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0069 BLUEBERRY HILL ROAD - Health
69 Blueberry Hill Road, Hyannis a= y�-1S4 i �I 0 z Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner, Owner's Name information is, HYANNIS MA 02601 1-10-15 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information n I forms the computer, r,use 1. Inspector: U"� IlV/111(/n 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 Cityrrown 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1-10-15 Inspectofrs Signature Date • The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design.flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does,not address how the system will perform in the future under M the same or different conditions of use. 5 t5ins•3/13 Title 5 Official Inspection .,surface Sewage Disposal System•Page 1 of 17' V Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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: Z 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 MET ALL PASSING REQUIREMENTS AT TIME OF INSPECTION 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 exMtration 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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 r t5ins•3l13 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 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water.:Sd lier, 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 El ® 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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. ❑ E. 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 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10A5 every page. Citylfown 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? 4 ® 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): 4per as Number of bedrooms(actual): 4 built DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 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 wM 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1500 GALLON TANK, D-BOX, AND 5 3050 INFILTRATORS IN A 40X10 FT AREA Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No . Water meter readings, if available(last 2 years usage (gpd)): Detail: 2013---------389 2014-------267GPD 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.): r Grease trap present? ❑ Yes ❑ No. Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No� Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/user 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 s 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 w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2009 AS 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: _Elcast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well orsuction1ine: feet Comments (on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.5 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 PER AS-BUILT Sludge depth: LIGHT TO MODERATE t5ins-3/13 Y 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 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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 LIGHT CLUMPING Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? WOODEN POLE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING EVERY 2-3 YRS 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 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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.): I . *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 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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 LEVEL NO LEAKAGE OR SIGNS OF CARRY OVER Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Y . Soil Absorption System (SAS) (locate on site plan, excavation not required): ` If SAS not located, explain why: NO OBSERVATION PORT FOUND, THE AS-BUILT CARD SHOWS ONE BUT WE WERE UNABLE TO LOCATE IT AT TIME OF INSPECTION t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 3050:; INFILTRATORS ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 q 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 f i# Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G1M , 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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: GREATER THAN 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: 12-2014 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: 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 Assessing As-Built Cards Page 2 of 2 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=249153&seq=1 2/4/2015 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 69 BLUEBERRY HILL RD Property Address ANDREW BEARD Owner Owner's Name information is required for HYANNIS MA 02601 1-10-15 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 Assessing As-Built Cards Page 2 of 2 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=249153&seq=1 2/4/2015 Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION ►✓W j�14)LL RD SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S AME&PHONE NO. SEPTIC TANK CAPACITY /{ l LEACHING FACILITY:(type) ��2N� (size) 0 NO.OF BEDROOMS n OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance B ween the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY �/111��c�j A-1-;65 B4-poll #SKr- OF A6 A-3-35 �- �`Y��1 Eg/ http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=249153&seq=1 2/4/2015 TOWN OF BARNSTABLE- LOCATION 9 �/ SEWAGE# 3� VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'SN/A ME&PHONE NO. SEPTIC TANK CAPACITY /5 L,C� 7 LEACHING FACILITY.