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HomeMy WebLinkAbout0445 NYE ROAD - Health h' 445`:Nye Road ' {Centerville , ' x 0 Q�ACD �.1 ND � I a (Go) ® sMQ��UUN���LLG - r ✓k� IVA v ,6 Nl -u r�•_,s �� V n 1 Fv- "\p Q v , V Itf i f 1� !}I()pl•I l�I C���IU:IV� l try V vro li�� ! 1 q4 Nye, � ��Y1�,rvillQl, � I I I I 0 p a leas sr�U� m� _ 4D?� I i i f ') < Commonwealth of Massachusetts 89 -// 9 a C Title 5 Official Inspection Form .�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessmentsr ,.�_,�!✓ 445 Nye Rd 'aw 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 3-6-18 page. City/Town State Zip Code Date of Inspection:` IF3 i7n'M� 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 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 Eva t' the Local Approving Authority, 3-6-18 "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 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 l ow VS , Commonwealth of Massachusetts r :a=1 Title 5 Official Inspection Form i`-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �_J4!✓ 445 Nye 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 3-6-18 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: ® 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: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal`system-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s� 445 Nye 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 3-6-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of.Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 445 Nye Rd Property Address Bank Owned (Contact David Holt Q Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 3-6-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts :a Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 445 Nye 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 3-6-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts _+ f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Noffor Vol u nta ryAssessments 445 Nye Rd t J' 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 3-6-18 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 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form llA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;!a 445 Nye 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 3-6-18 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - :a=�l Title 5 Official Inspection Form f_ ' J. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 445 Nye Rd Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Centerville MA 02632 3-6-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): Pump chamber. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 445 Nye 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 3-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2006 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts .a=1 Title 5 Official Inspection Form f i> I.+ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 445 Nye Rd , y 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 3-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts as Title 5 Official Inspection Form ' ,�Ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 445 Nye Rd Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 3-6-18. page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts (p Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 445 Nye 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 3-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Good condition with water at working level and no sign of back-up from field. 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.): Pump chamber in good condition with pump and alarm tested. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 - Commonwealth of Massachusetts :a=1 Title 5 Official Inspection Form il-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 445 Nye Rd Property Address a Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 3-6-18 page. City/Town 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: 1-37'x20' ❑ 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 field in good working order with no sign of back-up into d-box or surrounding stone. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts ;I (.0 Title 5 Official Inspection Form ' :.,1� Subsurface Sewage Disposal System Form -Not for Vol u ntary'Assessments 445 Nye 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 3-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts la Title 5 Official Inspection Form rlS� � �'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. ;.,✓ 445 Nye Rd _ t J' Property Address Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Centerville MA 02632 3-6-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately _jb ack - � . i �,- ' 37 T ry •, Y 6 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts :aa r Title 5 Official Inspection Form Ins t i,•, p 'i-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i. !" 