HomeMy WebLinkAbout0178 ARROWHEAD DRIVE - Health 1178 Arrowhead:
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TOWN OF BARNSTABLE
LOCATION l7,f 14/?,J0u/fl&540' SEWAGE #
YII,LAGE v>S,, W4, ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS a'
BUILDER OR OWNER Dv 1--le
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
4
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
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VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1 SO 0
LEACHING FACILITY: (size)
NO.OF BEDROOMS
OWNER gNi14
PERMIT DATE: . COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Welland 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 CGi!��' l�,r' 4,414/LO'e.
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t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 178 ARROWHEAD RD =Y
Property Address �.
PENNA
Owner Owner's Name
information is /
required for HYANNIS V MA 02601 8-15-16t`
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information (�
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
City/Town 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. 1 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 Evaluation by the Local Approving Authority
8-15-16
spector's ftnature 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
�V Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. CitylTown 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 ONLY A LITTLE OVER 2 YRS OLD AND MEETS ALL PASSING REQUIREMENTS.
I
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
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS ' MA 02601 8-15-16
every 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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 178 ARROWHEAD RD
Property Address '
PENNA
Owner Owners Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
i
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® 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
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less "
than '/z day flow
t5ins•3/13 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
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is 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
El E] Area
system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with.310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Citylrown 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
El ® 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): 2 -,
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is HYANNIS MA 02601 8-15-16
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 2 500 GALLON CHAMBERS WITH 4
FT OF STONE IN A 25X13 FT AREA.
Number of current residents:
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
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
2014--------------273 2015--------208GPD
Sump pump? ❑ Yes ❑ No
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•31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information .(cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
.gallons
i
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 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
178 ARROWHEAD RD
Property Address
PENNA
Owner Owners Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
4-2-2014 PER AS-BUILT
I
Were sewage odors detected when arriving at the site? ❑ Yes ® 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: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 GALLON
Sludge depth: LIGHT
t5ins•3/13 Title 5 Official Inspection Forth: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
M 178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityrrown 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
Scum thickness LIGHT
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.):
PUMPING UPON TRANSFER AND RECOMMEND PUMPING EVERY 3 YRS FOR
MAINTENANCE.
I
Grease Trap(locate on site plan):
i 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
f _ 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
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA. 02601 8-15-16
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
I
Material of construction:
I
❑ 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? El Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
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:
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 117
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 178 ARROWHEADRD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
i .
❑ 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.):
CHAMBERS WERE EMPTY AT TIME OF INSPECTION WITH ONLY DAMP 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 'r
Materials of construction
iIndication of groundwater inflow ❑ Yes ❑ No
- t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17"
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityrrown 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.):
I
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.):
l5ins•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
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Citylrown 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•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
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityfrown 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: NONE ENCOUNTERED DURING
PERC
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
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
4.
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
178 ARROWHEAD RD
Property Address
PENNA
Owner Owner's Name
information is required for HYANNIS MA 02601 8-15-16
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 .
I
TOWN OF BARNSTABLE
LOCATION /�2 j4 rr.0W h C-,yo/ Dr►Vlr SEWAGE# 090
VILLAGE HGfsar1ni!; ASSESSOR'S MAP&PARCEL 2 70-IY9
INSTALLER'S NAME&PHONE NO. s'o8-y2a-973��os=;,r✓��� ���^oS
SEPTIC TANK CAPACITY /SO o 6,e
LEACHING FACILITY:(type) 2-
NO.OF BEDROOMS
OWNERa/,f )Oex//Vq
PERMIT DATE: - 3/ / COMPLIANCE DATE: - /zY
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 BYso-e,
7.
rock
D -
Fee
No.
