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0204 MARSTONS LANE - Health
arris Meadow : I 9 ,I P i 4 J T OB kr�oTOWN OF B`ARNSTABLE ?®L .ATION me�1 4��nL: SEWAGE #�oo 7—.J 1 V r% V `.LAGS ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY JS 00 LEACHING FACILITY: (type) lriOW � (size) 30 Y"'s 0 NO.OF BEDROOMS 5- 11 BUILDER OR OWNER 8 T +JA fC e— PERMITDATE: Oct COMPLIANCE DATE: a Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by M of port ,0 ql 3 6, 7716 t .v�' g�Q TV ID t.ommonwealin oT massacnuseus ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 page. CityfTown 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. General Information filling out forms 1 on the computer, use only the tab 1. Inspector: S key to move your cursor-do not Trevor Kellett use the return Name of Inspector key. TK Septic Inspections Co � Company Name , 38 Vacation Lane Company Address West Yarmouth MA 02673 City/Town State Zip Code. 508-579-5502 S113144 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 15.006). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local-Approving Authority 4.15.15 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 office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. yY�yO'ti5 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �Y I� %,ommonweann or massacnusens Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 page. City/Town 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: ® 1 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 b 1. 1 - 1 r fr I TIC 7 %J11141d1 11 , Gl.l. VII V 11 N Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information on is Barnstable MA 02630 4.12.15 requiredd for every page. City/Town State Zip Code Date of Inspection B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. . 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 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 page. City/Town 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 ❑ ® 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 Y2 day flow t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachuse Its Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 104 Harris Meadow Ln ! , Property Address HOWE, JANICE M II Owner Owner's Name information is required for every Barnstable ` MA 02630 4.12.15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. ❑ Z 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. n ® 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,fort 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 al cesspool serving a facility with a design flow of 20OOgpd-, 1O,OOOgpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist asIdescribed 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 consideredlka 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 ithin 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 11 of a public water supply well If you have answered"yes"to any qL estion 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•W13 Tire 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 _ i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 page. City/Town 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 ❑ 0 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? ❑ ® 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;: 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name ! information is required for every Barnstable ( MA 02630 4.12.15 page. City/Town State Zip Code Date of Inspection D. System Information f Description: This system consists of a septic tank box and leaching feild i I i Number of current residents: 1 i i Does residence have a garbage grinder? ❑ Yes M No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report,) Laundry system inspected? I ❑ 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: current 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/scl t.; etc.): Grease trap present? ❑ Yes ❑ No I I Industrial waste holding tank present? ElYes ❑ No Non-sanitary waste-discharged to the Title 5 system? ❑ Yes ❑ No I Water meter readings, if available: Mrs-3f13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 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 0 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•3/13 Title 5 Ofidal 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 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 3/3/10 per boh Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.8 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: 2feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) 0 Yes ❑ No Dimensions: 1500g Sludge depth: 4 t5ins•3/13 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 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 page. City/Town 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 34 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 1 7 How were dimensions determined? Measured 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 is water tight and structurally sound with tees intact and liquid at the outlet invert, system does not need pumping 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 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 outiet.