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HomeMy WebLinkAbout0149 SHEAFFER ROAD - Health r , 149 Shedff& Road."a Centerville A= 171 �060 11 IN UPC 17534 N2.2-15 COR KASTING8,UN it Commonwealth of Massachusetts /7 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a �M 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name ~ information is � required for CENTERVILLE MA 02632 7-7-16 every page. Cityrfown State Zip Code Date of Inspection ILPI IV Inspection results must be submitted on this form. Inspection forms may not be alterediin any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. D.A.BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 rw' Citylrown State Zip Code 508-420-4534 S14297 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 7-7-16 In ignature 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 OV4r'.S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 149 SHEAFFER RD Property Address TRAMMELL Owner Owners Name information is, required for CENTERVILLE MA 02632 7-7-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. FUTURE PERFORMANCE CAN NOT BE DETERMINED UNDER THE SAME OR INCREASED USE. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. Cityfrown 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): I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every 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 '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous-tWo weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not- available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts _MmW=v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO DESIGN PLAN SYSTEM CONSISTS OF A 1250 GALLON TANK D-BOX AND A 3 BEDROOM S.A.S 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 years usage (gpd)): Detail: 2014----------184 2015---------167GPD SYSTEM NOT DESIGNED FOR GARBAGE GRINDER Sump pump? ❑ Yes ❑ No Last date of occupancy: currently occupied 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 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: currently occupied part time Date Other(describe below): General Information Pumping Records: Source of information: pumped 12-28-15 by Ellis brothers per reciept Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 1250 gallons gallons How was quantity pumped determined? tank size 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every 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: 2008 per as-built card Were sewage odors detected when arriving at the site? ❑ Yes t�3 No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 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: 1250 gallon Sludge depth: light heaviest at inlet end t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness light/clumping Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank was pumped in dec of 2015. recommend pumping every 2-3 yrs for maintenance 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w„ 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. CitylTown 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 01. 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.): box level no leakage or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: although the as-built shows an observation port none were found where it was shown. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM s 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: -4 3050 infiltrators ❑ 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.): no observation ports were located so exact level of ponding was not determined. . 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every 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 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3113 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 �M 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every 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: greater than 5feet 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: 7-2016 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: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 149 SHEAFFER RD Property Address TRAMMELL Owner Owner's Name information is required for CENTERVILLE MA 02632 7-7-16 every 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I -;A 5 H cr-,i a 11 n S P a ou t i F o Er RT Subsumico Mmage Disr, SYFMEPNY�A= Mutl-100,P-IfUllar-Aw n y se!