�
THE COMMONWEALTH OF MASSACHUSETTS Entered in co puler:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
4plication for Misposai 6psteni Construction permit
Application for a Permit to Construct(1,)/Repair((,)�[lpgrade( ) Abandon( ) ❑Complete System ❑Individual•Components
Location Address or Lot No./ZC A9Aj10UJH 0#4Cj O/'IVF Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 270•
Installer' 'ame, ddress� jd Tel.-No. Designer's Narpe,Address,and Tel.No.5,P*-YGp
��i�'J�1& -f/� r►�r_yr-r t',Sons
>�Igor
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(' )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title '
Size of Septic Tank Type of S.A.S. �I
Description of Soil
Nature of Repairs f or Alterations(Answer when applicable)ZNq g�� JeS�O�p ,$'i-;st�Tjl_ r/.�hk �—[ie A
6w/ LFI94e ef"&rS L�/i7,� !Y � raw.,= 'y'-D!/N�f
0
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 's Board of Health.
Date
Application Approved by 0 Date
Application Disapproved by Date
for the following reasons —
df -
Permit No. Date Issued
��
"lilt '
•t
No. =^iwwI Fee
_THE-COMMONWEALTH OF MASSACHUSETTS Entereduico puler: Yes
PUBLIC HEALTH D ISION -JO�WNaOF BARNSTABLE, MASSACHUSETTS
ftplitatio for- isposd pstem (Construction Permit
Application for a Permit to Construct(4),-Repair(6)iUpgrade( ) Abandon( ) E:1 Complete System ❑Individual Components
Location Address or Lot No./78 1;1 A%2vu/! vz Owner's Name,Address,and Tel.No. i
Assessor's Map/Parcel Z 70-/y ri A: ~ n
,-),=
Installer's ame,Address tAndTel..No. Designer's Name,Address,and Tel.No.S'jG 3 6 - I1 T 2
Type of Building:
h
Dwelling No.of Bedrooms r=x'i T: Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ),Cafeteria( )
Other Fixtures
r Design Flow(min.required) gpd. =Design,flow providedl gpd
Plan Date Number of sheets r'' Revision Date
` Title s
,.i s
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)�Li
'2 5"Gil
�} Date last inspected:
r;
Agreement:
r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in,
r accordance with the provisions.of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of f
Compliance has been issued by t is,Board of Health.
rie / Date
Application Approved by Date
-' Application Disapproved by Date
for the following reasons
4 Permit No. Date Issued - �//=
v
- - ------------------------------------ ----------------------------------- -- - ------------- ------- ---_- --- - - =�= r ------
T14 E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance N �
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(e—) ' ' Repaired Upgraded( )
Abandoned( )by
at ?T,,ri Nu /lvl i S has been constructed in acc ance
with the provisions of Title 5 and the for Disposal System Construction Permit No dated
Installer,/, s, Designer A44F d
#bedrooms-9 "r /3 r Grip o (? =_S/G k Approved design flow f gpd -y
The issuance of this permit shall of be construed as a guarantee that the system ilction as designed. / c' IMM4
C
Date Inspector if /
r 4V
No. v1( ��l / �. Fee /-- -V�1t�J�
1.� THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal *pstem Construction Permit.
Permission is hereby granted to Construct Repair( t:4 Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Constructtion must be •ompleted within three years,of the date of this permit.
Date ^A roved b 1 r��
PP Y
, J t �
i
Town of Barnstable
IHEE o Regulatory Services
Richard V. Scali,Interim Director
• sniuvsrnsce.
MASS. Public Health Division
'Eorrta�° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form '1
Date: Sewage Permit# I1/ly-�ag
Assessor's Map\Parcel) ?) �7
Designer: Me L4p r 4 � Installer:
Address: �� ,( l �, Address: 77
On was issued a permit to install a
(date) (installer) (`� f L
septic system at ( 4 f0��C, �LJ 2. rl"�i'�'��based on a design drawn by
(address)
dated
;1V;P
(designer)
I 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. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State &Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed in compliance with the terms
of the AA approval letters (if applicable)
OF
0A 7E + y
( taller's Signature)
No. 1140
� �a�
V � SqN rr
esigner's Signature) I TAR I)
PLEASE RETURN TO BARN ABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
i .
i
. I
Town of B AiMstable P#
of
� Department of Regulatory Services
�AHLZ. , Public Health Division Date
t6 q. tee$ 200 Main Street;Hyannis MA 02601
)
Date Scheduled � - - Time Fee Pd.