(type) :S— 2Q j�p� /T=(size) TAX l D t NO.OF BEDROOMS , OWNER � NIrl s PERMIT DATE: p COMPLIANCE DATE: Separation Distance Be weep 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 facili V. feet FURNISHED BY o4) Qr, A. , n w Nr 93W-03 / Fee r" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for SIB o aY bpStem Construrtion permit Application for a Permit to Construct( Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. y Owner's Name,Address,and Tel.No. Assessor's Map/Parcel i s /S / '� Installer's Name,Address,ands No.WIJ-1.J,fdr'j pj De igrier's Name Address,and Tel No. ox c'Z6 1-�b X/TI b�, �,4©�io G,l3Q;Y /�� rGL 2 Type of Building: //:-5_V Dwelling No.of Bedrooms / _ Lot Size C' sq.ft. Garbage Grinder( ) Other Type of Building S 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 ��O G/ Type of S.A.S. — 5 A0/X G/0 Description of Soil 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 beennis Bo ealth. d iG>i2��yJ/� Date Application Approve Date Application Disapproved by Date for the following reasons Permit No. '— 3 Date Issued r..�:ti.._*e.::., -.�^+..-�..:w...-:�..r'L.....ri.-.,�,,., ;..�r_.i�+"�.a+s..Y•.r*ra.w.:� .._..'u,;y�,s i,y',..... ..,...�.::,,,.:.,.,,�-..: ..�..-...,,.�«.w,r...,+:++,..._...—.J.-.! .. .... . ,. .r �Y.:. _ Noa� Fee •st` ;` THE,.COMMONWEALTH OF MASSACHUSETTS Entered in computer: �. .. �. �" Yes PUBLIC HEALTH 6IVISJON -TOWN OF BARNSTABLE',,M ASSACHUSETTS 2ppYication for Misposar *pstem Construction Permit Application for a Permit to Construct(y Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.6<? ,�'j i' y11/1 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel/ p* 5 3 4 Installer's Name,Address,and Tel. PI MS - De igner's NameVef ,Address,and Tel.No.� �IU 11�15YAR- Type of Building: L/ Dwelling No.of Bedrooms 7 Lot Size �S sq.ft. Garbage Grinder( ) Other Type of Building S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requited) 61 gpd Design flow provided �l gpd Plan Date Number of sheets- Revision Date Title Size of Septic Tank U ` ,Type of S.A.S. �� a. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: 1' 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 beenE* edb this Bo o Health.. , ., -�. l i- Date r i Application Approve Date .- Application Disapproved by Date !i for the following reasons a Permit No. jam q a Date Issued l - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifitate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( dr--Upgraded( ) Abandoned( )by (���� //v�(v at (a/ /� �� i ( has been constructed in accordance with the provisions of Title 5 and the or Disposal-System Construction Permit Nq,W�7-_C31 dated Installer ,�// � ati!'r' Designer #bedrooms (f Approved desi flow C gpd The issuance of this e , it shall of be construed as a guarantee that the system ill fun tion as designd. 0 Date p g Inspector----------------- —G'1� � =------=_-_-_--_-----=`=Fee No. 00.y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal bpstem Construttion Permit Permission is hereby granted to Construct( ) Re air Upgrade(�) Abandon( ) System located at ( U�621 // 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:Construction must be 'om leted within three years of the date ofrthis:pe::rmit. Date // �' G Approved'-by ��� J �\ ' 1 Town of iBarnstable . Services Regulatory, � R Thomas'F Geiler,;Director Public==�Health'Divislon Thomas McKean,Director 200 Main Street,Hyannis,'MA42601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Doran Date: Sewage Permit# Assessor's Map\Parcel_A Designer: Installer: a 6 Address: '130Address• On � tww d G as issued a permit to install a (date) i + (inst r septic system at l�rr�2(e based on a design drawn by (ad ess) ' /� �. tS� "dated (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 of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow (� .� Qr'� ,� GAF - (Installer's Signa ure) YE P No. 1140 ' � � �l ✓n �,, SANITAR��'a � 1 (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/Desiper Certification Form 3-26-04.doc y � SURVEY REFERENCE: .LEGEND sa PLAN OF LAND BY CHARLES N. SAVES„ PLS. r i attn� +PROPOSED CONTOUR t\ DATED: JUNE 18, 1964 I 0 AD ' ftdRPYH I I_ t_._- ® PROPOSED SPOT GRADE F -- BLUEB — g� EXISTING CONTOUR •`'• �,�; � C EDGE OF PAVEMENT +I 96.52 EXISTING SPOT GRADE e�uej 1 tom,, ry Nr)i iqd-. 'r \ - �� W— EXISTING WATER SERVICE a;t` l 1 \ 95.00 ft - -j --------_---- -------------- TEST PIT 5.00 I T � � /� . \ I O I L i AREA = 158 Sf I , Q ! BENCH MARK .� ` II .0 w ! TOP OF FOUNDATION i ELEVATION = 59. 25 o ! BARNSTABLE CIS DATUM i Jmi � e ;tnt LOCUS MAP N.T.S. > GENERAL NOTES: 0) 1• ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL j \ BOARD OF HEALTH AND THE DESIGN ENGINEER. j I I 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS \ OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE j \ I LOCAL RULES AND REGULATIONS, EXCEPT AS SHOWN: { - 310 CMR 15.405 (1) (A): I j 1) A 4 FT. VARIANCE FROM 310 CMR 15.211 TO ALLOW LEACHING \ EXISTING I TO BE 16 FT FROM SWIM POOL VS REWD 20 FT (liner provided). j 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR ! DWELLING ' j TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE j DESIGN ENGINEER. 