� rno ttn Ng Fll—llx�--ty—11411— is copied foo a4.- 04 site fuh 0 f Sr- cpjcposal,S us-Lom: PrQwde LA view ot the 9-wage ans vos all-sys?o-rn i-ml-john, at least two.Pern-.1pne-if rafrWerine-land-radks.sr benv In-lary'm bow du-:!all wells witr.ln 00,laaqf bo-w-M4M Vl-`A5I'Sl;Pz?ly ontem--Hie binkng Chfolk one,of the boxes bek-mi- 12 natnd-sfk�tcd-i in-the orea ho;ciw NLw v 6n CIV s9i k 1 y h: 1 j 6 Y ........... d 8 1 0 P Commonwealth of Massachusetts JAM Title 5 Official Inspection Form Subsurface Sewage Disposal/System Form - Not for Voluntary Assessments Property Address - Owner Owner's Name information is every //Q A �ctlo r wired for eve P? I,,V, `page. CIIy/Town State Zip Code DateofIn 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:forms Whe filling out n A. General Information on the computer, /r use only the tab Inspector: key to move your 1. cursor- not I M use the return key. Name of Inspector -77EC -- oh� �I Company Name �O Company Address City/Town /�,�`•_ State z0 g) Zip Code Telephone Num er / License Number B. Certification U, c0 I certify that I have personally inspected the sewage disposal system at this address and that the —1 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 16.000). The system: r�.r Ui- Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector' 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. t5ins•71I10 �/ f Tine 50fridal Inspection Form:Subsurf e Disposal System•Page 1 0!17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address S Owner Owners Name information is / Dot 6�� �� �o �� required for every � �Vf f page. City/Town State Zip Code Date f Insp ion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) Syste 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: I P `1'►C /a v► �r 1 G✓a S �-ea ��K oar cvH-er ho(4Se 44 �a� SeG �� See G�c' lvpP Ao% �UGo B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): l5ins•11/10 Title 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �n /',/ Owner Owners Name information is � J / required for every H 7�=1rV� / 'Q 1�L O� C �/ �0/// page. Cltyfrown State Zip Code Date of Ins ion B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(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•11/10 r11e 5 Vidal Inspection Form:Subsurface Sewage Disposal system•page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owners Name information is l required for every f" VV r e page. Clty/Towm State Zip Code Dat of Ins ction B. Certification (coot.) 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 15ins•11/10 Title 5 Official Inspection Form Subsurface sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every 30 page. Cltyfrown State Zip Code Date oynspecVon 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: ElL�J Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 2 Any portion of cesspool or privy is within 100 feet of a surface water supply or �/ tributary to a surface water supply. ElL'7 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. ❑ u 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 collforn 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 falls. 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. !sins-11/10 rlle 5 Official Inspection Forth:Subsurface Sewage Disposal system-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface SewageL,DisQposal System Form-Not for Voluntary �Assessments Z Property Address Owner Owner's Name /v! information is CQH ✓(/� 0�required for every page. Cityfrown State Zip Code Date offnspe4ion 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 ❑ L✓J 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? L�J ❑ Was the site inspected for signs of break out? Lf ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank nk 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: LJ ❑ Existing information. For example,a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Pan`.C is at issue approximation