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HomeMy WebLinkAbout0115 CARLOTTA AVENUE - Health mar o to Road [yannis A== 248 - 229 r7rA 1 TOWN OF BARNSTABLE LOCATION //r SEWAGE#. VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. /3�. /<,�' 10�1�- ,l'✓ �'1P-l�Z�' SEPTIC TANk4CAPACITY LEACHING FACILITY. (type) C,11ft� r C/ (size) 3'�C ?y 7 NO. OF BEDROOMS 3 ' OWNER rlalfl-rl PERMIT DATE: COMPLIANCE DATE: 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 ca ✓vim a 4p r v c- o C � No. Woly Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS RppliCAtion for Di5P4.5al *pgtem Con5trUCtion permit Application for a Permit to Construct( ) Repair/ Upgrade( Abandon( ) 2/complete System ❑Individual Components Location Address or Lot No. � '�` Q t9�. Owner's Name,Address,and Tel.No. s�- azQ Deae Assessor's Map/parcel Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size i l-3 Garbage Grinder (^Y� Other Type of Building $ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requi ed) gpd Design flow provided �✓s gpd Plan Date Number of sheets / Re/vision Date Title G',4�'IG �2 YJ`)tfW Of�SI�I� B/` /L S�C /.74-e— Size of Septic Tank �rO/1 Type of S.A.S. �ClG � Description of Soil Nature of Repairs or Alterations(Answer when applicable) a Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board Hea h. ��� Signed Date Application Approved by Aj, 01 Date6 Application Disapproved b : Date for the following reasons / Permit No. �— (fib`I Date Issued THE COMMONWEALTH OF MASSACHUSETTS. BARNSTABLE,MASSACHUSETTS Certificate of �orrarice THIS IS.TO CERT FY,that the On-sitee Sewa Disposal System Constructed ( . °) Repaired ( Upgraded Abandoned( )by �r�lGf// �^ _ at l �/ �61 has been constructed in accordance G e7 with the provisions of Titt 5 nd t e;for Di�/s 1osal Syste�m—Construction Permit No: dated �� Installer / 4���:�/ Designer. d� G�ll/�' -7 #bedrooms 3 Approved desi n-flow gpd. , The issuance of this perm h t e ns rued as a'guarantee that the system wil nc ton as desig ed Date a It, ' Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 - page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, IRS use the return Name of Inspector key. Eco-Tech Environmental rab Company Name 43 Triangle Circle Az Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B.'Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority June 22, 2013 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 h 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. I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 t Commonwealth of Massachusetts V ` w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking.and if a Certificate of Compliance indicating that the tank is less than 20 years old is'available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts Nsww W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i• ❑ 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 i 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 r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 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 waver 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 Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i_ Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The r 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 _ I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 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 const-uction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal:system•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 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 ears usage d 28 gpd 9 ( Y 9 (gpd)): Detail 2011-2012 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 W Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 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: owner 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 w Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 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: 4+ years. Certificate of Compliance for current system issued 3/26/2009 (Permit#2009-064) 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5 x 5 x 6-1500 gallon Sludge depth: 4 in t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to Lottom of outlet tee or baffle 30 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended every 2-4 years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plar): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ cther(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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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): I' 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 R Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. City/Town 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 at outlet inverts Comments (note if box is level and distribution to outlets equal, any evidence of solics carryover, any evidence of leakage into or out of box, etc.): D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Few solids in sump. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and was heard splashing down into the leaching system. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 w , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 6ommo.nwealth of Massachusetts Tilfle :5. Offi-,Gli,al "Inspection Form S'ubSurface Sewage Disposal System Form.-Not'for'Volunta,ry Assessments 115,Carlotta Avenue- Property Address - Gary Noke and Catherine,Carroll,,Noke: Owner Owner's Name informatifor Hyannis MA 0260.1 June 22, 201,3�required for every page. Cityrrown State: Zip Code Date pf Inspection D. System Information (coat:) Sketch`Of Sewage Disposal„Syst- ' Provide`a view of the•sewage disposal system;'inclwding ties°'to at least tuvo permanent reference laiadmarks or benchmarks Locate,all w,ells.witfiin 100 feet: Locate where public wafer supply enters the`.building. Check one of the boxes below: hand-sketch in the-area below 0 drawing attached separately � PTI� � cE(IIJG }; G(� (ZK 361 z - 7 �L 3 Zz C zLOTT A AvE� � uC 15ins,3113 `Title 5 Offc aYlnspoolion;Form Subsurface'Sewage Oisposh System•Page j5 of,77 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. Cityrrown 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: 25+ 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: 3/25/2009 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: Town of Sandwich GIS Department records You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows bottom of system to be 6.75 feet above the bottom of a witnessed test pit in which no water or groundwater mottling was encountered. Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 115 Carlotta Avenue Property Address Gary Noke and Catherine Carroll Noke Owner Owner's Name information is required for every Hyannis MA 02601 June 22, 2013 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Applicatiou for �Digogar *pstem cow5tructiou permit Application for a Permit to Construct( ) Repair(v) Upgrade( ) Abandon( ) U Complete System ❑Individual Components Location Address or Lot No. /l� �` O ive, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No. Type of Building: .. ,, Dwelling No.of Bedrooms _ Lot Size i �/aa & c�t./4Garbage Grinder (^ C/ Other Type of Building $ r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.requi ed) gpd Design flow provided - �!7 gpd Plan Date r Number of sheets Re/vision Date Title �J */ ®) Size of,Septic Tank �CQ Type of S.A.S. Description of Soil ZW �J Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boardqf Signed Date 43�Z Application Approved by Date 2.f—obi Application Disapproved b Date �— for the following reasons Permit No. - ob'1 Date Issued i - - - - 77 No. 000) Fee Entered in computer: i THE�COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for �t5po5al 4V!9tem Conotruction Permit Application for a Permit to Construct O Repair(1 upgrade O Abandon Complete System ❑Individual Components 114 Location Address or Lot No. //5-60,r10 p aj;e Owner's Name,Address,and Tel.No. -2-Yg- 2-,39 r . Assessor's Map/Parcel 1-5 Installer's Name,Address,and Tel No Designer's Name,Address and Tel.No. 7W4*1" Type of Building: Dwelling No.of Bedrooms Lot Size 11, /k/2.0r?qi-ft' Garbage Grinder (Alb Other Type of Building 905 No.of Persons Showers Cafeteria t Other Fixtures 7 Design Flow(min,;q&), e9 gpd Design flow provided gpd Plan Date 112 q Number of sheets Revision Date -,Title S'�;­-of Septic Tank 6 b et-- i-e Type of S.A.S. Description of Soil Nature of Repairs orr-Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Signed I r1 Date Application Approyed by Date Application Disapproved by: Date for the following reasons Permit No. n Date Issued q C4 THE COMMONWEALTH OF MASSACHUSETTS* BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired I-1-5/Upgradecl Abandoned b at has been constructed in accordance r with the provisions of Title 5 and the for Disposal System-Construction Permit No. >00- O�L( dated Installer 11 1 Designer 1055 OW& #bedrooms 3 3_;IV J Approved design-flow gpd 7, V fia The issuance of this permit—shaff,not be construed as a guarantee that the system will ffinAion as designed. 