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•3/13 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 w 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 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 even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is level and water tight with five outlets and no carryover Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. C Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Ofidal Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form-Not for Voluntary Assessments w 104 Harris Meadow Ln Property Address HOWE, JANICE M i Owner Owner's Name information is bl tae, required for every Barns MA 02630 4.12.15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Type: ❑ leaching pits number., ❑ leaching chambers number: ❑ `leaching galleries number: ❑ leaching trenches i number, length: ® leaching fields number, dimensions: 30x30 overflow cesspool number:p ❑ innovative/alternativei,system Type/name of technolIogy: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching at the this property consists of 5 pipes in a 30x30 foot field of stone there is no standing water or high staining in the stones of the leaching jII l ' I i Cesspools(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration Depth—top of liquid to inlet invert j, Depth of solids layer Depth of scum layer Dimensions of cesspool I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5in5.3113 �i. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Harris Meadow Ln Property Address HOWE, JANICE M Comer Owner's Name information is required for every Barnstable MA 02630 4.12.15 City/Town/Town State Zip Code 'Date of Inspection page. tY P P 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.): 15ins•3/13 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 104 Harris Meadow Ln Property Address HOWE, JANICE M Owner Owner's Name information is Barnstable MA 02630 4.12.15 required for every page. City/Town State Zip Code Date of Inspection D. System*I formation (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 I B 1 2 3 I O Al)29 A2)37 A3)49.5 A4)81 B1)24.5 B2)27.5 63)47.5 B4)77.3 t5ins•3/13 Title 5 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 w 104 Harris Meadow Ln Property Address HOWE, JANICE M i Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 page. City/Town 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: 50-60 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: USGS shows GW at 50-60 feet Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 104 Harris Meadow Ln Property Address HOWE,JANICE M Owner Owner's Name information is required for every Barnstable MA 02630 4.12.15 page. City/Town 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•3/13 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 17 Tanager Rd. Hyannis MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 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 A. General Information filling out forms on the computer, �� I ,•f use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the return key. Name of Inspector Cape Cod Septic Inspection Company Name P.O. Box 1466 Company Address Harwich MA 02645 City/Town State Zip Code 508-240-2500 S14995 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•sy . ® Pa es ❑ Con y Passes ❑ Fails ❑ s F rther Eva[ a Local Approving Authority 4-13-2015 In" cto ignatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""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 nder the same or different conditions of use. I Jz t5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M s 17 Tanager Rd. Hyannis MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 page. Cityfrown 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: ® 1 have not-found any information which indicates that any of the failure criteria described in 310 CMR 15:303 or in 310 CM 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•tfie 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts R_ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 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 ❑ ® 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 Y2 day flow t5ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 _ page. Cityrrown 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 6elowrhigh 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- 10,000gpd. ❑ ® 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•3/13 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 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 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): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-3113 Title 5 Official Inspection forth: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 M 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is Hyannis MA 02601 4-9-2015 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 4 Bedroom residential dwelling Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 45.08 gpd 9 ( Y 9 (gpd)): Detail: 2014-20,196 gallons 2013- 12 716 gallons Sump'-.pump? ❑ Yes ® No Last date of occupancy: .� Current 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? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c� 17 Tanager Rd_ Hyannis MA Property Address Jane Bella Owner Owner's Name information is required for every y H annis MA 02601 4-9-2015 -- page. City/Town State Zip Code Date of Inspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): Gen eral Information Pumping Records: Source of information: Unknown 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of V Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner owner's Name information is required for every Hyannis MA 02601 4-9-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1989 tank and d-box, block pits pre 1978 per BoH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 21 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): , Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 16"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: 1500 gallon Sludge depth: 5" l5ins•3/13 TiUe 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 s 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 page. City/Town 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 27" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? SludgeJjudge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grade to inlet cover 7" Outlet 5" Normal liquid level No sign of leakage SCH 40 outlet tee Recommended next pumping within 2 years Recommended maintenance pumping eve 2-3 years 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is Hyannis MA 02601 4-9-2015 required for every page. Citylrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 III , Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is Hyannis MA 02601 4-9-2015 required for every y page. Cityrrown 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 0" 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.): Grade to box 24" OK condition 1 outlet Normal liquid level No scum No sign of leakage No sign of failure Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 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 wM s 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 page. Cityrrown State Zip Code Date of Inspection De System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): 2 Block pits Grade to pit#1 9" Bottom 100" Ponding 6" below outlet invert Grade to pit#2 28" Cover 9" Bottom 122" Dry No sign of hydraulic failure 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachuset ts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 page. CitylTown 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-M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f - Commonwealth of Massachusetts Title 5 official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 17 Tanager Rd. Hyannis MA Property Address Jane Bella Owner Owner's Name information is Hyannis required for every y MA 02601 4-9-2015 page. CltylTown 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 t t t A B Z /--C 2 27- 36-)D 3 3Z- 0 /33_ 0 :3 7- (o -n-6 a Z-$ 1 Z; : 6 6 1 t5ins•3/13 Title 5 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 17 Tanager Rd. Hyannis MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 page. City1rown 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: >4 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: See below You must describe how you established the high ground water elevation: Elevations from USGS maps Elevations are approximate Property ELV. 49.0-50.0 Bottom of block pit#1 -40.67-41.67 Bottom of block pit#2-38.84-39.84 GW ELV. 23.0 Adjustment 2.1' MIW-29 Zone C 7.3' March 2015 Separation >4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 17 Tanager Rd. Hyannis, MA Property Address Jane Bella Owner Owner's Name information is required for every Hyannis MA 02601 4-9-2015 page. Cltyfrown 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 I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 MAR-16-2010 07:44A FROM:RJ BEUILACOUA 506-833-6359 T0:15087632694 P.2/3 Town of Barnstable d Regulatory Services Thomas F:Geiler,Director XAFK'� ' Public Health Division 61 Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508.862-4644 Fax: 508-790-6304 Date: 3 L120,X> Sewage Permit#�9' �V `{ g Assessor's �� .S� Installer&Designer Certification Form Designer: b(-rlan GrOC� f1 Installer: Rev)lac�u� Can. Address: Address: )�-�• i, On D' a O Q U. 6ejl1qRaA was issued a permit to instal l a (date) (installer) septic system at r`/S �0q N& /1!aA0LZ IuLne based on a design drawn by (address) l�r)fmn Grr!sSA)gr) dated �Oy ay, o Gaq (designer) l certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component z of the s ptic system)but in accordance with State&Local Re a ions. .Plan revision or certif as-built by designer to follow. Stripout(if requ' f ted and the soils we found satisfactory. NORMAN GPOSSMAN (Installer's Signature). Na. 12705 CIVIL S (Designer's Signature) Aix De Here) PLEASE RETURN TO BARNSTABLE PIMLIC 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:%office forrnAdesignercertirtwtion fbrm.doc Town of Barnstable 1.2 Department of Regulatory Services Public Health Division Date C 200 Main Street,Hyannis MA 02601 . 4 Date Scheduled v2 ; 'Time ' Fee Pd: ,vo _ :Soil Suitability Assessment for Sewage: Performed By: . zSposal �J Witnessed By Location LOCATION & GENERAL INFORMATIONINFORMATIONAddress_. / !aNe Owner's Name -:Y I / cJ /y 15 �''jC7vw Assessor's Map/Parcel• A7/c� / �8� Address !!! Engineer's Name tiOrm�N NEW CONSTRUCTION ©S,S�? REPAIR Telephone# Land Use V(�. j_2 So Slopes m � TD o®S�'k11 Surface Stones ' Distances from: Open Water BodyZoo, ��4 ft Possible Wet Area -.�_ft Drinking Water Well k la ft Drainage Way ft Property Line rz t Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&,perc tests,locate wetlands in rozimi P. ty to holes) o� L , f j :a l C w o Parent material (geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: LLrLe- em% . lle Weeping t5•orfi Pit Pace Estimated Seasonal High Groundwater Sa:� ✓ 'F Method Us DETERMINATION FOR SEASONAL.HIG✓II WATER TABLE:ed: Depth Observed standing in obs.hole. --�--- Depth to weeping from side of obs.hole: iu. Depth to Sall mottles: Index Well# in, Groundwater AdJ68tment in, Reading Date: Index Well level ft. AdJ,factor �4 AdJ,drowidwaterLevel qi Observation - Y XERCOLATION TEST b Hole rk II. L/4Date1't `)'1111C Time at 9" i(41 P_ z... ' Depth of Pere 49 50--0 1. . Time at 6' 1l S� Start Pre-soak Time @ t `" -�--- .