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HomeMy WebLinkAbout0053 WINGFOOT DRIVE - Health 53 Wingfoot-Drive Barnstable A = 349 - 073 _.y ,�r¢, ­7=- il { IL 43 , v � JAe'y - . 6 TOWN OF BARNSTABLE LOCATION �3 SEWAGE# VILAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) )` NO.OF BEDROOMS �\ OWNER y, PERMIT DATE: \ MPLIANCE DATE: Separation Distance Between the: oo��� Maximum Adjusted Groundwater Tolle,\� e 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 r7 TOWN OF BARNSTABLE SEWAGE # VILhAGE Cut, , -.4 ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. �1.5�1='t✓`i`���'/ a?g( SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: =MPL1ANCE DATE: _ Separation Distance Between the: C.? 3 Maximum Adjusted Groundwater Table to the Bottom v' `` c ng�acility Feet Private Water Supply Well and Leaching Fac Gy Tany 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 Al Sketch of at two QSPtsaj Systa_Pmvift a vfev of the sewage diyp�syyteM fir, W i Where P"-�MM*Mem the btaM&g Check One of the boXes belowm 160 V hard-sketch in the area below s ❑drawing alteched separately �i AK h F Ap�� t r" Q�ld t H / T7 A s eez` nh as m® Iwsmm�no�wmem.mssgnbms�mm•wo.�aaa ■ Complete Items 1,2,and 3.Also complete A. SI Item 4 if Restricted Delivery Is desired. ❑Agent o Print your name and address on the reverse 134 Mssee so that we Can return the card to you. I Received by(Printed Name) C. Date I ery ■ Attach this`liard to the back of the mailplece, or on the front If space permits. -. 1. Article Addressed to: D. Is delivery address different from item 1? Yes , If YES,enter delivery address below: ❑No Clyde K. Hanyen P O Box 497 Orleans, MA 02662 3. Service Type R ❑Certified Mall ❑Express Mail _. .__._. ❑Registered ❑Return Receipt for.Merchi Ilse ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) O Yes 2 Article Number (Transfer from seiv(ce'iabei) 7008 32 3 0 ,0 0 0 2 5178 2329 PS Form 3811,February ones is Return ece p 102595-02•M-1540 --- !` 7. ru >.�x E 1 1 n i � k 3 1 t e 0 u F zx (� k a Iti e r-9 Postage $ Ln ru Certified Fee ' ?�r !6PA Postmark•. O Return Receipt Fee i Here" O (Endorsement Required) i t"" 1 r Restricted Delivery-Fee O (Endorsement Required) rU Total Postage.&Fees �� mIs Sent To - ............................................. Street,Apt:No.; X �� fti or PO Box No. prl.( eor7 s Ml4 o•?LGA City,State,ZIP+4 f r J No. l/ ­05 3 Fee o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppCication for Dioogal *pmem Construction Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /o f !!�� j(Q Owner's Name,Address,and Tel.No. "-IIINVAssessor's Map/farceJS '✓s Installer's Name,Address,and Tel.No. Jtv T_3 GZ3 7 Designer's Name,Address and Tel.No. Type of Building: t"' � � Dwelling No.of Bedrooms �� Lot Size / � sq. ft. Garbage Grinder (/ 4D Other Type of Building /U ti < No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided • gpd Plan Date ��'l -- �� Number of sheets Revision Date Title Size of Septic Tank /'S'�7^J Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) g'�' /��C/J Date last inspected: Agreement: The undersigned agrees to ensure the co truction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5opwe nvironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this dof Health. Signed" Date Application Appro d by Date �Q Application Disapproved by: Date for the following reasons Permit No. �f J ­0 7 3 Date Issued 4 No. (/O' Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE,.MASSACHUSETTS Yes ` ZIPPYication for � gpogar *p!gtem Corlgtruction Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) Complete System Individual Components Location Address or Lot No Owner's Name,Address,and Tel.No. Assessor's Map/Parcel J 7� A $ O2/e-XA5 //Y,.O y ���LLL I �f�/ 1 s. Installer's Name,Address,and Tel.No. Sv I 3 2 GL 3 7 Designer's Name,Address and Tel.No. � t Type of Building: � , Dwelling No.of Bedrooms � Lot Size ��BS�p sq. ft. Garbage Grinder (N//a)7 ,z Other Type of Building i /�-O No.of Persons Showers( ) Cafeteria( ) Other Fixtures -7 Design'Flow(min.required) �`� gpd Design flow provided /"� /• 2 gpd Plan Date Number of sheets Revision Date Title r Size of Septic Tank �� �� } ! Type of S1.