Loading...
HomeMy WebLinkAbout0165 CASTLEWOOD CIRCLE - Health �65:Cas"tleuv.00d��Circle - Hyannis F/R A _;' 272�:�+046• J i I I i t Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle ? Property Address i Dimitar Arabadzhiev -q Owner Owner's Nam information is required for every Hyannis Ma 02601 11-6-18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S/ 13y�3 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. Co Route 130 uy Company Address Sandwich Ma 02563 City/Town State Zip Code rmv (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of-on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Opaby.lyaa h'@eUNnry Brett Hickey m�^^ ^4O4P� � ^•p� 11-6-18 pma:30f&f.OB 204II ASW 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. l5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every Y page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: .The system was in working order at the time of inspection. 2) 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): f l { t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18, c� Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) 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. a. 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: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ a Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/262018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection'Summary (cont.) -4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El a Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 'E Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ E Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ❑ 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. 5) 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 CA. 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 i El ❑ 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 t5insp.doc•rev.7262018' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No ❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ 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? El ❑ Were as built plans of the system obtained and examined?.(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? I - 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ a 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: F ❑ 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)] l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owners Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: no design plans 2 Number of bedrooms (design): Number of bedrooms(actual): NA DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: No design plans were on file with the board of health. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes No See below Water meter readings, if available(last 2 years usage (gpd)): Detail: "'2016-13,464gallons 2017-14,212gallons— Sump pump? ❑ Yes M No Last date of occupancy: currentDate t t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c� Commonwealth of Massachusetts �a Title 5 Official Inspection Form . . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle u Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma • 02601 11-6-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information '(cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: a Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Owner- last pumped 2 years ago 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: t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (P' 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owners Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: unknown due to lack of record Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 111011 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle , Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): 10" Depth below grade: ; Meet 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 1 Dimensions: 000gallons pn Sludge depth:, (J 28" Distance from top of sludge to bottom of outlet tee or baffle 311 Scum thickness 6" Distance from top of scum to top of outlet tee or baffle - 13�� Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should'be pumped every two years for maintenance. t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade. Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): off Depth.of liquid level above outlet invert 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.): The d-box was in working order at the time of inspection. 15insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes 0 No* Alarms in working order: ❑ Yes H No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. 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: 55'x4'x2' 0 leaching trenches number, length: leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address, Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching was in working at time of inspection with no sign of past back up. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA 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.): t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): - l l5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 2' Front 5' Garage � • g o 1 0 >96"O 0 0 o LEACAG TRENCH 4 0 • 0 0 O 0 0 0 O © >3' AC-27' BC_9' AD-56'6" BD-39' I y Ground Water t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ❑■ Surface water ■❑ Check cellar ❑■ Shallow wells Estimated depth to high ground water: NoGW@96"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 E) Observed site(abutting property/observation hole within 150 feet of SAS) M Checked with local Board of Health -explain: see below ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file for 191 Castle wood showed no GW at 96". The bottom of the SAS is 5' below grade showing that the SAS is>3'above ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c� Commonwealth of Massachusetts.-Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �a 165 Castlewood Circle Property Address Dimitar Arabadzhiev Owner Owner's Name information is Hyannis Ma 02601 11-6-18 required for every y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in'this section. 0 B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed F D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 4 TOWN OV BBARNSTABLE ' LOCXTION SEWAGE # oZ- VILiAGE Y 19 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. P d?-oN i SEPTIC TANK CAPACITY E x i s.T' LE CHING FACILITY: (type) (size) X a N OF BEDROOMS _'3 BUILDER OR OWNER J /y t 4 c .3l o-o W ^� PERMITDATE:�/Q 3ZP4c-_/ _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by AN o - • V,` � ram_ - No. Fee__�& THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplicatiOtt for Migool 6p$tem Cott!5truction Permit Application for a Permit to Construct( . j Repair( 4Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No.n l Assessor's Map/Parcel i27,- jf Installer's Name,Address,and fel.No. Designer's Name,Address and Tel.No. G•/� G O�/ 5 it D49✓/G ✓`J "q S'O n/ 5-0$ 2 7 s / —3 Type of Building: Dwelling` No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow -3 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue_4jiy this Board of Healt Signed p Date Application Approved b Date Off' Application Disapproved for the following s6Z Permit No. Date Issued No. ( r Fee _ THE COMMONWEALTH OF MASSACHUSETTS, Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS ZippYication�for Migo�al *pgtem Conoruction Permit Application for a Permit to Construct( )Repair( l'upgrade( )Abandon( ) ❑Complete System _O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel `t/ »- 6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No., sr Go S`e8 7-17 s / 3 Type of Buildin_g: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria Other Fixtures Design Flow gallons per day. Calculated daily flow �`3 #> !gallons. Plan Date Number of sheets ""� Revision Date ' Title i Size of Septic Tank 1 Type of S.A.S. t• Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: - Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health.--,' Signed 'In Date Application Approved b /fI/1' Date { Application Disapproved for the follow- ing 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 ( )Upgraded( ) Abandoned( )by at _ has constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer 10 OL e. Designer J��/a,�i /a.4; S rA ,✓ The issuance of this permit shall not be construed as a guarantee that the system will f netio as designed. Date d Inspector �� _•`No. I Fee ./ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS ligpoof *pgtem Con0ruction Permit Permission is hereby granted to Construct( )Repair(�YUpgrade( )Abandon System located at 2'c 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: Construc•ion must be co pleted within three years of the date of thi17) t. Date: Approved b / / PP Y v Town of Barnstable �F ZHE Tp .� Regulatory Services y4,P p� Thomas F. Geiler,Director � HARNSFABLE, • ' M^M Public Health Division TEn► '� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: f Y_IA 4 S,57*? Installer: Address: Address: . ICLK,60CLIICVl On —O /g �( ( � was issued a permit to install a (date) (installer) septic system at / Cif���wU o��j� based on a design drawn by (address) O!'l dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local-Regulations. Plan revision or certified as-built by designer to follow. 'P( S M (Days %`-0115, :afore) (Af Designers Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE :ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form • TOWN OF BARNSTABLE LOCATION' yII LAGS Y 9 �-S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 7 S! J 6 Z SEPTIC TANK CAPACITY Cie 7 i v o 0 LEACHING FACILITY: (type.)-.. 70- F (size) SS- X V X Z NO.OF BEDROOMS \ BUILDER OR OWNER /"t c So—a. ^� PERMTTDATE: i/ ,43Z-4�/— —COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by A✓ P, PC �7 RDy w I+lo r f ' �Z 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property l(S C^.JTLeS00.6 O\V Owner' s name VCL_wo%,jjC,, Date of Inspection PART A CHECKLIST Check if the following have been done: —Z"—Pumping information was requested of the owner, occupant, .:and ZeaTd-af HQzlt I/ h None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected 'for signs of sewage back-up. The site was inspected for signs of breakout. All . system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of __,,� sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. _ he facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. I 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential �- number of bedrooms number of current residents garbage grinder, yes or o' laundry connected to system, es r no seasonal use, yes o If nonresidential, calculated flow: Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping recor s and source of information: System pumped a art of inspectionor no i , volume Reason fo pumpin Typrof 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arriving at the site Yes or no SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B . � SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade:— material of construction: metal FRP other(explain) 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of . leakage, recommendations for repairs, etc. ) 1.I DISTRIBUTION BOX: Ova (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) • V 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS. (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs, etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' 5 amt.