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING I j j FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN j ENGINEER BEFORE CONSTRUCTION CONTINUES. j TOP OF F N D N j 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. j EL = 59.25 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF j ! THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. I w 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. co U 8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED DECK I TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. p 0 (j-, I 9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY j N Ji' J W p- ,-Cs j THE LOCATION OF ALL UNDERGROUND UTILff1ES, PRIOR TO BEGINNING I S `- ; CONSTRUCTION. 1 DECK i f t 10. EXISTING LEACH PITS TO BE PUMPED, CRUSHED AND REMOVED. FILL WITH CLEAN MEDIUM 2 MIN/INCH PERC SAND. j 11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION j 12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY j O o o p O o ! AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY i 13. NO PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING I / 40' _ ! 14. MUNICIPAL WATER SERVICE IS GREATER THAN 10 FT. FROM (0\j / 40 mi POL BA w ! PROPOSED LEACHING T -2 Q�p rn ! 15. PLACE 40ML POLY.BARRIER AS SHOWN FROM EL 56.50 TO 52.50 T� ao Existing Leach Pits j ) j ft 06F , (See Note 10) ! l OF R i 1 i P` s9� INGr0U1\ID DARRf�:�l �{. yin SWIMMING j ME \, O ! No. 40 N 1 POOL PROPOSED SEPTIC SYSTEM UPGRADE PLAN !, 69 BLUEBERRY HILL ROAD ANNIS MA 0 HY , SA I '� j s9N1tAR\p1� j , Prepared for: Mike Dedecko Engineering by: Surveying by: SCALE DRAWN ` i--- — --- — — — — — — — — — — — — — — — — —— — — — — — ------- --- J DARRENM.MEYER,R S. Eco—Tech Environmental 1"=20' DMM ZI1� 1 V 5,01 ft 95.11 ft r POBOX961 (508) 364-0894 SHEET NO. EASTSANDWICH,M402537 DATE: CHECKED 508-362-2922 02/11/09 DMM 1 of 2 ELEV. TOP NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FOUNDATION u�.. (Existing) 59.25 F.G.EL: 59.0 F.G.EL: 59.40 F.G. EL: 59.4 FINISH GRADE=59.5 s MAINTAIN 2% MIN SLOPE OVER LEACHING AREA /!!! BRING ALL COVERS TO GRADE 6" INSPECTION PORT W/IN 6" OF FINISH GRADE , 10* TEE'S ARE TO BE 14 0 0 ° 0 0 0 0 0 0 0 0 0 - L INV. 4" SCH 40 PVC INV. 6 S= 1 MIN. EL= 5 .77 EL= 56.50 ' a- INV. ti .o t GAS EL.= 56.92 BAFFLE . 0 0 0 0 0 0 IM1. 0 0 0 0 0 0 EXIST. PROPOSED DB-3 ° ° ° ° ° ° ° INV. EXISTING 1000 .GALLON SEPTIC TANK H-10 DISTRIBUTION BOX I_ 40, NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING 4) INSTALL INLET & OUTLET TEES AS REQUIRED FR,ERF 9" MIN. PIPE INVERTS PRIOR TO CONSTRUCTION 2) D-BOX SHALL BE SET LEVEL AND TRUE TO 5) INSTALL GAS BAFFLE ON OUTLET TEES. FPER T1 TLE 5 GRADE ON A MECHANICALL COMPACTED SIX OF BREAKOUT EL = 56.5 INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2) �' r INV. ELEV.=56.0 1 y 3) REPLACE EXISTING 1,000 GALLON SEPTIC ` A N Gr _ » TANK WITH 1500 GALLON SEPTIC TANK MEYER �_ DOME' 'sry E 24 30.5 IF FAILED, DAMAGED, OR UNDERSIZED. SEPTIC SYSTEM PROFILE No. 1140 "' E INVERT 1 BOTTOM EL.= 54.0 --�� �jSIE%, I----34.5" 51 SEPARATION'6.00 FT. 120" INFILTRATOR 3050 SPECIFICATIONS BOTTOM OF TH-1 EL:- 48.0 SOIL ABSORPTION SYSTEM (SECTION P#: 12468 DESIGN CRITERIA IL SOIL I L LOGS NUMBER OF BEDROOMS: 4 BEDROOOM DESIGN SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF) DATE: FEBRUARY 1 1, 2009 DESIGN PERCOLATION RATE: <2 MIN/IN SOIL EVALUATOR: DARREN MEYER, R.S., CSE DAILY FLOW: 110 G.P.D. ° WITNESS: DON DESMARAIS, BARNS. HEALTH AGENT DESIGN FLOW: 440 G.P.D. 01 GARBAGE GRINDER: NO (not designed for garbage grinder) Elev. TH- 1 Depth Elev. TH-2 Depth SEPTIC TANK: 440 gpd x 2 = 880 gpd USE EXISTING 1,000 GALLON SEPTIC TANK 59.50 0" 59.50 A 0" (440) = 594.59 S.F. A LOAMY SAND LOAMY SAD LEACHING AREA REQUIRED: 74 10YR 3/2 , INLET END 4.5"DIA ACCESS PORT FOR INSPEC770N. 58.67 B 10" 58.s7 B 10" USE FIVE (5) INFILTRATOR 3050 UNITS WITH 2.88 FT. STONE (OPEN) LOAMY SAND LOAMY SAND f ON THE SIDES & 1.38 FT. STONE ON ENDS: 40' L' x�- 10' W x 2'D 10YR 5/8 10YR 5/8 a BOTTOM AREA: 40 x 10 = 400 SF 56.50 36" 56.50 36" SIDE AREA: (40 + 10) X 2 X 2 = 200 SF TOTAL SQUARE FEET PROVIDED = 600 S.F. vs. 594.59 S.F. REQ'D DESIGN FLOW PROVIDED: 0.74(600 S.F.) = 444 G.P.D. vs. 440 G.P.D. req'd PERC®54.17 ° ° ° ° PROPOSED SEPTIC SYSTEM UPGRADE PLAN MEDIUM MEDIUM SAND SAND INFILTRATOR 3050 2.5Y 6/4 2.5Y 6/4 69 BLUEBERRY HILL ROAD, HYANNIS, MA � Prepared for: Mike Dedecko NOMINAL CHAMBER SPECIFICATIONS I' Engineering by: Surveying by: SCALE DRAWN ' 38" DARRENM.MEYER,R.S. Eco-Tech Environmental 48.0 138" 48.0 1 N.T.S. DMM SIZE (W x H x L) 51 ' x 30 ' x 85.4 Po Box981 (508) 364-0894 WEIGHT 80.0 LBS. PERC RATE <2 MIN/IN. ("C" HORIZON) PERC RATE <2 MIN/IN. ("C" HORIZON) EASTSAAl ICH•MA02537 DATE: CHECKED SHEET N0. NO GROUNDWATER OBSERVED NO GROUNDWATER OBSERVED 5o8-3M22922 02/1 1/09 DMM 2 of 2 r - i }t / TOWN OF BARNS ` BLE LOCA T ION SEWAGE # VILLAGE V 4 n i S ASSESSORS MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY g, LE QACFHNG-FACUXrY:(type) T o— (size) c;2 NO.OF'BEDROOms BUILDER OR OWNER PERMUDATE: CONULIANCE DATE: Separation Distance Between tbe: Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Faeiility (If any walls exist on site or within 200 feet of k=hing facility) Feet Edge of Wetland and LeacWng Facility(If any wetlands exist within 300 feetpf leaching acitity� Feet Furnished by � ►-rj rT) 1 9i zz. O � � n 4 d r l Town of Barnstable P# ,Y Department of Regulatory Services > Public Health Division Date MAK 200 Main Street,Hyannis MA 02601 lE�Nt►t� Date Scheduled d� Time Fee Pd, Soil Suitability Assessment for S age Disposal Performed•By 'ly-e n t .(_// Witnessed By. / f LOCATION& N G ORMATI Location Address ��' �,ner's Name i` �,��,y-D�� Address Tn"h Assessor's Map/Parcel: En ineer's Name NEW CONSTRUCTION / REPAIR Telephone# Land Use ���G �( Ro) S S � Slopes y P ( Surface Stones � Distances from: Open Water Body Z�ft Possible Wet Area t 2tz) ft Drinking Water Well i'SD ft Drainage Way f-92—ft Property Line >/ V ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) TOP OF FNDN EL = 59.25 o DECK LLJ \� o �o�u DECK i'-ft. o 0 0 0 0 / 40' T _2 40 mi POL' BA P ;,.X XD Existing Leach Pits i (See Note 1 D) i j -- - GROUkiD i Parent material(geologic) � Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Pace N��•— Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in, Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor— Adj.Groundwater Level,, a PERCOLATION TEST note tI.Th.ne__�Observation Hole# Time at 4" Depth of Peres, Time at 6" Start Pre-soak Time @ /o /o Time(9"-6") ' End Pre-soak 46 � 4 Z ti/ Rate Min./Inch !/ Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) . Original: Public Health Division Observation Hole Data To Be Completed.on Back----------- ***If percolation test is to be conducted within_100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1)rweek prior to beginning Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA.) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel)— Ott(D D � f DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel d`� Idu an b yx3/,' �✓ ���.��� �' ell• no( z� G DEEP OBSERV TION HOLE LOG Hole# Depth from Soil Horizon Sotl ea:t're Soil Color Soil Other Surface(in.) (US ) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSE VATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten I Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes _ Within 500 year boundary No Yes Within 100 year flood boundary No— Yes . Depth of Naturally Occurrint=Pervious Material Does at least four feet of naturally occurring per , material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occur.ing pervious material? Certification I I certify that on l l (date)I have passed the soil evaluator examination approved by the . Department o viro ental Protection and that the above analysis was performed by me consistent with . the required tr inin ,e ertis, and ex a 'ence described in 310 CMR 15.017. Signature Date ll QASEPTIC%PERCFORM.DOC t Commonwealth of Massachusetts Title 5 Official Inspection . Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 5z1. Inspector: 4-, Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenaMe of o'n site sewage disposal systems. I am a DEP approved system inspector pursuant to SectiddA5.340 of Title 5 (310 CMR 15.000).The system: ❑ Passes is rs J❑ Conditionally Passes ® Fa s, ❑ Needs F her Evalua - n by the Local Approving Authority � N � 10-28-08 co Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the i 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. /31 t5insp•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 t r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not"found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B System Conditional) Passes: Y Y ❑ 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,wi4l pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 -- I Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is Hyannis required for MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy.is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS.and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has aseptic tank and SAS and the SAS is less than•100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static'liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 'b day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any iportion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 69 Blueberry Hill Rd - Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El ® 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 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 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp-03/08 Title 5,Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 8-08 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: Last date of occupancy/use: Date Other(describe): t5insp-03108 r• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/,Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank..Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 1981 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp•03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"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.): 3 Good condition Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No - - - - - -------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: 20" Distance from top of sludge to bottom of outlet tee or baffle 12 Scum thickness $ 4" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12 How were dimensions determined? Tape t5insp-03/08• - Title Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 16 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 9 Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp-03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 16 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with stain line above invert. . r Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pits have visible stain lines at and above inlet inverts. t5insp•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA 02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. p G 3S' A -F-S' t5insp•03/08 Title 6 Official Inspection Form:Subsurface Sewage Dsposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Blueberry Hill Rd Property Address Fannie Mae Owner Owner's Name information is required for Hyannis MA •02601 10-28-08 every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: Town maps show ground water at 20'. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 ?_ '—.._ z."_' t.. z" ,E�.'•. r- a.�,.�r. .'�.-e ,,,,_,."-'.,:.- -" "^LTA ",r....; _ -c�,�w'S-ME -SAS` :p, .w J Arw---- `.- ,:"r^ .�1' :st1c�=-"''u— -'•` aT �—�W+. \. — �Y odd o—fi-E—rlrur�ers� - axac = - 17.E P '>i OfTe;B _Seprspecfo* mlon -off P. . ox 2T19 �Q - Teaticke MA 02536 { � `� �n�eonenentol Prote�t�on �v .j08)564-6813 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM — CERTIFICATION E Property Address 69 Blueberry HIII Rd.Hyannis Address of Owner ?Jt3 Date of Inspection 10/03198 (If different)_ Name of Inspector:John Gracl Manos:82 Melrose SL Arlington,Ma.02174 Company Name,Address and.Telephone Number CERTIFICATION STATEMENT w:a certify_.that-have:personally,inspected.;the ewge.di,sposalsystemaat his address and that the information reported below is true•aceurate . and complete as of the time of inspection..The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X_ Passes 41. Conditionally Passes Needs Furt#er Evaluation By the.Local Approving Authority Fails ` Inspector's Signatures Date: 11U9196 The System Inspector shall submit a"copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection: The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY. Check A. B,C, or D`. A] SYSTEM PASSES:: _ X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303..,Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes, no,or not determined(Y, N,or NO). Describe basis of determination in all instances. if "not determined",explain why not.)' The septic tank is metal,.cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115/95) One Winter Street • Boston,Massachusetts 02�108 . FAX(617)556-1049 • Telephone(617)292-5500 W47� R ta, - .,t. _ •-:'.i: .t.:............:..._ '..:' .. '.... ...�,�.. .'a+,.0-.,, .. ..r,�.na .u.ar...::.�'(!•�..7.'�-_uxw�k 3rl��.�$'�..?.A:v.., !"Y.r5�,'.Ei.`'i�?>i� w... i.0 ., .. > .. I RYA YM1r? j� s '' z, s r `L SUBSURFACE SEWAGE oiSPOSAL`SYSTEM_INSPECTION'FORM PART A 7. . I CERTIFtCATION.(continued) :• is ',P_rope fty Address _69.Blueberry HiII Rd:Hyannis - ' Owner:. Mancs',82 Melrose M-Arlingion,Ma 02174 -Date otInspection:10103196 i , cagebackup or breakout=or hlghstatic water level_obseryed in the distribution boxis due to a broken 4 setttedar tipe�cen�isfibu Tort bax Tstem wrf4 pass►nspectl�It{yvath_appmvaLof tF1�Board of Health) -- — - -- = — broken pipe(s)are replaced - obstruction is removed _ -- - distribution box is leveled or.replaced _The system required pumping more than four times a yeardue to broken or obstructed pipe(s). The system-will pass inspection.if(with approual:of the Board of Health): - broken pipes)are replaced obstruction is removed ' 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,the public health, safety and the environment: 1) SYSTEM MILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE.SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL.PROTECT THE PUBLIC HEALTH AND _ SAFETY.AND THE ENVIRONMENT: Cesspool or privy.is within 50 feet of a surface water Cesspool or privy-is within 50 feet of'a bordering,vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and:is.within 100 feet to a surface of water supply or tributary to a surface water supply., The system has.a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. _ The system has aseptic tank and soil absorption system and,is'within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from.a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free.from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER - II D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be . contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. ;(revised 1 115I95) s -• F' a ...,a ays_.YC_ Vy �,-. �#• _� �IFS �,, _ zt t SfiJBtURFAGE SEWAGE DISPOSAL;SYSTEM INSPECTION FORM ,.�.�,.,�- '-�-..,-„-�.�—•--"_.." ,�.. `..s'� sfk�iF�if'-A�i�('C,SfaLft�,ttec#}F'r—=----. ..—�F �--� , k Qrope-ty Address 69Bluebenylillmd Hyannis ivartos 82MelroseSCArlington NIa 02174- `,hNOP 1o�sls6 � 'Qate_at`J'ns�ectlan t a 'D]SYSTEM FAILS(continued) - Static.liquid level in the distribution box above outlet invert dueto an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2.day, flow Required pumping more-than 4 times in the last year NOT due to clogged or obstructed pipes) Numbers of times pumped Any portion of the Soil Absorption System, cesspool or privy is below.the high groundwater . _elevation '.. Any portion of a oesspool or privy is..within t00 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. If the well has been analyzed to be acceptable, attach copy of well.water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen... E]..LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: . The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 mapped Zone II of a ' public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please.consult the local.regional office of the Department for further information. (revised 11115195) P � IN 3 � �� 4 ^� a+s _"'_"_ , �*+a"''--'� ..- +' - 'x-:2',.�,� -''i .b',✓_,`' �.�, "'arc+ x�a.•- ,,.-t:.r .. -"".`� r•--- s o`.� y"-�. .._"mom"" . a a "'- ,-"` �._ - _z-., �^'� �n -'°O .z4lz -M SUBSURFACE SEWAGE DISPOSAL-SYSTEM iNSPMTION FORM L ---�� �.•�:�� - �. -.-,tom-� � � _P/CR'�8- �*� :�•...�-z�:�� � �� s ��� �. ,�Y�Yz�,e-w'.��„, ,-•-n��k'fFCCIS�---- '^T` - m _Pro pe rty Ad d ress.--69`Blueberry Hill Rd.Hyannis - OWnef:° ;Manos:92 Melrose sLAFlington,Ma 02174_ - ate. - _ . 1D103I� ;Date oftnspe -C b Check if the following have been done:. -. X Pumping information was requested of the owner,occupant, and Board of Health. - X None of the system components have been pumped for at-least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of-water have not been introduced into the system recently or.as part of this inspection.. _ As built plans have been obtained and examined. Note if'they are not available with N/A X The facility or dwelling was inspected for signs of sewage back-up:' X The system does.not:receive non-sanitary or industrial waste flow., 4. X The site was inspected for signs of breakout. X All system components,.excluding the Soil Absorption System,have been located onthe'site.. X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or,tees,material of construction,dimensions, depth of liquid, depth.of sludge,depth of`scum. X The size and location of the Soil Absorption System,on the site has;been determined based on existing information or approximated by non-intrusive methods. X owner and occupants, if different from owner were provided with information on the proper maintenance of Sub- Surface facility o e � ( P tY • Surface Disposal System.. (revised 11115195) r PM s 4 t Y Y tl ., ' .=jc•,.rr... -.. _ .. ... ... ... - .a Yr'.�'*-f.4 F4G-x_��'i• 2•�:CSPYA2l..a .._:. E}H^ �`.�'.��5 r . _ r SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM - w PART C- __ SYSTEM IdFORMATION. Property Address:. 69 Blueberry Hill Rd.Hyannis r Owner:, Manos:82 Melrose, wArlington,Me.02174 - 'Date of lnspec orr:>_ 0wis-, - - - FLOW`.CONDITIONS RESIDENTIAL:A - `^' besign flow: 440 gallons' --Number-of bedrooms:-4 - Number of current residents: 1 - ,Garbage grinder(yes or no); Yes _ Laundry connected to system(yes or no): Yes - Seasonal use(yes or no): No _ Water meter readings,if available: n1a 17 Last date of occupancy`na COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day,., Grease trap present:(yes or no)_to Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no)No Water meter readings, if available: nla Last date of occupancy: We OTHER.: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped In the last two years ' System pumped as part of inspection: (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: Na TYPE OF SYSTEM - X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool . Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,,date installed(if known)and source information: 1981 + , v Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) t z • r:r r .^ SUBSURFACE SEWAGE DISPOSAE.SYSTEM INSPECTION FORM ` - -� - - PART Q RM�cTtETN Eeolvtfi k ` Y k e - Rropei3yAddress:- 69'BlueberryH111Rd.Hyannls. " ' _ s__, ' `' _' DWnef; Manos 82MelroseStArlington,Ma 02174 �,.: _ Date of,lns action ,10103196. -_- T;.. _. ��'(I�ocate onns�it plan) �r _ _ -�---� w � ,--- -�'_ �------.�,�-•.----' if ._Depth-betowgratle 1�-.-_ ._-::,. -- --= -.-: ,;• - -� - - -- - �.. Material of construction:X concreate metal_FRP other(explain), <Dimensions: L8"6•H5'7'W4'10• - x. Sludge depth:3' Distance from top of sludge to bottom of outlet tee or baffle: 24'.' .Scum thickness::o Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of-outlet tee or baffle: o Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,edepth of liquid level in relation to outlet invert structural inte n evidence of leakage,etc.) - Septictank and all components are structurally.sound.Recommend pumping system every two years for maintenance GREASE TRAP: (locate on site plan) Depth below grade: nla Material of construction: concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:Na Distance from top of scum to top of outlet tee or baffle:Na Distance from bottom of scum to bottom of outlet tee or be Na Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, . evidence of leakage,etc.) Na revised 11/15195 fI Wes, jt ' 1 �C Rj R R a '�:M e Sfi18SURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION"FOR M__: = -PART C - "' _ - SYSTEM INFORMATION,(contlmred)- - _- - Property Address: 69 Blueberry Hlli Rd Hyannis - Owner: _ Ntanas 82MelroseStjkm ttoon;ma.02174-• I Date of`Mspectfbrr 10103/9B TIGHT OR HOLDING TANK: cate do site plan).