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HomeMy WebLinkAbout0055 HARBOR HILLS ROAD - Health 55 Harbor Hills Road Centerville l' A = 247 052 I li No. 4210 1/3 ORA Pendaflexe 10% i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd V� Property Address Marco Jr& Renee Bernasconi Owner Owner's Name / information is required for every Centerville ✓ MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road VQ Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 09/08/2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has an H-10 1500 gallon septic tank with an H-10 D-Box feeding 15 Biodiffusers H-20. At the time of inspection no visible failure criteria was found. Per owners request septic was pumped after the inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ , 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts ,P Title 5 Official Inspection Form <1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is r:,quired for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ® 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 water supply 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 custodymust be attached to this form.] ] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ !% 55 Harbor Hills Rd u— Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: .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 town water 9 ( Y 9 (gpd))� Detail: In 2019-18,000 gallons were used and in 2018-10,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Harbor Hills Rd V� Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Inspector Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Drivers estimate Reason for pumping: owners request t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments(on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts �v p Title 5 Official Inspection Form yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 55 Harbor Hills Rd V Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is Centerville MA 02632 09/03/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2'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: H-10 1500 gallon Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1" 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 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is Centerville MA 02632 09/03/2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form t�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U- 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 15 Biodiffusers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form +_ 110 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is Centerville MA 02632 09/03/2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ** As-Built from the BOH attached on next page** t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Assessing As-Built Cards https://townofbamstable.us/Departments/Assessing/Property Valu.. f TOWN OF BARNSTABLE LOCATION WAGE# VILLAGE ASSESSOR'S MAP&PARc, ^INS T NO. 1� � �`�NI y. SEMCTANKCAPACn'Y /�dD LEACIIINd FACILITY: NO.OF BEDROOMS At]tn/� d+4udl7ac,I� OWNER f K AA / AA L PERMfr DATE: COMPLIANCE DATE: SepaationDietoce the: Munn mt Adjusted Groundwater Table to the Bottom of Leaching Facility Fat Privme Water Supply Well and Leeching Facility(Ifeny walls exist on silo or within 200 feet ofleaehitig ficllity) Feet Edge of WW-d and Leaching Feeility(Ifany wetlands east within 300 feet of leaching facility) Feet FURNISHED BY a /4/ -3g A� - P,�,l - 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feetfeet 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: I augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts ry Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Marco Jr& Renee Bernasconi Owner Owner's Name information is required for every Centerville MA 02632 09/03/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION WWAGE#cw/— J. VILLAGE ASSESSOR'S MAP&PARCEI, INSTALLER' &iSi No— Coto SEPTIC TANK CAPACITY LEACHING FACILITY:(type) p size) NO.OF BEDROOMS r zv; I A ff'� OWNER e Ali, I tin PERMIT DATE: COMPLIANCE DATE: 7/1 Separation Distance Be Veen 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 �� ems" P 5' G Z _ C% ii 41 i Oro i i < .• mxv.. urn ._ J Town of Barnstable Barnstable Regulatory Services Department edcaCft BA ST" 11 MASS. Public Health Division s639• ♦ u 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70083230000251782213 1/10/2011 D Today Real Estate t,L1 c/o David Holt 1533 Falmouth Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 55 Harbor Hill Road, Centerville MA was last inspected on December 30, 2010, by Shawn McElroy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system"Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. You are ordered to repair or replace the septic system within Sixty(60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OFT.IDE BOARD OF HEALTH Pomas McKean,R.S., CHO Agent of the Board of Health