-, 101 16� DEPTH TO GROUNDWATER � y depth to groundwater method of determination or approximation: 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? /Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day Y Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to surfac water supply? . Y a e within a Zone I of a public well . within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only.; not the SAS.) ? Cwithin 50 feet of a private water supply well? less than 100 feet but greater than. 50 feet from a private water supply well with no acceptable water quality analysis? If the well_ has been analyzed to be acceptable, attach copy of well water analysis . for coliform bacteria, volatile organic compounds, ammonia nitrogen = and nitrate nitrogen. , v ICKEY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM CERTIFICATION Name of Inspector: Donald Perkins Company Name: Hickey Construction Company; Inc. Company Address 38 Rosary Lane, Hyannis, MA 02601 tel : (508) 771-4128 Property address: 14? C�g'L�R-�ana� Ci��� Certification Statement : I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, (:accurate and complete as of the time of inspection. The insp,ectiori was performed and any recommendations regarding upgrade, maintenance, and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems. Check One: � I have not found any information which indicates that the system fails 'to adequately protect public health or the environment as defined in 310 CMR 15. 303. Any failure criteria not evaluated are stated in the FAILURE CRITERIA section of this form. I have determined that the system fails as defined in 310 CMR 15. 303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s signature: � —C `� 4 Date: _1 k8 4I Original to system owner: �� �L� w�%B Copies to: Buyer (if applicable) approving authority i 38 Rosary Lane Hyannis, rMA 02601 508-771 -4128 -IRO A Ex7=;TIVE OFFICE OF E\. 7% N N I E NT 7 F.ki R S DEPARTNIENT OF EN-VIRONMENTAL PROTECTION C Z 5 02 FAILED INSPECTION <04 17-A TITLE 5 OFFICIAL INSPECTION FORA — NOT FOR VOLU-NTARY' ASSESS'NIE'. TS SUBSURFACE SEWAGE- DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: -5-- a/�Ok-ARCE� < rT Owner's Name: LOT j Owner's Address: (J., Date of Inspection: RECEIVED co Name of inspector: (please Company Name: OCT 0 5 004 LM a i I i n 'A d ress: TOWN OF BARNSTABLE' HEALTH DEPT. Telephone Number: CERTIFICATION STATEMENT I certif%.. that I have personally inspected the sewage disposal sysce-.n 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 CINIR 13.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approvina Authority Fails Inspector's Signature: , Date: 1,t12 Thesystern inspector shall'submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)I within'30 days of completing this inspection. If the system is a shared system or has a design flow oflO.000 ,apd or greater. the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The orieinal should be sent to the system owner and copies sent to the buyer, if aocilicable, and the approving authority. Notes and Comments 1�4;��`,yam IS �� ��iC CG� /r%'/ `/!/�� ""This report only describes conditions at the time of inspection and under the conditions or 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 Inspection Form 6/15/2000 page I OFFICIAL INSPECTION FORA — SNOT FOR VOU."N'TARY ASSESSMENTS SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART A CEERTIFICATION (continued) Property Address: S C#_5//6 406wl (211 Cc l Owner: 1 Date of Inspection: Inspection Summary: Check A,B,C,D or E/ ALWAYS complete all of Section D A. S,.-stem Passes: t..:-.- I have not found anv info�:��ation which indicates that any of the failure criteria descrice- in :10 CNIR 15.303, or in 3 10 C-NIR 15.30= exist. Any failure criteria not eva!uared are indicaCed be!w . Comments: B. System Conditionally Passes: One or more system comoonents as described in the "Conditional Pass"section need to be reolaced or 4 repaired. The system. upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or riot 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 exfiltrarion or tank failure is imminent. System %gill pass inspection if the exisrins tank is reolaced 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 Certiticare of Compliance indicarins that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken. settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than G 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: i OFFICIAL INSPECTION FORM - NOT FOR '�'OLu."TAR�' ASSESS..'vIE:.NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM I`•SPECTION FOR-NI PART A CERTIFICATIO`+ (continued) Property Address: / Owner: Date of Inspection: J�/J C. Further Evaluation is Required by the Board of Health: IV /� Conditions exist which reeuire furher evaivauon by the Boaru of Health in order co dete.�ir.e it the s:s:em is faiiing to protect pubiic health, safer}-or ch: environment. 