I
Soil Suitability Assess ken' t for Se wa / Dis os
Performed By: /� ;� ✓� ` Q� ` Witnessed By:
i
LOCATION & GENERAL INFORMATION
Location Address 0 v�Tl Owner's Name V��,.jn(r VE Pi t I A
01 A I Address a�"•v
Assessor's Map/P4rcel: y I Engineer's NatneI
NEWCONSIRUt.EION REPAIR Telephone# Sot 360 —330
Land Use Ke S i to Ei, T)hl— Slopes(40) ® �- Surface stones
Distances from: Open Water Body �2 0 ft Possible Wet Area ?Z,®0 ft Drinking Water Well
i
Drainage Way j ft Property Line ft Other ft
' ' I
SKETCH:(street name,dimensiods of lot,exact locations of test holes.&perc tests,locate wetlands in proximity to holes)
C:>
M :v Z10
i
:'?
A CZ
A-V
' I
i
i .
i
Parent material(geologic) '� G ►� ' r v Depth to Bedrock q�
Depth to Groundwater. Standing Water in Hole:' i Weeping from PIt Face R� 1�
Estimated Seasonal1jigh Groundwater !
D&ERMNATION FOR SEASONAL HIGH WATER T"LE
Method Used:
in. Depth to soft;.tottlra: Jn.
Depth obperved standing in obs.hole: I in, groundwater Ad)usttnent
Depth toiweeping from side of obs.hole:
1 ! Adj.factor.�,._� Adj.Oroundwaterlevel,,e
Index Well#� Reading Date index Well level
' I
PERCOLATION TOT Date TIML
Observation I Time at 9"
Hole# ! ��
Time at G" .�-.----
• Depth of Pere '
Time(9"-6"
Start Pre-soak Time.@ _ )
End Pre-soak -J —
��Rate MinJlnch �
Site Failed:
Site Suitability Assessment: Site Passed Additional Testing Needed(YIN)
•
Original:.Public Hce lth Division Observation Hole Data To Be Completed on Back—
***If percolaOn test is to be conducted within 100' of wetland,:you must first notify the
Barnstable C44servation Division at least one (1)week prior to beginning.
1
DEEP OBSERVATION HOLE LOG Hole# _
Depth from Soil Horizon Soil Texture . Soil Color Soil Other
.Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel
'�- 13S 61
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel)
DEEP OBSERVATION HOLE LOG Hole# q JAL
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel
a
DEEP OBSERVATION HOLE LOG Hole# N
Depth from Soil Horizon Soil Texture Soil Color Soil Other
I
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. ra I
I
t
i
jFlood Insurance Rate Map: /
Above 500 year flood boundary No_/ _Yes
V
Within 500 year boundary Nc Yes,
Within 100 year flood boundary No— Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring per ous material?
Certification C�
I certify that on (date)I have passed the soil evaluator examination approved by the
Department of EnvironrAental Protection and that the above analysis was performed by me consistent with
the require tr 'ni ,�expertnd experience described in 3:10 CMR 15.017.
Signature Date �+
Q:\SEPTICVERCFORM.DOC
?ME T
Town of Barnstable Barn
Regulatory Services Department j
ftC
IIA LE MA-M I
6'9. ,0 Public Health Division
�FODA°�A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2851 0725 '
September 30, 2013 ��7 713
Mr. & Mrs. Jerome Penna
178 Arrowhead Drivev7 P
Hyannis, MA 02648
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 178 Arrowhead Drive, Hyannis, MA was inspected on
9/06/2013, by Mike Hudson, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system needed further evaluation
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:.