of distance is unacceptable)(310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): 7 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): �J t5ins•11110 rifle 5 Of(Iaal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Nameinformation is required for every � page. Citylrown State Zip Code Date of 1 pection D. System Information Description: / 000 G 4 CA Jet L�10&-I Soso s G' S�0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ET"-No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 0"No Laundry system inspected? ❑ Yes E No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes / o Last date of occupancy: 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-11110 TAIe 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is e 6Z / 3required for every -- � N 7�✓y�Ile � � a page. Cityrrown State Zip Code Date 9N Imp6ction D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: J Source of information: Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: 100� gallons _ How was quantity pumped determined? Reason for pumping: Type of S em: Septic tank, distribution box, soil absorption system ❑ Single cesspool Cl 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): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sena a ois g posal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l�4 fie,-✓-1,- Property Address Owner Owner's Name information is required for every p`^ ✓�� P 1'''G � �a' page. City/Town State Zip Code Date of nape n D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: a 00 T ;I I., I1, ©RL5 r 17 �L p(,V /Jo>e' Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material o construction: ast iron 40 PVC El other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): l/ Depth below grade: feet 37o Material onstruction: 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) p❑ Yes ❑ No Dimensions: ' O Sludge depth: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is eNrV` required for every page- City/Town State Zip Code Date At Insp lion D. System Information (cunt.) / n l"w!, �u �&rf ?o Ke�G r� L 2 Septic Tank(cont.) — Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 0 USie✓yc 0/ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): c i vvt I h/ 1)o 7L -14 rs 41 I 7..e, TGi.. �./ Gv►� des lh 00C/ (0�✓/ i0 Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Tine 5OfTcial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts -- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address / Owner Owner's Name information is Pv1 ✓f/6 �� ��/,C/ 0�3� // �o �/ required for every !L l page. City/Town State Zip Code Date f insp lion D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form T Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lz9 S� Property Address Owner Owner's Name information is ` vt p� G-? /30 required for every /� _ page. Cityrrown State Zip Code Date ot Inspedion D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 61o� LOtAe Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1�9 '- ea l4r- ej Property Address Owner Owners Name information is cey4Vv// AX OC-O� 3a // required for every page. City/Town State Zip Code Date of I spa on D. System Information (cont.) Type: �H� � �, S t/ ❑ leaching pits number. ❑ 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.): /—//ls G�7t�`1 ✓� G 4-7 (:5;?P4 CL � 0( 1!�4-r 07/— 47 ff - 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-11/10 Till@ 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not forVoluntary Assessments / / 92a7tr �d Property Address Owner Owners Name information is ) required for every CP'^T�yV�l� 0'`6 ZI 11 .T17 11 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.): t51ns•11/10 Tille 5 Official Insp ection Form:Subsurface Seviege Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l q9 54e"�'1�� /�"-C Property Address Owner Owner's Name information is required for every �H V' D oc 6 ZL // page. City/Town State Zip Code Date Ins lion 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 blic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately t=-,-o'1 1►�sP10c�t�, I 151ns-11/10 Title 5 Official Inspection Forth: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 