445 Nye 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 3-6-18 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: 6'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: Original design plans show groundwater at 6'. Leach field was raised to accommodate high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist:on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F 445 Nye 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 3-6-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth 14 /7 J 1 q of Massachusetts Title 5 Official Inspection Fora _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name / information is August 13, 2015 Centerville ✓ MA 02632 Au required for every g page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, RS use the return key. Name of Inspector Tech Rapid Response Company r� Company Name 155 George Ryder Road South Company Address Chatham MA 02633 City/Town State Zip Code 508 364-0894 1328 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: Z. Passes . ❑ Conditionally Passes ❑ Fails - ❑ Needs Further Evaluation by the Local Approving Authority �S August 13, 2015 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 .z. report to the appropriate regional office of the DEP.The original should be sent to the system owner CL. and copies sent to the buyer, if applicable, and the approving authority. c� ****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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is g required for every Centerville MA 02632 August 13, 2015 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: ® 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: Inspector's Notes==> The septic system described,herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4- 5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and 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. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with'a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 6 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is Centerville MA 02632 August 13, 2015 required for every g page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval'of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is required for every Centerville MA 02632 August 13, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal colifo_rm 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,critena 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 Yz day flow t5ins•3/13 Tire 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is required for every Centerville MA 02632 August 13, 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOTdue 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 ammohia 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—IW PA) or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Y I Commonwealth of Massachusetts = Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is Centerville MA 02632 August 13, 2015 required for every page. City/Town State Zip Code s Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �Y 445 Nye Road -Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is Centerville MA 02632 August 13, 2015 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information Description: A system sized for five bedrooms was installed by Arch Construction in 2006. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 155 gpd 9 ( Y 9 (gpd)): Detail: 2013:52,000 gallons 2014:61,000 gallons Sump pump? ❑ Yes ❑ No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is required for every Centerville MA 02632 August 13, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner Was system.pumped.as part of the.inspection? ,_ :.:, t+ -• 3 ❑. Yes ® No If yes,volume pumped: gallons' How was quantity pumped determined? Reason for pumping: Type of System: - - ® - Septic tank, distribution box, soil absorption system ❑ Single cesspool I ❑ 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): Pump chamber 151ns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Nye -M 5 e Road Assessor's Ma 148 Parcel 119 Y p Property Address Mary Lyons Owner Owner's Name information is August 13, 2015 Centerville MA 02632 Au required for every g page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and.source of information: Age: 8+years. Certificate of Compliance for a new system was issued 9/8/2006 (Permit#2006-387 at Health Department). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): - Depth below grade: 2 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: - 1 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: 10.5 x 5 x 6-1500 gallon Sludge depth: 4 in 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 s .. Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 445 Nye Road -Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is required for every Centerville MA 02632 August 13, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and tees appear structura►.,ly sound and functioning as intended. No evidence of leakage in,or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is Centerville MA 02632 August 13, 2015 required for every 9 page. City/Town. State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: El concrete ❑ metal El-fiberglass El-polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes . ❑ No Alarm level.- - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 151ns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 445 Nye Road -Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is required for every Centerville MA 02632 August 13, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet inverts 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.): Distribution box appears structurally sound with no evidence of leakage in or out. Few solids in sump. 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.): Pump Chamber appears structurally sound. Float switches and pump were observed to be operational. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 445 Nye Road -Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is August 13, 2015 Centerville MA 02632 Au required for every g page. City/Town 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: 1 -20x37.5ft ❑ 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.): No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching field stone and no standing effluent or effluent contact staining was observed in the stone or overlying soils. 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth ofMassachusetts� _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is required for every Centerville MA 02632 August 13, 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids, Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is Centerville MA 02632 August 13, 2015 required for every 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately a LOoC ATgOonNS P� —OF SEPTIC COMPONENTS �G —DISTANCES IN DECIMAL FEET �P A B 1 23 33 2 27.5 , 37 DISTRIBUTION 4 3 15 49 BOX 4 36 64.5 2 PUMP ' CHAMBER 3 1500 GALLON O SEPTIC TANK 1 A B THIS SKETCH IS BEST VIEWED IN EMS TWO . COLOR FORMAT D WELL L§NG 0 445 NOT TO SCALE z 3 199 Cif cc ¢ N 508364-0894 NYE ROAD 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 445 Nye Road-Assessor's Map 148 Parcel 119 Property Address Mary Lyons Owner Owner's Name information is required for every Centerville• MA 02632 August 13, 2015 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: 7 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: 9/112006 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: Approved design plan on file with the Board of Health shows bottom of system to be 5 feet above the adjusted high groundwater elevation. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 ICI P#Town of Barnstable. 3 Department of Regulatory Services 1 ' h Division Date l �i Pubhc.Healt 200 Main Street,Hyannis MN 02601 Date Scheduled 'Time' j Fee Pd. (�I ! i Soil Suitability Assessment for•Sewage D717�sal Witnessed By QS Performed By: i LOCATION & GENERAL INFORMATION Location Address .' �5 NYE R0AD Owner's Name />?/CA9>2 b,,l[Y .f E N Fr=AV J L LE Address Assessor's Map/P4rcel: ���/� I Engineer's Name 1). ���� NEW CONSTRj�nON REPAIR Telephone# eS0 F 3 G'Z- 2ct Z'Z- Land Use � 1 "�'r l Slopes(%) S Surface Stones U�F Distances from: Open Water Body?-UU it Possible Wet kea7?-00 ff Drinking Water Well Z-V U ft Drainage Way 74 �0 ft Property Line U ft Other ft` SKETCH:($treet name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Set ram• aS�c� I i i i i i i i Parent material(geologic) � pv "S I Depth to Bedrock Depth to Groundwater. Standing Water in Hole:' i_ Weeping from Pit Free Estimated Seasonal�jigh Groundwater 2FtPJvffN TIO FOR SEASO�' AL HIGH WATER TAIL-9 Method Used MM !U i N t/A In. �_ in. Depth to Sol]mottles; Depth db�served standing' obs.hole: P Depth toiweeping from side of obs.hole: i in. Groundwater dJuatment � Index Well# Reading Date:T_i _ Index Well levdl Act,fat'toC Adj.Oroundwater Level.— PERCOLATION TEST . Date 8 e co 7i'ilene l2 Observation I Time at 9" Hole# Time at G" Depth of Perc start Pre-soak Time.@ Z� Time(9"•0) End Pre-soak r C 9 Rate MmJlnch Site Suitability Assessment: Site Passed Site Failed; Additional Testing Needed(Y/N) Original.Public H01th Division Observation Hole Data To Be Completed on Back----- ***If percolajipn test is to be conducted within 100' of wetland,you must first notify the Barnstable C44servation Division at least one(1)weak prior to beginning- . • DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) A coam S" to IL4 s g 35 84�44 Mediam Sa. t 4 20 Lt_-- o R.7/v DEEP OBSERVATION HOLE LOG Hole# Y Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling' (Structure,Stones,Boulders. Consistencv.