-- -- _-..- --- -- - -- ��. :. ... ...—, J Depth below.grade: nla = _ Material of construction: _concrete;metal_FRP_othei(explain) ~ Dimensions: n1a y Capacity: nl • gallons ` Design flow: n1a gallons/day:: 1 Alarm level: Na - 1.. Comments: 1, .. a} (condition.of inlet#ee,:condition.of alarm'and,float-switches;etc.)''" Na ,f.�•;: V�r s'. I' DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: Liquid level with bottom ofplpe... Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.). 0-box is structurally sound i, PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no) - Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) n1a i i } ! I If . (revised 11H5/95) ny II } I I b ..Aa'7txa`��g.`-4.cF �• �'d�-��.a x�".,-� ''$k�s�+y�µ3e��'`..r,��a'��"r'���-�''e'saa��".",� u•�'�.-�--. mow;��`y�. 'RT?'" }'�tszxzm..�'�t%r3�^✓ Mgg f""" 3^� '''��_'- 1 4 4 2a� -�•q�i�j•'W+_�°` �a�"�-,a'�-----�—s�.,,,,�-c "� �•�.-,., �-��-�s-_'',*�•„-ate ,••. t .� R �� Rx ��t a" •,} o 5tft3St9R!~AIiESEWAGE DISPOSAL SYSTEM INSPECTION FORM " h (caritihuedf an — _ - — - - ~- — _ 3 3 �_P`ropartg Address�89 BTuebe�t9ff`RtF,.>'Cyannig ,� �'` ` °� �_ SOIL ABSORPTION SYSTEM (SAS}:X (locate on site plan if possible; excavation not required;but may be approxirnated by-non-intrusive methods) If not'determined to be present,'explain: nia Type: - -leaching . g pits.,number: 2.1;000gallon[each pit leaching chambers;.number:nfa - leacFiing.galleries,number: nfa leaching trenches,-number, length: nfa leaching fields, number, dimensions:nfa overflow,cesspool, number:Na y , _:Comments;(note condition of'soil,'signs;of hydraulic failure,level ofponding, condition of.wegetation, etc.);n, The leach pits are structurally sound and functioning property CESSPOOLS: ._ (locate on site plan) . Number and configuration: nfa , Depth-top of liquid to inlet invert: nfa Depth of solids layer. nfa Depth of scum layer: nfa Dimensions of cesspool: nfa Materials of construction: nfa Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) Na Comments*(note condition of soil; signs of hydraulic failure, level n/a of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: n/a" Dimensions: Na Depth of solids:nfa Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PrivyComments (revised 11115/95). z , MEN- G J'FY �'^'�'e~ .,.1 SUBSURFACE SEWAGE DISPOSAL"SYSTEM.INSPECTION FORM PART C - N(" SYSTEM INFORMATIO conttnued) - — Property Address :69 Blueberry Hill Rd.Hyannis Owner. - ='Manos:82 McGose SE Arlington,Ma.02174 ` Date'of Inspection:10103196 - SKETCH OF-SEWAGE DISPOSAL:SYSTEM• _- Include_tiesFta atleast'two permanent references landmarks or benchmarks _,. .-Iocaf6altwells within:,.100'; 14 10 �. 16C o 3S _ DEPTH TO GROUNDWATER Depth to groundwater:12. feet a method of determination or approximation: USGS Maps and Charts f 5. ------------- (revised 11115195) I` "^r N ..........�� ....... F��.............................. 1 3 THE F cH BOARD OF HEATH Ts / -------- "v .........OF...... -. Appliratinn for Biiivniial Vvikii Tnntitrurtinn rantit Application is hereby made for a Permit to Construct ( or Repair ( } an Individual Sewage Disposal System at: c, _ Location-Address or Lot No. ..� ... f�G 4 S'efY..�r Address ------------------------------------- O Address Installer Address ..» QType of Building Size Lot__/ ._ ____Sq. feet g _-___Expansion Attic ( Garbage Grinder f a Dwelling No. of Bedrooms____..__.. _______________________ p-, Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) f-4 Othe fixtures -------------------------------- /� Design Flow....___ ff d gallons per person per day. Total daily flow.___._..___'�._7 Q_.._ g 11. -•••• •-g P P P y y dons. WSeptic Tank iquid capacitv_t,4 d-,�-gallons Length................ Width................ Diameter................. Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No....... ------- Diameter....... Depth below inlet......... Total leaching area.... d_ ':sq. ft. Z Other Distribution box (. � Dosin ank ( ) Percolation Test Results Performed by./ � ' �4__ .._tz.�?f' ............................ Date ' aTest Pit No. 1••_.,,4-�-.minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil......�-`-��.... --�.�.1.-`---/a'--�.......l�-•--- --- -- - � - V '--•-••--•------•-••---------•-----•----••--••----••-----•---••-•••---•••---- W VNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------___•_-_-____. --------•--•--•-------•---•--•-•••....-••-•-••--••-•-••...••---••••---••••-••--•----------------•-----••--•-•-•----------------•----•------•--•••--•---•----------•----------•-•-•••--•--••-•--•-_---_.