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HomeMy WebLinkAbout0078 BRISTOL AVENUE - Health 78 Bristol Ave Hyannis A=291-144 o Commonwealth of Massachusetts . ` Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name information is required for every Hyannis MA 02601 1-23-13 page. Cityffown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information `��pnlurulup� on the computer, OF use only the tab �� key to move your 1. Inspector: o�� .• 9�y cursor-aonat James D.Sears JAMES kee the return Name of Inspector :-+ Y- Capewide Enterprises,LLC * * reE Company Name % _ I V: ci 153 Commercial Street rNSPE���.�`�� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 _S1623 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.060).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1-23-13 pector'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 report to the appropriate regional office.ofrtkre D P. The original should be sent to the system owner and copies sent to the buyer. if applit able?and t a 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 conditionUs of�usy'p tjl 319visM9 Jo NIA01 L& d I f 3 t5ins-11110 This 5 Official Inspection 161 TM urtace Sewage Disposal System•page 1 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Bristol Ave. Property.Address Aaron Margolin Owner Owner's Name - information is required for every Hyannis MA 02601 1-23-13 page, City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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 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): i tSins•11110 Tale S of.ldal Inspection Fom.:Subsurface Se%op Disposal System•Page 2 of 17 Commonwealth of Massachusetts y Title 5 .0ificial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name ` information is required for every NI Hyannis A 02601 1-23-13 page. Cityfrown 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): ❑ 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 tltU Tale 5 Offidal Mspedion Form:Subsurface Sewage Disposef System•Page 3 of 17 Jw l L`t I J V-7.`tf-p Y' ' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 78 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name -- information is Hyannis MA 02601 1-23-13 required for every page. CltyRown 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 eoo*W is less than 6° below invert or available volume is less than Yz day flow u9ns-11110 Title 5 Offidal ON"Ciion Form:Subsurface Sewage Disposal System-Page 4 of 17 v c• i �-r i v vv.��t.. r•- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name information is required for every Hyannis MA 02601 1-23-13 page. Cityrrown State Tip 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 coliforrn 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- 1 0,000g pd. ❑ ® 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•11110 Title 5 Ofridal kspeulon Form:Subsurraoe Sewage Olsposal System•Page 5 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 78 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name i iquiredonis for every re Hyannis MA 02601 1-23-13 quired page. Cityrrown State Zip Code Date of Inspection C. Checklist i 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? i ❑ ® 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? i ® ❑ 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•I WO Tile 5 official Ins2selion Form Subsurface Sewage Disposal System•Pape 6 of 17 i • .rail c-r iv va.-rvN r•• Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron.Margolin Owner Owners Name information is Hyannis MA 02601 1-23-13 required for every �._ page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal tank D.Box and two chambers. Number of current residents: 2 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 ears usage 2011-9,00o Gaps . g ( Y 9 (9pd))' 2012-43,500Ga1's Detail: Sump pump? ❑ Yes CK No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11110 Mda 5 Waal Inspecdm Fortn:Subsurface Sewage Disposal System-Page 7 or 17 i Commonwealth of Massachusetts Title 5 official Inspection Form A Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron Margolin _ Owner Owners Name -� information is required for every Hyannis MA 02601 1-23-13 page. Cityfrown 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: NA 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•11/10 TWO 5 Ofrrdal frispection Form:substaface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name information is Hyannis _MA_ 02601 1-23-13 required for every y ___. 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: 1996 Permit # 96- 177 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 30" 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.): Pipeing is 4"PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 22"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 1500 Gallon Precast Dimensions: Sludge depth: t" t5ins•11110 Title 5 OftW Inspection Form Subsurface S&Asge Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name — requit requited is Hyannis MA 02601 1-23-13 requited for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29' Scum thickness 0„ -- -- -- -- Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 and covers at 22" below grade in and outlet tee's. No sign of leakage or over loading. 