¢1�.S. � �'�G '�'� .d/ ��►�W pi JCS �� Description of Soil Nature of Repairs or Alterations(Answer when applicable) D. 3'O-' /U60 fc� � h�q_C /y5-ef-o Alefgdeel u�w Gvv cM Date last inspected: Agreement:— The undersigned agrees to ensure the co truction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title a Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this of Health. Signe Date Application Appro d by Date /Q ' Application Disapproved by: Date for the following reasons rr��l�' J Permit No. O��/ / "053 Date Issued Q 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 e reG, ^5 8 A Z. 5 j �N S at s3 (H/� O/L<Ue, 6l,Mm has been constructed in accordance with the provisions of e 5 and the for Disposal System Construckon Permit No. �/ —0-te-3 dated Installer ��Clit t 734,V 71-4 Designer -DolW C/9 #bedrooms -erl- Approved design flo7/.2 gpd The issuance of this ermit shall not be construed as a guarantee that the system willN nc0 designed. Date 3�t Ll� Inspector ram, 2 - -- ———---——— ———— ————— —— —— ————————— _ _ No. �`_ !� 1- G Fee ./00 THE COMMONWEALTH OF MASSACHUSETTS T { S PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS v s 3tgpogar 6pgterrY Co gtructton VerrrYtt Permission is hereby granted to Construct ( Repai ( Upgrade ( ) Abandon ( ) System located at -5 //At/ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.. Provided: Construction ust be completed within three years of the'date of this e . it. Date _3/ ! 6h/ Approved by f Town of Barnstable Barnstable A9-America�ty ti Regulatory Services Department � 1 • • OD • lARNISTABLE. b . ,0� Public Health Division �ATf°""AYA 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO ti Certified Mail # 7008 323000025178 2329 March 14, 2011 Clyde K. Hanyen P O Box 497 Orleans, MA 02662 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 53 Wingfoot Drive, Barnstable,MA was last inspected on 03/04/2011,by Reid C..Ellis, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: 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 distribution box is leveled or replaced. You are ordered to repair or replace the septic system within 2 Years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future. enforcement action. PER ORDER OF THE OARD OF HEALTH Thomas McKean, R.S., CHO ^ Agent of the Board of Health CERTIFIED MAIL# Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATEI.doc f Commonwealth of Massachusetts Title 5 Official Inspection Form File 19 Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 53 Wingfoot Drive,iCuaunaquid , MA 02675 �' ' Property Address. Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name information is required for GurnmaquW, MA 02675 MA every page. _��VoWnI 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 A. General Information I forms the (� computer, r,use 1. Inspector only the tab key to move your Reid C. Ellis cursor-do not Name of Inspector use the return key. Ellis Brothers Const. Company Name 23 Enterprise Road, P.O.Box 59 Company -o pany Address Yarmouth Port, MA 02675 'ed'0 Citylrown State Zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address andjthat 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(n` site<:) sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.34,.,0 of Title 5(310 CMR 15.000).The system: ❑ Passes conditionally Passes ❑ Fails N ❑ Needs Further Evaluation by the Local Approving Authority -r 1-91 Inspecto 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. tsins•0!JM Title 5 0ffidal Inspection Fom[Su mdace sewage Disposal system•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name information is required for Cummaquid,MA 02675 MA /Gf every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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: .r'g 2.liv 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", "non 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 efilation 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): Ohs•09/08 Title 5 Official Inspection Force Subsurface Sewage Disposal System-Page 2 of 17 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name information is Cumma uid, MA 02675 MA required for q 3/4'I every page. Cityrrown State Zip Code Date of inspection B. Certification (cont.) B) ystem 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): L� distribution box is leveled or replaced Y ❑ N ❑ ND(Explain below): i ❑ 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): . r C) Further Evaluation is Required b the Board of Health: El Conditions exist which require furt r evaluation by the Board of Health in order to determine if the system is failing to protect publ health, safety or the environment. 