� — -► Time(9"•6") End Pre-soak It i 55 of 44i- 'aT 12r aD f1:.Q� Rate Min./Inch------------- J._ / + Site Suitability Assessment:. .Site Passed Site V e Failed: Additional Testing Needed(YIN) LY Original: Public Health Division Observation Hole Data To Be Completed on Back----------- *'k*If percolation test is to be conducted within 100' of wetland, you must first n otify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:\S EPTICU'ERCFORM.DOC I DEEP.0BSERVATION HOLE LOG Depth from Soil Horizon I07e# Surface(in.) Soil Texture .Soi]Color Soil (USDA) (Munsell) Mottlin Cher g (Structure,Stones;Boulders. -Consistency,% ravel 14 49144. DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Hole# Surface(in.) Soil Texture Soil Color (USDA) Soil Other (Munsell) Mottling (Structure,Stones,Boulders. Consisten__ DEEP OBS ERVATION HOLE LOG Hole# (USDA) Depth from Soil Horizon `Soil Texture Surface(in.} Sail Color Soil Other (Munsell Mottling (Structure,Stones,Boulder s. Co i to Y.g' Gravel) Z.—28'. }�{� cal'` 7, -- 2.S DEEP OBSERVATION HOLE LOG Hole# L Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell Mottling (Structure,Stones,Boulders. _ 1 Zik 0 / Consi ten 1 I Z _ 45�, g Div a i1 p �G -Z Flood Insurance Rate Ma Above 500 year flood boundary No_ Yes Within 500 year boundary No_ Yes Within 100 year flood boundary Nov-- Yes . Depth of Naturally Occurrin Pervious Maternal Does at least four feet of naturally occurring pervious ma area proposed for the soil absorption system? terial exist in all areas observed throughout the If not, what is the depth of naturally occurring pervious material? Certification W24R.-Q-ic I certify that on �: ,� Ihave passe the soil evaluator examination approved by the Department ofEn ironmenctio�r'"l"d the+` c the required training, ex per y aXprence dcrd�n lOve analysis C SMR 15.017 armed by me consistent with . Signature , 0.'`oit11Ltk Date A--2 Q:\SEPTlC\PERCFORM.DOC RM.DOC No. FEE s COMMONWEALTH OF MASSACHUSETTS Board of Health, o -T-A81,£ MA. APPLICATION FOP ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( - ❑Complete System Individual Components Location Q 4ARQUI, C LA-416 Owner's Name moseiZr 4imie6 Map/Parcel# 2.`7y O8 7 A Address p Lot# *A Telephone# Installer's Name Designer's Name ^�< `T D 55 Address V; a.Y fyPSTP o ' an AddressFA4&40LfTa MA Telephone# I Telephone# 660 g 49- I� 0 Type of Building�I�1T 6LV,- rIW/L-y AL e1 s�MJ� � L'1��i�� Lot Size —If 4 41o5Y, sq.ft. Dwelling-No. of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) f�`S'p gpd Calculated design flow 56 Design flow provided 6424�1 gpd Plan: Date ik4O✓. Number of sheets Revision Date Title ij io6aAf7E Le,( G„z, J*-1 f4rL�U�?/ ?4��J� Description of Soil(s) A. 1?!5 Soil Evaluator Form No. t 'Name of Soil Evaluator. E, Date of Evaluation (-&3-45 — DESCRIPTION OF REPAIRS OR.ALTERATIONSflo,J�l �`a�. �'�bOS( 'PITS 1►.1�i -t.� Flo 19 The undersigned agr o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to o e system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date ons .j,T " ,...r ��;-'' .,. �:+^• •:` L - ' 3 . 7y r F tY Y No. a I' (1 .�� FEE /� 1 O V WL.tI.ll TH. r MASS 1 1lSi�H N'ETTIJ' t A.t`Y.iM.nW`rnr.a�yfM'•� ..•}��rl� Board of Health; Ig)A2!J�T/�RI Ir `7-AILA: -lie s .. .: S 'S A�B��������� FOR DISPOSAL SYSTEM ��� e T JCTION PERMIT Repair(,for a Permit to Construc ;.Repair Upgrade(, ) Abandon( -. ❑Complete System [Individual Components Location (� -�AtZIz.15 L YJp r!% Owner's Name n c f-e)ast r, -jAd1 ow-e P• � / Map/Parcel# �`jG� a�7 _ Address . 'v ' 1-J LA. Lot# F'.d. Telephone# � —4& Installer's Nameet� ✓�4 'T Designer's Name �4 i2 MAr� MOSS M°�� Address . �,a t-.fP -1-Je ke Address r'•-3 Q �, 13�x 97 �. _ LMac�� i� Telephone# Telephone# rj Type of Building 1 a.!G:l--& L`/ J]u)e-WI-�C�i A r;,: xj 14 Lot Size sq.ft. Dwelling-No. of Bedrooms Garbage grinder O Other-Type of Building t -" S - No.of persons Showers ( ),Cafeteria ( Other Fixtures Design Flow (min.required) ¢CSC) . gpd Calculated design flow Design flow provided gpd Plan: Date QC-�• Z.�,. .ZDO�), ,Number of sheets Revision Date Title ncA� O-- paopc 5eb 6F,=1 L 1.?06(�Xf,215- Lo::S-l r;r3 /l�� � IZrLr S kfL-'71�G1.J Description of Soil(s) 5f � > Soil Evaluator Form No. Name of Soil Evaluator J.E . '6}!>L-e—( Date'of Evaluation DESCRIPTION OFREPAIRS ORALTERATIONS Lax I ' 47 - k?>0 X (T S The undersigned agr/oeeltafi llltthe above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to oe system in operation until a Certificate of Compliance has been issued by the Board of Health. t F � Signed i } n p'ec£ions No. FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, �441- )278 MA. CERTIFICATE OF COMPLIANCE CE Description of Work: C 4vidual Component(s) 0 Complete System r The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned'( ) by: at lT f �2/Z/s /LI r�G(,iJ 4 W lf, &AZi-S 1-C has been installed in accordance with the provi ion of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to application No. Bpi /'.. l dated Approved Design Flow (gpd) Installer ! Designer: , rew, GSShI � ) � V. g /� �• Inspector: � �,^� '� 11,bl:' Date: The issuance of this permit shall not be construed as a guarantee that the system will function'as designed. No., FEE ! �� COMMONWEALTH OF MASSACHUSETTS Board of Health, � �Gu J`� /� MA. LDISPOSAL SYSTEM CONSTRUCTION PERMIT F ssions is hereby granted to; Construct'( ) Repair( ) Upgrade(V Abandon( ) an individual sewage disposal system �`7z ;2X/S /ri1d h /JI �✓f�T�r �h as described in the application for sal System Construction Permit No,���dated /C ed: Construction shall be completed within three years of the dte of this pe`mif.)All local conditions must be met. Rev.5/96 A.M.Sulkin Co.Boston,MA Date �d/i� Board of Healt� APPLICANT: . -ADDRESS: DESIGN FLOW: 5 S� /Zr(Q 6eaG, /,Qor/ gpa REVIEWED BY: ; DATE: N/A, OK NO Le al boundaries denoted [310 CMR Street, Lot, tax parcel number and lot number noted on plan [310 , CMR 15.220(4)(u)] �✓ Locus Provided [310 CMR 15.2204(t Plan proper scale? (1"=40'for plot plans, 1"=20' or fewer for com onents) [310 CMR 15.220(4)] V Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for