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 15ms•11110 Title 5 Olndal hwedim Form SubsuRace Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron Margolin _ Owner Owner's Name information is requ(red for every Hyannis MA 02601 1-23-13 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.): .A h' 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: p. Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dale Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 JQ11 L-t 1 j%Jv.-t-tv �/• L Commonwealth of Massachusetts Tithe 5 Official Inspection Forrn Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name - requiretionis y H annis MA 02601 1-23-13 Required for every page, Cilylrown State Zip Code Date of Inspection D. System Information (cost.) 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.): D Box is 16"x16"-30" below grade w/two lines out. Box is clean and solid, No sign of over loading or solid carry over. r Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in.working order. ❑ Yes ❑ No i . 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. t5lns-1 ill 0 Tille 5 Official ins pection Fomt: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 78 Bristol Ave. Property Address Aaron Margolin _ Owner Owner's Name information is Hyannis MA 02601 1-23-13 required for every page. City/Town State Zap Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields . number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 500 Gal dry well chambers. Chamber's are 3'below grade wl one cover at 22". Chamber's are dry and clean. No sign of over loading or solid carry over. 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-11110 Tdle 5 Offidal InspecEon fomr 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 78 Bristol Ave.. Property Address Aaron Margolin Owner Owner's Name information is Hyannis MA 02601 1-23-13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids - — -— Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ISMS•11110 T2e 5 Official ins3edon Fortre&tisulaw Sewage Disposal System Page 14 of V Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Bristol Ave. _ Property Address Aaron Margolin Owner owner's Name information is required for every Hyannis MA 02601 1-23-13 page. Citylrowm 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 Gins•11/16 Title 5 Ofridel hupedlon For:Subsurface Sewage Oisposar System•Page 15 of 17 Assessing As-Built Cards Page 1 of r TOWN.OF BARNSTABLE !J LOCATION `� l'I.i,v,+ eve SEWAGE 177 VILLAGE ASSESSOR'S MAP Bt LOT Z /_ INSTALLER'S NAME dr PHONE NO.—,#KtA-*Z0 2tt) SEPTIC TANK CAPACM 15'00 64 L LEAC qG FACII=. (type)Sao GK.I L.sr�. (sin)C?..i Xis a NO.OF BEDROOMS B=ER OR OWNER �Tz4' SJ PERMPTDATE:S-7-96 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted droundwater Table,sad Bottom of L=cbing Facility Fee Pfmte Want Supply Well and Leaching Facility (if any wells exist on site or within 200 feet of leaching facility) Fee Edge of wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) F Ftunished by. 07 S' '�6 ,bb� �96t `�'�• b' O O O :4'town.bamstable.ma.uslAssessing/HMdisplay.asp'mappar--291144&seq--1 8/2512.01 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 78 Bristol Ave. Property Address Aaron Margolin Owner Owners Name information is Hyannis MA 02601 1-23-13 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 1 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 propertylobservation 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: Auger Hole 5' below bottom of leaching no G.W. Auger Hole at 10' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ms-I111G Title 5 official hspeuion Form:Subsurface Sewage Disposal System-Page I s of 17 i r• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 78 Bristol Ave. Property Address Aaron Margolin Owner Owners Name — information is required for every Hyannis MA 02601 1-23-93 page. Citylrown 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 i •t5iins-1'.110 Title 5 Official Inspection Forth:Subswface Searage Disposal sysiom-Page 17 of 17- , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 Bristol Ave. Property Address Aaron Margolin Owner Owner's Name information is required for every Hyannis MA 02601 1-23-13 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way-Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms ��uUuunur� on the computer, use only the tab 1. Inaperor: .l �`tH OF key to move your .Z cursor-do not ��; G use the return James D.Sears _�, JAM ES .:m key. Name of Inspector o - Capewide Ente rises,LLC * :'* t/fl. I I Company Name • 153 Commercial Street 4e& . fNSP����o`�� ComparryAddress Mashpee MA 02649 City/Town state Zip Code 508-477-8877 _S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the infommation reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Falls ❑ Needs Further Evaluation by the Local Approving Authority 1-23-13 pecbrs Sfgrteture Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform In the future under the same or different conditions of use. Rine•11r10 Thle 5 Of6Nel tnepxtion Fam Ufta feoe 3"$go Disposal syswm T Page 1 of 17 C ..