rj Property Address Owner Owner's Name information is Piv" 1 required for every ✓V ��/� page. Cityrrown State Zip Code Date o nspe ion D. System Information (cont.) Site Exam: ❑ Check Slope ` �4 59. T ❑ Surface water ❑ Check cellar ❑ Shallow wells / / //0 F,stimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with loc oard of Health-explain: �S A4 4�s ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: vvl � ✓�,I� �� � �,Pr � G vJ Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-11/10 Title 5 Otnlcial Ins pection Porto:Subsurface Sewage Disposal System-Page 16 of 17 IL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form --Not for Voluntary Assessments l ( 7 SflPa� i� WC / Property Address Owner Owner's Name information is !� required for every P`� '�vi �// 0,21 370/// page. Cltylrown State Zip Code Date bf Ins ection E. []-'Inspection Completeness Checklist []/Inspection Summary:A, B, C, D, or E checked 62 'nspection Summary D(System Failure Criteria Applicable to All Systems)completed (a/system Information—Estimated depth to high groundwater IT/Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 11 j TOWN OF BARNSTABLE LGC ATION -Cff-C ooc&. SEWAGE # bo Sr Y'J<.A, e- VILLAGE ASSESSOR'S MAP & LOT !LJ INSTALLER'S NAME&PHONE NO. Sacs-51/0 T90'1 y SEPTIC TANK CAPACITY I()()! CA LEACHING FACILITY: (type) 3050 (size)3 3 X 1 iS X�- NQ OF BEDROOMS 3 BUILDER OR OWNER �u� PERMIT DATE: COMPLIANCE DATE: 3Z11?/D Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a 3A y5 _ 3g : = ( `A5 50- 39 J 2--� r Ap No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Apprtcation for Dtgpoal *p.tem Con0tructton Vermtt Application for a Permit to Construct( ) Repair(4 Upgrade( ) Abandon( ) ❑.Complete System ❑Individual Components Location Address or Lot No.s g0jA A PL4_ 4AvJ-A O er's Name,Address,and Tel o Assessor's Map/Parcel P () 0,3'7//C' low5 ��� Installer's+Name,Address,and Tel.No. �� �S� Designer's Name,Address and Tel.No. 1-I S 1 l yovU3 G 10 e MO 2 cl 0' ����/4 ae- 11 !/L+.f S #Y&-m I5 tq*� l 7`{- T8.7'-1��9- Type of Building: Dwelling No.of Bedrooms - Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building 3/ No.of Persons Showers( ) Cafeteria( ) Other Fixtures aa Design Flow(min.required) gpd Design flow provided 3✓® gpd Plan Date 7 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S.��� $[j Q[Nt5�l C CkpM,6,j" Description of Soil _ o.nA 4= 0 a:2,n—A-Q 57 S( Nature of Repairs or Alterations(Answer when applicable) P Date last inspected: Agreement: The undersigned aAtw_ehe c nstruction a ten nce of the afore described on-site sewage disposal system in accordance with the prov e E nmenta o nd not to place the system in operation until a Certificate of Compliance has been iss HeSi kt,) Date f/ 11167 Application Approved by Date C/ Application Disapproved by: Date for the following reasons Permit No. d� Date Issued Q f Vj4�\(y,•"ryf�'��y.(y' `�•e�y ia^, r- !•`' A'•,t.���r •r ;q ht Ary r �d� •� { No. .�/� .�� Fee • THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �II Zl'pprication for Miopo!5al 6potem Conotructtou Permit Application for a Permit to Construct( ) Repair(Vf Upgrade O Abandon O ❑.Complete System ❑Individual Components Location Address or Lot No. (�/ � Owner's Name,Address;and Tel. o; Assessor's Map/Parcel 1 P / O��1(� QS �/�"'r/' Sl�,n//J// {�T I �O 3 S �E,� led 'I Installer's Name,Address,and Tel.No. �dT�S� Designer's Name,Address and Tel.No. L-15 J4 L OoU$ F-C, 9-0 1 c 2 d A1*04 y ,� r� s , y ►,��5 wry-, '77-(- �87—I& 3� Type of Building: i ! Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building vx��_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures I Design Flow(min.required) gpd Design flow provided 330 gpd Plan Date /D Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S.