01 Date //9- Inspector ----------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS P&LIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS /0 0. =111145po5al *V.4tem Construction Permit Permission is hereby granted to Construct Repair Upgr ade ( ) Abandon System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of th1__p—er4 permit. nn Date 3 [, Yl Approved by.!!�&.. -Adam I Town of Barnstable r# Departitnent of Regulatory Services • sexNaTea Public ublic Health Division Date t �Ar i639•A�a�, 200 Main Street,Hyannis MA 02401 .n Date Scheduled � �� ��'L� l/'// ...-�' Time� Fee Pd.-4/ Soil Suitability Assessment for Sew e Dis oral Performed By: -S%�1�� C�� /'�/1-� � fi r �Witnessed By: PoolLOCATION & GENERAL INFORMATIONv Location Address 15 �A�\���� A J e Owner's Name z 11 ",J F'.S�sirll� # / { 3S�1 C y1����1.,J Address �fitL.'A� Assessor's,Map/Parcel• � �_ C en� � Engineer's Name f} S a ueN i ruo� NEW CONSTRUCTION REPAIR S 2 v VA 5 Telephone# 5p�- -?���_,5Z, Land Use Slopes 30 p ( ) i Surface Stones A.,1�1 _ Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line /o ft Other ft SKETCH: (street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands fn proximity to holes) f y �n i Parent material(geologic) d liTa H Depth to Bedrock Depth to Groundwater. Standing Water in Hole: `N�rt Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil mottles: In. Depth to weeping from side of obs.hole: In, Groundwater Adjustment fr. Index Well# Reading Date: Index Well level AdJ,factor- Adj.13roundwaterLevel T� Observation PERCOLATION TEST Dute 3 og Thne Hole# Time at 9" Depth of Pere �8 ' Time at 6" � Start Pre-soak Time @ Time(9"-6") End Pre-soak 7'era. Rate MinJlnch �Z Site Suitability Assessment: Site Passed�� Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the- Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SF-PTIC\PERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Sdil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. ,} Consistency,%Oavel `t DEEP OBSERVATION HOLE LOG Hole# 'Z Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,% ravel 32 14, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,9P Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No t� Yes Within 100 year flood boundary No� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? " If not, what is the depth of naturally occurring pervious material? .. Certification I certify that on 1" HA-t (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required tra' ' x ertise and experience described in 3 10 CMR 15.017. Signature Date 3 G r' Q:\S.EPTIC�PERCFORM.DOC r Town,of Barnstable �FiHE� °'''tip Regulatory Services Thomas F. Geiler, Director rt BARNSCABLE, ,1 . 9� i639gq. Public Health Division �0 prfDMA'�A Thomas McKean,Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: J7_7 Log Sewage Permit# Assessor's Map\Parcel 04$/72-9 Designer: k"A'5 PE Installer: lor h�� � Address: 923 ,-e-z­7zF7- e-A Address: c�I (ifur�'/`}/ , C7 f5�R5 �A 6 On adZJ�©(date) (installer) &, ,5/. 1 was issued a permit to install a septic system at // 04L4_' e7T ice, based on a design drawn by (address) 57&P/l&-u hv-A-S dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. li 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. � & J OF en q (I sta er's gnature) _ BLS F CIVIL ` No.35461 `' ( 'esigner's Signature) (Affix esig er'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:\Septic\Designer Certification Form Revised.doc �.� Commonwealth of Massachusetts w=i rn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for VoluntaryAssess- ena eis Property Add asj.s' Z,,,,-V70(, ,e— _ Owner Owner's lame — — reaon'iredl or is G3 0r1 is / �A n d 601 oZ every page. City/to State Zip Code Date c r.soec`ic-; Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General information When filing out forms or,the computer,use 1. Ins t r: only the tab key to move your cursor-do not use the return n I Name of Inspector key. �if� V/ ,�_ FG A/ C any Name �n 70 20-'( /'�o' — � Com any Address U Gty/Town State Zlp Code 1-Te1ephoKe Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM 15.000). The system: 4 ❑ Passes ❑ Conditionally Passes Fads $ . ❑ Needs Further Evaluation by the Local Approving Authority ( ; U i ❑Cq .,.,. -i L �7 3 Inspect is Signature Date f3 The stem inspector shall submit a co of this inspection report to ',he Ap rp inc -� Y P PY P P ` � ` � � �;;no,�(,zoa�c- of Health or DEP)within 30 days of completing this inspection. If the system is a spar d s st ,r has a design flow of 10,000 gpd or greater, the inspector and the system crrr,er shall submit t�:e report to the appropriate regional office of the DEP. The original should be sent to t"e s..,,1e 7 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. 15inse•o3/ca Tit!e 5 Official Inspection Ill Commonwealth of Massachusetts r 'Title 5 Official Inspection Form = 1=� Subsurface Sewage Disposal System Form -Not for Voluntary Assessme—'s Property Address Owner Owner's we e infornation is required for C+hh tf coc� G every page. City/Town state Zip Code Date of In,scec;ion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E J always complete all of Section D A System Passes: ❑ 1 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. 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 exflltration 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 anc; if a, Ce-ificate of Compliance indicating that the tank is less than 20 years old is availab!e. ND Explain: ❑ Observation of sewage backup or break out or high static water I vel in t-e distriu icn o c to broken or obstructed pipe(s)or due to a broken, settled or uneven distr: do , box. Svsta--. •, ii pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed - !oinsp•03/08 - T!tie 50Fci2!Inspection=„-..,:Sabs,.r__=_S='``=_ f Commonwealth of Massachusetts ,al Title 5 Official Inspection Form IS1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments N3 _ Propert A dress y 2 GHpvte-- Owner Owne ame n n requir anon is f �—O T required.or every page. City/To State Zip Cope Date of inspection B. Certification (coat.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). i ne 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 de°ermine 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 _ 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 sys e n (SAS; a^,u theS.^-.S is °r✓;`�::_: 100 feet of a surface water supply or tributary to a Surface water sucoly ❑ The system has a septic tank and SAS and the SAS is within a Zone ' of a D 1 C ,, . supply. ❑ The system has a septic tank and SAS and the SAS is within �0 supply well. tSin-;•03/09 Title 5 a - .: .--- _ -- -OY.c. �Ins _._. ._ S,;os.- I Commonwealth of Massachusetts I=^ Title 5 Official Inspection Form r I\ Subsurface Sewage Disposal System Form -Not for Voluntary Assessment's Al_111r, Property Address Owner Owner's Na, e information is 71 � 160 y -�4/_ required for / �q ✓jh� — every page. City[Town State Lip Code Date of Insoecricn B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 570 Beet 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 cc!ifo:m bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen, is e uai to o; 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: Yo-u must indicate `'Yes" or"No"to each of the following for all inspections: Yes o ❑ Backup of sewage into facility or system comooner It due to overloaded c / clogged SAS or cesspool ❑ �,/ Discharge or ponding of effluent to the surface of the ground or s,:'a0e ,♦ater s U due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet rove: -ue to Sr or clogged SAS or cesspool. -- iquid depth in cesspool is less than 6" below invert or c .sb!e .-•iu e es= than '/2 day flow - ❑ equired pumping more than 4 times in the last year NOT�fue 4,3 32ce: 1: o structed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ❑ Any portion of cesspool or privy is within 10.0 tributary to a surface water supply. '5i Sp•03i08 _ _ Commonwealth of Massachusetts r= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y l Property Address Owner Owner's/ ame information is required for T✓ ad 6 0� every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (coat.): 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 sucp y el!. ❑ L1� Any portion of a cesspool or privy is less than 100 feet but greater t ian 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 -ai!s. The system owner should contact the Board of Health to determine v:hat 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 th;e fo!!0%'Ving, in addition tot e questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking :.a`ar supoly ❑ ❑ the system is within 200 feet of a tributary to a surface driing ;„=ter c ❑ the system is located in a nitrogen sensitive area (Inte7i;i `:. Area — IWPA) or a mapped Zone II of a oub!ic v.later su.)p,y