i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evalu ion by the Local Approving Authority 12-30-10 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. P I � t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste •Page 1 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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 ❑ obstruction is removed t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 J i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (corgi ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 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. - t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 '/2 day flow ❑ ® 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. t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 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 ® ❑ 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 CM 15.302(5)] t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 8-2010 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Town--pumped 2000 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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): Cesspool overflowing into leach pit. Approximate age of all components, date installed (if known) and source of information: 1970's Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 24 feet Material of construction: ® cast iron ❑ 40 PVC Orangeburg ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 12 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: 6x6 block cesspool Sludge depth:. 12" Distance from top of sludge to bottom of outlet tee or baffle 40" Scum thickness 5 Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments µM 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Block cesspool acting as main tank with water not at operating level. 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: r Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gal ❑ 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.): Leach pit was filled to capacity at inspection with stain lines above inlet invert. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch 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. UDC" A t r � t5insp official document-03/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 15 I i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 55 Harbor Hills Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 12-30-10 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: 20 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 and town maps show groundwater at greater than 20'. t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BARNST LE OCA T ION �� arbor- 911 SEWAGE �- LAGtE �L ci/��l v u l e— ASSESSOR'S MAP 8c LOT STAf LER'S NAME&PHONE NO. EPTIC TANK CAPACITY CFlIl`1G FACILITY: (type) p!~�' (size) O.OF'BEDROOMS a BUILDER OR OWNER PE DATE- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (if any wells exist Feet on site or within 200 feet of teaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet gf leaching /+ Feet Furnished by C fit � '�e � O� � o A 0-39 ' Q _ 0 - y 9 , • I Town of BAIMStable P.# Department of Regulatory Services Public Health Division Date ernsa. i6 IL tee$ 200 Main Street Hyannis MA 02601 • ~rFD IM't�' Date Scheduled �,2 7 Time_�______ Fee Pd._� w . I . . i it ,Suitability Assessm'er�t fo - 1Sewc�ge D spos Z „< S h �1 Performed By: li�'�fl �'� Witnessed By: G i LOCATION & GENERAL INFORMATION Location AddresS Owners Name1°�O8V A4. r k4, ��,S -F A N `I I Address PX osoD¢3 ,�- Des 265-- 004 3 ngineer's Name 75 Assessor's Map/P4rcel: 7 QSZ PAV-9-04 M. M, NEW CONSIRU�'t,ON REPAIR Telephone# Soe 362 -Ili 7-2_ Land Use �7`( ' `��+�' Slopes(�o) Surface Stones 1 Distances from: Open Water Body > ft Possible Wee Area '>'2-Cr-�' ft Drinking Water Well � � ft i Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proxitnity to holes) • o, ✓ �OPK S74-02.20••E 100.00 0 \2 K R• 1-- 3 4k45 0° 0M 4233 ' `GRAVEL Ap \DRIVE O 0 9 �E�K /i \\�GPS\ \ fY r t, 1 .. E.'-,. w w o 413 /; SGF�42.94 wl. O N o f i� ; �. C.41 EI w U as ./ PO i O I I � 0 0 GEC'�0•• I a . e. 1-- oaK PP2q I I56}SF• Q to rasp. ports 0-0 41.1 pREP' 3 4 S74'02'20'E 100.00 1 „) Parent material(gedlAgic) 4.5 I Depth to Bedrock Depth to GrouudwaFer. Standing Water in Hole:' /V '�1 Weeping from Pit Face Estimated Seasonal i-Iigh Groundwater WA i DtTERMNATION FOR SEASONAL HIGH WATER T"LE Method Used: � . • i Depth �bperved standing in obs.hole: _ in. Depth td sgll M0tths: In. Depth tolweeping from side of obs.hole in. ©r0undwnter AdJustment it- Index Well# Reading Date: Index Well levdl .. Adj.f1etoC-^ Adj.fJraundwnter Level i PERCOLATION TEST Date Observation I I Time at 9" ir�L Hole# i Ft S Time at 6" Depth of Perc ' ® Time(9"-6") Start Pre-soak Time.0 b 1 I -- End Pre-soak Rate MinJInch Site Suitability Assessment: Site Passed � Site Failed Additi ;__ onal Testing Needed(YIN) - Original:.Public l,e'alth Division Observation Hole Data To B e Completed on Back---- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Cdnservation Diszsion at least one (1) wedk prior to beginning. r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders., Consistent %Gravel 14 DEEP OBSERVATION BOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel) AT DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistent %Gravel DEEP OBSERVATION HOLE LOG Hole# — Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consisten ra I .t Flood Insurance Rate May: Above 500 year flood boundary No Yes _ Within 500 year boundary No Yes. .- Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist.in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pelvious material? Certification I certify that on 0 (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performed by me consistent with the required raining,expertise and experience described in 3.10 CMR 15.017. C/`� Signature - - Date Q:ISEPTIC\PERCFORM.DOC No. v "l I— Fee /0-6)� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplitatlon for Disposal *pstrm Coneftuction i9ermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No % �� Owner's Namc.Address,and Tel.No. Assessor's Map/Parcel a Installer's me,�A dress,and Tel.N /� D si ner's Name Address and Tel.No 2�r2 E sv Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building J� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided�l gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank, /"' /,�j�� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)�� rY� 22j,n Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt Signed Date 0 �� Application Approved by Date Application Disapproved by Date for the following reasons L� Permit No. I - Date Issued /—3 f—I 9C)It c9� No. Fee �7 ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION'-TOWN OF BARNSTABLE, MASSACHUSETTS , Yes Y' 2pplitatlon for Disposal *pstem Construction 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 yob L' (��'j 7.-- t Installer's Name,Address,and Tel.No.�,U�///� �i17, Lp Designers Name,Address,and Tel.NO.57- �9�1K 6, Type of Building: OZ> DwellingNo.of Bedrooms V Lot Size r ?Z1 sq.ft. Garbage Grinder( ) Other Type of Building ,�S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) � � gpd Design flow provided f3�� gpd Plan Date Number of sheets Revision Date Title f Size of Septic Tank ggF- � Type of S.A.S. Description of Soil. i , Nature of Repairs or Alterations(Answer when applicable) '� I Date last inspected: t ~Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of A Compliance has been issued by this Board of Health. -� Signed Date �d Application Approved by .- Date Application Disapproved by Date for the following reasons Permit No. dw U Date Issued 31-1 --.---------------------------------------- f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(,/111" Upgraded( ) Abandoned( )by at _ r has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0 (" �ddated Installer Designer #bedrooms Approved design flow 3 3 U . gpd The issuance o thi permit shall not be construed as a guarantee that the system will no'orb s designed. Date Inspector z , �. ----------------------- -----------------_------------ ------------------- No. C) —0 1?C) Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. r Provided:Construction must be completed within three years of the date of this permit. r C Date ~ 3 1 Approved by < t Darren Meyer, R. S. 17815850293 p. 1 Town of BarnstableRegulatory Services Thomas F. Geiler,Director Public Health Division Thomas lV'IcKean, Director 200 Main Street, Hyannis,INIA 02601 Office: 508-862-464 4 Fax: 305-790-6304 Installer& Designer Certification Form Date: 1 Sewage Permit- Assessor's Map'Yarcel Designer: dnstaller: Gam"„' ,,�• Address: � 0X1 S r Address: / On gas issued a permit to Install a (date) (insta ler) septic system at S S �� PULI`, KV based on a design drawn by (address) v �,.I�r.1✓�, % ��� r dated (designer) X I certify that the septic systerr. referenced above was installed substantially accordin; to the design, which may incltede minor approved cha;ng�s such as lateral reiocation of rile distri3ution box andrgr septic tank. I certify that :he 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 comeonew of the septic system) but in accordance with State & Local Regulations_ Plan revision or certified zs-built by designer,o follow. / o DARR N M. R -� (Installer's Signatur N 1 0 CISI ? Cat/ �f�� MNITAR�A� (Designer's Signatur ) (Affix Designer's Stamp Here) PLEASE RETURN TO BA,R'VSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE B ARNSTABLE PUIILIC HEALTH DIVISIOy, THANK YOU. Q: Heal th/Sepric;Desigrmr Certification Eorrn 3-26-0,Pdoc .