1. System will pass unless Boar I of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is nc t functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 0 feet of a surface water ❑ Cesspool or privy is within 0 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Tile 5 Official htspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wingfoot Drive, Cummaquid MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner owner's Name information required forte Cummaquid, MA 02675 MA ;3iwl►i every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) YHlftth 2. System will fail unless the Board of (and Public Water Supplier,if any) determines that the system is functioninE in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and sc il absorption system (SAS)and the SAS is within 100 feet of a surface water supply ortributar to a surface water supply. ❑ The system has a septic tank and S S and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S S and the SAS is within 50 feet of a private water supply well. - ❑ The system has a septic tank and SAS and U ie 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, rformed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of arr monia 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 ❑ 12( Backup of sewage into`facility or system component due to overloaded or clogged SAS or cesspool ❑ 13/ 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 t5irrs.091Q8 Title 5 orficial inspection Form:subsurface sewage Disposal system•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owners Name information is Cumma uid, MA 02675 MA JJ required for q ��� �1 every page. Cityrrown, State Zip Code Date of Inspection B. Certification (cont.) Yes Na ❑ 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.] ❑ M 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 thasm E) Large Systems: To be considered a largehe 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 feE t of a surface drinking water supply ❑ ❑ the system is within 200 feE t of a tributary to a surface drinking water supply ❑ ❑ the system is located in a n trogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped one 11 of a public water supply well If you have answered"yes"to any question in Se ion E the system is considered a significant threat, or answered"yes" in Section D above the large s stem has failed.The owner or operator of any large system considered a significant threat under S on E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. Th system owner should contact the appropriate regional office of the Department. t5hs.09= Title 5 Officd 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 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owners Name information for Cummaquid, MA 02675 MA 3f 4 every page. Cityrrow n State Zip Code Date of I�tition C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No VJ Pumping information was provided by the owner, occupant, or Board of Health ElWere 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, 6l din9 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): 7 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5irts•09/08 Title 5 Official Inspection Form:Subsurfaos Sewage Disposal System•Page 6 at 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wingfoot Drive, Cummaquid, MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name information required for re Cummaquid, MA 02675 MA q every page. Cityrrown. State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes Z No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 2 No Laundry system inspected? ❑ Yes No Seasonal use? _ ❑ Yes No 9 ( Y g (gpd)): " ..� .._._. Water meter readings, if available last 2 ears usage , f Detail Sump pump? ❑ Yes 534NO Last date of occupancy: f Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personstsq.ft,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 syste ? ❑ Yes ❑ No Water meter readings, if available: t5ins-t><= 'r e 5 official irspechon Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form UV5Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name information is required for Cummaquid, MA 02675 MA every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) eol Last date of occupancy/use: . Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? 0 ❑ Yes Er"No If yes,volume pumped: gallons AM J 'y Howwas quantity pumped determined? Reason for pumping: Type of yytem: 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/Altemative 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 1/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-o9m Title 5 Offidal Inspedion Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts_ UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wingfoot Drive, Cummaquid, MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name information is required for Cummaquid, MA 02675 MA 3 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed(if known)and source of information: a "/7o7t 71 �' � ."7�d�t-y'� .S (�Ii.� ��jl/7�O �/�ifjr'y� /spo,�I L hawks 'rasY-�,vw»'d Were sewage odors detected when arriving at the site? ❑ Yes /No Building Sewer(locate on site plan): �1_J ,�-way�o � d/��dre✓ 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.): Xrw C Septic Tank(locate on site plan): ; Depth below grade: feet Material of construction: �ncrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: W14-A years Is age confirmed by,a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: �e Sludge depth: t5ins•OW8 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 53 Wingfoot Drive, Cummaquid, MA 02675 Property Address Clyde K Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name r information is Cumma uid, MA 02675 MA 1 L-4 1 required for q every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) mil°f�L 7,- w.�s 4 f!3-—2-011 'P Distance from top of sludge to bottom of outlet tee or baffle Scum thickness C7 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle T 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.): T- � A W �> P Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal E I fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet t or baffle Distance from bottom of scum to bottom of o tlet tee or baffle Date of last pumping: Date i t5ins•09/08 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 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name inforequired forte Cummaquid, MA 02675 MA every page. Cityrrown- State Zip Code Date of Inspection D. System Information (cunt.) 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 pum�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 swit(hes,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•osroe ride 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wngfoot Drive, Cummaquid, MA 02675 Property Address Clyde K Hanyen-P.O.Box 497, Orleans, MA 02662 Owner Owner's Name information is Cumma uid, MA 02675 MA I �/ required for q every page. cityrrown. State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate n site plan): Depth of liquid level above outlet invert p q e 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.): /j Al s Aew -VZ Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chambe r, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: � � Ab4, Al 0irs•QTP@ TMA 5 0-RicJ k gn Fg-: aftc-9 a 9om!§y%@m-P@p 12 gf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K Hanyen-P.O.Sox 497, Orleans, MA 02662 Owner Owner's Name information is required for Cummaquid, MA 02675 MA every page. Cityrrown. State Zip Code Date of Inspection D. System Information (cont.) Type: [+� leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation etc):): ze- Cess ols(cesspool must be pumped as a o ins lion locate on site plan): Po ( P P P P �inspection)( P ) 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-091oll Title 5 Official Inspection Fonn:Subsurface Sewage Disposed System•Page 13 of 17 f Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Wingfoot Drive, Cummaquid, MA 02675 Property Address Clyde K Hanyen-P_O.Box 497, Orleans, MA 02662 Owner Owner's Name information is Cummaquid, MA 02675 MA 3/ i �) required for every page. Citylrown. State Zip code Date of Inspection D. System Information (cost.) 