• System is in hydraulic failure
You are ordered to repair/replace the septic system within sixty (60) days from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
i
as Mcn, R.S., CHO Kea
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\178 Arrowhead Dr Hy Sept 26 2013.doc
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
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 A. General Information
filling out forms
on the computer, V I
use only the tab 1. Inspector:
key to move your
cursor-do not Mike Hudson
use the return
� key. Name of Inspector
Septic-wiz Environmental Services
_�I Company Name
31 Midway Dr
Company Address
Centerville MA 02632
City/rows State Zip Code
508-367-5669 DEP SI#4254
Telephone Number License Number
B. Certification
1 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 Evaluation by the Local Approving Authority
09/09/13
Insp , or's Si u Date
The system inspector shall submit a copy of this inspection report to the Approving'Authority(Beard
of Health or DEP)within 30 days of completing this inspection. If the system is a Ettad systenrgr
has a design flow of 10,000 gpd or greater,the inspector and the system owner s as I'llsubmit theme
report to the appropriate regional office of the DEP.The original should be sent toUhhe system o vger O
and copies sent to the buyer, if applicable, and the approving authority. �n
Ay, �
****This report only describes conditions at the time of inspection and under the conditions of�tse
at that time.This inspection does not address how the system will perform in the future antler C
the same or different conditions of use.
CD r"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sevrage Disposal System-Page 1 of V
I 2
Print Scalloped Potatoes Recipe -Food.com- 85629 httD://www.food.com/reciDeDrint.do?rid=85629
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
Property Address '
Ruth Penna
Owner Owner's Name
information
required for every Hyannis MA 02601 09/06/13
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:
I
❑ 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
B) System Conditionally Passes: w
❑ 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):
2 of 4 04/24/2011 01:38 PM
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
178 Arrowhead Dr
Property Address -
Ruth Penna
Owner Owner's Name
information is H annis MA 02601 09/06/13
required for every y
page. Cityrrown 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
15ins•3/13 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
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
page. Citylrown 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:
i
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-3/13 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
, 178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
Page_ Cityrrown 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.
❑ (0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
�. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
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): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
�. Commonwealth of Massachusetts
Up Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
-
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
page. Cityrrown. State Zip Code Date of Inspection
D. System Information
Description:
3 bedroom contemporary
i
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
2011 - 101 GPD
Water meter readings, if available(last 2 years usage(gpd)): 2012 -74 GPD
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
CommercialAndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancyluse: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumping station, home owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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.
1
❑ 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
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Estimated 40 years old plus, no info at Barnstable BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
vented thru roof, no leaks
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
I
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions:
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information
required for every Hyannis MA 02601 09/06/13
page. Citylrown 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
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?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (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
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information
required for every Hyannis MA 02601 09/06/13
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,
i
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
I
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
f I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
I
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.):
i
* 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 Forth:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: (1)6' radius w/3'
stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
med sand, hydraulic failure, ponding, damp soil and abnormally lush vegetation present
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration (1) leaching block
Depth—top of liquid to inlet invert Above
Depth of solids layer 2' plus-pumped
Depth of scum layer 6-8
Dimensions of cesspool 6' radius
Materials of construction concrete block
Indication of groundwater inflow ❑ Yes ® No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 _
1
Commonwealth of Massachusetts
UWTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
page. Cityrrown 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-3113 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
178 Arrowhead Dr
Nt Property Address s r
Ruth Penna
Owner Owner's Name
information is Hyannis MA , 02601 . 09/06/13
required for every
page_ Cityrrown 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
K
t ,
t5ins•3/13 r 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
178 Arrowhead Dr
Property Address
Ruth Penna
Owner Owner's Name
information is required for every Hyannis MA 02601 09/06/13
page. Citylrown 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: 15
feet
Please indicate all methods used to determine the high groundwater 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:
Reviewed USGS water resource and topographic maps
You must describe how you established the high ground water elevation:
Reviewed USGS topo and water resource maps.
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
3
178 Arrowhead Dr
Hyannis, MA
A B
Al - 58' B1 - 50'
A2 - 62' B2 - 60'
O O
1000 gallan
l leach pit w/
2 washed stone
1000 gallan
Leaching cesspool
7 >.