u ades]-i not, a variance is required [310 CMR 15.412(4 ] Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d) Location all buildings existing and proposed 310 CMR 15.220(4)(c)) t/ Location and dimensions of system components and reserve areas [310 CMR 15.220(4)(e)) S stem Calculations [310 CMR 15.220(4)(0) dail flow se tic tank capacity(required and rovided) soil abso tion s stem (re uired andprovided). whether system designed for garbMe grindef V North arrow[310 CMR 15.220(4)( )] Existing and ro osed contours [3.10 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)J, 1/ Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h)and (i)J 1/ Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)1 1/ Percolation test results match loading rate? [310 CMR 15.242] Certification statement by Soil Evaluator[310 CMR 15.220(4) ')) Observed and'Adjusted gfbundwafeftmethod for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)J Location of every water supply,public and private, [310 CMR 15.220(4)(k)J Address /0 171kiV I5 *a��J 17q . Sheet l of within 400 feet-of the proposed system location in the case of'surface water supplies and ravel packed public water supply within 250 feet of the proposed s stem location in the case within 150 feet of the proposed system location in the case < of rivate water supply wells v Location of fall surface waters and wetlands located up to-100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310.CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4)(m) (if water line cross see 310 CMR 15.211(1)[1]) � Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR 15.220(4)(0)] r/ Stampof designer [310 CMR 15.220(1 and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] Test Holes adequate (two.in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310.CMR 15.405(1 k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75'of system [310 CMR 15.220(4)( )] Materials specifications noted? [various sections of 310 CMR 15.0001 System components not> 36" deep(unless Local Upgrade Approval or LUA,requested) [310 CMR 15.405(1(b)] Address ��� // ��U� �L � Sheet 2 of 7 Size OK? 310 CMR 15.223 1 inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee.14" or IV+S"per foot for increase ft depth [310 CMR 1.5.227(6)]. Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)]l 1, ✓ peth) regarding installation on stable compacted base [310 CMR 8(1)] ation between inlet and outlet tees (no less than liquid 310 CMR 15.227(2) Outlet elevations at least 12" above high groundwater t as described 310 CMR 15.227(5)) or permitted for es under LUA [310 CMR 15.405(l)(k)] • tninall imum cover 9" (Tanks buried more than 9" must have risers openings and on the d-box) [310 CMR 15.2228(1) and.310 V CMR 15.232(3)(0] ' Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8" (b 7/07) [310 CMR 15.228(2) Access to within 6 " of grade - one port for systems<1000gpd, two fors stems>1000 d 310 CMR 15.228(2)) ✓ All at-grade covers secured-to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buo ancy calculation Required/Done: [310 CMR 15.221(8)] H-20 Where a ro riate? [310 CMR 15.226(3)] Setbacks from resources[310 CMR 15.211] Required when other than single-family dwelling or flow>1000 d [310 CMR 15.223(1)(b)] First compartment 200% daiiy flow; Second compartment 100% dail flow[310 CMR 15.224(2) and (3)] "U"pipe through or over baffle; outlet of each compartment with _ as baffle or a roved filter[310 CMR 15.224(4)] Address /f G Sheet 3 of 7 I— , Located at least ten feet from any water line? [310 CMR 15.222(2) kDisposal piping at least 18" below water line (when water and ✓ rcross, see 310 CMR 15.211.(1)[1outs re uired/ rovided ? [310 CMR 15.222(S)]t blocks s ecified in force mains?310 CMR 15.221(6)(c)] of sewer line not less than 0.01 (1/8"/ft) 0.02 preferableMR 15.222(6)]. lProperpitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphonproblem/(leachfield below pump chamber) t/ Endca s or vent manifoldspecified? Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 ✓' CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) 1Stable compacted base[310 CMR T5.221(2)and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer).[310 , CNfR 15.323(3)(a)) Riser if deeper than 9" [310 CMR 15.232(3)(01 Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR15.232(3)(e)] . Watertight cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] Capacity(emergency storage above working=design flow)? [310 J CMR 231(2) Proper setbacks [310 CMR 15.211 (same as septic tanks)]' Watertight 20-in minium access manhole at least 20"MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, ✓ 1 disconnects accessible) Alarm floats- alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310.CMR 15.231(6) and (8)] Stable Compacted Base [310 CMR 15.221(2)] .Buoyancy calculations needed.?Provided? [310 CMR 15.221(8)] Address �/ �" / (iyt/� y/`x Sheet 4 of 7 —r— I Calculations correct? ✓ 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation togroundwater? [310 CMR 15.212)] A e ate s ecified as double washed [310 CMR 15.247(2)] System Venting required/provided?(system under driveway or >36" dee ) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] - Breakout requirements met?(No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] Chambers and Gal. in trench configuration supplied with inlet eve�ry 20 ft. [310 CMR 15.253(6)] ✓ Each.structure with-one inspection manhole (if>2000 gpd must be tograde) 310 CMR 15.253(2)] Aggregate 1'.minimum-4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15.253(1)(a)J t/ In bed configuration, inlet every 40 s . ft. [310 CMR 15.253(6)] rgater 'minimum 3'maximum [340 CMR 15.251(1)(b)] t% -maximum length [310 CMR 15.251 1) a J m separation.2x effective depth or width whichever 3x if reserve between trenches [310 CMR 251 1)(d)] along contours [310 CMR 15.251(2)] Breakout OK?1310 CMR 15.211(1)[4] and Guidance Document] !