HomeMy WebLinkAbout0105 BRISTOL AVENUE - Health -.� 105 Bristol Avenue
_ Iyannis . F/R
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TOWN OF BARNSTABLE
;LOCATIONar•-S le I Aue SEWAGE #
VILLAGE I�ygh ASSESSOR'S MAP&LOT o1 /U U
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
j LEACIaINc FACII.rrY: (ty ) / �.{� (size) 39 X/l x �'
size
NO,OF'BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of beaching Facility Feet
-Private Water Supply Well and.Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) // Feet
Furnished by
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TOWN OF BARNSTABLE
LOCATION 1 0 `� (SQL- I��1 SEWAGE# - 3
VILLAGE ASSESSOR'S MAP&PARCEL a CI J-f (78
INSTALLER'S NAM&PHONE NO. a K n k1 f-1 GrG y cx_ Q 5
SEPTIC TANK CAPACITY e5! [ lA 2La C)&)F 60 S
LEACHING FACILITY:(type) �� S�� ��(.. (size) k O W X qD L X
NO.OV BEDROOMS
OWNER
PERMIT DATE: t < <<p COMPLIANCE DATE: :2 1 r 7 Li&2
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) � Feet
FURNISHED BY S- CV C �C/A
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S
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No. � 'VA Fee
THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Mispo8AY *pstem Construction Permit
Application for a Permit to Construct( ) RepairV f Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. tO� C�S v-Q, Owner's Name Address,and Tel.No.
Assessor'sMap/Parcel '�`'``\15 _ N\Xkt dd�Ckr�
Installer's Name,Address and Tel.No. I J Designer's Name,Address and Tel.No.
5co ��,nu� ��3 Ord YC,r.-,o R �
s Wpd a Y`
Type of Building: v 0 b S
Dwelling No.of Bedrooms H Lot Size sq.ft. Garbage Grinder 4q
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) h,1 i (1 gpd Design flow provided 4 gpd
Plan Date 7 Number of sheets Revision Date
Title -
Size of Septic Tank -X� S�k c 1--b J �k ab 0 6 ype of S.A.S. 13C,%�,
Description of Soil l�pd� r�. /0 W SG Ll Q_d 111/�G � a_ d F•�(Q
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued b is Bo Health.
i
gn Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
-44
Permit No. Date Issued
_• VA V
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for Misposal bpstem Construction Permit
Application for a Permit to Construct( ) Repair'(./ Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ko,5-��(�S 1 Owner's Name.Address,and Tel.No.
' ,7/Assessor's Map/Parcel C, 1— IMI N N4 t �3 C�pv"
Installer's Name,Address and Tel.No. J Designer's Name,Address,and Tel.No.
s Cc. �� 3 o�d Yr-rn..o. SAC 2 \�c,c, sue,
ae0 1 a on e 7 a �`�
Type of Building: IJ 061
A I
Dwelling No.of Bedrooms l,( Lot Size9 53 sq.ft. Garbage Grinder(I y
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 1-,A gpd Design flow provided Y 4 4 gpd
Plan Date —] "� 1 1 In Number of sheets Revision Date
Title "
Size of Septic Tank 2b 4° pe of S.A.S. U �O GCA, C�n G�M6trS
Description of Soil M1 sr—--1 /C1 C,, x W 0,1 U89 �t.P
Nature'of Repairs or Alterations(Answer when applicable)_
o�
w
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued b is Bo Health.
' igne 71��
! Date
1
Application Approved by % Date ,
i
Application,Disapproved by Date
for the following reasons
Permit No. Date Issued
----------------------------------------------------------------------------------- - '- ------ ----------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(L/ Upgraded( )
Abandoned( )by C
at (b� c\ ��,1'��' r^ n ft has been cons ct d in ac�Vewith the provisions of Title 5 and the for Disposal System Construction PermitNo /
6
Installer L-\(�C ,y✓ Designer. �rnGt
#bedrooms ( 1l Approved desi %ow y J and
The issuance of this permit shall not be construed as a guarantee that the system will function designe•.
Date ( _ Inspector / u/ /) 1
- - = ---------------------------------------------------------=- =---------
No. 49 Fee�—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
Misposai &pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(V) Upgrade( ) Abandon( )
System located at (�` � tNV%T-A
i
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:Constructio t be om5pted within tliree years of the date of this permit.
t \>
Date Approved by
Town of Barnstable
' Regulatory Services
'Richard V.Scali, Interim Director
s►srear�as,
Public Health Division
nut' Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: I(0 Sewage Permit# a 01(2--?yjAssessor's Map\Parcel [ 0 v
Designer: !CM?i{EU k k A�S,�C Installer: 1540— T— to•
Address: 171 Address: US 0" YAW00T14 �Rh
g`�kiyu s , A. a2.<cc I
oZto�o
On l ` ( Co SC471- K was issued a permit to install a
(date) (installer) CC
septic system at 1 ("�� CA ��yCt�ase2Yon a design drawn by
(address)
dated 7 7
(designer)
certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State& Local Regulations. Plan revision or
a certified as-built by designer to follow. Strip out(if required)was inspected and the soils
?� were found satisfactory.