%Gravel) 36" a �,-get" C 1 l�lc�w�►-1 . 'a4 a,s DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cons iste vel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. it Flood Insurance Rate May: Above 500 year flood boundary No— Yes X_ Within 500 year boundary No X Yes Within 100 year flood boundary No x 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? --- e If not,what is the depth of naturally occurring per ioJ us material? r Certification Ace I certify that on I , ?/ (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required ' ing,expertise nd experience described in 3,10 CMR 15.017. / , Date Signature -�-- Q:\SEPI'ICVERCFORM.DOC Town Of Barnstable' Regulatory Services Thomas F.Geiler,Director 30z 1 Ti18$E. a Public Health Division . � Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form Date: (1 Q 6 Designer: ( �h i 19A !'"t Installer• A C-a�-V x 7- Address: . L / Address: dv k was issued a permit to install a (date) (installer) septic system at 4ql�) RdPCO based on a design drawn by (address) dated (designer) j certify that the septic system referenced above was installed substantiall according g to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank: -- -- I certify that the septic system referenced above was installed with major changes (i.e. greater-than 10' lateral relocation of the SAS or any vertica tion of any component of the septic system)but in accordance with State& Play revision or certified as-built by designer to follow. moo`' DARRI - ' o. 1 0 I 'taller's Signatu ) so/sTE�N �1�_) 4N1TAR\P (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNS ABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL, BOTH THIS FORM AND AS- BUILT CARD ARE RECETVEI?BY THE.92NSTABLE PTJBLIC HEALi`DIVISIOI�T. THANK YOU. Q:Healtb/Septic/DesignerCertification Form No.. �� c� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE.-MASSACHUSETTS s Zipphratiou for �Digdnl 6pztem Cottgtruction Permit Application for a Permit to Construct O Repair(-<Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. f Owner's Name,Address,and Tel.No. Assessor's Map/Parcel jzl l Installer's Name,Address,and el.No. Designer's Name,Address and Tel.No. Type of Building: _ Dwelling No.of Bedrooms S Lot Size ZAd-3 €� sq. ft. Garbage Grinder Other Type of Building ( No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �Z�; red)_ gpd Design flow provided SS gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank �S a a /s`o o �u N-,e Type of S.A.S. d X 3 7, ' r 4e l ✓( Description of Soil Nature of Repairs or Alterations(Answer when app icab 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 DDXd of Health. S' e Date �,7 �4,,j Application Approve by Date Application Disapprove Date for the following reasons Permit No. Date Issued No. . 0o Fee D THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNST/� LE MASSACHUSETTS Ts 2ppricatioi for MiqA4W. p!6tern Congtructfon Verna Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or3,ot No. / f Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 14.1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,q AeAY (, ..� sT UIn2/Z r r/ /"1 FY e'cL 5'b y 77S i 3u12 > 7 y 834-' OS/J Type of Building: Dwelling No.of Bedrooms Si Lot Size-2 0d.-S F_ sq.ft. Garbage Grinder`h;/ Other Type of Building ( t-r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 5 5� d gpd Design flow provided S`sT 5 gpd Plan Date 5 drC' Number of sheets Revision Date Title Size of Septic Tank �S'a o �l s'o o f u �/' Type of S.A.S. -2,d X 3 7, Description of Soil _ _ r Nature of Repairs or Alterations(Answer when applica Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this-Board of Health. -� -- r S'.gned. /z%i' Date Application Approved�y Date Application Disapproved-b� Date for the following reasons dq— Permit No. Date Issued 14 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 7 at �/ �/ /✓y E /C has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No 6 . �_ dated 4 . InstallerA07_< ice' Designer I E #bedrooms 5 Approved design flow, gpd The issuance of this permit shal not/be-conk ed as a guarantee that the system ill function as des igned. Date //� 1 In Inspector G --------------------------------------------- No. Fee / ®� T'hE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1i!5po.5ar i§p5tem Congtruction Permit Permission is hereby granted to Construct ( ) Repair (/vl Upgrade ( ) Abandon ( ) System located at and as described in the above Application for Disposal System Construction Permit.The a licant recognizes his/her duty to comply with Title 5 and the following local provisions or special con d`iti Provided: Construction must be completed within three years of the(,ate of this e :it. Date Approd by a r TOWN OF BARNSTABLE LOCATION SEWAGE 4ZeO VILLAGL'���/7�2/// B ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. C s� S G 7 773` SEPTIC.TANK CAPACITY/Sd O M /4 �4 LEACHING FACILITY:(type)41-1-4��G-e rrt (size)3 ��.