e!i If you have answered "yes" to any question in Section E the system is co-ic'ered a or answered "yes" in Section D above the large system has failed. The caner,Dr _- system considered a significant threat under Section E or failed under Sectic:-� D system in accordance with 310 CMR 15.304. The system owner should coy Etact t e regional office of the Department. .5lrsp•03/08 Tri<SOffcizl?rroec';en Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal Syste Form - Not for Voluntary Assess:� e^ts Property Address 2 C, 0 Owner Owner' ame iniormaticn is required required for pin n' (�d-401— every page. City/Tow State Zip Code Date o`irspect or: C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the fc!lo',V;n Yes No ❑ Pumping information was provided by the owner, ecauoant, or Bcard of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ []/ as the system received normal flows in the previous Iwo week period? Have large volumes of water been introduced to the system r ecently or as par° of —' J his/ 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 uo? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located or-, site? ❑ Were the septic tank manholes uncovered: opened, and the interior of the tar,`.-; inspected for the condition of the baffles or tees: material of cor,st:action, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different from owner) ;�rov�;ded ,tiri h information on the proper maintenance of subsurface se% ace disposals sre s? The size and location of the Soil Absorption System (SAS) or. the sire -as been determined based on: ❑ xisting information. For example, a plan at the Boars of 'e lt�:. — Determined in the field (if any of the failure criteria r elates to r C U approximation of distance is unacceptable) (31 U Ci%-`R i 0%( t5ins:•03/08 Ti@e 5 0ffida!Ins„ec'.oc or::Si� e __--__ _.--s—• a = N Commonwealth of Massachusetts =r= Title 5 Official Inspection Form of Subsurface Sewage Disposal System Form -Not for Voluntary A,ssessmen-s Property Add Owner Owner's ame reream, ation is cuirad.or Gi G 00� T— every pace. City/ ow State Zip Code Da- �s Insp=_czio^ D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actua!): ,3.3o DESIGN flow based on 310 CMR 15.203 (for example: i 10 opd x�o bedrooms): l;I f bedroos): — y o Number of current residents: - Does residence have a garbage grinder? Yes _vi`o Is laundry on a separate sewage system? [if yes separate inspection required] L Yes i`F No Laundry system inspected? L✓ Yes i No Seasonal use? I Yes '�� N Water meter readings, if available (last 2 years usage (gpd)): Sump pump? i^1 Yes 4 'o �i Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow(based on 310 CMR 15.203): Gal Ions oer day (co-` Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? _' Yes ''' i"I C. Industrial waste holding tank present? - `'e= N.o Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Oat Other (describe): 15osp•03108 Title 5 Officie!In=p=tion For..;.S_`s_;;=-=Se:a=-=_,-.;_.:.. :_—•�_-_--,._ Commonwealth of Massachusetts Title 5 Official Inspection Form G�=W Subsurface Sewage Dis osal System Form - Not for Voluntary Assessments Property Address Owner Owner's NK information is & o required for G n ti� ?d 6 — ••—/ every page. City/Town State Zip Code Date of inspection D. System Information (cont.) General Information Pumping Records: Source of information: - Was system pumped as part of the inspection? ❑ Yes i❑ 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 a�;;/) ❑ Innovative/Alternative technology. Attach a copy of the curre..nt operation and maintenance contract(to be obtained from system owner) and a copy o= latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. _ ❑ Other (describe): Approximate age of all comp ents, date insta ed (if known) and source nfor 2ti n: Were sewage odors detected when arriving at the site? t5in-o•03/08 Title 50`idaf __­ Commonwealth of Massachusetts rimer Tile 5 ffl�lal Insp�ctl®n Form Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments Property Address /= G k7 -- Owner Owner's /I lx i��fcrrnaron is required /�for �^h t� -- even,pace. Citvr own" State Zip Code Date o,!nsPec:ion D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: feet later ial o nstruction: cast iron ❑40 PVC ❑ other(explain. Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: tot 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 cem ffi Ica te) ❑I !es ❑ i do ---------------------------------------------------------- -------------------------------- ----------------------------- Dimensions: -- — — Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle --- — Scum thickness -- Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? gins?