I certify that the system referenced above was constructed ict��lionce with the terms
of the RA approval letters (if applicable) n 0
• i max..
a, 5
nsta er's Signature)
NJ_
(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:1SepticTesigner Certification Form Rev 8-14-13.doc
Town of Barnstable
' Department of Regulatory Services
B Public Health Division Date
6 7
e
200 Main Street,Hyannis MA 02601
• rE[)
Date Scheduled b Time /1) Fee Pd. D
Soil Suitability Assessment for S7:fm
'Performed-By: 5T�9H-e— � A li—��s3 f� /�cWitnessed By: lle5
LOCATION&.CZENERAL INFORMATION
Location Address { t O�vner'e Name
V V r
Address t p�' �c C 15,)d 1_ ^, Q-Q-
Assessor's Map/Parcel: OJ I U Engineer's Name
NEW CONSTRUCTION ll REPAIR Tela hone# 3-61 0 VI311�
Land Use Slopes(%) C'`' Surface Stones
Distances from: Open Water Body w ft Possible Wet Area ` ft Drinking Water Well ft
Dmlhage Way ft Property Line 60-- ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pare tests,locate wetlands in proximity to holes)
�C—
V
A4-�o111
Wei,
Parent material(geologic) Depth to Bedrook Z¢:r 4-
Depth to Oroundwater. Standing Water In Hole: Weeping from Pit Fnee
v
Estimated Seasonal High Oroundwater
DE t RMINATION FOR SEASONAL•HIGH WATER TABLE
Method Used:
Depth Observed standing in obs.hole: In, Depth to soll mottles: ►n,
Depth to weeping from side of obs,hole: In, Groundwater Adjustment ft.
Index Well-ir Reading Dato: Index Well loYol Arj,thetor,,,,,_,,,..,Act►,Groundwater•1-eval,,,_,
PERCOLATION VEST Uwe 00
Observation ,
Hole# Time at 9"
Depth of Pero �O r Time at 6"
Start Pro-soak Time 0 C7=u�' Tima -6")
End Pro-soak L s
Rate Min./Inch . 2—
I
Site Suitability Assessment: Sito 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 Conseirvation Division at least one(1)week prior to beginning.
Q:ISEPTICU'BRCFORM.DOC
1 DEEP.OBSERVATION HOLE LOG Hole# I_
Depth from Sall Horizon Soil Texture Shcl Color Sall. Other
Surfacc(in.) (USDA) (Munsell) Mottling (Stnuctum,Stoners;Boulders.
. , tsistency.96'Oravel) •
S� ,, L 5
Zz- � L S •f o�.� fly
DEEP OBSERVATION HOLE LOG Hole#
Depth from Sall Horizon Soil Texture Soil Color Soil Other
Surfaco(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
' 5 10 ell— /,
l
i
DEEP OBSERVATION HOLE LOG Hole#
Depth from Sall Horizon Soil Texture Sall Color Soil Other
Surface(in.) (USDA) (Muuscll) Mottling (Structure,Stones,Boulders..
.1
DEEP OBSERVATION HOLE LOG Hole#
Depth from Sall Horizon Sall Texture Soil Color Boll Other
Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders,
Flood Insurance Rate Map:
Above 500 year Mood boundary No— Yes
Within 500 year boundary No= Yes '
Within 100 year flood boundary No., Yes
J)epth of Naturally Occurring Pervious hlaterlal
Does at least four feet of naturally occurring pervious materlal exist in all areas observed thrpughout the
area proposed for the soil absorption system? y'
If not,what is the depth of naturally occurring pervious material?
Ceiti� fication
I cerdfy that on (date)I have passed the soil evaluator examination approved by the
Department of Envir ental Protection and that the above analysis was performed by me consistent with .
the required trains ,e ertise and experience described in 10 CMR 15.017.
Signature Datts
Q:WHPTi NPBRCFORM.DOC
Town of Barnstable Barnstable
��°F T►IE T°��
Regulatory Services DepartmentBARNSUBM
Public Health Division I
i639. 10
'tifo r+a�' 200 Main Street, Hyannis MA 02601 200�
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1520 0000 1968 9699
June 24, 2016
Nikki Brian
107 Bristol Avenue
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 105 Bristol Avenue, Hyannis, MA was last inspected on
05/26/2016, by Sean M. Jones, a certified septic inspector for the state of Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of the 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Leaching facility with standing liquid level at or above the invert pipe (per
Town Code 360-20 h).
You are ordered to repair or replace the septic system within two (2) years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S. C
Agent of the Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\105 Bristol Avenue Hyannis.doc
I
of TME
Town of Barnstable
• snncvs-rnsLe,
039. ,� Regulatory Services Department
Public Health Division
200 Main Street, Hyannis MA"02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000) -
An"x" marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code
§360-9.1)
XLeaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
I Parcel Detail Page 1 of 3
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Logged In As: Parcel Detail Thursday,June 23 2016
Parcel Lookup
Parcel Info
Parcel ID 291-100 I Developer Lot LOT 1 ^A
Location 105 BRISTOL AVENUE I Pri Frontage 96
Sec Road SUFFOLK AVENUE I sec Frontage 94
Village Hyannis I Fire District HYANNIS
Town sewer exists at this address No I Road Index 0186
ra--�
Asbuilt Septic Scan: 7}
291100 1 Interactive Map
: gar
Owner Info
owner BRIAN, NIKKI co_ — I `
Owner
s een 107 BRISTOL AVENUE street2'
city HYANNIS state MA Izip'02601 (country
Land Info
Acres 0.22 I use Single Fam MDL-01 I Zoning RB I Nghbd 0104
Topography Level I Road Paved
utilities Public Water,Gas,SeptiC) Location
Construction Info _
Building 1 of i
Year 1961 --- I Roof Gable/Hi Ext Clapboard
Built Struct p Wall p 'I
20—woo
Living '1664 T I Roof'As h/F GIs/Cm Ac None I °
Area Cover p p I Type
2I
style Colonial wall Drywall Rooms 4 Bedrooms 2 BAS 12
FUS
Bath,Model Residential I Flont Carpet I Rooms 2 Full-0 Half I BMT 2 Is °
Grade Average I Type Hot Water I Rooms Total -Rooms
Stories 22 Stories Heat Fuel Gas F acid- Poured COnC.