�41 MAP ECOJECH PARCEL , O52 Environmental LOT www.eco-tech.us THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 55 Harbor Hills Road _ West Hyae Owner's Name: Francis and Nancy Lane Owner's Address: 772 Neponsett Street Norwood,MA 02062 Date of Inspection: November 19,2003 NOV 2 6 2003 Name of Inspector: (Please Print) David D. Coughanowr,R.S. OF e.ARA,:TAB AL FH DE _r Company Name: Eco-Tech Environmental — — Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: (508)364-0894 CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000).The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature �. �`� Date: UDV 241 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority NOTES AND COMMENTS Inspector's Note=> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 V OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Harbor Hills Road West Hvannispon Owner: Francis and Nancy Lane Date of Inspection: November 19,2003 INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D: A] System Passes: Yes I have not found an information which indic ates Cates that any of the failure criteria described in 310 CMR 5.303 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. Answer yes,no, or not determined(Y,N,or ND). in the_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. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of Board of Health). broken pipe(s)are replaced obstruction is removed distribution box-is leveled or replaced. ND explain The system required pumping more than four 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 obstruction is removed ND explain 2 .� Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Harbor Hills Road West Hvannisport Owner: Francis and Nang Lane Date of Inspection: November 19,2003 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 and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)tbat 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 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form 3) OTHER 3 • _ I Page 4 of 11 U OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 55 Harbor Hills Road West H sport Owner: Francis and Nancy Lane Date of Inspection: November 19,2003 D)System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form) No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 1515.303,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 You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 H 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. 4 ' Page 5 of 11 Y OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 55 Harbor Hills Road West Hyannisport Owner: Francis and Nancy Lane Date of Inspection: November 19,2003 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? n/a _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? including Y _ Were all system components,exelti the SAS located on site? n/a Were the septic tank manholes uncovered,opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Y _ Was the facility owner(and occupants,if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: X Existing information.For example,Plan at the Board of Health. Y _ Determined in the field(if any of the failure criteria related to part C is at issue,approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 ' Page 6 of 11 �s OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 55 Harbor Hills Road West Hyannisport Owner: Francis and Nancy Lane Date of Inspection: November 19,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan on file at Health Dent. Number of current residents 2 Does the residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no):no :(If yes, separate inspection required) Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings,if available(last two year's usage(gpd): 41 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CMR 15.203):: gpd Basis of design flow(seats/persons/sgft/etc.): Grease trap present: (yes or no)_ Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no). Water meter readings,if available: Last date of occupancy/use:- OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System last pumped 3 years ago(Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: Septic tank,distribution box, soil absorption system X Single cesspool X Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternate technology. Attach a co of the current operation and maintenance on gy copy p contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe) APPROXIMATE AGE of all components,date installed(if known)and source of information: Age uncertain—no records were available at Health Dept. Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Harbor Hills Road West Hyannisport Owner: Francis and Nancy Lane Date of Inspection: November 19,2003 BUILDING SEWER_(Locate on site plan) Depth below grade: 2 ft Material of construction:—cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments:(on condition of joints,venting,evidence of leakage,etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK:none (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or battle: Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: none (locate on site plan) Depth below grade: 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: Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Harbor Hills Road West Hyannisport Owner: Francis and Nancy Lane Date of Inspection: November 19,2003 TIGHT OR HOLDING TANK: none (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/day Alarm present(yes or no):_ Alarm level:_ Alarm in working order(yes or no):_ Date of last pumping: Comments:(condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: none (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments:(note if box is level and distribution to outlets is equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.) PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 i Page 9 of 11 �Y OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Harbor Hills Road West Hyannisport Owner: Francis and Nancy Lane Date of Inspection: November 19,2003 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located,explain why: Type: _leaching pits,number_ _leaching chambers,number _leaching galleries,number _leaching trenches,number,length _leaching fields,number,dimensions X overflow cesspool, number 1 —innovative/alternate system Type/name of Technology Comments:(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Soils above overflow cesspool appeared unsaturated.No evidence of surface ponding breakout,lush vegetation, or other evidence of hydraulic failure was observed. Observation hole dug into cesspool stone showed no level of standing effluent. Stone was dry with no effluent contact staining. CESSPOOLS: Yes (cesspool must be pumped at time of inspection)(locate on site plan) Number and configuration: two in series—overflow cesspool is described in preceding section Depth-top of liquid to inlet invert: 8 inches Depth of solids layer: 1 inch Depth of scum layer: 3 inches Dimensions of cesspool: 6' x 6'approx. Materials of construction: concrete block Indication of groundwater inflow(yes or no): no Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Soils above primary cesspool appeared unsaturated.No evidence of surface ponding breakout lush vegetation, or other evidence of hydraulic failure was observed Outlet pipe was fitted with a tee PRIVY:none (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.): 9 a , n Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY AS SESSMENTS SSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Harbor Hills Road West Hyannisport Owner: Francis and Nand Date of Inspection: November 19,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100'(Locate where public water supply enters the building) OVERFLOW • CESSPOOL LOCATIONS A B PRIMARY 0 SPOOL 1 16 f t 16 f t 2 19.5 ft 35.5 ft DEGK 6 EXISTING DWELLING # 55 J Z J W H 3I HARBOR HILLS ROAD NOT TO SCALE 10 •Y Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 55 Harbor Hills Road West Hyannisport Owner: Francis and Nancy Lane Date of Inspection: November 19,2003 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 25+ feet Please indicate(check)all methods used to determine high ground water elevation: Obtained from system design plans on record-If checked.date of design plan reviewed 3/30/99 Observed Site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of health-explain: _ Checked local excavators,installers-attach documentation) X Accessed USGS database You must describe how you established the high ground water elevation. Town of Barnstable GIS Department records indicate that property is over 25 feet above the groundwater table. 11 i LEGEND W. HYANNISPORT Mq�N CONTOUR PINE STREET ® PROPOSED SPOT GRADE S�FFT ' cn I, -- 98 -- EXISTING CONTOUR LOCUS PARCEL ID: PROP. 1 ,50OG + 96.52 EXISTING SPOT GRADE H55 ILL ARBOR Op ROAD rn 247/57 SEPTIC TANK PARCEL ID: I. W- EXISTING WATER SERVICE 0 -247/53 TEST PIT S7 12" Gd.P OD 44$.50 12" 4 02'20„E OAK v OA O O / TBM: CDR. 100,p - tf CRAIG�LLE BEACH ROAD Mo O O 41.3 BLHD=42.33 n� SNE ! ONw� / LOCUS MAP / 12" cEss- OAK LOCUS INFORMATION � DECK ! _ PLAN REF: 103/127 O H-1 f i; �i 1. oR�� ` ``` 39.7 TITLE /295 39.68 P RCELE ID: MAP9247 PAR. 52 N / pp i i \� ``v_' O FLOOD ZONE: "C" 0 ,��i 41.3 f 1>82.�/%' /' GP,S \ `� Q COMMUNITY PANEL: 250001-0008-D DATED:7/2/92 T -2 PARCEL ID: z 4 _ #5 5 %' '�W �` 0 247/58 / �� h' SEPTIC SYSTEM �? c CESSf '-O i TOF=42.94 s' C IY1 AKA 8) W\, REPAIR PLAN C� LOCATED AT: J 55 HARBOR HILLS ROAD 41.0 ,asp 12'2 N o W. HYANNISPORT, MA. / Port, OAK co' a PREPARED FOR S74o2' 41.7 \\PARCEL ID: z �? MARK K. BUTLER 247/5.2 JANUARY 29, 2011 CIO 1 Q AREA- 7,496t S.F. i Q� 0.00 a i �- �� ��•�� OF Mgss9 PARCEL ID: I f � o D N ,r 247/51 40.3 ME 'R 0 No. 1140 'GENERAL NOTES: 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 8. L AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED SANITA TO R�a� 29 11 BOARD OF HEALTH AND THE DESIGN ENGINEER. TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPLICABLE THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING LOCAL RULES AND REGULATIONS. CONSTRUCTION. 