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 hydra ilic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 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 53 Wingfoot Drive, Cummaguid , MA 02675 Property Address Clyde K Hanyen-P.O.Box 497 Orleans, MA 02662 Owner Owners Name information is 4 required for Cumma uid, MA 02675 MA every page. Cityrrown State Zip Code Date of Inspection / D. System Information(cons) A v 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: M/hand-sketch in the area below ❑ drawing attached separately - ' 91tJanr AOU Ilk r�✓IAWV I t Ale Al m AW i• All 1-7 a�7 4P', i t5ins•0901 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f • \ Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497 Orleans, MA 02662 Owner Owner's Name j information is Cummaquid, MA 02675 MA �l911 required for every page. CitylTown State .Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Sloped ❑ Surface water /V ❑ 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 st describe how you established the high ground water elevation: d' .7A( Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ms.09M Title s official kispeclion Form:Subsurface Sewage Disposal Systern-Page 16 of 17 is • Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 53 Wingfoot Drive, Cummaquid , MA 02675 Property Address Clyde K. Hanyen-P.O.Box 497 Orleans MA 02662 Owner Owner's Name j information is Cummaquid, MA 02675 MA 3/41�l f required for every page. City/Town State Zip Code Date of Inspedion E. Re ort Completeness Checklist 7ifispection Summary:A, B, C, D, or E checked 1,0spection Summary D(System Failure Criteria Applicable to All Systems)completed stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-oc" Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 " ATION SEWAGE PERMIT NO. VILLAGE C:U H�l 4►6Jt110 � � �� v � '/�� I N S T A LLER'S NAME i ADDRESS QO 86-f-T 3 out. Co t iuc. M, !�A-¢.wI CA, 1A55. S U I L D E R OR OWNER �,l� 6Qc nau - Gc1 u t.t �ctyt p I't+e�t't'S, GrJN u<tQc��d, l✓l d DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Og� t50o'G`:Si'= fl pp V A t A- To TAM Ic A- To 40 x A- To PIT- 0 1 4Z' g- To PIT ' A\- ro PiT 4-v tj- ro f%T K Z - 27' W ► La C- FooT .DO-,vie THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH e *pfiration for Diiipoottl ork,i Tonotrurtion rrutit Appli tion is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: ✓✓ �`�` LO'T i -------------- ------------------------------------------------------------------------- Location --••••-•---- •-----...------------------------------------------------------------------------- Location-Address or Lot No. - C o� -'(LP._cTU 2 --•--------"' n� T------ a '°L� ^' w ---�- L�,c�U(Z-C�-'-----C�e' ftTresswFST�2N�n,�!o, /{A Instal er Address U Type of Building Size Lot---.�'SS �"'-.....sq. feej Dwelling—No. of Bedrooms............ ___________________________Expansion Attic ( ) Garbage Grinder (ice ) p, Other—Type of Building ____________________------ No. of persons...................._------- Showers ( ) — Cafeteria ( ) a-' Other fixtures --------••--------------•---- •............................ W Design Flow..................��...._._•--_.-__.--gallons per person per day. Total daily flow-----------3. X2______.-_____---__.---gallons. W Septic Tank—Liquid capacity_/_.5_gallons Length__......_.. Width____ --------- Diameter................ Depth___ -__-__. x Disposal Trench—No.•------------------ Width.................... Total Length.................... Total leaching area................----sq. ft. Seepage Pit No---------- Diameter.....1v........ Depth below inlet........6.......... Total leaching area_..-5- ---sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `-' Percolation Test Results Performed by..w wFccf � r_Ff�!+! K�: /'..... Date.... Z-3- v f--------------- a Test Pit No. I...... -._____minutes per inch Depth of Test Pit-----�_��__------ Depth to ground water...... Test Pit No. 2................minutes per inch Depth of Test Pit------/`/1.._. Depth to ground water___--------­--•-____•. -----------------------------------•---- --•-••. ••••--•---•------------------------------...-----......----•--••---------•------------•-•••--...---•-..... D Description of Soil--- 5 '. ---------•-------------------------------------------- i W -----------• ----------_--------------------------------------...................................................................................................................................... UNature of Repairs or Alterations—Answer when applicable.......................................................................................I........ ---------------------------•--•--•-•-•-•••••----••-••---•--••••-••••-••-•-••----•--••-•----•--••••••--•---•--•-.._.._..