Gross 26166
Area
i Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
8/26/2015 New Windows 201505498 $9,697 6/30/2016 REPLACEMENT
12:00:00 AM WINDOWS UVAL .30
10/10/2012 Insulation 201206164 $2,800 6/30/2013 INSULATE
12:00:00 AM
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=22655 6/23/2016
Commonwealth of Massachusetts OD
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave
Z
Property Address N3
Nikki Brian W
Owner Owner's Name ay
information is
required for every Hyannis Ma 02601 5/26/2016 =
page. City/Town State Zip Code Date of Inspection
fV
C?
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:out forms A. General Information /^ 2
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
S.M.Jones Title V Septic Inspection
Company Name
74 Beldan Ln.
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com SI4522
Telephone Number License Number
B. Certification
I certify that 1 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
5/26/2016
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
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
4otri- M
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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):
II
l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
i
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is Hyannis Ma 02601 5/26/2016
required for every y
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owners Name
information is Hyannis Ma 02601 5/26/2016
required for every y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
page. CityrFown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑, Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
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
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
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:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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-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
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
system installed 10/27/04 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Joint were ok, no leaks, vented through the roof
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 gallons
Sludge depth:
10"
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
i
Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
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
2'
Scum thickness 711
Distance from top of scum to top of outlet tee or baffle
3"
Distance from bottom of scum to bottom of outlet tee or baffle
6"
How were dimensions determined? opened covers, took
measurements
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 overdue for cleaning.Water level was even with outlet, tank was structurally sound
i
Grease Trap(locate on site plan):
Depth below grade: feet
i
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
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.):
I
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•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
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is Hyannis Ma 02601 5/26/2016
required for every y �
page. Citylrown 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.):
Water level was even with outlets but had stain lines that indicate it has been overloaded.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
s.a.s. consists of 5 3050 Infiltrators in a 39'x11'x2'trench. Leaching facility was video inspected from
d-box and was found to be full with 0"of available leaching.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r 105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
page. CitylTown 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
t ��K �-
._ 0 0'0 �,
I
I
. tar
A I.,- A) 26
s'exit- C Dyqtfd
15ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal Systen•Pace 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
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: 12'+
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:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M '< 105 Bristol Ave
Property Address
Nikki Brian
Owner Owner's Name
information is required for every Hyannis Ma 02601 5/26/2016
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
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Offcia.1 Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave) q-07y
Property Address
First Option Mortgage Corp. aq � - IUD
Owner Owner's Name
information is required for Hyannis MA 02501 3-10-08
every page. City/rown 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
1. Inspector:
Shawn Mcelroy
Name of Inspector
Shawn Mcelroy Enterprises
Company Name
29 Atwater Dr
Company Address i
E. Falmouth MA �4 02536n
Ctty/Town State 1 Zip Codes
1-568-495-0905 S13971 t l r
Telephone Number license Number C,
N �r
3
B. Certification N �;
r
1 certify that 1 have personally inspected the sewage disposal system at this addre and Omit the'�
information reported below is true,accurate and complete as of the time of the ins ection. The inspection
was perforated 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
3-10-08
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
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.
t5insp•OaW TO--5 Official @aspecFnn Fiormc Subswface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner owners Name
information is required for Hyannis MA 02601 3-10-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B„C,D or E/ahvays complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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.
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 exfiftration or tank failure is imminent.
System will pass inspecfi:on 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 Heatth):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp-08106 Trtlie 5 Official Inspection FomL Subsurface Sewage OiEposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Foram -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Name
information is Hyannis MA 02601 3-10-08
required for y
every page. Cityrrown Site Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cost.):
U1W
❑ 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 its 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•08/06 TM65,0 fidaf tbspec' Forcrx Subsurface Sewage Disposal SysLem-Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection' Form
Subsurface Sewage Disposat System Form -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Name
information is required for Hyannis MA 02601 3-10-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
C) Further Evaluation is Required by the Board of Health(cunt.):
❑ 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 Flow invert or available volume is less
than%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 portion of cesspool or privy is within 100 feet of a surface water supply or
❑' �' tributary to a surface water supply.
t5insp•08/06 Title 5 off vial tnspecAai 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
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Flame
information is
requi red for Hyannis MA 02601 3-10-08
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cunt.):
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 nit►ate 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 deterrni.ned that one or more of the above failure
criteria e)dst 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 It 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•08/06 Title 5Ofricial Inspection Farm:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Name
information is required for Hyannis MA 02601 3-10-08
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,
dimension,%.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.
13 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)]
i
t5insp•06/06 Tdte 5 OffxW hrspection Form:Subsurface Sevralge Dmposal System-Page 6 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal!System Form-Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Name
information is required for Hyannis MA 02601 3-10-08
every page. Cityrrown 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?[f yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available past 2 years usage(gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 1-08Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seatsipersonsisq.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-08= Fide 5 Official Unpecbm,form:.Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Dsposat System Form -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Flame
information is Hyannis
MA 02601 3-10-08
required for y
every page. Citylfown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: WA
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) (f yes, attach previous inspection records, if any)
❑ InnovativelAltemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed(if known)and source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp•08/08 Title 5 Official Inspection Form:.Subsurface Sew-age Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection dorm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Name
information is Hyannis MA 02601 3-10-08
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Building Sewer(locate on site plan):
Depth below grade: 28"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.):
Good condition.
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
--------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000 gal
Sludge depth:
8"
Distance from top of sludge to bottom of outlet tee or baffle 24"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 16"
How were dimensions determined? Tape
t5insp•06106 Tille5Off ialInspectionFom-Subsudace Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposat System Form -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner OwnePs Name
information is required for Hyannis MA 02601 3-10-08
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.):
Good condition with all baffles in place.
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
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•08106 Titre 5 Ofridall lbspecOon Form.,StdsurEace Sewage Deposal System•Page 10 of 15
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Name
information is required for Hyannis MA 02601 3-10-08
every page. Cityrrown 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.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box(f present must be opened) pocate 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.