1 1 LEGEND HYANNIS
a.�
PROPOSED CONTOUR `
_ ® PROPOSED SPOT GRADE -
v EXISTING CONTOUR ROUE. 28 W o
c; + 96.52 EXISTING SPOT GRADE
` s W— EXISTING WATER SERVICE o
TEST PIT • _ . � 'yq1N z
'. PINE ST. STREET J LOCUS
LOT 21
,
,
Q i I DRIVEWAY FENCE LOCUS MAP
LOCUS INFORMATION
Cul
r i 46.9
PLAN REF: 159/41
TITLE REF: 26160/102
PARCEL ID: MAP 270 PAR. 149
O LOT 22 /�' ZONING: "RB"
FLOOD ZONE: "C"
1 AREA=9,439t S.F. ��\\ COMMUNITY PANEL: 250001-0005-C DATED:08/19/85
0 y PARCEL ID: SEPTIC SYSTEM
o Q 10"HOLLY `� 270/101-035
c.BAs. , #178 a REPAIR PLAN
COR. PATIO
W TOF=49.50 ,' LOCATED AT:
Q I TBM=,48.50 PROP, I ,5000 178 ARROWHEAD DRIVE
� I r
w�—w �,4� o t V ' H ,ram . 5ETPIC TANK HYANNIS, MA.
—�
CESSPOOL PREPARED FOR
OHW \\\ 0 G r
UPOLE - RUTH A. & JEROME
PENNA
JANUARY 09, 2014
''1 2
2 2
FENCE^"------�___ �� OF
121.49 Mgss9�
46.2 o� DARKEN M. y�,
I UVEF�
—No. 1140� � ✓�
LOT 23 i
�Ecisc�° r
PARCEL ID: S48I Th?\
270/101-036 i
MEYER & SONS INC.
�^ GRAPHIC SCALE P.O. BOX 981
20 0 10 20 40 80 EAST SANDWICH, MA. 02537
Y
(508)362-2922 -
( IN FEET )
1 inch = 20 ft. -{ REVISED: 01/3.1/14
SHEET 1 OF 2 J#1619
T.O.F. NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS
Sr EL: 49.50 NOTE: PLACE RISERS OVER ALL COVERS W/IN 6" OF GRADE FINISHED GRADE (47.0)
. �F.GEL: 48.0 F.G.EL: 48.0 F.G. EL: 47.0
n
MAINTAIN 2% MIN SLOPE OVER LEACHING AREA
TOP TANK=EL. 47.25 ' 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2"
STONE OR FILTER FABRIC
4 DOUBLE WASHED STONE
6 4" SCH 40 PVC
10"I ffilirE ®®® 0 ®®®®14" s� ®®EE333E ®®TEE'S ARE TO BE S= 1% (MIN.)4' scH 4o Pvc INV.45.20 2' EFF. DEPTH ®®®®a®®®®®
INV.46.0
f INV.45.0 4' 2 X 8.5' 4'
INV. EL. 46.50 GAS PROPOSED DB-3
BAFFLE EFFECTIVE LENGTH = 25'
DISTRIBUTION BOX
INV. 46.25 INV. 'ELEV.= 44.10
PROP. 1 ,500 GALLON SEPTIC TANK
GAS BAFFLE TO BE INSTALLED ON ��� �F Mgssq� BREAKOUT
OUTLET TEE AS MANUFACTURED BY (�A/�f���REN ys ELEV.= 45.10
TUF-TITE, ZABEL, OR EQUAL o `�MEYER TOP CONC. ELEV.= 45.10
No. 1140 INV. ELEV.= 44.10 •®®~ 0 ®®
NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING ®®®®®®®
PIPE INVERTS PRIOR TO CONSTRUCTION 'Q£6IsiER�� ®®®®®®®
2) TANK AND D-BOX SHALL BE SET LEVEL AND TRUE SftjhA \P' I BOTTOM EL.= 42.10 ®®®®®®®
TO GRADE ON A MECHANICALLY COMPACTED SIX I 1 +l 3.75' S FT. 3.75'
INCH CRUSHED STONE BASE, AS SPECIFIED IN 3�311
310 CMR 15.221(2) ` SEPARATION > 5.0 FT. EFFECTIVE WIDTH 12.5'
3) INSTALL INLET & OUTLET TEES AS REQUIRED SEPTIC SYSTEM PROFILE BOTTOM OF TESTHOLE EL: 35.40 T SOIL ABSORPTION SYSTEM SECTION)
(500 GALLON LEACH CHAMBER)
GENERAL NOTES: DESIGN- CRITERIA
1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL LOGS P#: 14228
BOARD OF HEALTH AND THE DESIGN ENGINEER. NUMBER OF BEDROOMS: 2 BEDROOM EXIST./3 BEDROOOM DESIGN
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF)
OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE DATE: DECEMBER 11, 2013
LOCAL RULES AND REGULATIONS. SOIL EVALUATOR: DARREN MEYER, CSE 1614 DESIGN PERCOLATION RATE: <2 MIN/IN
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR WITNESS: DONNA MIORANDI, BARNSTABLE HEALTH DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.D.