('q� �$(� {�(h45�T C C.W7q-R.tlyelrlo Description of Soil o� (tom r�e� �� ,.,� — 57 41 t I • JI i Nature of Repairs or Alterations(Answer when applicable) P'l Amp S ` I f Date last inspected: i Agreement: ff The undersigned agrees tciens'ure the construction a � ten ce of the afore described on-site sewage,disposal system in Ii accordance with the provisions of Title/ a En '� mental ode nd not to place the system in operation until a Certificate of Compliance has been issue ar e Si ed A 7 Date Application Approved by 4 Date 0 i Application Disapproved by: , Date for the following reasons � Permit No. Date Issued —————————————————————————————— ——— —————, s.a`t• THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS i Certificate of (Compliance THIS IS TO CE FfY,that the On-site Sewage Disposal Syyst,,em Constructed (� Repaired (� ) Upgraded ` Abandoned( )by �t o- ��`�"2V C.-i I.(jam. at q has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. � Z—J dated I ' /l Installer R+� � $yI 1�iTl� f� Designer f) ju I #bedrooms Z Approved design flow gpd i The issuance of this permit shall not be cjon/strue as a guarantee that the system will1 fansf o -•esigned. `� / / q` Inspecto� j Date � �+ r �Po 17 1 No. Oro Fee /00——— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS i lwiopooar 6pztem Cow5truction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade Abandon ( ) System located at I and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction (t'bbe completed within three years of the date of this p Date f �'m s/ Approve by To*n of Barnstable .®f`"�t° ,o Regulatory Services Thomas F.Geiler,Director * anxxsrAsie, Public Health Division �i0'Fcnw�°, Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Designer Certification Form f, Date: �� /(i�� Sewage Permitff Assessor's Map\Parcel Designer: Installer• jZ Address: L `^�' y/knl:�115 f' C.T GL*--� Address: On /f /-o was issued a permit to install a (date) (installer) septic system at y eQ.�ker ?_C� based on a design drawn by (address) -- _- _ �•-�_� _1.,.aA t�,v — - --dated- -1.0.1 5 - (designer) _I 1 certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater th 10' lateral relocation of the SAS`or any vertical relocation of any component of the sep system) but in accordance with State&Local Regulations. Plan revision or cert' ed t by designer to follow. e�®Oe�N OF Mq S4 sp `off mo oe A nstaller's Signature) LiSE� G. `-4 _mom : 00 = L,ggS : `no tic 0143: t(Designer"sir a e) (Affix ��rr�� p'S @ p Here) �iio�►e PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION: CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTII. BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION THANK YOU Q:Health/Septic/Designer Certification Form 3-26-04.doc Town f Barnstable P# Department of Regulatory Services f� avwernet� MAM Public Health Division h�°� 200 Main Street,Hyannis MA 02601 Date Date Scheduled Time �flll ----- Fee Pd. . Soil Suitability ���'Assessment for Sewa e D' Performed By: g Disposal. Witnessed By: / LOCATION& GENERAL Location Address l�'7 S eh INFORMATION Owner's Name Address �>Assessor's Map/Parcel: 7 160 Engineer's Name j-�S/-� L�cr>`/S NEW CONSTRUCTION REPAIR Telephone# l 7�0 -Cf Z Land Use �0 Slopes Surface Stones Distances from: Open Water Body ft Possible Wet Area --�_ft Drinking Water Well --__ft Drainage Way----_ft Property Line —___ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands �n proximity to holes) Y r Parent material (geologic) Depth to Bedrock - Depth to Groundwater: Standing Water in Hole: �. Weeping from Pit FAce Estimated Seasonal High Groundwater c-,j D•-TK 'IIATA'I'ION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: a^-ln, Depth to soil mottles. Index Well# in, Groundwater Adjustment In. Reading Date: Index Well level ft. -a .� Add,factor Adj.CJroundwater 1ave'l m Observation PERCOLATION TEST Hole# 2 Time at 9" Depth of Perc V Time at 6" Start Pre-soak Time @ 0 ©0 End Pre-soak. Rate Min./Inch Site Suitability Assessment: Site Passed V'. � 1` Site,Failed: Additional Testing Needed(Y/N) Original: Public Health Division �-- Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one (1) week prior to beginning. Q:SEPTI0PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel 2-9-101 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.