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp-08106 Title 5 Of=W trtspeclion FormL Subsurface Sewage Disposal System-Page 11 of 15
I i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Name
information is required for Hyannis MA 02601 3-10-08
every page. Citylrown 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: 5-Infiftrators
❑ leaching galleries number.
❑ leaching trenches number, length:
i
❑ leaching fields number,dimensions:
❑ overflow cesspool number
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Good condition with no sign of back-up or break out.
t5insp-08f06 Title 5Official htspection Form:Subsurface Sewage Deposal System-Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposat System Form -Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owners Name
information is required for Hyannis MA 02601 3-10-08
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
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•08/06 Title 5 official Inspection Farm:Subsurface Sewage Disposal System•Page 13 of 15
,L
Commonwealth of Massachusetts
® Fitts 5 Official inspection Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�y 105 Bristol Ave (A.K.A. 107 Bristol Ave)
Property Address
First Option Mortgage Corp.
Owner Owner's Name
information is required for Hyannis MA 02601 3-10-08
every page. Cityrrown State Zip Code Date of Inspect-.'on
D. System Information, (cons)
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 binding.
I
A 9C4C
I �
II 0 A
`0 r♦ t.�
t5insp-08/06 'Me 5 Official lisped frnm:Subsurfaw Sewage Msaosal System-Rage 14 of 15
v
Commonwealth of Massachusetts
. �� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
105 Bristol Ave (A.K.A. 107 Bristol Ave)
f Property Address
f First Option Mortgage Corp.
Owner Owner's Name
information is required for Hyannis MA 02601 3-10-08
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (coot.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to 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 propertyfobservation 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:
Original design plans on file show no water at 121.
t5insp•08/06 We 5 Official,Ihspechm Fume:Subswface Sewage Disposal System-Page 15 of 15
y Town of Barnstable
OF THE 1pk
Regulatory Services
BA121,,,s,,,B Thomas F. Geiler, Director
MASS. .`0�
9. Public Health .Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax:. 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts,Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
not does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
`17 TOWN OF BARNSTABLE
LOCATInr;,�� Td� SEWAGE #
a
VII.%AGE s S ESSOR'S MAP & LOT t� I
INST,U.LER'S NAME&PHONE NO. �L
SEPTIC TANK CAPACITY / n C,
LEACHING FACILITY: (type) :30 5 �f- �i �T'� (size) 9 1CII t X
NO.OF BEDROOMS
BUILDER OR OWNER PERMITDATE: ° 10L// COMPLIANCE DATE: G y
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
.. within 300 feet of leaching facility) Feet
Furnished by
� I
� O
o.
r
No. T Fee Q
THE-COMMONWEALTH OF MASSACHUSETTS, Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes
01poYication for Mqu a l *pgtem Construction Permit
Application for a Permit to Construct( . )Repair CV/)Upgrade( )Abandon( ) ❑Complete System "vidual Components
Location Address or Lot No. 105 'pjQ�`�i�L A uENE*j Owner's Name,Address and Tel.No.
H 4)ANn11 S I 1.
Assessor's Map/Parcel I I Oo AM
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
OSCvtGe 15it-AY @.nvy�r1 GCS,
Type of Building:
Dwelling` No.of Bedrooms -4 Lot Size sq.ft. Garbage Grinder( / �-
Other Type of Building /VO fJ F- No.of Persons 4' Showers( pl�Cafeteria( 1
Other Fixtures LP&3fr p2='4 � TctlSr-) :,;1jSjk I l,iAt�wl(�4X
Design Flow 44O gallons per day. Calculated daily flow 4,5 4` 3(�p -gallons.
Plan Date ID lgaN 04 Number of sheets Revision Date "
Title
Size of Septic Tank Type of S.A.S. "Gal-!_c cil a`
l cju 4.1 ►vimLv ll t X 3$ -T26xSC%t
Description of Sorl"_
Nature of Repairs or Alterations(Answer when applicable) �O��C5C1
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 provisid 'of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss, by his Boazd of
Sig ed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. ���/�J-'�rZ62 Date Issued D
i.
No.�— � a EJpX� Fee Q
l� y' ~4. ma,
+ N�Rh.: Entered in computer:
E COMMONWEALTH OF MASSACHUSET _
' PUBLIC HEALTH DIVISION -TOWN OF'BARNSTABLEs SSAHUSETTS Yes
application for Mie;pogal *pMem Conelruction Permit
Application for a Permit to Construct( . )Repair V)Upgrade( )Abandon( ) ❑Complete System V/Individual Components
Location Address or Lot No. 105 _Be%STtZ)L p uE�1Ea Owner's Name,Address and Tel.No.
N MBA W i
Assessor's MMap/Parcel >)pririI S 1 a9 I (OO CAM E i
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Oho t S SQP-�n C swu k Ge j t1 ")Y E o v 1,Zb-,,
' CoU3 S3�o Sy ^ o`+ c�
Type of Building:
Dwelling No.of Bedrooms .4 Lot Size MCA sq.ft. Garbage Grinder
Other Type of Building h o tJ F_ No.of Persons - Showers(kel Cafeteria( V5"'
Other Fixtures _ l QA-rU(2-!e TrNFr`1 C_,majk1 l.0\v,. ?-r
Design.Flow -440 gallons per day. Calculated daily flow 4 S 4 3� gallons.
"Plan Date 1) Jam o4- Number of sheets ( Revision Date
Title C SC
Size of Septic Tannk Type of S.A.S. �� 'Cyl�e�r tom,/d' Fes•
Descriptionof,So � 1 i^ c�' r -�n 1 u 3 72 E7)1C A
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 Certifi-
cate of Compliance has been iss d bvithis Board o h.'