•03;08 ?';tie 5 0-M021 Inseectior,=a c:c! Commonwealth of Massachusetts r, Title 5 Official Inspection Form i Subsurface Sewage Disposal Sy/sum Form - Not for Voluntary Assessments II J Property Addre:/_ c:;,del 0 yr Owner Owner's Name ') information is /f /yf,� (-)a60/ (7`" —Al— 6 required for ahnIS / every page. City/Town State Zip Code Date of inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: Data Comments (on pumping recommendations; inlet and outlet tee or bale condition, st ct rel i�egriy 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 Depth below grade: — -- Material of construction: ❑ concrete ❑ metal El fiberglass ❑ ooIvethvlene :5inso•03108 - Title 5 OriGal Inse=-`ien c.ar,7r:c:•�,�.=---�_...=_`---�___ _-._-•_° r Commonwealth of Massachusetts t Title 5 Official Inspection Form '`' �� =1 Subsurface Sewage Disposal System For!/m� Not for Voluntary Assessmer s -J Properly Address Owner Owner's NK G information is / � required for vl✓1�f �'// nl every page. City[Town State Zip Code Date :;f!nspacti :n D. System information (cont.) Tight or Holding Tank (coat.) Dimensions: Capacity: gallons Design Flow: gallons per c'ay Alarm present: ❑ Yes [) No Alarm level: Alarm in working order: 711 Yes I 'i ?\io Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? j� Yes No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover. a-:y evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumas in working order: 1 Ves i ;c Alarms in working order: Y=; 45insp•03108 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Dis osal Syste Form l- NNot fo Voluntary Assessme7 ?roperty Address _/__ �� Owner Owner's Na required for me information is every page.eve a e. City�own State LIP Code Date Os^!nSP, CT n � D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances. etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: — ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — --- -- Comments (note condition of soil, signs of hydraulic failure, level Of pondirg, _�a:--p soil. c�-idltip . o' vegetation, etc.): :gins ^0�!DS Tile 5 Cficia;!nsp Nip❑ Commonwealth of Massachusetts := r� Title 5 Official Inspection Form I Subsurface Sewage Dis osal System Form -Not for Voluntary Assessments � Act— Proper' y Address / Lx Owner Owner's Na information is required ror [/Ill _S eve,v page. City/Town State Zip Code Date c-!ns^ectiOn D. System Information (cost.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)„ Number and configuration — — 40 Depth —top of liquid to inlet invert Depth of solids layer — Depth of scum layer Dimensions of cess000l Materials of construction / � k1 Indication of groundwater inflow ❑ Yes ` !I No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of veretaticn, etc.) C/14-�0 �I ✓. Privylocate on site lan : ( plan): Materials of construction: — Dimensions — --- ----- Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, cenc tics cf ve-e`.at,on,, etc.): t5insp•03i08 Title 5 of ici zl Commonwealth of Massachusetts `Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form - Not for Voluntary Assess.men s /c,WC, Property Address z�- v1aL4-e— — Owner Owner's Name information is /�,.�6p � _ 1 _ required for w every page. City/Town State Zip Code Date of!nspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposa! system inc';udinc tics to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ad- i5insp•03108 i�:kS Official lnsoedior.r"or-.c5�__s:, �. Commonwealth of Massachusetts Title 5 Official Inspection Form i_i Subsurface Sewage Disposal System Form - Not for Voluntary,Assess-!e, s Property Address Owner Owner's N me information is required for - eveN p24e. CltwrTow stag Zio Code D2t=of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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 ❑ ed site (abutting property/observation hole within 'ISO feet of SAS) Checked with local Boar of Health - e lain: ❑ Checked with local excavators, installers - (attach documentation), ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: _coo jj" , t5inso•03l08 Title 5 Otfi^ial Inspection.F_r:Se___ra_e=__'' ___c_sa - - - - -;. - .. .-.;:; - ....,..-,c .,�...- .. ,.•+- --. . .,_... ,yR...::^C+ry"*es .,q,!- t^*.,;*.o-;+ c;'9T'k ,aY,-:^:.;.e+'±':eafi,+a...�. -ow,"--^+efz'.°"'!°`_,° F.' 'r,r '.:fi "s'm" n , w .