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 10. EXISTING CESSPOOLS TO BE PUMPED, REMOVED, AND FILLED W/ CLEAN MED. SAND D A R R E N M. MEYER, R.S. TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION DESIGN ENGINEER. 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY P.O. B 0 X 9 81 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY FROM THOSE SHOWN HEREON SHALL BEREPORTED TO THE DESIGN ENGINEER BEFORE CONSTRUCTION CONTINUES. 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING EAST SANDWICH, M A. 02537 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 14. ALL PIPE TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPEC. OTHERWISE) 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 15. THE DESIGN OF THIS SYSTEM DOES NOT ALLOW THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF FOR THE USE OF A GARBAGE GRINDER (5 08)36 2-2 9 2 2 HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 16. NO WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. SHEET 1 OF 2 41297 r NOTE: TO PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:3834 FOR A DISTANCE OF 15' AROUND THE PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. T.O.F. EL.=42.94 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. Uf MAS . F.G. EL.=42.Ot F.G. EL.=41..3f F.G. EL: 41.30f F.G. EL: 41.30(MAX.) �DA�t E Ms9`y 9" MIN COVER/ No. 1140 L - 15'f 36" MAX COVER L = 20' L = 1O'(MAX) INSTALL TWO INSPECTION PORTS (MIN.) ® S=1% (MIN.) EL. 40.50 : 0 S=1% (MIN.) 0 S=1% (MIN.) Q 4'SCH40 PVC 4"SCH4io# 0 PVC 4"SCH40 PVC /51 10^ 74• a 11.27RT I'LLINVINV.=39.42 a8"uovro INV.= 39.17 LEVEL PROPOSED INV.=38.70GAS BAFFLE D-BOWS OF 5 UNITS"6i251'/UNIT5' WEDGE = 32.0'/ROW INV.=38.9 �_� INV.= 37.95 SOIL ABSORPTION SYSTEM (PROFILE) PROPOSED 1,500 GALLON SEPTIC TANK RESTORE VEGETATIVE COVER EXISTING SEWER OUTLET TO TO LL WITH CLEAN PERC SAND 75" ►{ ELEV. 39.78 _ TO TOP OF CHAMBERS NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING. PIPE INVERTS PRIOR TO CONSTRUCTION 2) TANK AND D-BOX SHALL BE SET LEVEL AND TRUE BREAKOUT=TOP ELEV.=38.34 ;,<• TO GRADE ON A MECHANICALL COMPACTED SIX INV. ELEV.= 37.95 INCH CRUSHED STONE BASE, AS SPECIFIED IN BOTTOM ELEV.= 37.01 WEIIIIIHEMMEM- EXISTING SUITABLE 310 CMR 15.221(2) 2.83' MATERIAL 3) INSTALL INLET & OUTLET TEES W/GAS 5',.MIN. ABOVE BOTTOM OF 76.. BAFFLE AS REQUIRED T.P. EXCAVATION OR G.W. EFFECTIVE WIDTH = 3 x 2.83' = 8.49' r� 4 CONTRACTOR MAY REPLACE PRECAST TANK WITH POLY (6.71' PROVIDED) USE 3 ROWS OF 5 16"-HIGH CAPACITY PROFILE ADJ. GROUNDWATER EL:=30.30 -=- ADS BIODIFFUSER UNITS-NO STONE TANK, MUST MEET 310 CMR 15.226 (2)(c). _ W/CONTOURED WEDGE' SEPTIC SYSTEM PROFILE TYPICAL SECTION 16° N.T.S. N.T.& 11.2" DESIGN CRITERIA SOIL LOG P#: 13186 NUMBER OF BEDROOMS: 2 BEDROOMS EXISTING/3 BR DESIGN ( ) DATE: JANUARY 27, 2011 r 34" ►1 SOIL TEXTURAL CLASS: CLASS 1 "0 i_ 3 SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE #1614 SECTION END CAP DESIGN PERCOLATION RATE: <2 MIN/IN WITNESS: DAVID STANTON, BARNSTABLE BOH DAILY FLOW: 330 G.P.D. Elev. TP-1 Depth Elev. TP-2 Depth 16"" HIGH CAPACITY (H-20) BIODIFFUSER UNIT DESIGN FLOW: 330 G.P.D. 41.30 0" 41.50 0" A LOAMY SAND A LOAMY SAND MODEL 16" HICAP GARBAGE GRINDER: NO (NOT DESIGNED FOR GARBAGE GRINDER)PROPOSED SEPTIC TANK: USE PROPOSED 1,500 GALLON CAPACITY 40.30 B 1DYR 3/2 LENGTH 76 1DYR 3/2 „ 40.58 11" r, NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT 12" B TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY LOAMY SAND LOAMY SAND EFFECTIVE LENGTH 75 LEACHING AREA REQUIRED: (330) = 445.94 S.F. IOYR 6/8 1OYR 6/8 SIDE WALL HEIGHT 11.2" DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. .74 37.97 C 40" 38.17 C 40' OVERALL HEIGHT 16' DISTRIBUTION BOX: DB-3 (3 OUTLETS (MINIMUM)) OVERALL WIDTH 34"' 4640 TRUEMAN BLVD PRIMARY S.A.S. 13.6 CF HILLIARD, OHIO 4JO26 �� PERC O 36.50 MEDIUM SANG MEDIUM SAND CAPACITY USE 3 ROWS OF 5 - 16 ADS BIODIFFUSER H-20 UNITS-NO STONE 2,5Y 7/4 2.5Y 7/4 (101.7 GAL) ADVANCED DRAINAGE SYSTEMS, INC. AND EXTENDED WITH 0.75' W/ CONTOURED WEDGE BOTTOM AREA: (GENERAL USE APPROVAL FOR 4.73 SF/LF OF BIODIFFUSER) PROPOSED SEPTIC SYSTEM SITE PLAN (BIODIFFUSERS) 15 UNITS x 6.25 LF x 4.73 SF/LF = 443.43 SF 30.30 136" 30.50 132" 55 HARBOR HILLS ROAD, CENTERVILLE, MA (WEDGES) 3 UNITS x 0.75 LF x 4.73 SF/LF = 10.64 SF Prepared for: Mike Dedecco TOTAL AREA = 454.07 SF PERC RATE <2'MIN/IN. ("Cl" HORIZON) DESIGN FLOW PROVIDED: 0.74GPD/SF(454.07SF) = 336.01 GPD > 330 GPD req'd NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE DRAWN e DARRENM.MEYER,R.S. Boo-Tech Environmental NTS D.M.M. • I, Darren M. Meyer, R.S., CSE, hereby certify that 1 am currently approved by MADEP pursuant to 310 CMR 15.017 PO BOX981 (508) 364-0894 to conduct soil evaluations and that the above analysis has been performed by me consistent with the DATE: CHECKED SHEET NO. EAST SANOW/CH,MA 02537 requirements of 310 CUR 15.017. I further certify that I have passed the Soil Eval. Exam in October, 1999. 508-382 2922 01/29/1 1 D.M.M. 2 Of 2