Sig ed Date lclr"_)�lw
Application Approved b 1 Date Ab IA OL
Application Disapproved for the following reasons
/ Permit No. Date Issued D
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE Y, th t the O -site ewage.Disposal System Constructed( ) Repaired ( )UpgradedX)
Abandoned( )by r
at S U D has been construct d in ccoodance
with e p vi i of Ti .and the for Disposal System Construction Permit No.9, t)d y—51,h dated I u
Installer ` Designer
The issuance of this permit shall not be construed as a guarantee that the , ste will lfunction as esi. ed.
Date Inspector S "
-- _.. . . OC`—'�/ � — S � --——--—————————--———————— ^. .. . . . .-
No. � Fee/422
I
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi.gpooal *pgtem Congtruction Permit
Permission is hereby granted jo C•nstruct( )R air( )Upgrade X)Abandon( )
System located at ��, K12 M7 &r/�2 `j / ,
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.
Provided:Constructi n must b completed within three years of the Cate of th7 e
Date: J Approve
117 TOWN OF BA.RNSTA.BLE
LOCATION �� TdL SEWAGE #
VILLAGE -S S ESSOR'S MAP & LOT_ 0 v
INSTALLER'S NAMF&PHONE NO. 4 >
SEPT(C TANK CAPACITY U�J
s t
~ I LEACHING FACILITY: (type) 0 OS � (size)
NO.OF BEDROOMS__ `
BUILDER OR OWNER
PERMITDATE: I 0-�COMPLIANCE DATE: y
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300'feet of leaching facility) Feet
Furnished by
0 D /,
<< A), _
i d
61
i 55Pc Cove,—
01/24/2015 00:39 FAX Z 002/002
Town of Barnstable
� Er Regulatory Services
= Thomas F. Cciler, Director
rMAU
public Health Division
E° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 10,127/04
Designer: Shav .Environmental Services. Inc. Installer: Robert Septic Services.
Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street
MA 02536 Yarmouth, MA
On 10/20/04 Robert Septic Service was issued a permit to install a
(date) (installer)
septic system at #105 a.k.a. #107 Bristol Avenue Iivannis MA based on a design drawn by
(address)
Shay Environmental Services Inc. dated 10/25/04
(designer)
_XX 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,
of MAS�n
CARMEN yG�
n 11er' ature) o E.
U SHAY
�} No. 11, 1
7 ,mr.Qn,� f _ s�NrTna1��
(Designer's Signature) (Affix DesigNEMIramp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS I Q M AND AS-
BUILT CARD ARE RECEIVED BY THE BAPNi STABLE PUBLIC HEALTH DIVISION,
THANK YOU,
Q: Hcalth/Scptic/Dcsigner Certification Form
OCT-27-2004 WED 11:55AM Ip; PAGE:2
LED INSPECTIC
41 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIROR'ME TTA�,I FFAIR
DEPARTMENT OF ENVIRONMENTAL PROTECTIO
r
o W
FAILED IN':% ION
e"
Lop
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
l05
CERTIFICATION
Property Address:—�BRISTOL AVE.HYANNIS,MA 02601 <Q�1_ b6
Owners Name: SMITH tiAF Z
Owners Address: 107 BRISTOL AVE.HYANNIS,MA 02601 `-- ��- -
OARCEL ; l 0.0
Date of Inspection: 10/22/04 LOT ;W ( _—�.
Name of Inspector: (please print) JOHN GRACI,INC.
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
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 mamten ce of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Tit 5(310 CMR 15.000). The system:
_ Passes
_ Conditional sses
_ Needs Furt valuation by the Local Approving Authority
X Fails
Inspector's Signature: Date: 10/22/04
The system inspector shall submit ac py of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspectioi 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.
Notes and Comments
SYSTEM FAILED TITLE V INSPECTION.MAIN CESSPOOL WAS PONDING WHEN DIGGING UP. LIQUID LEVEL
IS OVER ALL PIPES.OVERFLOW COMPONENT UNDER SHED-DID NOT EXPOSE-IN HYDRAULIC FAILURE
BASED ON MAIN CESSPOOL BACKING UP.
****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.
Title 5 Incnrntinn Fnrm A/1 S00nO 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 107 BRISTOL AVE. HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
SYSTEM FAILED TITLE V INSPECTION. MAIN CESSPOOL WAS PONDING WHEN DIGGING UP. LIQUID
LEVEL IS OVER ALL PIPES.OVERFLOW COMPONENT UNDER SHED-DID NOT EXPOSE-IN HYDRAULIC
FAILURE BASED ON MAIN CESSPOOL BACKING UP.
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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: n/a
n/a 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
- distribution box is leveled or replaced
ND explain: n/a
n/a 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: n/a
r -
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 107 BRISTOL AVE. HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
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.
_ 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility 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:
n/a
I
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 107 BRISTOL AVE.HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS
or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than %z day flow
X Required pumping more than 4 times,in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to'a surface water supply.
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility 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.]
YES (Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I WPA)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.
a
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 107 BRISTOL AVE.HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection ?
i
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out
X _ Were all system components,excluding the SAS, located on site
X _ 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?
X _ 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:
Yes no
X _ Existing information.For example,a plan at the Board of Health.
X _ 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(3)(b)]
S
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 107 BRISTOL AVE.HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
FLOW CONDITIONS
RESIDENTIAL
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: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd))r.Rfer C J
Sump pump(yes or no): NO 3
Last date of occupancy: n/a b
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sqft,etc.): n/a
Grease trap present(yes or no): NO
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: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
_Septic tank,distribution box,soil absorption system
X Single cesspool
X 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)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components, date installed(if known)and source of information:
1964 PER OWNER
I
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7-of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 107 BRISTOL AVE.HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: (locate on site plan)
Depth below grade:')
Material of construction'o ncrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: n/a
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
Page 8•of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 107 BRISTOL AVE.HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
NONE
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
i
R
Page 9-of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 107 BRISTOL AVE.HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
OVERFLOW CESSPOOL overflow cesspool, number:
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
DID NOT EXPOSE,OVERFLOW LOCATED UNDER SHED.MAIN CESSPOOL WAS PONDING WHEN
DIGGING UPAND LIQUID LEVEL IS OVER ALL PIPES INIDCATING THE OVERLFOW CESSPOOL HAS NO
EFFECTIVE LEACHING LEFT AND IS IN HYDRAULIC FAILURE.
CESSPOOLS: X(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: 1
Depth—top of liquid to inlet invert: 0"
Depth of solids layer: I"
Depth of scum layer: 1"
Dimensions of cesspool: 6'X6
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
SOIL WAS PONDING WHEN DIGGING UP,LIQUID LEVEL IS OVER ALL PIPES.SYSTEM FAILS
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n/a
Q
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 107 BRISTOL AVE.HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
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.
in
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 107 BRISTOL AVE.HYANNIS,MA 02601
Owner: SMITH
Date of Inspection: 10/22/04
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
i
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT.
it
t
-4- SCHEDULE ALL OUn FROM TW'
4�P. 1, .
TIO'
*NOTE: ALL`:PIPES ARE TO 8 J SEc N, DtsTRsuTioN9wsHALL'9E
-ET PIPES
CONCRM 60"
iEA CHING S SET LEVEL RA AT'LEAST 2 FT.
40 C.
't A
10:min. - .SYSTEM.
in.,from PR OFILE VIEW.
VENT-,PilP �6�1_eost'24 inches 1:010' "Zi-
ion se to seotic.tank
1xisting 'roun�at �Q'u rl 7
bs
chedule 4 PVC w/Chartoal Odor Filter stud .
-noN `(Assurned) SOP66 ton r-'-A F�:�..-,
100.00, k sit S Not Ao Scale 2'
ELEV TOP OF FouNDA V� Z�
w in"of finlehiod
Wash"pedifft"
Grade over D-Box.t- MOO over SAS 9&00
2iedsam Septic Tank �9&00 KkX=
15.5" INLETIlET .
A Ud Cvta�.d Stiww
00
poem
S 0.02 -10tP
IN"del J11"
DIST BOX
WAi
3 HOLE H T
FEED-Elev.or Gralot
.3 mum ve To FEED
EXIST.
or 4 SCH. 40�Tise
I.IMU A 0.01* per foot Exist PIPE
-35'
Tl PLAN SLCTION :. 'COOSS ' SE
nm EXIST.roumK SEPTIC TANK
DasT.niulm UJ
-H-10 6 c ON
0.soft 0 24 Ei4vtive
** ; 1 11) , I I Effective Depth SIdeslat,
4, . 1� 11 0)
CONCRETE nAL IFOUNIM two)
ol
CartaeRnare oil 0
,�, Units 0 6.251 31.25 "BOX 3 HOLE -H-10 DISTRIBUTION
To 41�lifi
6 In.of 3/4'-1 1/:r lf� I - -
0 . , _, . 1.25
SYSTEM..PROFILE > 4 .5, NOT TOSCAUE�Ir.compacted stone
CA
kisOT 4 , a
Not to scol�
38
4
r Effective Width Effective Length
GENERAL `NOTES,
compacted stone SOIL ABSORPTION SYSTEM <SAS)'-
1 Contractor is' responsible for DI safe notification
COMPONENTS MOST HAVE RISERS TO WITHIN 6" BELOW GRADE A I�; I - I . 11 1 .1 . - 1 . 1 1 1
Bottom of Test Hale 1 Elov.-86.00 o and protection
No Groundwater Observed 0 144' M INFILTRATOR MODEL�'a05O (H-20 LOADING)/ SUMNER &,DUNBAR all underground utilities and pipes.
2. The septic,tank' on distr�t
(OR:EQurvALtNT) ylion box. shall be set
stone.
level,on '6" of 3/4 2
'OVERALL HEIGHT OF INFILTRATOR IS 30* /EFFECTIVE HEIGHT IS 2e
NOTE: Backfill should'be clean sand or gravel with no
stones Over,3",.Am.size.
stem"I ' b' ct to inspe tion durin' installation
4. This Sy is su Je c
9
Shay Environmental Services, Inc.
5. by, CarmenE..
The contractor shall-install,this system in accordance
with Tiltle V of the Massachusetts state code, the approved plan
PERCOLATION TEST and Local Regulations
6. If, during installation the contractor encounters "any
Date of Percolation Jest: OCT., 14-2004 soil conditions or site conditions that ore different
Test Performed By- CARMEN E. SHAY, R.S., C.S.E. LOT #2 from`those Shown 'on the 'soil log or in our design
Results Wltnessed By: WAIVER ,( per Barnstable B.O.H.) installation must haft & immediate notification be
EXCAVATOR: UNKNOWN �0 made to Carmen' E., Shay - Environmental Services, Inc.
0:1 Ih i ' machinery shall drive over the
Percolation Rate-,,� Less Than 2 MPI 0 247 7. No vehicle or �heavy�
Failed septic 'system unless noted as,,H-20 septic components.
TEST 'HOLE
10 LeachLeach ELEV.- 98.100
-------- 8. Install, Tuf ite gas baffles or equals on all outlet tee ends.
PL PW\ 9.,All 'Distribution Lin I es diameter Schedule 40 NSF PVC pipes.
shall be 4* d
104.65' 0
10. All solid piping, tees fittinqs� shall be 4" diameter
Test Hole co
No. 1 U- CV Schedule .40 NSF '• PVC pipes with water tight joints.
ELEV. 11. 'Municipol Water. is Connected to ALL OF The Residence and Abutting
DEPTH SOILS 0 Properties Within' 150 Feet.
98.00
t7
Loomy 0 THE PROPERTY LINES ARE APPROXIMATE AND
Sand
EXIST. 1000 gal. -10.51 COMPILED FROM 'THE,SURVEY PLAN GENERATED BY
6. 10 V 4/2 0 Septic Tank ------ WHITNEY & BASSETT. ENGINEERS OF BARNSTABLE, MA ENTITLED
A 97.50 SUBDIVISION PLAN OF LAND IN BARNSTABLE, MA
Loamy 2 1/ DECK LC PLAN #,,14024-D,SHEET 1, - DATED DECEMBER 1958
Sand 0 1 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
10 YR 5/6 40 Mil Liner To Extend IT SHOULD BE USED FOR NO 'PURPOSE OTHER THAN
6' B. 94,50 THE SEPTIC SYSTEM INSTALLATION.
From Elev. 94.50 to 92.50
Med. An+RAL-Gkl-HNE
Exis TiNc
sand and . 10 feet beyond foundation
4 BEDROOM Q I EXISTING LEACH PIT TO BE PUMPED OUT AND
7-5 Y 6/6 & REMOVED TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION
42"-144* C, 186.001 0 HOUSE
NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
Jf05
FROM THE EXISTING' LEACH PIT TO BE DISPOSED
OF AS°PER BOARD OF HEALTH SPECIFICATIONS.
NO WETLAND
S ARE PRESENT 200' OF THE PROPERTY
ASSESSORS MAP 291, PARCEL 100
I'LOT #I
I ASPHALT LEGEND
13,260 Square set DRIVE*Ayi�
Perc #1
DENOTES PROPOSED
Depth to Perc: 42" to 60" F1_0 4-_711
SPOT GRADE
Perc Rate= Less Than 2 MPI
Groundwater Not Observed
% T�) DENOTES EXISTING
No Observed ESHWT X 104.46
:3 SPOT GRADE
ADJUSTED H2O Elev. None 82. 17' -1
va P F
PL
PROPERTY LINE
PROJECT BENCH MARK
98
PROPOSED CONTOUR
TOP OF FOUNDATION 96P
ELEV. 100.00 (Assumed)
13 -1 1� wo_fl� A VE72V LT-E7 - - - -- -97 EXISTING CONTOUR
(40 FOOT RIGHT OF 'WAY)
DEEP TEST HOLE &
2-tar DIAM. ACCESS MANHOLES PERCOLATION TEST LOCATION
6 FOOT STOCKADE FENCE
INLET -InE
OUT FT
PLOT PL
A N
THE ACCESS COVERS FOR THE SEPTIC TAW,
OtSTRIBUTION BOX AND LEACHING COWPONENT
SET DEEPER THAN 6 INCHES BELOW FINISHED
GRADE SHALL BE RArWD TO WITHIN 6",OF OF PROPOSED SEPTIC SYSTEM UPGRADE
STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. PREPARED FOR
INSTALL TLF-ITTE GAS BAFFLES OR EQUALS
PLAN VIEW
LOdAL UPGRADE VARIANCES REQUESTED: MR . 'WILLIAM SMITH
3-24* REMOVABLE COVERS
1. Request a varciance to reduce the distance from the SAS to the AT
Foundation from 20 feet to 16.0 feet for Maximum Feasible Compliance.
r # 105 BRISTOL AVENUE(cka # 107)
. _ ._ A 40 Mil Rubber Liner to Be installed as Shown.
3" min. clearance 14LET`7'r'*_.
JT
INILET--C=- rn�'Fl r min. inlet to outlet HYANNI'S ' MA
OUTLET
%
5' -7 Design Calculations V��A OF 4fq PREPARED BY:
• -00 a-111.0114 Liquid depth Number 'of Bedrooms: 4 Equivalent to 440 Gal./Day (440 Gal./Day Min. per Title V)
arbage Grinder. No G
4.9 1 y RHEY E. SHAY
Leaching Capacity Proposed: 330 Gal./Day Minimum (Win. Per Title V) (1A
1:,P� !�-!72A 4' Septic Tank 2 x 440 Gal./Day,= 880, USE EXIST. 1,000 'GAL Septic Tank., 0 20 :40 50 KENVIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch
CROSS SECTION END-SECTION Bottom Area: 0.74 got/sq. ft. x�' 418sq.'ft. = 309.32 gallons� P.O. BOX 627
Sidewall Area: 0.74 gol./sq. ft., x 196 'sq. ft. = 145.04 gallons GIST EAST FALMOUTH, MA 02536
Providing: - 454,36 gallons -"[VITA N
TYPICAL 1000 vtALLON' SEPTIC TANK SCA ' 1 "=20' TEL/FAX 5081-548-0796
EFFECTIVE L
ME
KNOCKOUTS
,914
t ,F� 82.
Use: (5) HIGH, CAPACITY INFILTRATOR CHAMBERS, HAVING, A 2' DEPTH, LE:
NOT TO SCALE SCALE: V'=20' DRAWN BY:, CES DATE: OCTOBER 22, 2004
(3' W x 6.25' L) TO BE USED WITH 3' OF WASHED STONE ON THE SIDES AND
3.75' OF WASHED STONE ON THE ENDS. CT#SD649 ET 1 OF 1
PROJE FILENAME: SD649PP.DWG SHE
ACCESS COVERS MUST BE WITHIN 9" MINIMUM. MIN 2" OF NE INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NO TES :
6" OF FINISH GRADE `6' MAXIMUM COVER OR FILTER FABRICABRIC
FIRST 2' TO 1 INVERT OUT SEPTIC TANK: 96.86 DESIGN FLOW:
BE LEVEL CHARCOAL FILTER
4'V WITH INVERT IN DI ST. BOX: 96.77 4 BEDROOMS AT 1/O G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION
101.2 18' MIN INVERT OUT D I ST. BOX: 96.6 BEDROOM EQUALS 440 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
4" DIAM PIPE 97.4 3/4" - I I/2" DlA INVERT IN LEACH CHAMBER: 96.4
DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER: 94.4 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCHMARKS
96.86 96.6 2' H-20 El
BAFFLE OAS 96.77 $ 96.4 94.4 ADJUSTED GROUND WA TER: N/A SEPTIC TANK REQUIRED:
SET. SEE SITE PLAN.