••••-•-••----•-•-•-----••------•-----------•-•-••-•••---•-•••••••---.._.._...•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance heeglued' by t oaro of health. 11ong --- -- --------------------- ----------------------- •-�... ... S3----DaApplication Approved By---••-•- •---•••-----••-•••-•••------•--•-••-•••••. - - �� ---`------------ Date Application Disapproved for theasons:---------•---------------------------------------------------------------------------------- - - ---------------------------•----•----------------------------------•---------------------------------------------------------------------------------------------------------------------------------- Date PermitNo----------------------------------------------------- Issued.................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... T-prrtifirtttr of (11.10m0anrr TH IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by....... - -- -•---•......---•-•.... ............. ••... --- Ins - at ---�----------- ------------- --------•---------�-----------------------------•--------------------•---•- ------------- has been installed in accordance with t ovisions of TI i' j of he,tate Sanitary C s ` ibed in the application for Disposal Works Cons -on Permit No.___. ___".._ 5.__..__.. dated_._ _ _ ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 13E CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ....................................................------------- Inspector................................................. --------------•------------------ THE COMMONWEALTH OF MASSACHUSETTS 1. BOARD OF HEALTH ......................` --'--_---------f\jOF.-....-....�`!` :!<.�10.S�..A.... .................. --- ApV irntinn for Diiipnstti lVarkri Tomitrnrtinn rprutil Application is hereby made for a Permit to Construct (X or Repair ( ) an Individual Sewage Disposal System at: L-CT 1 � l ................----....-...................................................................... --...•--•'••----"---•---•--'•-..._-------••---------•---------------........---•----------------- Location-Address or Lot No, �Z `T� 'N ~ C c T�ACTU CZ, w I, N�-� Gou T..........D-R A S r------------------------------ ---- p � �``'N ....6'�^ T................Address L _(!�.//+ p! ►lA^i"1�( ' Install Address _ dType of Building +� Size Lot--- __r _5______.....Sq. feet U Dwelling—No. of Bedrooms.__________.__________________________Expansion Attic ( ) Garbage Grinder �+ P4 Other—Type of Building ____________________________ No. of persons____._______________________ Showers ( ) — Cafeteria ( ) Q, Other fixtures -------------------------------- W Design Flow..................z"S__________________gallons per person per day. Total daily flow------------ v....................._gallons. a: Septic, Tank—Liquid capacity_,<< gallons Length----57......... Width....A........ Diameter________________ Depth___ ........ W Disposal Trench—No __________ Width _________________ Total Length .__ Total leaching area__ ___________sq. ft. x - Seepage Pit No-________�-_:___. Diameter ___/:Q:_______ Depth below"inlet = Total leaching area �3 ___sq. ft. Z Other Distribution box" ( ) Dosing tank ( )Percolation Test Results Performed ......................... Date__.!F15A�`-)---------------­ Test Pit No. 1______ ______minutes per inch Depth of TestPit_____ .. Depth to ground water...... LT. Test Pit No. 2................minutes per inch Depth of Test Pit-------�_Y_--____ Depth to ground water:__y�........ -••---•--•--•---•---•••--•----•---••----•--•-••-----------•-•-'•••-••-•---..._...--•-•••--------•-----------------•••------••--••--•----•-------------••••-- O Description of Soil ri/;/ii�,1' �------------- 4 •--.__4 G -r-/-1/;I-•--�--f �L-----•--------------•--------------------- s U ___-•-•...---•-•----•-- W -----•---------------------- ...............----•-------------_-•-- ----------•----------------•-----•-------•• ................................. -----------------------------------•---------- V Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------_............................ . ....................................