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HomeMy WebLinkAbout0040 FRANKLIN AVENUE - Health 'ankle Hvan.ris � — --- -- - _ p' 2- 2 433 - b �r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 FRANKLIN AVE Property Address a.. DIPIERRO Owner Owner's Name information is required for HYANNIS V MA 02601 12-12-16 every page. Citylrown State Zip Code Date of Inspection ' F-� 4 Inspection results must be submitted on this form. Inspection forms may not be altered in arty 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 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: 1 ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority -------- 12-12-16 'TMrrecfd-rs 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. � I ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 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: ® 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: AT TIME OF INSPECTION SYSTEM MET ALL MINIMUM PASSING REQUIREMENTS. NO OBSERVATION PORTS WERE FOUND ON S.A.S. SO ACTUAL LEVEL OF PONDING/STAINING COULD NOT BE DETERMINED. D-BOX WAS VIEWED BY CAMERA . AS-BUILT CARD WAS NOT ACURATE AT ALL. THIS REPORT DOES NOT PREDICT THE FUTURE PERFORMANCE 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 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 j every page. Citylrown 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 i ❑ 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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 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: 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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M . 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every page. Citylrown 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 i ❑ ❑ 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 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 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 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS BUILT CARD SYSTEM CONSISTS OF A 1500 GALLON POLY TANK D-BOX AND A 3 BEDROOM S.A.S CONSISTING OF 5 INFILTRATORS I Number of current residents: 0 Does residence have a garbage grinder? , ❑ Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: HOUSE VACANT Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercialllndustrial 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every page. CityrFown 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 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every 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: 2006 PER AS-BUILT 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.): I Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ® polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GALLON Sludge depth: t5ins-3/13 Tide 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 r� 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every 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.): POLY TANK HAD SOME DISTORTING OF PLASTIC AROUND COVERS TYPICAL OF POLY TANKS SOMEONE HAD PUT CONCRETE COVERS ON TOP OF THE PLASTIC ONES. RECOMMEND PUMPING AT TIME OF TRANSFER FOR MAINTENANCE AND AT LEAST EVERY 2-3 YRS THERE AFTER. i 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 i Commonwealth of Massachusetts a. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate.on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•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 M 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 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.): BOX WAS VIEWED BY CAMERA DUE TO THE FACT THAT THE AS-BUILT CARD DID NOT SEEM ACURATE. THERE WERE NO SIGNS OF FAILURE VISIBLE IN THE D-BOX. 4 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: UN ACURATE AS-BUILT CARD AND NO OBSERVATION PORTS FOUND. > 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 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5INFILTRATORS ❑ leaching galleries number: i ❑ 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.): INFILTRATORS WERE NOT LOCATED BECAUSE THERE WERE NO OBSERVATION PORTS FOUND AND THE AS-BUILT CARD WAS NOT VERY ACCURATE. 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 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every page. Citylrown 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.): THERE WERE NO CLEAR SIGNS OF FAILURE IN AREA OF S.A.S. SHOWN ON AS-BUILT. 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.): t t • j 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 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 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 4 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 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 every 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: OVER 5 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: 12-2016 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: i ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: i You must describe how you established the high ground water elevation: SOIL LOG ON DESIGN PLAN f Before filing this Inspection Report, please see Report Completeness Checklist on next page. II t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 40 FRANKLIN AVE Property Address DIPIERRO Owner Owner's Name information is required for HYANNIS MA 02601 12-12-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 PL ----------------------------------------- LOT #57 & :#58 19„200 Square Feet TEST HOLE #1 I ELEV.= '98.00 I _ -~ I ------------------ ----- i TEST HOLE #2 ELEV.= 98.50 I 4".. PVC J.'3��'"4 r "'� •.. �:-:.'•;: D-Box Vent TENCH MARK i l ►. '=�''_� �ck �;:-; <<�, �,•;�` )UNDATION 7.25' 00.00 (Assumed) o I � Foiled I .Cesspool r- 59� r _ i 2 ------------------ ---M:� _ram;NEW 1500 GAL i rk O 112, I I � I � j I i #40 - ! I I EXISTING E1VSTINC I GARAGE .Z 9aDR00A1 HOUSE � � I EXIST. -y o IORNEWAYI --=------------- -------- ---= -t �`- 9., I I Ze rn A VEN ZTE (40 FOOT. RIGHT OF WAY) «, ON .. �ti TOWN BARNSTA.BLE LOCATION r i oV SEWAGE# �'-'��G✓'®9� VILLAGE ' ,A SOR'S MAP& INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY c I LEACHING FACILITY: (ty~pee)) +/� -i`-- (sizey ' NO.OF BEDROOMS `--/ BUILDER OR OWNER PERMITDATE:; 2 a- -�-O ko COMPLIANCE DATE: Separation Distance Between-the: Maximum Adjusted Groundwater.Table and Bottom of beaching 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 i 4Z 3 62 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments L1 C) yaS,J '< _ Propertress Owner Owner's ame information is required for X A N N i 5 Ira— •� Z� every page. City/Town I State Zip Code Date of Inspe on 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 forth. Irnponant: A. General Information When filling out forms the computer, r,use 1. Inspector only the tab key to move your 3 t cursor-do not Na, f Inspector use the return L-1 AfM?S S Z' P"Cl S ES?V i C L key. Company Name el t Corn any Address I N" City/Town State Zip Code SZ%IT- .3`��i — r1`t�: S 13 0 a9 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 CM 1 .000).The system: asses ❑ Conditionally Passes ❑ Fails Needs Further Eval n by the Local Approving Authority Inspe s ignatur Date or' 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. VAI Z/ -t5i one 1 �+v'�'�� �' Title 5 Official Inspection Forth:Subsurtace Ise. ,,sposal System•Rage 1 of 17 Commonwealth of Massachusetts 4- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Properly Address Owner Owner's Name information is required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A C,D or E/always complete all of Section D A) System Passes: /1have 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: C47 ram; f*— rr. ,�L.. . --tom-f!, 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,09p08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection 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 ❑ ND (Explain below): fir ❑ 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•09108 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 N Property Address _?4-lNL Owner Owner's Name information is required for 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 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: t t You must indicate"Yes" or"No"to each of the following for all inspections: I f Yes No ❑ / Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool f Discharge or ponding of effluent to the surface of the ground or surface waters El QX I due to an overloaded or clogged SAS or cesspool i 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 ❑ LLL"`��� than day flow i t5ins.09ro8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ir i 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 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 d chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- ,b00gpd. ElThe system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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•09= Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of W 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 page. CitylTown 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? 