- .. .., - ,+ ene.GS*n•. ,. F.x..1 Nt ...,. ""'++R ... -cw. a ,."c*�.. .M^a'"".. _,. ... .., �. .., .•. 77 v 41 .s r '. , .- ... , .::r ., .✓. ..:.,. '. :. ., ..: era'-. '., r -.. :: ... 1. ,. x i, r , , v YWIN COVER ACCESS COVERS MUST BE WITHIN INSPECTION . 36 MAX COVER Na. ER T EL E V A.I T] ONS . DES I GN- CR I TER I:A GENERAL NO T „• .. PORT GEE L ES . 6 OF FINISH GRADE -. . - 9 3 _ w : CLEAN SAND BACKFILL , INVERT AT BUILDING: ��'._ DESIGN .FLOW. 99.62 FIRST,2 TO FILTER FABRIC AROUND AND OVER R CHAMBERS 97.0 3 BEDROOMS AT l/ PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION BE'LEVEL _ 2 E INVERT IN SEPTIC TANK. 0 G.P.D.G VER UNIT INVERT'OUT.SEPTIC TANK. 96,75 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4• DI PIPE 96.32 - INVERT I N D 1ST. 'BOX , o INVERT OUT D I ST. BOX: 96. 15 NO GARBAGE GRINDER 2. VERTICAL DATUM IS-ASSUMED. . FOR BENCH MARKS 97.32 � 96.75: 96. I5 3 SET. SEE S I TE PLAN. 97.0 " GAs 96:32 2, 96.0 _ 95.75 , INVERT I N LEACH CHAMBER: 96.0 BAFFLE SEPTIC.TANK REQUIRED. ND R AP FILTER FABRIC 2 E c r BOTTOM OF LEACH CHAMBER. 95.75 3 OUTLET 330 G.P.D. 'X 200V - 660 GAL. 3. ALL CONSTRUCTION METHODS AND MATERIALS AND D-BOX 9 CULTEC CONTACTOR.FIELD ADJUiTED GROUND .WATER: N/A SEPTIC TANK PROVIDED: ' 1500GAL. MIN. MAINTENANCE OF THE SEPTIC SYSTEM SHALL I500 GAL DRAIN C-4'S I N BED FORMATION. 3 x 3 `OBSERVED GROUND WATER: N/A CONFORM TO MASS. 'D.E.P. TITLE 5'AND LOCAL SEPTIC TANK 13'r x 24,`1 x 3'd BOTTOM OF TEST HOLE 1: 89.0 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. 6- CRUSHED STONE OR DESIGN PERC RATE 'C 5 MIN/INCH COMPACTED BASE SOIL TEXTURAL CLASS - 1 4, ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER PROFILE NOT TO SCALE " EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD / 0.74 GPD/SF - 446 S.F. REQUIRED THAN 4' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. N DRAIN CD4'S /NL BED FORMATION.FIELD 7EL DF p 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 6.7 SF/LF-482 SF x 0.74 GPD/SF-357 GPD APPROVED EQUAL 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED SOIL -TEST PIT DA TA PRECAST CONCRETE OR APPROVED POLYETHYLENE. INDICATES � INDICATES BOTH SHALL BE WATERTIGHT. D-BOX SHALL BE WATER PERCOLATION OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE TEST - GROUNDWATER OUTLET. TP sl P*12484 _ TP *2 7.. BEFORE CONSTRUCTION CALL "DIG-SAFE-. HORIZON TEXTURE COLOR HORIZON TEXTURE COLOR 1-886-DIG-SAFE AND THE LOCAL WATER DEPT. 0- 100.0 0' 100.0 FOR LOCATION OF UNDERGROUND UTILITIES. LOAMY IOYR LOAMY IOYR ' Q SAND 2/2 A SAND 2/2 • 8 SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE LOAMY IOYR LOAMY IOYR DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION B B OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE SAND 4/6 SAND 4/6 4 9 CONSTRUCTION INSPECTIONS. ,g3 30' .................. 97.5 32- .,,,,...,,,. -----........................ 97.3 (c MED-COARSE IOYR MED-COARSE IOYR FETE 9. EXISTING CESSPOOLS TO BE PUMPED DRY AND 9 cuLTEc ConrcaeTOR � # SAND AND 5/8 SAND AND 5/8 ' FIELD DRAIN C-4'S v oatvE GRAVEL GRAVEL BACKFILLED. !` TP-246'- /1� - 4 PO 'i' �O D-BOX p °r�sis gP.r, e<01 $ NO WATER NO WATER k� 132 89.0 132 89.0 _ DATE: MARCH 5. 2009 3I f f 2c�n l BM. CORNER OF CESSPOOL.'' PATIO. EL-99.69 TEST BY: STEPHEN HAAS - WITNESSED BY: DONNA MIORANDI PERC RATE: C 2 A41N/I NCHjj Of Z ,0ArSTEPHEN 5 KA. �"J FI a CESSPOOL 1500 GALLON f L 0 T 73 `' No 35461 " T� SEPTIC TANKPfC1SIE��q`,�@44 N , - 5 5 �z, i\ 108 5 .43.20 L t S 75 4 S zS T / C S Y"S TE M - DES / G -/ / S CARL O TTA A VE LIE . "AP 2.48 . PARCE-L 22-9 + , PREP,4RE0 FOR PIVE sroi T .f- - �r LEGEND , s i.. .. _ CONCRETE BOUND r � l-L QCUS I � A { , m� . _ ___ � VAR l ANCES REQUIRED :RED : W .. . WATER L 1 NE - � / " �� "`�--- S C.4 L E . / - 2 O MA R CH e5 . 2 O O 9 HYDRANT ` ' �-j TITLE S. MAXIMUM FEASIBLE COMPLIANCE -G GAS L!NE EAGI_ E` S U R V E I NG,r, I NC ` r SECTION I5.2II:{l1 MINIMUM SETBACK DISTANCES OHW-- OVER HEAD WIRES. _rTl0 ' IS REQUIRED BETWEEN THE SAS AND A SLAB FOUNDATION, 6 ' IS PROVIDED. LIGHT POST _-� 923 FRou t 4e , 6A / r�o (, A 4' VARIANCE I S REQUESTED. -E- UNDERGROUND ELECTRIC LINE �' Y ci r mo u t h p o r t MA 02675 lr ,•,,}' j �_�?k f`� 1 -T UNDERGROUND TELEPHONE LINE / / /G//{I/11II � ( 508 ) 362-8 1 32 �► 1 508 A-32-5333 j// ..� -CTV-- UNDERGROUND CABL EV I S ION LINE NE / �t/ C M1 ) Y , '--- C; ,. -}- 40„�4 SPOT ELEVATION ' �-40 -_ kXISTING CONTOUR ` { ] PROPOSED CONTOUR L OCUS MAP 0 /0 20 40 _' JOB NO: 09-011 FIELD CFW/EEK CALC: SAH/CFW CHECK CFW DRN: SAH