� .g As-Bullt Cardsr.. , Ass Sinv Page 1'of • i f � 'DOWN OF BARNSTABLE LOCATION 7 eme sEwAGE#9d 17 7 VULA ASSESSOR'S MAPdt LOT Z /— r INSTALI.FB'S NAME dt PHONE NO. 20 y SEPW TANK CAPAMY JJ00 C-4 tr L.EAcH NO FACiz lrsr: (m)sae 1wi 66 4,,2G2 (sire)aj-x-2J-xa � - NO,OFBEDROOMS BUD DER OR OWNER PE.RM7TDAM-5--719 COMPLLANCE DATE: .. Separation Distance$etv=the: Maximm Adjusted droundwater Table mod Bottom of Leaching Facility Fee PlivM 111W Supply Well and Leaching Facility (If any wells exist an site or within 200 feet of leaching facility) Fee FAIP of Wetlnad mad Leaching Facility(If any wetlands exist within 300 feet of leacbiog facility) q F Furnisbed by 7� ibb� � �` ��• O O O s-7V t t , r � / :4'town.bamsfable.ma.us;Assessing/IJA4display.as p?mappar=291144&seq=1 8/251�o t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: 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 p key. DOUGLAS A BROWN INC Company Name P.O. BOX 145 Company Address CENTERVILLE MA 02632 Cityrrown State Zip Code ca [508-420-4534 S14297 E� rv) Telephone Number License Number 13.11Certification � Irtifjr that I have personally inspected the sewage disposal system at this address and that the L&I r - P iY P 9 P Y _ information reported below is true, accurate and complete as of the time of the inspection. The inspection 0 c, wa`s=performed based on my training and experience in the proper function and maintenance of on site se4Qe 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 8/25/11 4nspectoe�X"ign.ture Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 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 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cityfrown 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 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): ��,�•09lOo Title 5 Official lnspef%on Forwr Sutauffax Sewage Disposal System•?age 2 of 1 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cdyrrown 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): ❑ 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 Forme Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 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: i 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 Y2 day flow t5ms-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. City/Town State Zip Cade 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. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either`yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat, or answered'yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09i08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cltyrrown State Zip Code Date of Inspection C. Checklist I 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 ❑ Z 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): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Vo!untary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cltyill own State Zip Code Date of Inspection D. System Information Description: SYSTEM CONSISTS OF A 1500 GALLON SEPTIC TANK D-BOX AND 2 500 GALLON CHAMBERS SURROUNDED WITH STONE Number of current residents: 1 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)): Detail 09----156 2010----187 Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ms-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Volunta.y Assessments 78 BRISTOL AVE Properly Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. CityTrown 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•09/08 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 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: 1996 ACCORDING TO 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.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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•09i08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cityfrown 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 iDistance 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.): RECOMMEND PUMPING EVERY 2-3 YRS Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09I08 Title 5 Offgial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 eve a C' every page.e. �y frown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i I Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day iAlarm 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 (sins•as oa Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cityfrown 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 SIGNS OF LEAKAGE I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ms-09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 112 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forms a Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. City/Town Spate Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): CHAMBERS WERE OPENED AND WERE DAMP AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE 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 t5ms-09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sevrage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Properly Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•09A0 Title 5 Official Inspection Form:Subsurface Sewage Dsposal System•Pape 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposall System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS requiredfor MA 02601 8125/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) .Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•osme Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is HYANNIS required for MA 02601 8/25/11 every page. Cltyrrown 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: 5+OFF AS-BUILT CARD 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage l7isposal System•Page 16 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 78 BRISTOL AVE Property Address ZAPPALA Owner Owner's Name information is required for HYANNIS MA 02601 8/25/11 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•09M Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Pape 17 of 17 Assessing As-Built Cards Page 1 of 1 TOWN.OF BARNSTABLE LOCATION ��'/✓ I SEWAGE #l6_/,7 VILLAGE fV,1&,ffYl/.S ASSESSOR'S MAP&LOT L / INSTALLER'S NAME dt PHONE NO._L�f7��C071`�1 y 7/—y'3�P P SEPTIC TANK CAPACITY _ lfoo GK C LEACHING FACHM: (type)Soo (sir) NO.OF BEDROOMS BUILDER OR OWNER &ea V PERMITDATE:.SE`7-96 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Fee Private Water Supply Well and Leaching Facility (If any wells exist �1 on site or within 200 feet of leaching facility) /U Fee Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Fee Furnished by ;e r .J O O http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=291144&seq=1 8/25/2011 Ve/ TOWN.OF BARNSTABLE ? S� �'I'S / Ise -l �' LOCATION J � SEWAGE # !�6 7 7 i VILLAGE �`��'���✓` ASSESSOR'S MAP&LOT L INSTALLER'S NAME&PHONE NO. G��y��On�1 `l 7/ SEPTIC TANK CAPACITY I S-o0 G.t L LEACHING FACILITY: (type)Soo Ct &gdmS &,-j 62 (size)Q X-23'Xa I NO.OF BEDROOMS BUILDER OR OWNER Ilea IV PERMTrDATE:S—7--96 COMPLIANCE DATE: "' Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S 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 i within 300 feet of leaching facility) 11114 Feet Furnished by i ---� . �L� O 0 0 - - o� qq� q�, /j� ! ��a� . � �� , ' No. 9 91(e / Fee a' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplication for Xmopooaf *potem Cow6truction Permit Application is hereby made for a Permit to Construct( )or Repair(V10'an On-site Sewage Disposal System at: Location Address or Lot No. Owner's N e,Add ess and Tel.No. 7� Sri sfo�ave 7 r 6�� ��• ; eQ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -L��tlS 1' Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(_1�0 Other Type of Building B5/ 8�!Ge No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow f/O gallons per day. Calculated daily flows gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answy when ap licable) / !?C% B76S��lG� 2,3 q)e 2 Date last inspected: Agreement: The undersigned agrees to ensure the construction f 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 Certifi- cate of Compliance has been issued I. ' Boar of lth. Signed Date .� P/W Application Approved by Application Disapproved for the following reasons Permit No. Date Issued '� � ...r.-­7 Fee 410 _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplication for Miqual *pgtem Cow9truction Permit Application is hereby made for a Permit to Construct( )or Repair(VI"an On-site Sewage Disposal System at: Location Address or Lot No. Owner's N e,Add ess and Tel.No. 7g eti, �trlvile 7�r6�� y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 90,(7-d Zo,*i e'4o�5 lr Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(-16P Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures I Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) JY Dd9ll� SP %G 4�1 00 Zell iZ,3 Nk 2 'Date last inspected: Agreement: The undersigned agrees to ensure the construction oaf 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 Certifi- cate of Compliance has been issued t Boaz of H alth. Signed ---f Date Application Approved by Application Disapproved for the following reasons / Permit No. � Date Issued '�' '` ,� Y` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO C RT'.FY,that the n-site Sewage Disposal System installed( )or repaired/replaced( on by 0�7`D�p % r0,1.5247 for as /'% ve � o /S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated s f g.e� Use of this system is conditioned on compliance with the provisions set forth be]o — No. J ✓��� Fee / y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mi.gpo/gal *pgtem Con!5truction Permit f/ Permission is hereby granted to o l&/e�,;,/Z / GDA'y� to construct( )repair( tan On-site Sewage System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: � Approved •- � 1II ',` '� � � "� � /'fir`V J � � i r J I J � AGME PRECAST 520 THOMAS B. LANDERS RD., HATCHVILLE, MA TEL. (508) 548-9552 rl 102 PRECAST LEACHING CHAMBER 500 GALLON r 2-18A ; 500 GALLON LEACHING CHAMBER 1001, a E31 E2 '0 24" 102" CHAMBER IS TAPERED, WALLS ARE 3" THICK \ 4" KNOCKOUT - 20" DpAMETER COVER r \ 4" KNOCKOUT — 4" KNOCKOUT i 58" 4" KNOCKOUT i SPECIFICATIONS CONCRETE MINIMUM STRENGTH: 4,000 p.s.i. at 28 days REINFORCEMENT: 6 x 6 x 10 GAGE WIRE MESH DESIGN LOADING: STANDARD`�UNITS: AAS HO-10 a' H-20'(Optional,and available uponrequest) • f C:nM � ..�.. ..X 1...� � .. ;.. �..�-.�:..-.---•.._4..a.+-«+✓re. ..:.- .'.�-_ - _ �,_ ...k+,...-a+..!" 't•.�.,w.�-"'.r.•'R'.��:ff".:+• ,,' '�3 _7. e,,'s i .-x: 4`� ,y. ,w ,. - °�.T....� � _ � �; ��� .� �. J t r;r�' � �a , -.+ear AJ° 'i. ,. !• a,. J C, CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I, galorT J ��d�o i , hereby certify that the application for disposal works construction permit signed by me dated s-�7�9d , concerning the property located at 7q 6&isXP1 QPe meets all of the following criteria: ere are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system ✓ e observed groundwater table is 14 feet or greater below the bottom of the leaching facility : ere is no increase in flow and/or change in use proposed /,Th There are no variances requested or needed. I r SIGNED : 40DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTARLE N1,,MER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted].