98 EXISTING SPOT GRADE ® c� � z " —W EXISTING WATER SERVICE o ROUTE gq a° a —G EXISTING GAS SERVICE 8 g =-0.H:Wt OVERHEAD WIRES ' < F'ArLROAD _ n LOCU TEST PIT BENCHMARK X 105.22. �Z - Granite 106.44 N 61'13'20" W jO Ln 75.00' + 105.68 R\ g PARCEL ID: 317-19;� � o c c a 7526 S.F.f 106,2y3 r;l c' i 106.22 105.90 I I 5 0 BENCHMARK SET I o OUTSIDE CORNER/BOTT. STEP EL.=106.17 (ASSUMED DATUM) 106.09 I / X /EXISTING LOCUS MAP J-96 HOUSE(#3620) ' r ; o4,Bo 1 � � r ;r NOT TO SCALE F.r.o. =1os.7f � GENERAL NOTES: _ 1 �r 0 4 r EXISTING SEPTIC TANK 105.78 ( Fr r TO BE PUMPED, RUPTURED, 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL o x BM 10 ,8 O �x .1 r i FILLED WITH SAND AND BOARD OF HEALTH AND THE DESIGN ENGINEER. 106,1 I j ABANDONED, OR REMOVED. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 0 105.78 , N r r OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE 105,24� j, Oo ! r N I o r LOCAL RULES AND REGULATIONS. OCn N 3 o v rr ti 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR PROPOSED N O 00 13 r �u o I i t r TO INSPECTION AND APPROVAL_BY THE BOARD OF HEALTH AND THE SEPTIC TANK �/ �,� r -DESIGN ENGINEER. r I I T I 'I i \I M i t ( 4•`ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING I I i I I I r EXISTING LEACH PIT wFROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN LJ_l l_J J_1 x 10 4.71 �\ / TO BE PUMPED, FILLED WITH .ENGINEER BEFORE CONSTRUCTION CONTINUES. Nisi 1 i / r t I SAND AND ABANDONED. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. INSTALL 40 MIL POLY LINER _ 3 Z TOP OF LINER, EL.=103.0 ?�i �Ni-i i /� O� r I 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF BOTT. OF LINER, EL.=1010.0 v TP 2 _� �I-i -I i��C��� (n I THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION: 4 J_.L J, 102.23 X 1 _18 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. 2.85' CB X 17 103TP-1 ' '92- 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 0 ,57 102,9 ,IOS .79 +� 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS 104,99 /103,42 7� CB--- _ _ ( AGREED UPON BY•OWNER AND CONTRACTOR OR AS-OTHERWISE B 29 DIRECTED BY THE APPROVING AUTHORITIES. ,.1.02.— `-N_ 61'13'2 " W _J 10. IT SHALL BE THE RESPONSIBILITY OF THE -CONTRACTOR TO VERIFY sidewalk _ 99,35 ��d�-ak- THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING _ CONSTRUCTION. P edge e of Pavement � 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 100.95 99A00 9 98,.96 p , 98.30 98,00 IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). MAIN (Route 6A) STREET 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE INSPECTED BY HEALTH DEPARTMENT PRIOR TO BACKFILL. 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. PETER T. Gs PROPOSED. SEPTIC SYSTEM UPGRADE PLAN MCENTEE r CIVIL "' 3620 MAIN STREET Rte 6A , BARNSTABLE, MA No. 35109 �p SZ OWNER OF RECORD Prepared for: Michael Jones, P.O. Box 521, Hyannisport, MA 02647 qo SEG/ E� ��� Engineering by: SCALE DRAWN JOB. N0. JONES, LUCILLE Y & KEITH D TRS En Works, Inc. 1"=20' P.T.M. 168-12 Engineering c/o MICHAEL JONES g• g -7 l I�� v P.O. BOX 521 12 West Crossfield Road, Forestdate, MA 02644 DATE CHECKED SHEET NO. J r HYANNISPORT, MA 02647 (508) 477-5313 6/11/12 P.T.M. 1 Of 2 Al 9 NOTE: TO PREVENT BREAKOUT, A 40 MIL POLY / LINER SHALL BE INSTALLED ALONG THE .EXISTING SEPTIC TANK PROPOSED D—BOX END ON THE S.A.S. (SEE SHEET 1) HOUSE(#3620) INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & WATERTIGHT TOP OF LINER, EL.=103.0 106. T.O.F.