% ravel a L S 16'le- Z 32-18 MhS ?,-5y DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C nsiste c o Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consi ten ° ra Flood Insurance Rate Map: 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 aterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? _ Certification L I certify that on (date)I have passed the-soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. Signature Ala Date AE*k67 r Q:\SEPTIC�PERCFORM.DOC EXISTING 1000 GAL TANK DISTRIBUTION BOX INFILTRATOR 3050 CHAMBERS CROSS SECTION LOCUS PLAN ADD GAS BAFFLE NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE BM 100.0 97.7 MIN 2° 5LQPE OLD STAGE 7,7 r- COVER TO BE WITHR 7 6"OF GRADE * r I INSPECTION PORT TO BE WITHIN 6" OF GRADE n 4"SCR40P.V.C. 3"M JM MIN.9"COVER /4"-1 12"DOUBLE WASHED STONE ASHLEY m a"scx.ao P.v.c 3" 1/8"-1/2" WASHED STONE r- =o. =0.ot MQ1. existing 13" 3" a^sC0.40 1MN.0 OR FILTER FABRIC 94.9 \ ¢ ¢ 94,0 W 2.0 44 4.0 2 9 / 2 L7 , \ N 2 10.0 94.2 92.0 ti MIN rHisrLe 8.5'. 4 1.6'- 4.25'-- -1.6' 38 _G ' S HOLE 86.2' 7.5 SITE SPECIFIC NOTES DESIGN CALCULATIONS GENERAL NOTES M171 P6o ALL PIPING TO BE SCHEDULE 40 P.V.C. ADD GAS BAFFLE TO OUTLET TEE ON TANK EXISTING BEDROOMS 3 ® 110 G.P.D.= ALL LOCATIONS OF UTILITIES SHOWN ARE AS 0.34� acres FLOOR PLAN 330 G.P.D. MARKED BY DIG-SAFE AND ARE TO BE PIT MAY BE PUMPED AND FILLED OR REMOVED - - NOT TO SCALE VERIFIED BY INSTALLER PRIOR TO REMOVE ANY CONTAMINATED SOIL NO. of UNITS 4 CONSTRUCTION " DEPTH BELOW INV. 2' THERE ARE NO KNOWN WETLANDS WITHIN WIDTH 7.5' 150' OF THE PROPOSED LEACHING FACILITY UNLESS SHOWN. INSTALLER TO NOTIFY DESIGNER 24 HOURS PRIOR TO LENGTH 38' THERE ARE NO KNOWN POTABLE WELLS WITHIN BEGINNING OF JOB TO COORDINATE INSPECTIONS SIDEWALL AREA 182.0 SF 150' OF THE PROPOSED LEACHING FACILITY, F.,,� BOTTOM AREA 285.0 SF FIRST FLOOR TOTAL SQUARE FEET 467.0 SF WIT THERE 50EOFOTHE PROPOSWN ED LEACHING CAPACITY SIDEWALL 00.74 134.7 G.P.D. FACILITY CAPACITY BOTTOM 0 0.74 210.9 G.P.D. THIS PROPERTY DOES NOT FALL WITHIN A CAPACITY TOTAL 345.6 G.P.D. FLOOD ZONE AS SHOWN ON FIRM MAP THIS DESIGNTLE (( DOES NOT REQUIRE VARIANCES TO TTHIS SYSTEM NOT DESIGNED TO SUPPILEMENT3ALL REGULATIONS. BARNSTABLE DR ROO RAM ACCOMODATE A GARBAGE MALL CONSTRUCTION SHALL BE IN ACCORDANCE 100, DISPOSAL WITH TITLE 5 REGULATIONS.AND BARNSTABLE SUPPLEMENTAL IN-LINE ELEVATIONS PROPOSED AS-BUILT SURVEY INFORMATION Shed PROPERTY LINE DATA FROM KITCHEN DDJDdG BEDROOM BEDROOM INV. ® HOUSE (EXISTING)ROOM C INV INTO TANK 94.9 Bornstoble Survey Consulting 1971 INV OUT OF TANK 94.65 vegetable INV INTO D-BOX 99.15 PLAN TO BE USED FOR INSTALLATION Ve g FAMILY INV OUT OF D-BOX 98.99 OF SEPTIC SYSTEM ONLY ROOM OOM HOT INV INTO INFILTRATOR 98.9 NOT FOR DETERMINING PROPERTY LINES TUB BOTTOM OF INFILTRATOR 96.9 BENCH MARK F!?T'I'n,'.7 OF !%Rc HOIF_ `•c.2 _:_ _._.. �..._._ WATER TABLE NONE ENCOUNTERED CUR OF TOP STEP 100.0 (ASSUMED) LIVING} BEDROOM BATH ROOM DATE: OBSERVED BY: WITNESSED BY: SOIL LOGS OCT 2, 2007 LISA C. LYONS DONNA MORIANDI y� SOIL EVALUATOR BOARD OF HEALTH ELEV. OBS. HOLE #1DEPTH ELEV. OBS. HOLE #2DEPT 97.7 0„ 97.7 0" A LOAMY SAND A LOAMY SAND gazebo BENCHMARK SET 1 OYR 2/2 1 OYR 2/2 97.04 8" 96.95 9" LL) Right COr, top step B LOAMY SAND B LOAMY SAND LO deck N E(.=100,0 (AssumL-00 95.37 1 OYR 4/6 28" 95.04 10YR516 32" CV Ln C1 CI L0 X �-- MEDIUM/COURSE SANr MEDIUM SAND 48" 2.5Y 5/6 2.5Y 6/6 SAS DIMENSIONS 89.3 C2 MEDIUM SAND 101" 89.5 C2 98" MEDIUM SAND 2.5Y 6/3 2.5Y 6/3 #149 4 3050 CHAMBERS WITH END CAPS 86.2 138" 86.2 138" 1.6' STONE ON SIDES;4'STONE( N ENDS PERC RATE<2 MINS. INCH OVERALL DIMENSIONS: 7.:i X 38' paved drive PIT TO BE PUMPED P # 1 11967 30 perennial AND FILLED OR garden REMOVED pit 11' 10' i)[ MASS'.ys�, SEPT!C DESIGN PLAN 1 101 . �. T X X x�c ►� 11s� '�Ni c� PLAN SHOWING: 1 d�� !� r �p S � � PROPOSED SEPTIC SYSTEM REPAIR IN BARNSTABLE it 3: + FOR: DRAWN BY: LISA C. LYONS BRIAN SMITH DESIGNED & CHECKED BY: pa O•� ���� LISA C. LYONS S C \ iir�l,'rS p":I""••��,��`, *R.S. L149 SHEAFFER ROAD,CENTERVILLE ION REvrsloxs: DEscRiPT10N: DATE: LE 1 : 20 I11 111�'1 LOT#: DATE:SHEA�FER R4ADM><�P6o OCr,OBER S,200ISA 1 CERTIFY THAT THIS PLAN CONFORMS TO LISA C. L YO N S R . S (50$) 790-9270 TITLE 5 AND BARNSTABLE B.O.H. REGULATIONS HYANNIS, MASSACHUSETTS (774) 487-i638 (EXCLUDING WAIVERS SPECIFIED)