�-/1��0 X,,6�< NO.OF BEDROOMS �S OWNER PERMIT DATE: / d 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 on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist ,,r within 300 feet of leaching facility) 4'L 6py- Feet FURNISHED BY GLG l� �/- 3 � c - l�ca. =o2 2, = �3� ` G r 0 0 G�- 0 �f� = l�G �r Purl' ,- /)G/ o g � `� �' TOWN€} �ARY�ISTABLE VI .AtiF� 0 e�'I � t,r `�� ASSESSOR' &LOT`L5��'-//9 7N5TALLER`S NAN ' Pjao NO S8M. C UNK CAPACITX' 37^. 6 LFACfIf�TG�ACI�i'd'g hype) � EtJiIDER OR OWi�R MAMDATE COivIPI:iANC1 DATE: Separation D stance'Between ". ater Maximum Adjusted CaoundwTable to the Bottom of Leactit ngFaGlity i~eee Pxivate Water Suppty;9eli andLeacl>3ng FaciitCy zany�rtIis east; ott atta ur aathrn?AD to ieasinrcg fatty) Feat Edge of Weti;and and'Leach�ng T�aaity(If any wetia�ds exist within 3( 'feet n IeacEEing facs�ityy P Feet Furnished by `' C� ,�k f � 3 - i h y - I- a3 ' 6 -1 - 33 ' a 7s" Q a- 37' Ate- 36 " LOCQTI N ' / SEWo,GE PERMIT UO. IMST&LL t./l e, ADDRESS BUILD 5 E` D E SS DATE PERNt1T ISSUED D ATE COMPLI &MCE ISSUED ; � �� I L0 \ w I I _ �d �19P F ASSESSORS MAP: 14$ p NOTES: . TEST HO, E LOGS 3 PARCEL : 1101 BUOYANCY CALCULATIONS 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH SOIL EVALUATOi'; •D. r' IZ5 �� THIS PLAN, 1"5 MAssACHusETTs TITLE V k TOWN OF FLOOD ZONE: (JO N 1��2.k� '-"'� t{ I�ros�LW aAu�ox xlo sic TANK, WITNESS �� 1.� BOARD OF HEALTH REGULATIONS. REFERENCE:(, (P?13�1 DATE: '� k N+ +Q, r ��'. B_D_�. A f j l l'a6'x 1.63'x 62.4= 6,713# 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLAT I N R%TE:_L'2M I"i IWAJ SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO GROUND COVER INSTALLATION.INSTALLATION.LrAiz--0,-7 V � 11'x6'x.75 x 120 - s,94o# �UrLt� �� Di1 TH- I , ,w1,0 " TH-2L-44•° EMPTY TANK 11,000# 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION � Tl k e1) CLOT (LA-A � o �✓!�( '-- „� LVA*W y ''I 4 DETERMINATION.ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE LpAA^ / GROUND COVER+EMPTY TANK>UPLIFT �0 �+�! G �b IOy14- /( �t� 3Tj 5,940+11,000 a li. > 713 IM .� LoAm► Ab• b 'r7• -- --_. BUOYANCY CHECK O.K. 1 IT °�-7� g a d' �-� ^'7���g PROPOSED 1500 OALiM PUMP C A1�tRER k 4) ALL PIPING TO BE C SCHEDULE 40 Q 1/8 -/ FOOT. (UNLESS 1�3,D SPECIFIED OTHERWISE) um m"IV 4 p LOCAT ION MAP ��fi•S� r 11scp/��, I _ _ -_ � C�Y, ''I ,4, Q LI � tj�Tltp ?-�� � 11'a 6'a 1.93'x 62.4= 7,949# S) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A BENCH MARK �N of MAs o S4- IL,T �' Slt✓T 3� GARBAGE DISPOSAL. GROUND COVER: . l l'x 6'x.75'x l20 = 5,940# o (Oy�/ � 1°YR7r 16) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) 9�z EL NAIL IN DRIVE y�•► I/)ANt v 0 9b`f tarn � ti , F rTANK 11s 000# MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON ELEVATION = 52.55 _ , BARNSTABLE GIS DATL IM II/►W I WA Meta I VM A BASE OF 6"OF CRUSHED STONE. s o. 1140 . �O `�✓ $ROO Z•SY`� (�-„ 2�6�_ GROUND COVER+EMPTY TANK>UPLIFT , (,EJ1�Ltt1 GrSTEa 4 3��d '�J o sy4o+11,000 - 1 �.. >7 7) ay- `nw, wi ec- umcwy i ge1Pt.�t�-- sgN1 AR�N ��f* CYw a 064n Cam' Fib p 1 JZ �. BWYANCYCHECKO.K s w �� � �I �w Ft-- 4i �ga � niub---- - ---__- emu;=gD�,_ SEPT C SYSTEM DES I GN �� N�+ t.� yrri 6e 1 I ��P � ��• �?,� FLOW ESTIMATE \� S W4( DROOMS AT I( GAL/DAY/BEDROOM - S�GAL/DAY ✓ Lz" Tb EL- 4z,o 0P, -Pf pf ''6, LAlE* htJb . O � O SEPT C TANK W1 UE_ftrJ fAPDlV,�/1 SOWZ 10 nIST0n L• 40 Atit- P EL.. AL/DAY x 2 DAYS USE 4j00 GALLON SEPT I C TANK—4EW of SO�t. SOIL ABSORPTION SYSTEM I o Pcl W6 - 0� Lx Wl vJ x LEdtl�N4 f-It !Z. _1Ja I TL-lrn�r�S-w��,J_1 f'f= Or P> AT.lhnll,� (zy ti x9 ♦ \O ). SIDE AREA: w� / ` BOTTOM AREA: 377• S x. W x 0.7q = 55S GPD ` SEPT ' C SYSTEM SECTION PUMP (RAMOE-9- tim �� Nam. T©f E� 2 7 Lo(..AnON n 1 LEA eke ` +qp t0'• !4M X EL-4�,Q +.q1- !r►sialt 21w�iske�t Sf*+ne 9 ' fr�►s BAc 4y•27 ti �{.S B� D BOX ¢�:70 47.46 our orl ��/Z" Double1150o GAL 4�. tf�•est 97.�� 4060 STD>v� 46.40 0 \ W SEPTIC TANK fz;y /tv 0ss) {----- 37.5'4 x ZD 50 Te C14 A-Al r3bZ 1 ��alll'l w� �h�~gsk AtZbSTF- yv E 4i-�D 1 I\ ---�•--- --- -------- 114 [� Io,, a�.�! ko% SITE AND SEIVA PLAN-4.100-OST (� 4 -2Z [ � SEWAGE a fls1 �.• _33 n• 4 m i9" m� � z f o�G—.�w,97 GN �`V"� LOCATION : 441� N�6 (ZDAriD Nd 43 q� �Gl rf J!L4-,G MA pVM P Gi1_A4W f9*�D �A c-7bt� 1r►M TtI 'r 3• pv m 11i c,E,%- '%A i " ore. E v*%- wl Q PREPARED FOR : DONS ! 5 .T► o(ZF4'wtc,. - - y*04 MER-c�u>eu t,Evr zr G°*'T Z'S -- & &FIST cONTUVR_ 2 -+ Ac., Lro i W $E? ,(�IRLvIr (• -o,rv� _PV_ __ _ 5� El.tc-TiRtCg�. pE� Am'r f,�ggUI ebb DARKEN M. MEYER, R.S. SCALE -- -- P.O. BOX 981 DATE: 2 ob PeoP Co�Tov� W EAST SANDWICH, MA 02537 DATE HEALTH AGENT Ph: (508) 362-2922