/ minimum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum se aration between lines 6' 310 CM R15.252 2)(d ] (/ Maximum separation.between lines and outside of bed 4' [310 CMR 15.252(2)(e) Aggregate depth below discharge pipes 6" minimum, 12" maximum. [310 CMR 15.252(2)(g)J Separation between beds 10'minimum. [310 CMR 15.252(2)(0] Vol Bottom area used in calculations only 310 CMR 15.252(2)(i)J Address mL` Sheet 5.of 7 Pressure Dosed System ? Provided pump andpiping calculations as required [310 CMR 15:220(4)(r)] Pressure dosing required on all systems >2004gpd or alternative systems under remedial approval [310 CMR 15.254(2)and I/A ✓ Remedial Use Approvals] If used in gravelless system -'make sure Yet.is-directed as not to scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000 d)goodlo, note on plan [310 CMR 15.254(2)(d)] v Construction in fell -Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Im envious barrier and/or retaining wall ? [Guidance Document] IImpervious barrier installation must be supervised by. de'signer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional En ineer(310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and t/ Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) (3.10 CMR 15.255 (2)(e)] Check DEP Approval fetters for credits and design conditions r/ If used with pressure dosing do not allow pressure discharge to scour soil interface 7- Was f -DEP Approval Letter provided and/or have you ed the letter for conditions? v Is the technology being properly applied and does it meet all DEP Approval Conditions? fv Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on,separate circuits C/ Did the applicant submit an operation and maintenance. manual? Has applicant submitted.a copy of a maintenance .� Are the variances listed on the plan'? [310 CMR 15.220 (4)( )] RLS.Sfamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed - (Refer to 310 - CMR 15.414] Address Sheet 6 of.7 20 t- :.p Is the system in a Designated Nitrogen Sensitive Area (Zone II fo a public supply well)? [310 CMR 15.2145 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such k-- existin systems] Is the system proposed on the same lot as served by private well ? ` [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR . 15.216(1)] Pumping to septic tank? [310 CMR 15.229 Shared System [310 CMR 15290 Address 1&4 1/ Sheet 7 of 7. 4 LO�CAT .ION SEWAGE PERMIT NO. VILLAGE AA&A iMSTA l ER'S A III ADDRESS T ' 1- OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED jvNG Room AD9 i 1i0 rol�l��' W .i s� ,t r f ....... FEm3........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----------TOONN/..W------.......OF...........5..&J.Z.-W.6j.A.13.L.e.......I........................ Appliration for Disposal Workii Tvnst�urtiv* tt Punfit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at:N&rzei,, hjr_&vo,,v L&mr-, 5,&tm6j&BLs L o..T * 5 .................................................................................................. I ---------------------------- ................................................................... _,Lc t,';".Add or Lot No. -Address .............. RIL5................................ Af Js.../Af_4_VPJ&..UUR.....I�MITANA__IhU.-4. Owner Address ................................................... ................................................. Installer Address Type of Building Size Lot_44455_3.......Sq. feet U Dwelling—No. of Bedrooms-------------4...........................Expansion Attic Garbage Grinder ( 4 P4 Other—Type of Building ............................ No. of persons--_______________________-__ Showers Cafeteria ( P4 Other fixtures --------------------------------- Design Flowilayj :BZvW0wA ........ .X.1.5P.YP..............gallons perms per day. Total daily flow._.____.4.6.0.........................gallons. Ix Septic 'r.tnk—Liquid capacity.15.0.0..gallons Length________________ Width---_-_-._--.._-_ Diameter____-.-.-_--____ Depth--.------------- Disposal Trench—No_.................... Width_____ ------------- -- Total Length-_________________-- Total leaching area....................sq. ft. Seepage Pit No......J.'VJ_0..... Diameter--------(0......... Depth below inlet------&........ Total leaching area_ PU-----sq. ft. Z Other Distribution box ( ) Dosing tank ( ) -f Percolation Test Replis Performed by------JZ_(_CkAr----- -a-03-4-q -------F!1.?...... Date....101.7-1-18-6--------------- 4 1 Test Pit No. I.TJPI.minutes per inch Depth of Test Pit--- 12---------- Depth to ground water...___V6_4.__e..... A it_ -Test Pit No. 21 11�7_minutes per inch Depth of Test Pit.... ........ Depth to ground water...... .................... ------------------------..... ............................................................................................. 0 Description of Soil______________________ __A.C./ap op i.........�14�......................................................------------------- U ....................................................?--- .... .....................1----------------------------/---------------------------------------------------------- 6-----------------I... .. ... ..rt....... 1 Am.— ................. / .....50"- U N!(ture of Repairs or Alterations—Answer when applicable............................•____..._.___..._.__..__._._......._....... ------------------------ -----------------------------------------------------------------------------...................