3 OUTLET 4-500 GAL LEACHING CHAMBERS OBSERVED GROUND WATER: N/A 440 G.P.D. X 20OX - 880 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND
EXISTING D-BOX W/2.5'± STONE AROUND. 10'N x 40'1 x 2'd BOTTOM OF TEST HOLE *1 : 91.2
SEPTIC TANK PROVIDED: 1500 GAL. EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL
1500 GAL H-20 ESTIMATED GROUNDWATER ELEVATION CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
SEPTIC TANK 6" CRUSHED STONE OR FROM AREA GROUNDWATER MAPS 79.0± SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
COMPACTED BASE
DES ION PERC RATE l 5 M l N/l NCH
PROFILE : NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFF 1 C OR GREA TER
440 GPD / 0.74 GPD/SF - 595 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH-
N STANDING H-20 WHEEL LOADS.
PROVIDED: 4-500 GAL LEACHING CHAMBERS
W/2.5'± STONE AROUND. A-600 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR
600 S.F. x 0.74 - 444 G.P.D. APPROVED EQUAL.
C8/DH FND SOIL TEST PIT DA TA& 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
PRECAST CONCRETE OR APPROVED POLYETHYLENE.
INDICATESPERCOLATION
_� /ND/CA D BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER
PERCOLATION _ OBSERVED
TEST ? GROUNDWATER TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE
TP s1 Ps15080 TP 02 OUTLET.
HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR
o ro1.2 0- /01.2 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE".
A LOAMY IOYR SAND 416 A LOAMY IOYR SAND 4/6 1-888-D l G-SAFE AND THE LOCAL WATER DEPT.
5' - - - - - - - - - - - - - - - 100.8 6" - - - - - - - - - - - - - - - 100.7 FOR LOCATION OF UNDERGROUND UTILITIES.
(, 99 B LOAMY IOYR B LOAMY IOYR
1, VV UP 50-Sli '6 y SAND 5/8 SAND 5/8
22' - - - - - - - - - - - - - - - 99.4 24' - - - - - - - - - - - - - - - 99.2 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
\ Cl M
SAND AND 6/6 SAND AND 6/6 EDI UW IOYR C/ MEDI UM IOYR DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
GRAVEL GRAVEL OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE
9z3.s /J / B \ CONSTRUCTION INSPECTIONS.
40'
00
�..� 1oo_a
/ N $2• 120 NO WATER 91.2 120' NO WATER 91.2
DATE: JUNE 21. 2015
TEST BY: STEPHEN HAAS
\ WITNESSED BY: DAVID STANTON
CB/OH FND / q�(� // `� PERC RATE: C 2 MIN/INCH
m 1 '
100.9 V AR I ANCES REQUIRED .-
TITLE 5. MAXIMUM FEASIBLE COMPLIANCE
\\ \� \\ EX►sT�N pWO-L SECTION 15.211: (1) MINIMUM SETBACK DISTANCES
pM
gEpRp r oo/5 20 oarc m� CRIDH FND 20. I S REOUI RED BETWEEN THE SAS AND THE FOUNDATION. 18' IS PROVIDED.
L 0 T I z AN 2' VARIANCE IS REQUESTED.
9. 937± S.F. SECTION 15.221: (7) GENERAL CONSTRUCTION REQUIREMENTS FOR ALL SYSTEM COMPONENTS
\\ \ THE TOP OF ALL SYSTEM COMPONENTS SHALL BE NO DEEPER THAN 36" BELOW GRADE.
A VARIANCE IS REQUIRED FOR THE SAS TO BE 4'± DEEP.
O \ \ Ap
EXISTINGt\
O \ \ SEPTIC TANKTP
\ CB/SEAL ND
RV
D-BOX
0
a
m \ BM. ON SONOTUBE " ° _�11
\ \ c
.� ,L4,. d+ 3's •,d,''
z \ EL-99.l9
m �\ EXISTINf-
4-500 � LLON j
'SAS �04- Q�" LEACHING\CHAMBERS +101.6 1 SEPT C S Y S T E M D E S / G N
I 5 66 \ W/2.5'r STONE AROUND
I I I i
l OS BR / S TOL A VENUE . MAP 20 / . PARCEL / 00
ROUTE 28 `, \\`, BA R N S TAB L E . H YA N N l S ) MA .
\
PREPARED FOR :
LEGEND N l K K l B R l A N
s oL pvE �� -0 CB CONCRWATERELENEDUND
R N O SCALE l - 20 J U L Y 7 . 2016
HYDRANT N
Locus GAS LINE STEPHEN A . HAAS
s s OHW- OVER HEAD WIRES
LIGHT POST y \ ENGINEERING , INC
--E- UNDERGROUND ELECTRIC LINE / �� o _ P . O . B o x 16
-T- UNDERGROUND TELEPHONE LINE /A
4 Sc. u t h D e n n i s MA 02660
( 0/ t�P --CTV- UNDERGROUND CABLEVISION LINES '� ( 508 ) 362-8 1 32
+40.4 SPOT ELEVATION
LOCUS MAP 0 /0 20 40 . _..••40-••-•._ EXISTING CONTOUR
40 PROPOSED CONTOUR JOB NO: l 6-04/