0,-' ❑ Was the site inspected for signs of break out? Lam' ❑ 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 3 C i t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N Property Address Owner Owners Name information is required for every 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? ❑ �ave 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? Lam' ❑ 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): �'� Number of-f eedroomsY(actual):-:-- 0� ---a DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms t5ins•09108 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 M Property Address - Owner Owner's Name information is required for every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: / Does residence have a garbage grinder? ElU Yes QO Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ilVo Laundry system inspected? ❑ Yes ❑ No Seasonal use? Bel L'T v 5 ,A k'Q Y ❑ Yes D. o I Water meter readings, if available(last 2 years usage(gpd)): Detail: � �' �•-4t-i._c'> �t.>S `x-{STr� ;�U"I �I S�l� I-1.2U YI25 , i Sump pump? ❑ Yes o 1 Last date of occupancy: Date i Commercial/industrial Flow Conditions: i 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 El No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 . i t 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 State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) f Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: N �vc1� V e Source of information: / Was system pumped as part of the inspection? El Yes • o If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Typ7em: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ 1 Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and t maintenance contract(to be obtained from system owner)and a copy of latest i inspection of the I/A system by system operator under contract Z ❑ Tight tank. Attach a copy of the DEP approval. I ❑ Other(describe): I I Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 • t5ins•09M I ` r _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 Property Address Owner Owner's Name information is required for State Zip Code Date of Inspection every page. Cityfrown D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: z0C)k-, Were sewage odors detected when arriving at the site? ElYes QA/o Building Sewer(locate on site plan): i } Depth below grade: feet Material of construction: ❑cast iron 940�pVC ❑ other(explain): ` Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): fvC� �? r[1�,P MS Septic Tank(locate on site plan): I Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ofyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No � r S'Xsx it Dimensions: �I Sludge depth: Title 5 official Inspection Form subsurface sewage Disposal system•Page 9 of 17 t5ins-09108 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 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle N t� ei Distance from bottom of scum to bottom of outlet tee or baffle q'r�' Ti S How were dimensions determined? �F>4Sc ��E% MF�� 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 t5ins•09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Property Address Owner Owner's Name information is required for State Zip Code Date of Inspection every page. Cityrrown 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.): i i i *Attach copy of current pumping contract(required). Is copy attached. ❑ Yes ❑ No • of 17 t5iru�•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 I - f r1, I t I Commonwealth of Massachusetts Title 5 Official Inspection Form of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. CityfTown 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 4�;— 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.)-. ►5 (�cy is- '�2 e, e 4 C) Sot_i 02� C—Z'C o ff I\►0 v Isom 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: JNL (Aa�2-P 1� t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments N Property Address IN Owner Owner's Name information is required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Type: ❑ leaching pits number: ®� ` �t^e.s 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.): A _D 1101—, �s�C ry� NG " IZ�C) QS 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 t5ins•09= Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Property Address Owner owner's Name information is required for every page. Cityrro` n 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.): i t5ins-091D8 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 N _ Property Address Owner Owner's Name information is 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 blic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately z � ti5 3 la3 s Z i i t5ins•09/08 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 Property Address , Owner Owner's Name information is required for 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: Ova feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record Zoo 6 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: OL Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 official inspection Form:Subsurface Sewage Disposal System.Page 16 of 17 j , I I I - f - , i ; r '-'��� ti y i i i I � I I s .. � h 1 ' 1 �t 1 i 1 i 1 . t t ,t. 1 r� - 1,--i'0'*-N n BARNSTABLE LOCATION SEWAGE # �' a9� VILLAGE A E/SSOR'S MAP & INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY c LEACHING FACILITY: (type) �`-- (size) NO.OF BEDROOMS BUILDER OR OWNER i _Liz PERMTTDATE: 2 -0� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 8-1 i +, j.al r i • 1 NO..I� � ` Fee / Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for lhgpo$al *_ p5tem Con5truction Verna Application for a Permit to Construct O Repair O Upgrade Abandon O XComplete System ❑Individual Components Location Address or Lot No. y1/ IST Owner's Name;Address,and Tel.No. Assessor's Map/parcel`R _ 0,7 Installer's Nam Address,and Tel.No. Designer's Name,Address and Tel.No. 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) '3 3 b gpd Design flow provided -3, Plan Date 156 Number of sheets Revision Date Title Size of Septic Tank CTD v Type of S.A.S. Description of Soil 17f9 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar alt . / Sign Date ! 1 D Application Approved by Date 3 Application Disapproved by: Date for the following reasons v Permit No. Date Issued Fee ' Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS ...PUBLIe1gE4LTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ' Yes �nnlication for �DtgogaY �&pztem Construction Permit ,. Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) KComplete System ❑Individual Components Location Address or Lot No. 7 to rit k i� ST Owner's Name,Address,and Tel.No. , 1 ' i Assessor's Map/Parcel.a _ D �T. Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Y„ h w• Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures — ( j Design Flow(min.required) t� gpd Design flow provided ",� 3 33 � l Plan Date ��� 1,L/i r/O Number of sheets Revision Date Title .. #✓ V/=�\ � i Size of Septic Tank G Type of S.A.S. I � • � � Description of Soil l7 v , Nature of Repairs or Alterations(Answer when applicable) `J Date last inspected: y Agreement: y �. 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 lace the system in operation until a Certificate of P P Y P Compliance has been issued by this Boar o alt . . Sign Date trI �� t.. Application Approved by Date 3 T Application Disapproved by: Date i for the following reasons \ 1\ Permit No. Date Issued ; THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERT� t the On-site Sewage Di s osal System Constructed ( .) Repaired ( ) Upgraded (� Abandoned( )�by 1 at �q �� r ti � � U a-d`� has beenconstructed in accordance L, / with the pro ' ' s of Title 5 and the for Disposal System Construction Permit No. �`�!/ 9 dated � Installe Designer �/'�U• #bedrooms Approved desi n flow 3� gpd The issuance:of this permit sha Ir�nnott be cconstrued as a guarantee that the system�func'o as eslgned. Date. � �l� Inspector No. Q�206 —c Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 1=izpogal 9)pgtem Congtruction Acrmtt Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( bandon ( ) System located at b J CA- 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: Constructi n mu rbe completed within three years of the dat of this p - 'i. Date �� (�P Approve 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, cfh��-- �t��`? ,hereby certify that the engineered plan signed by me dated concerning the\property located at 0 y-- meets all of the. following criteria: • This failed system is connected to a residential dwelling only...There.are no.commercial or business.uses.associated with the.dwelling. • The soil is.classified as.CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or.may conduct deep test holes and percolation tests.at the site without a health agent present. • There is no.increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the. Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) -A(R .00 B) G.W. Elevation Z,5 +adjustment for high G.W. 2 s = Z TSD DIFFERENCE'BETWEEN A and B SIGNED :_a DATE: NOTICE Based upon the above information;a repair permit will be issued for bedrooms maximum.. No additional bedrooms are authorized in the future without engineered septic system plans. Z9 C gASeptic\perceXemp.doc I p(o i:).c[u: ereoaration or clans ana Jnecitications The plans and specifications for every on-site system shall be prepared as follows: (1) Every system shall be designed by a Massachusetts Registered Professional Engineer or a Massachusetts Registered Sanitarian provided that such Sanitarian shall not design a s stem designed to discharge more than 2,000 gallons per day.pursuant to 310 CMR 15.203. Any other agent of the owner.may prepare plans for the repair of a system.designed to discharge'not more than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided they are reviewed by a Massachusetts Registered Sanitarian and approved by the approving authority; (2) Every plan submitted for approval must be dated and bear the stamp and signature of the designer, 3) Every plan for a new system or plan for the upgrade or expansion of an existing system which requires a variance to a property line setback distance, must.also reference a plan which bears the stamp and signature of a Massachusetts Licensed Land Surveyor in accordance with M.G.L. c: 112, § SID; 4) Every plan for a system shall be of suitable scale(one inch =40 feet or fewer for plot plans and one inch = ZO feet or fewer for details of system components) and shall include ptction of: (a) the legal boundaries of the facility to be served: n' (b) the holder and location of any easements appurtenant to or which could impact the /" system; (c) the location of the all dwelling(s)or building(s)existing and proposed on the facility Zaa didentification of those to be served by the system; ) -the'location of existing or proposed impervious areas, including driveways and rking areas; location and dimensions of the system (including reserve area); (f) stem design calculations,including design daily sewage flow, septic tank capacity quired and provided); soil absorption system capacity (required and provided); and _ whether system is designed.for garbage grinder,' (g) North arrow and existing and proposed contours; (h) location and log of deep observation hole tests including the date of test, existing grade elevations marked on each test, and the names of the representative of the approving authority and soil evaluator; location and results of percolation tests including the Gate of test and the names of V th representative of the approving authority and soil evaluator, name and certification number of the Soil Evaluator of record; (k) location of every water supply,public and private, 1. within 400 feet of the proposed system location in the case of surface water supplies'and gravel packed public water supply wells, within 250 feet of the proposed system location in the case:of tubular public water supply wells, and 3. within 150 feet of the.proposed system location in the case of private water supply wells; location of any surface waters of the Commonwealth, rivers, bordering vegetated wetlands, salt marshes, inland or coastal banks, regulatory floodway, velocity zone, surface water supplies,tributaries to surface water supplies,certified vernal pools,private water supplies or suction lines, gravel packed or tubular public water supply wells, s surface drains, leaching catch basins, or dry wells; and the location of any nitrogen sensitive area identified in 310 CMR 15.215 within which portions of the proposed system are located. location of water lines and other subsurface utilities on the facility; bserved and adjusted ground-water elevation in the vicinity of the system; a complete profile of the system; (p) a note on the plan listing all variances to the provisions of 310 CMR 15.000 sought � r conjunction with the plan; Iq) . the location and elevation of one benchmark within 50 to 75 feet of the facility '✓ which is not subject to dislocation or loss during construction on the facility; (r) when dosing is-proposed, 'complete design and specification of the dosing system /�- proposed including but not limited to dosing chamber capacity (required and provided), pump curves and specifications, number of dosing cycles and depth per cycle; (s) when a Recirculating Sand Filter or equivalent alternative technology is required or roposed,a complete plan and specification for the system,including a hydraulic profile; t a locus planto show the location of the facility including the nearest existing street; �� the street number and lot number, if any, of the facility; and. t/ (v) the materials of cons truction.and the specifications of the system. i Town of Barnstable CF tHE Tp� o Regulatory Services Thomas F. Geiler, Director BARNSTABLE, 9�A i6.39. �0� Public Health Division Thomas McKean, Director 200 Main Street;Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 3 Z3 b Designer: Shay Environmental Services, Inc. Installer: Address:. P.O. Box 627 Address: Zi". _East Falmouth, MA 02536 On 010 o .2> was issued a permit to install a (date) (installer) septic system at 40 "S�, , 4,_A P0vV\S based on a design drawn by (address) Sh Environmental Services, Inc. dated 1 ay 12 310(, (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. 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 i. of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. ,TN OF MASS\r CARMEN y`� (Installer's Signature) SHAY N No. 1161 I •p o SANITAR\Pa (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE 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:Health/Septic/Designer Certification Form TOWN BARNSTABLE LOCATION i� SEWAGE 40 VILLAGE m_I S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. l SEPTIC TANK CAPACITY LEACHING FACILITY: (type) -�`-- (size)"? ') l61 K NO.OF BEDROOMS BUILDER OR OWNER - PERMITDATE:_T - COMPLIANCE DATE: Separation Distance Between-the: Maximum Adjusted Groundwater.Table and Bottom of beaching 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 Eck 3 i 3 5 H 1h�4y�� s . 3 62i : � � � .. �3 � *NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE 0 Least 24 inches tall SECTION A -A ssaAxn�xAttx =-+ I 10' min. from Schedule 40 PVC w/Charcoal Odor Fllter FROM SHALL THE f Existing Foundation house to septic tank D-BOX Wier must PROFILE VIEW OF ADDITION TO LEACHING SYSTEM sET IEVETFOR AT iEA�sT�2 FT. - 1� ,Y CONCRETE COVER -_ �f � 1 � q TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Septic tank covers must a within 6 in. of finished grade ,}_•-- within 6 in. of finished grade over SAS- 91LOO to 9&50 3" of 1/8' - 1/2' Washed Peaston " 2 Grade over Septic Tank- 99.00Grade over D-Box- 98 50 ll - _ 3-5'OUTLET r � Apc,+ad It Je 3/4" to 1 1/2 " Washed Crushed Stone �\: KNOCII(�� (e`•��a i 31 t j r. - 5.5• f 12' MET S - 0.02 3 HOLE H-10 4'PVC(CAPPED)MSPECTON PORT TO BE { . OUTLET 6. ° e. Ea•n Sg!�.' p a'1 n ,`�[� �l .n N Maximum Cover INSTALLED AND TO BE YATHIN 8'Of GRADE `'/ L ° / `{ x 40 t({ \ 0 12' NEW S-0.01 or Greater ST. BOX Top OF System-Elev. -9&25 . r���c �`' o v, EXIST. PIPE ^ N 1,500 GAL �. s- 0.01"per {oat • 0"Effective Depth - 15.5' 1.7s' FROM EXIST. FOIINDAi rn z SEPTIC TANK Cp n o.,sr1N a1 N u) 5' n H-10 s ur,lts a 6.zs = so, PLAN SECTION CROSS-SECTION Af' 7 tra�d rl n I � l CONCRETE FULL FOUND+► • n d rn 0.83' (10 inches) 6 h.of 3/4'-, ,/rJA, 31.2s' 3 HOLE H-10 DISTRIBUTION BOX ( v;r.•,aAy SYSTEM PROFILE > compacted stone > ° ` tgpa M>ry A!+c• y.4 c S _2 o rn NOT TO SCALE i Not to Scale - • 37.25 P4 c o ' > 3.5' 3.5' n Effective Length 92DOO S21iM KA&M c o 10, SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES - 6 In.of 3/4'-1 1/Y a compacted stone Q Effective Width INFILTATROR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE m 1. Contractor is responsible for Digsafe notification, Verification of Utilities o (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes. i? Bottom of Test Hole 1 Oev.-87.5D NOTE OVERALL HEIGHT OF INFILTRATOR IS 18" FFECTIVE HEIGHT IS 10" 2. The septic tank and distribution box shall be set Groundwater Observed - NONE OBSERVED level on 6" of 3/4"-1 1/2" stone. 3. Backfill should be clean sand or gravel with no stones over 3" in size. PERCOLATION TEST 4 bylsCarmen Estem S Shay to Environmental ection dServc Services, installation 5. The contractor shall install this system in accordance Date of Percolation Test: FEBRUARY 28, 2006 with Title V of the Massachusetts state code, the approved plan Test Performed By. CARMEN E. SHAY, R.S., C.S.E. and Local Regulations. Results Witnessed By. WAIVER (Per Barnstable B.O.H.) t 2d• 6. If, during installation the contractor encounters any EXCAVATOR: Shay Env. Svcs. -----_97 soil conditions or site conditions that are different Percolation Rate: Less Than 2 MPI 0 42" _ ---------------------- from those shown on the soil log or in our design LOT #57 & #58 installation must halt & immediate notification be Test Hole Test Hole made to Carmen E. Shay - Environmental Services, Inc. No. 1 No. 2 ��' 19,200 Square Feet +/- 7. No vehicle or heavy machinery shall drive over the DEPTH SOILS ELEV. DEPTH SOILS ELEV. septic system unless noted as H-20 septic components. 0 98.00 0 98.50 / 8. Install Tuf-rite gas baffles or equals on all outlet tee ends. Sandy Loam Sandy Loam 5 T. - 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. 10 YR 3/2 10 YR 3/2 TEST HOLE #1 10. All solid piping, tees & fittings shall be 4" diameter As 97.25 0"-9" As 97.75 1 ELEV.= 98.00 Schedule 40 NSF PVC pipes with water tight joints. I I ® 11. Municipal Water is Connected to ALL OF The Residence and Abutting Sandy sandy I Properties Within 150 Feet. Loam Loam 1 10 YR 5/6 10 YR 5/5 I ------98 9"- �" Be 94s3 I ,,,.---------------------- THE PROPERTY LINES ARE APPROXIMATE AND. 9"- 40' Be 95.17 I Medium/Coarse Medium/Coarse # COMPILED FROM THE SURVEY PLAN GENERATED, BY Sand Sand I �' y EELEV.H� TNEY 98.50 ENTITLED "SUBDIVISION PLAN OF LAND IN HYANNS, MA, 2.5 Y 7/4 25 Y 7/4 I i' 36.5' DATED JUNE 1941 AND PLAN BOOK 65 PAGE 101 42"- 132 C, . 40 132 C, I 1 4" PVC ��;'`�„�'--r� S� �- � D-Box AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN, I Vent e • • • • f, IT SHOULD BE USED FOR NO PURPOSE OTHER THAN PROJECT BENCH MARK I i ' `t:s3;,',"<<;' : '�`: p THE SEPTIC SYSTEM INSTALLATION. t�;y•g TOP OF FOUNDATION I 37.25> EXISTING CESSPOOL TO BE PUMPED OUT AND FILLED IN PLACE. ELEV. = 100.00 (Assumed) i Failed CID (D I Cesspool " NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE I / FROM THE EXISTING CESSPOOL TO BE DISPOSED 2 ' i OF AS PER BOARD OF HEALTH SPECIFICATIONS. _ LOT #59__. NEW 1500 GAL „' Perc #1 " " -- 5EPrIC-T��rvt�.---_ _ ____. _--- --___�__.________ T'r,ERE ARE NO WETLAI!CS-ARE PRESENT w!THIN 200 OF THE PROPERTY Depth to Perc: 42 to 60 t / f0. ' LOT #56 Perc Rate= 2 MPI C i i ASSESSORS MAP 292 PARCEL 037 12, Groundwater Not Observed No Observed ESHWT 1 LEGEND 1 � ADJUSTED H2O Elev. = None I 1 co 104X1 DENOTES PROPOSED 1 / #40 SPOT GRADE 3-24'ouw. ACCESS MA""°tFs EXISTING EXISTING GARAGE 2 BEDROOM x 104.46 DENOTES EXISTING HOUS SPOT GRADE PL PROPERTY LINE I I MET 1 -1 % i l\ 0 96P PROPOSED CONTOUR T ET INLET `� `� 011 EXIST. THE ACCESS COVERS FOR THE SEPTIC TANK, % 4 / I DRIVEWAY( .>' -- -- DISTRIBUTION BOX AND LEACHING COMPONENT / r. -97 EXISTING CONTOUR T•-•rr�r -_,,T SHALL BE RAISED TO WITHIN 6" OF FINISHED GRADE. __? T STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EQUALS 97--- -� j 1V ��'I___ ---------------- �--------- ---- 99 � DEEP TEST HOLE & PLAN VIEW ON ALL OUTLET TEE ENDS / rt rn PERCOLATION TEST LOCATION 3-2e REMOVABLE COVERS� � I 6 FOOT STOCKADE FENCE Wmin. min:ckwvnee' :: Q/ is MET C,�V I IMINW 8' �2'min. inbt to ou6et / .J uuTLET ME Liquid Nwl P LAN E§ • 4'-0'mIn P LOT ba °". = "°"W depth FRA NKL IN AVENUE OF PROPOSED SEPTIC SYSTEM UPGRADE _. ,.•-... _..: -_ , PREPARED FOR 51 (40 FOOT RIGHT OF WAY) CROSS SECTION END-SECTION MR. J O H N B R U N E LLE AT TYPICAL (H-10 LOADING) 1500 GALLON SEPTIC TANK #40 FRAN K LI N AVENUE NOT TO SCALE May Substitute with 1500 gallon H-10 Polyethylene Tank-George O'Brien Co. HYAN N I S, MA Kitchen Both Bedroom 9 /Dining ZH of PREPARED BY: Design Calculations Number of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Gal./Day Min. per Title V) EXISTING oz EN c CARMEN E. SHAY Garbage Grinder: No GARAGE Bedroom (� 1 V f�i jl 1 Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) Living Room Septic Tank : - 2 x 330 Gal./Day = 660 USE NEW 1,500 GAL. Septic Tank. SH ENVIRONMENTAL SERVICES, INC. SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch NO 1 Bottom Area: 0.74 gal/sq. ft. x 372.5 sq. ft. = 275.65 gallons P.O. BOX 627 Sidewall Area: 0.74 gal./sq. ft. x 78.72 sq. ft. = 58.25 gallons 0 20 40 50 EAST FALMOUTH, MA 02536 Providing: = 333.90 gallons SANITARIP� TEL/FAX : 508-539-7966 2 BE HOUSE FLOOR SCHEMATIC Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1„=20' DRAWN BY: CES DATE: MARCH 14, 2006 TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1"=20' PROJECT SD876 FILENAME: SD876PP.DWG SHEET 1 OF 1 ON THE ENDS. NO STONE UNDER.