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signedc�o - I. ...................... ..... /A a IT-1- Application Approved By------- ------------------------- ......... ---------- Date Application Disapproved for the following reasons:................................................................................................................ .................................................................................................................................................................. ............................--------- Date PermitNo......................................................... Issued........................................................ Date ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .....................................OF...........................--..--..-....------------•---•----------------.-........----'- ApplirFa#inn for Riipv al Works 01nntrur#inn Punfit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -------•---------------•--•-•-------------•--•-----•----....----------••••••••-•--•----...-•-•-•-- ••----•-•-•••••--------•--•••-----••-•----••-•---•....---•-••---•••-••••-----••---•-••-•••-••-•-_.. Location-Address or Lot No. ..........................................•-......_......•......---•----..._--•......••--•-__•-•.- .....•••--•---•-•...-••--•-•-•.._...__•...._..---•••--•...•••'••-•--------•-•....•-•-•-------••••- Owner Address W Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms---------------_............._..............Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons-........................... Showers ( ) — Cafeteria ( ) Other fixtures ----------------------•-•••-'-'••-•••------------•---- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity___________gallons Length................ Width---------------- Diameter_______________ Depth------___-___- x Disposal Trench—No_.................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter____________________ Depth below inlet.................... Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test 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_____-________________-. 0 Description of Soil------------------_---------- •--------------....._..----------•-----------------------'-----------...-'-----------------'---•-------------------------..-•-•''- x W U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... -••-•-----•'"---••••---------•- Date Application Approved By------ --- .---------------------------- . -------{lp plpli;b------------ Date Application Disapproved for the following reasons-----------------•---------•----------------------------------------"-------------------------------------••••-- --------------------------------•-----'-•------------------------------------------------•--------------------------•-•••••---------------------------------------------------------------------------- Date PermitNo..................... .................................. Issued--------.............-................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................I................................ C9rr#if ira#r of Twnntph anrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---•••----••-••••-� -----•------ _____--•--------------------------------------------------------------------------------------------------------•-------____ Installer has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit ______________ dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST U AS A GUARANTEE THAT THE SYSTEM WIL 'FRICTION SATISFACTORY. DATE-•'-f = . ,_ Inspector_.. -••••- "••••• -'-'-----••••-'•••-•----••----------•-•'••-•....---••--•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................I...OF................................ " ......... r.s/� FEE--.-I �i��n��tl nak,� Cnnn�#rnr#inat anti# Permissiol,jehereby granted-------------42.4---- ,.---________---•-----------------------____-------------•-•-------•-•-•----•-•----------------- to Construct ) or epair ( an/ Individual Sewa e Dispo1 -sal System at No. ................................. 3�.!yyy/// ��-�_,� ��� J __________________��k! .t ______.____ _may _ Street L �/9� as shown on the application for Disposal Works Construction Permit No..................... Dated__/_2_/__ --�J-G'-___-__•_ DATE. --------•---•-----------•------.__..'.............................. oard of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS T 51. cl q s { P IT e {to / La.T , 44, 3ti SQ FT CY �C) 3 P L A,, 1 P ## i i q #ZA #3� 'EST TEST TEST FG` 7-9. _zz- f >latia TO E tLl i ' E�A►..• q tit�t; { Su05o�i. SU3 SPt� SUB sobs_ fit. t {NV, Str-r i c 54, 33 O ?.Er�4 \/E t1�`ivt� MA L Tvr44 jb ALL f.� ci r�Y C-L" s�HoY Cis LA tijL)L.y f4— MATtVZI A L- • SILL W^SH e A f C, _ sTd�1� G�kv C1.- F s m1 E -�i'F"-"� jp' ----+�t�1•r• �t��1,.�: F'1�M 3L�C - 4$E,I�Rc�C7 N4�. -skmo st CLAY 9R t X S1\W D w tr" Ly.S t X raRobv�� DA1 L�( �l..C�t = c t s��. $ i5c� o P P-0 F I LQ 5E M C- `rA A W z 4-4tc>x z..0ofo 88o GYM P N o [Z•Z•© Pamc• 1-9srs -1�- IZ.iG4ktc> fit!tzz46acc, PE to/-1 /60 SkPiFwALt_ Am; W krf4E tg,;;o �� ?At;,- 4A umaN-y �*?A2*Tta �� a r V. of AeAr TIA 1.� � �F' X 2 v. ' t So _5 t". X I. O Q 5 D G. P..A. TOT L T>SS N: 4Z•5Y, aT A L D AM LOW = C O of E�P C at NTT ON vWrIt . i' I c.Mi'tk C)R, i•-e5..5, RICHARD o At FEE p 1 w Na.2••,dk3$ •r. ti i C .R�' a t=t ra PLOT P t A aV A SGA�E 4 LD GATE 7-3i Z CE<R'T t F'`< T� -VNT T�� pt�o Ea akbdkl" tlty SHOWN L T M€ P LfN K FOR J o H N H 1•�?