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:TTL p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee d by the board of hean- Signe Date Application Approved By---- = �L - --�---2���= 1-•------ t Date Application Disapproved for the following reasons---------------------------•---------------------.......---------------------------------------------------_-•--- ............................•-••-•-•-----------------•••----••-•---•--•-•----------•--•-•••-•••--•------- Date PermitNo......................................................... Issued_....................................................... Date ' N �N �> No........................ FEs................... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH o w..►11- , pplirFaiion for UiipnnFal Workii Tnnitrnrtiun ramit Application is hereby made for a Permit to Constructkoy0000r Repair ( ) an Individual Sewage Disposal System at Location-Address or Lot No. ----------------------------------------------- ------------------------------------------ -•----.......-----..._..------........._....-- Address Installer Address .. Type of Buildin , / Size Lot. S __��__� __._._Sq. feet Dwelling No. of Bedrooms__.__ ` "!_____________________________Expansion Attic Garbage Grinder ® p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q+ Oth r fixtures ..................... -•-•- Desi n Flow_.._ gallons per person per day. Total daily flow_...... '� Wg ------ - - ------ �---- ...................gallons. WSeptic Tank Liquid capac>tyb .gallons Length .............. Width__................ Diameter---------------- Depth................ x Disposal-Trench No .................... Width�ss ._.. Total 'Length Total-•le�hing-area....................sq. ft. Seepage Pit No .._, - _____ Diameter _-:Q'cy�._. Depth below inlet...... ......_ g � ?^.. q.._ Total leaching area_. _ s ft. Z Other Distribution box Dos' tank ( ) '-' Percolation Test Results Performed by - --.r _t? --------------- -- ---- Dat � '� _ -- ,-a Test Pit No. 1---I•'-1;? minutes per inch Depth of Test Pit____________________ D.�th to ground water------------------------ GT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... �..L ----------- o f Description of Soil.._.i'. "'_ ..``. �"____._r3-.__ .....w�► .... '_._.. x V ------....•-------------------------------------------------------------------------------••----------------------. --------------------------------------------------------------•-•----- W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable______________________________________________________ _______________________________________ ----------------------- .......................................--....................................................................................................................................... Agreement: The undersigned agrees "to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T` �.' p 5 of the State Sanitary Code—.The undersigned-further agrees not to place the system in operation until a Certificate of Compliance has bee iss4e by the board of hCa F Sign . ••-- -----_.... . -• •-----•-•--------------•-- Dat Application Approved BY r' `c' .. •- ------------------- .�' 2-'rye ............... Date Application Disapproved for the following reasons-------------------------------------------------------------------------------=--------------------------•---- ....•---------------------------------------•--------------------------------------------•-•-----•--------••-•--•---•---•--•--•-------------•---•••-•---••••-•----•-•••••-•-----...-•--•-.. ............ Date PermitNo......................................................... Issued-------------------------------------------•--•-------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEAL t O F...... ....................... TrrfifirFatr of &-inaptiFanrr THIS IS TO CER TIF atAe Individual Sewage Disposal System constructed ( " ) or Repaired ( ) by . . .. = ----- f •--- +. / staller at l_�e_... r � a E' err-- -= has been installed in accordance with the provisions of LE //5 of The State Sanitary Code as described in the application for Disposal Wor Construction Permit No��_`.___-�1_s dated'.:''7' .. r THE ISSUANCE OF -4S CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE y SYSTEM WILL FUNCTION SATISFACTORY. b DATE............................... 1� _� ? _..._............_. Inspector..._.... �"'? .............. rr THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT .. �y ............OF..... ..... .. .. . ... . .+ •:............... No......................... FFE........................ Uifivnoal Works Tomitrurtion ramit Permission is herebygranted -• - g �`"=----- to Const c``t��O or air ) an In ' wge D sp sal System at No. I -l ' -+ - " - Street as shown on the application for Disposal Works Construction i it No 11....... Dated..Z y_2--`y ....... Board of Health DATE.... .......................... FORA 1255 HOBBS & WARREN, INC., PUBLISHERS �.,... - , - W " ` • " GUM ���� s r � �� Su,�So14. sugsalL• At -=s00 ' v 9q C i ;cam c IO I 16, . � P,eo P• .LQT SroNE ,o���: LUT o/ 99 �94 sz5 6 lot. • PezoR �,eDy. 8z. L 144° 87. �f4' 'ilo.B, MO W,49 7 AVCGUcJ TE .5 7T /--/ O , E 5.01 ` - - ze_ 7-o i.,. N /eEeo/eDs SCALE ; TO WAI WA TER 16 F9 VA / L A.8 L E /A/SP. 'e. 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