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE
DESIGN ENGINEER. GARBAGE GRINDER: NO (not designed for garbage grinder)
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE NEW 1,500 GAL. SEPTIC TANK
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN Elev. TP-1 Depth Elev. TP-2 Depth
ENGINEER BEFORE CONSTRUCTION CONTINUES.
5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 47.10 A 0" 46.90 A 0" (330) = 445.94 S.F.
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF LOAMY SAND LOAMYSAND LEACHING AREA REQUIRED:
74
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 46 10 10YR 4/2 12" 10YR 4/2
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. B 45.90 B 12" USE TWO (2) 5OO GALLON PRECAST LEACH CHAMBERS W/ 4'
7. WATER SUPPLY PROVIDED BY PRIVATE DRINKING WATER WELL. LOAMY SAND LOAMY SAND STONE ON ENDS & 3.75' STONE ON SIDES: 25' L X 12.5' W X 2'D
B ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED IOYR 5/8 10YR 5/8
TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 44.35 33" 44.15 33" BOTTOM AREA: 25' x 12.5'= 312.50 SF
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE C C
THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING MEDIUM MEDIUM SIDE AREA: (25 + 12.5) X 2 X 2 = 150 SF
CONSTRUCTION. SAND SAND
10. EXISTING CESSPOOL TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. 2.5Y 6/4 TOTAL SQUARE FEET PROVIDED = 462.50 vs. 445.94 REQ'D
PERC ® EL. 42.0 I 2.5Y 6/4 IN FLOW PROVIDED 07446250 SF DESIGN . . . . = 342.25 G.P.D. vs. G.P.D. re 1. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION ( ) 330 G 'd
9
11 2. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY PROPOSED SEPTIC SYSTEM UPGRADE PLAN
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY
�.1 13. NO ABUTTING PRIVATE WELLS WITHIN 150' OF PROPOSED LEACHING. 35.60 138"
14. NO WETLANDS WITHIN 100' OF PROPOSED LEACHING. ,35.40 138" 178 ARROWHEAD DRIVE, H YA N N I S, MA
15. ALL PIPING TO BE 4" SCH 40 0 1/8-/FT (UNLESS SPECIFIED) PERC RATE <2 MIN/IN. ('C' HORIZON) Prepared for: Penna
NO GROUNDWATER OBSERVED
A I Design and Topographic Plon by: SCALE DRAWN
• I, Darren M. Meyer, R.S., CSE, hereby certify that I am currently approved by MADEP pursuant to 310 CMR 15.017 MEYERB SONS, INC. N.T.S. DMM
to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX 981
requirements of 310 CMR 15.017. I further certify that I have passed the Soil Evol. Exam in October, 1999. EAST SANOW/CH,MA 02537 DATE CHECKED SHEET NO.
' 508-362 2922 O 1/09/1 4 DMM 2 of 2
REVISED:03/31/14