�R��� 3A N, t 4'!G 1 t4Sir. "S SVNQI3�_ ? Aff L4 1vt'C ToFltl 26 24 21.8 24 26 28 27.7 - - _ 23� / // 28 / / 29+0 , 30 26+6 / / Lot 7A � \ - - - - - - - - -// / N/F _ / Howe � 26+5 � - 28+7 / 2 - _- - - - - 31�2 29+1 36.83, 32 30 i 126.46' �29 9 - _/ 32,5 32 N - - - - - - ' 3 - - - New pressure line from - - - VENT _ . /No etlands or - �- - - - - -� 34 M 31.3 _ l�' / 3 cabana grinder pump110 32.5 �/ pota wells - - - - Proposed _ ,Meyers model MRG20 / 1 oil within 2 - Pool or approved equal -/ S�por s f q - - - - - - � 35 - - - - - - - - _ _ ~ 67.38, 2 NIF a cones OBSERVATION j� , - 4 - //_ - N/F b � � � Heath 32 /1 � , - - /34 PORT - - o � � {- 900 S.F 1 3�10 1 _ \- - - - 36 J ' Reserve ' 900,S.FJFIE�.LWA 3 3� - - - - -\ 7+3 area 1 -\- ItW 1 39.7 f ressure - - Proposed 14 �P. I 11 ' Existing index ''ewe, Cabaa\na t t _ , bluestone patio (1 bedrogm) _ / a 37 �1 377..2 1 39.9 39.138� \ \ \ \ / 1 1 1 ` _ 39.8 Xl 38 34 I W ,' - - \ -TBM=40.0(assumed) S rock blu ' at / l + 38�6 3g DB 5 ice er of double - _ 107' Remove , 40A - - 3911 40 35.1 i / _ E ist.D Box Exisfin 40 1500 allon / Pump out&fcll in �(' _-- - 39 S .4 ep ' Tank„ 25 - _ + ,,existing pits / I + 41.3 I `Exist.irrigation well �1 n on- otable _ P Exist. tone Existing Bedroom 36 / + / retainin wall 43.1 -�, 4 l�edroom / 42� 39.9 Dwelling 46.5 House #104 37.2 i // 464 38 40 42/ 44 46 o a M V ) N I 1 279/067 _ \ N/F Schelter I I � M L O T 5B ' 71,492+/- S.F. 1.64 Acres \ 8,543 S.F. Exist. bit. conc. \ driveway / 2SZ S�, 2791063 N/F Tyrrell LEGEND 2791083 NIF Exist. Spot Elev............. 35_3 Clinger Exist. Contour................ - - - -36 - - - - Prop. Spot Elev.............. 35.9 Prop. Contour................. 36 Setback Dimension........ 13' Test Pit Location............ 20 10 0 20 40 PLAN SCALE / FIRST FLOOR ELEVATION TOP FOUNDATION ELEVATION _ - SEPTIC SYSTEM PROFILE _ - NOT TO SCALE VENT WITH - _ CHARCOAL FILTER BASEMENT FIN. GRADE AT FIN. GRADEOVER FIN. GRADE OVER FOUNDATION SEPTIC TANK FIN. GRADE OVER ELEVATION 40.1 - 40.0 39.5 DISTRIBUTION BOX SOIL ABSORPTION SYSTEM _ 38.0 OBSERVATION 36.0 - / PORT RISER SET TO W/I 6"OF FIN.GRADE APPROX. INVERT - _ 3'7.21/ __ _ h � F - ___ "7_ _._.,_ _ _APPROVED _- Existing 4" ID„ ILE FABRIC 33.35 2" GEOTEXT gravity line � O - - - - - - - - - � 36.80 EXISTING 14 35.55 SUMP ------- 4'_PERF.PVCPIPE -------- 1500 GALLON o 35.33 33.00 32.85 NOTES: SEPTIC TANK 4 35.50 New pressure line from 30' new cabana grinder pump H-10 LOADING 5 HOLE DIST. BOX 32.35 1. ELEVATIONS BASED UPON BARNSTABLE GIS. GAS BAFFLE ON OUTLET TEE Meyers model MRG20 2. TOPOGRAPHY RESULT OF ON-THE-GROUND SURVEY. W/BAFFLE 3. PROPERTY LINE INFORMATION FROM BOOK 632,PAGE 42. or approved equal �, INVERT LEVELERS ON 4. NORTH ARROW NOT TO BE USED FOR SOLAR ORIENTATION. ALL OUTLETS 30' 5. ALL PIPING TO BE CAST IRON OR SCHEDULE 40 PVC. 6. ALL SYSTEM COMPONENTS TO BE INSTALLED IN ACCORDANCE SEPTIC TANK SET LEVEL AND TRUE TO GRADE 3' S DIST.LINES @ 6'0"O.C.=24' 3' WITH SEC TITLE V AND LOCAL BOARD OF HEALTH REGULATIONS. ON 6"CRUSHED STONE BASE ON H-10 LOADING 7. NO CHANGES TO LOCATION/ELEVATION OF SYSTEM COMPONENTS MECHANICALLY COMPACTED NATURAL MATERIAL _ TO.BE SET ON A LEVEL _ WITHOUT WRITTEN APPROVAL OF ENGINEER AND BOARD OF HEALTH. .. .. .. _-,_ 8. NOTIFY ENGINEER 24 HRS.IN ADVANCE FOR AS-BUILT INSPECTION. AND STABLE BASE � i2743 _ DESIGN DATA SOIL EVALUATION LEACHING FIELD DATE OF TEST: NOV. 23, 2009 (Not to Scale) NUMBER OF BEDROOMS....... 5 EVALUATOR: JACK CAUL'EY G.P.D./BEDROOM.......... .................... 110 G.P.D. SOIL AiSORPTION SYSTEM 'WITNESSED BY: TOTAL DAILY FLOW... DON DESMARAIS ... 550 G.P.D. TOWN OF: BARNSTABLE GARBAGE DISPOSAL.., NO PERC RATE: <5 MIN/IN LEACHING REQUIRED. .. ....... ........... 550 G.P.D. SOIL CLASS: I 0.74 GALS./S.F LEACHING PROVIDED........................ 666 G.P.D. ) SEPTIC TANK REQUIRED.......:.......... 1500 GAL. GROUND WATER: NONE ENCOUNTERED SEPTIC TANK PROVIDED....... ........... 1500 GAL. 0 37.1 TEST PIT#1 A 0" 37.2 TEST PIT#1 B 0" 33.1 TEST PIT.#2A 0" 32.5 TEST PIT#2B *NOTE: EXCAVATE TO ELEVATION 32.35 OR LOWER SIDEWALL AREA ......... .. ........ - - - S.F. LOAMY SAND AS SOIL CONDITIONS REQUIRE,TO REMOVE ANY TOPSOIL, "" 12" O/A LOAMY SAND 12" O/A 12 O/A LOAMY SAND 12" O/A LOAMY SAND SUBSOIL,SILT, CLAY OR OTHER UNSUITABLE MATERIAL BOTTOM AREA... ................................ 900 S.F. BENEATH THE INLET INVERT OF THE SOIL ABSSORPTION TOTAL AREA........................................ 900 S.F. LOAMY SAND � SYSTEM FOR S'AROUND THE FOOTPRINT OF THE FIELD. TOTAL AREA X 0.74 G.P.D./S.F........... 666 G.P.D. LOAMY SAND LOAMY SAND EL. 30" B 2.5Y 6/6 EL. 30" B 2.5Y 6/6 28" B 2.5Y 6/6 30.6 34.1 MEDIUM SAND MEDIUM SAND COARSE SAND SANDY LOAM 48" C1 2.5Y 4/4 i° 48" C1 2.5Y 4/4 60" C1 2.5Y 6/6 CO 48" B 2.5Y 7/4 Barnstable Harborcc U I U OC W STRAT. LAYERS j � STRATIFIED STRATIFIED STRAW. LAYERS FINE TO SAND SAND MEDUM SAND MEDIUM SAND 2.5Y 8/3 2.5Y 8/3 2.5Y 8/3 _ 2.5Y 8/3 144" C2 EL. 25.1 144" C2 EL. 25.2 144" C2 EL. 21.1 144" C EL. 20.5 PLAN OF PROPOSED co j _ NO MOTTLING NO MOTTLING NO MOTTLING NO MOTTLING SEPTIC SYSTEl�'1UPGRADE LOCU 13 CD v LOT 5B9 #104 HARRIS MEADOW LANE athiss BARNSTABLE MA v La _ V � a LOT 5B* *NOTE: 0-f , DATE: Nov.24,2009 SCALE: As Noted „ Rte sq ASSESSOR'S MAP ........: ............ 279 Lot 5B is the current lot number for the former Lot 5A. OWNER/APPPLICANT y�sA �r PARCEL:....................................... 087 The property lines were recently modified and approved LOT:.........., ........... 5A b the Planning Board on Nov. 2009. The changes m Robert&Janice Howe �-' i S A Norman Grossman PE,PLS Y g g may o G�osSt�nnr� � ; HOUSE NUMBER: ......... ............ #104 not have yet been noted in the Towns system. The approved 104 Harris Meadow Lane No. 12705 P.O.Box 97 ZONING DISTRICT:........ ..:...... RF-1 plan is on file at the Registry of Deeds in plan book 632, pa e 42. Barnstable MA oEvtt East Falmouth,MA 02536 g 508-548-1920 .EGl51E'�� Q LOCUS ssb��