--............................................:..................................................................................................................... Agreement: f The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with j the provisions of TITIZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has by t and o th. . n • Application Approved BY.................. ------------------------------------------------------------ l Date ;Application Disapproved for th of wing reasons______________________________________________________________ -•--------------••---------_. ------_...--- -------------•-------------------------------•---'------------------------------------------------------------------- ----------------------------------------------------------------------------- Date PermitNo--------------------------------------------------- - Issued------------------------------------------------------- Date 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tatifiratp of QW.111mphana TIP &ZO CERTIFY, That toe Individ al ewage isposal System constructed ( ) or Repaired ( ) Instl� at.................................................................. * r••-'--•- ----------- ---------------------------------------------------------------------------- - -- - -------•----------- has been installed in accordance witli f rovisions of TI 4of,6ef"te Sanitary s ` 'bed in the application for Disposal Works Construction Permit No.......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................................-------------------.....- Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .3 oF................................ ................................... No......................... FEE........................ 7ni��n Permission is !re _•--------------------•---- X__­ � r _,­ to Construct Indi e r sP9:,JtSystem atNo------- --------------- -----------------------•--••-••--------•--• .. ..-----------•.•.---- --..__. - = -.. _..•-•-•----- ' street as shown on the application for Disposal NVor1`s' nstruction Permit Nei `._____• Dated.......................................... ---------------- Board of Health DATE......... •-•-- `--•----•...._--•••-•'-- `. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r\ SECTION - SEWAGE' - SEPTIC TANK - - "D"BOX - - LEACH TOP OF FDN . (:�rJ ncavG Aug uwjy� .r•Q . (MSL) fo>� F+ c���-i.,,.c>r - °...t$ACH F��"i^9 /''�M►� ' 'PU+.CL w�Tl4 C.L,rs.AW "2"OF°re T ` G.OA�,'r�•@*. ayp...•b. -- � WASHED STONE - �1�-•1C COV fc.1Z?G 6�.Jk"�.' ! � f" f � �. \ � \ \ �J Zr ` V -•,. ---�___._.�_�°,f. _-- � J, [S°25+.o To U � Ir \S \\� \i S �c� \�^�,•`\\�w ` , > �\ N OUT- IN• ' j LT S ` OUT ti f, * • TICNK ELEV. ELEV. ELEV. Q�.4, /;,.o ' ELEV. ELEV. �'� - g C « �/ ` r WASHED STONE TEST HOLE LOG \\ 1 Alif TEST BY F-H.41ucKL_CY,•f>,1=. I thv�Pam`? � 3.0.to. r ♦. Gad r � J WITNESS TEST DATE '/ DESIGN 3 BEDROOM HOUSE T.H. # 1 43.E T.H. # 2 6yL Q�11 ELEV. �O" ELEV. NO t { f I \ DISPOSER P DISOSER L.o�,nej`• Sores, t..o,o. Ar PERC RATE MIN/IN. I '..�30 • J © �3t� >�6 V � . r lb � FLOW RATE 3 _-C_>(GAL./OAY ) 48 SEPTIC TANK rb• } wry �(h' 4�•Co RE&D SEPTIC TANK SIZE c � sTa,rM f 3 � �, / t 1 3et� LEACH FACILITY >b � f, C ) > SIDE WALL _ C (z s } r______ G/D. (>; w to �g.s S� BOTTOM ( G D. TOTAL Z& l •o = 54.4.`7 USE: T"``�' LEACHING \ WATER ENCOUNTERED NOTES: (UNLESS OTHERWISE NOTED) , L09 1. DATUM,(MSL)`TAKEN FROM._._ _ t `r�_____.QUADRANGLE MAPt, 2.MUNICIPAL WATER ( p�/ �� Uf �9•q "1,• �4, /' ___._-__'__-_-_'___-'•-•_-___'-'-"_-AVAILABLE ,��° --� �5�, " `��'' �"'_"."` •gall; 3. PIPE PITCH: Ik"PER FOOT 4. DESIGN LOADING FOR ALL PRECAST UNITS: AASHO - '1c> -44 y�-�: ARNE f 1 5. MIN-GROUND COVER OVER ALL SEWAGE FACILITIES: (1) FT. /CT ARNL �� ;p ` ,` 0. b "'—a—DISTANCE AS CERTIFIED 6. PIPE JOINTS SHALL BE MADE WATER TIGHT f<- H. l " , i - 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. oI;aLh r IA. <. r STATE ENVIRONMENTAL CODE TITLE 5 ,63Gi5 +F" I HEREBY CERTIFY THAT THE BUILDING SITE PLAN OWN ON THIS PLAN IS LOCATED ON THE ,y WINGFPc+T W�S'i"C GdaTE'�. WA 9 t,' ;u OND AS SHOWN HEREON&THAT IT OCUS: fiGIS1E�'�? y 6RM TO THE ZONING BY LAWS OF THE '\trU SUC{`1 r `•�. tr`. ( { (�F �c �tn�l►.�I,dc�ul17�aAin�3ttar'3L.0 t�1AS�. A R'f4� tr+55r«V�1! / . 'a r NSTRUCTED. DATE r REF: l"e>j 1�1 c4p►e e�►gineerin� PREPARED FOR:C:'711�4 1'-!�2-1'TTC": S i CIVIL ENGINEERS M LAND SURVEYORS ------------ C. _,EA t REG. LANDSURVEYOR CONTOURS (EXISTING) -'-'•'------- _*t?�..:i, i I�r � I�" a � (PROPOSED)-O-O-O-O- APPROVED DATE 'T• t. ,mouth& Orleans,MA SCALE •Maa�.. ..-+a► `- - DATE 4