= 7E A OUTLET AND SET TO 6" OF FINISH GRADE COVER SET TO 6" OF GRADE PROPOSED S.A.S. BOTT. OF LINER, EL.=101.0 INSTALL INSPECTION PORT OVER END UNIT T.O.F.=106.7t f F.G. EL.=105.8E F.G. EL.=105.0t F.G. EL: 105t F.G: EL: 105.3(MAX.) morn � 6 tK ff MAINTAIN 2% GRADE (MIN.) OVER S.A.S. L = 10' L = 7' L = 1t' 7M7 7 INSPECTION �p ® S=1% (MIN.) p S=l% (MIN.) ® S=1% (MIN.) TI 1 ril d` 4"SCH40 PVC 4"SCH40 PVC 4"SCH40 PVC I U �� ij, 6" (n(n 101 I 6' 10 :7 .75 T O O Q ia" INVERT C' p INV.=103.00 48' LIQUID _IOf INV.=101.90 LEVEL GAS BAFFLE INV.=102.27 PROPOSED INV.=102.10 (6 ROWS OF 4 UNITS AT 5.0'/UNIT) = 20' `__ — INV.=102.75 D—BOX . SOIL ABSORPTION SYSTEM (PROFILE) PROPOSED SEPTIC TANK S.A.S. LAYOUT MODIFY INTERIOR PLUMBING TO EXIT I ESTABLISH VEGETATIVE COVER HOUSE AT, OR ABOVE, INV.=103.10 BACKFILL WITH CLEAN NATIVE OR 1 PERC SAND TO TOP OF CHAMBERS - - 21" .6-t ' EAL OUTLETS NOTES: BREAKOUT=TOP . 2" 2'� YSEAL INLETS 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP ELEV.=102.33 INVERTS, PRIOR TO INSTALLATION. i INV. ELEV.=101.90 2) SEPTIC TANK & D—BOX SHALL BE SET LEVEL AND N TRUE TO GRADE ON A MECHANICALLY COMPACTED BOTTOM ELEV.=101.00 in SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN 2•83' ? Do 310 CMR 15.221(2). 4' MIN. ABOVE BOTTOM OF 3) INSTALL INLET & OUTLET TEES AS REQUIRED. T.P. EXCAVATION OR G.W. EFFECTIVE,WIDTH=17.0' 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE EXISTING SUITABLE N Top View ' D—BOX Section AS MANUFACTURED BY TUF—TITE, ZABEL OR EQUAL. NO G.W., EL=95.5 T i MATERIAL TH SEPTIC SYSTEM PROFILE NOE SEPARATION 6 ROWS FBETWEEN AEACrc H ROW & NO HC UNITS STONE63.25" N.T.S. TYPICAL SECTION —� - 16" SOIL LOG 34.5" DESIGN CRITERIA DATE: MAY 25, 2012 (REF#13,644) SOIL EVALUATOR: PETER McENTEE (SE#1542) NUMBER OF BEDROOMS: 2 BEDROOMS WITNESS: DON DESMARAIS R.S.—HEALTH AGENT TOP VIEW CLASS II Elev. t SOIL TEXTURAL CLASS: TP— � Depth. Elev. TP=--,2 Death - so'— DESIGN PERCOLATION RATE: 6 MIN/IN 104.0 0" 1104.3 0" END CAP END CAP DAILY FLOW: 220 G.P.D. FILL FILL FRONT VIEW SIDE VIEW 102.7 16 A '102.8 18" END CAP A DESIGN FLOW: 330 G.P.D. SANDY LOAM 1, SANDY LOAM REAR/TOP VIEW GARBAGE GRINDER: NO 10YR 4/2 10YR 4/2 NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT SIDE VIEW 102.2 22' •j1 D2.3 24" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY ,. LEACHING AREA ,REQUIRED: 330 GPD = 550.0 SF B PERC B DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. ( ) SANDY LOAM 36"/48" I SANDY LOAM 0.60 GPD SF 10YR 5/8 10YR 5/8 MMOUB. 4640 7HILLIARD, OHIO 302 / 99.5 54" 99.6 56' 4640. TR MA BLVD Are 36HC DETAIL ak PROPOSED SEPTIC TANK: 1500 GALLON CAPACITY C1 PERC C1 ADVANCED DRAINAGE SYSTEMS,INC. PROPOSED D—BOX: 1 INLET, 6 OUTLET (MINIMUM), H-10 RATED SANDY LOAM 54'/66`' SANDY LOAM 2.5Y 5/3 2.5Y 5/3 PROPOSED SEPTIC SYSTEM UPGRADE PLAN USE 6 ROWS OF 4-ADS Arc 36HC UNITS WITH NO 3620 MAIN STREET Rte 6A BARNSTABLE MA SEPARATION BETWEEN EACH ROW & NO STONE 95 5 C2 SILT LOAM 102" 99•5 C2 SILT LOAM ' 105" ' ' Prepared for: Michael Jones, P.O. Box 521, Hyannisport, MA 02647 BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.80 SF/LF OF UNIT) 5Y 5/3 5Y 5/3 Engineering by: SCALE DRAWN JOB. NO. (Arc36HC Units) 24 UNITS x 5.0 LF x 4.80 SF/LF = 576.0 SF 94.0 1 120" 94.3 - 12011 NITS P.T.M. 168-12 PERC RATE: 6 MIN/IN. ("B & C" HORIZONS, TP-1) Engineering Works, Inc. NO GROUNDWATER FNCOUNTERED 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.60 GPD/SF (576.0 SF) = 345.6 GPD (508) 477-5313 16/11/12 P.T.M. 2 of 2 i