1. Svstem will pass unless Board of Health determines in accordance wich 310 C:NIR 1:.303(1)(b) chat the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet or a surface water Cesspool or privy is within 50 feet of a borderina vegetated µetland or a salt marsh A/f� Svstem 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 can{:and SAS and the SAS is within a Zone I of a public water Supply. _ The system has a septic tank and SAS and the SAS is within 30 feet of a private water supply well. _ The system has a septic.tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis. performed at a DEP certified laboratory. for coliform free from pollution from that facility an bacteria and volatile organic comoounds indicates that the well is dher the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pom. provided that no ot failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 'V 3 I OFFICIAL INSPECTION FOR — `SOT FOR VOLUNTARY ASSESSNIE`TS SUBSURFACE SEWAGE DISPOSAL S�C'STEti1 I�iSPECTIOti FORA PART A CERTIFICATIO-N (con(inued) Property Address: Owner: Date of Inspection: Y D. System Failure Criteria applicable to all SN.Stems: You must indicate "yes" or-,no" to each of the following for all inspections: Y_s `o oa_ �( Bac::up of se Aa°= into facility or syst_m component due to overloaded or clo � SAS or cesspool D i Schar?e or pOnCtng of eitluen, t0 the surface of,he -S.round or surface «'a[erS due IO an OyertOad'd Or clos2ed SAS or cesspool Static liquid level in the distribution box above outlet inve:, due to an overloaded or clogged SAS or cesspool p1. Liquid depth in cesspool is less than 6" be!o«v inve or available volume is less that. '�: day `(s). Required purnoina more than a times in the last }'ear NOT due to clogged or obsrlcted pipe(s1.`umber of times pumped Any portion of the SAS. cesspool or privy is below high around water elevation,. Any potion of cesspool or privy is within 100 fee'.of a surtace water supply'or tributary to a surface water suooly. Any portion, ortion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 lea of a private «'ater supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a or ��'ater 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 ; ppm, provided that no other failure criteria naivsis must be attached to this form.( are triggered. A copy of the a (yes,No)The system fails. I have determined that one or more of the above failure criteria exist as therefore the system fails. The system owner should contact the Board of described in 310 CivIR 15.303. Health to detaznine what will be necessary to correct the failure. Iv E. Large Systems: ff To be considered a large system the system must serve a facility with a design flow o(10.000 gpd to 15,00 gpd• You must indicate either.1 s" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drink water suppl} the system is within 200 fe=t 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 rl in ered a significant threat. or If you have answered "yes" to a qustem has failed. The om ter or oper E the SVS[dM is ator any large system tons tio dered�ae,ed '•yes" in Section D above the large_ significant threat under Section E or failed under Section D shall upgrade the system in accordant with l0 CivIR regional office of the Department. 15,304. The system owner should contact the appropriate , OFFICIAL INSPECTIO` FORM - NOT FOR ',,-'0LU`TARY ASSESS:-IENTS SUBSURFACE SEWAGE DISPOSAL SYSTEti1 IN'SPECTIO:N FORM PART B CHECKLIST Property address: docA-� O.vner: Date of Inspection: Chec if the Follo«'inz have been done. You must ir,dicat_ ",-es' or"no" as to each of the fol!c�air.g: Yes N,o A. Pumping information was provided b�� the owner. occupant, or Board of i-iealth Were an, of the system compori-nis pumped out in the previous cA-o weeks as th_ system received no „ al flo-s in the previous r.%o week period —ALHave large volumes of water been introduced to the syste-t recently or as par of this inspection ? Were as built plans of the syste n obtained and examined? (If they were not available note as V;A) a «'as the facility or dwelling inspected for signs of sewage back- up Was the site inspected for signs of break out? IJ _ Were all system components, 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: Yes no Existing information. For example,a plan at the Board of Health. Determined in the Feld (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (3 10 Civ1R 13.302(3)(b)j 5 OFFICIAL I`SPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO` FORM PART C SYSTENI INFORMATION Property Address: Owner: Date of Inspection: Al FL W COtiNDITIONS RESIDENTIAL ,Numb,-; of bedrooms (design): Number of bedrooms (actual): DESIGN now based on 3 10 CMR 15.203 (for example: 110 gpd x = of bedrooms): E113O `umber of cw:ent residents: Does resident_ have a garbage grinder(yes or no): 40 Is laundry on a separate se«age system (yes or no):/qZ(if yes se?ar-Ee inspection recui;,-dJ Laund-v system inspected (yes or no): = Seasonal use: (yes or no): Q Water meter readings. if available(last 2 years usage (gpd)): 7,W��� Sump pump (yes or no): Last date of occupant.:: )/ MNI:`IERCIAU INDUSTRIAL Type of establishmenr. Desisn flow(based on 3 10 CNIR 15.303): °?d Basis of design flow(seats/persons/sgft,etc.): Grease trao present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system (yes or.no): _ Water meter readings. if available: Last date of occupant},'use: OTHER(describe): GENERAL INFORM ATION Pumping Records �� 0e� ,�� Source of information: /l/ Was system pumped as part of the inspection(yes or n W,�Q _ If ves. volume pumped: gallons -- How was quantit< pumped determined? Reason for pumping: TYPE OF SYSTEM • Septic tank. ; soil absorption system 7w— 0 /V1 _Single cesspool _Overflow cesspool _Privy,• - _ Shared sN stem(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 -Alternative owner) Tight tank _Attach a copy of the DEP approval Other(describe): Appro. _mate ase of all components, date instal (if known) and source of'o formation: d / Were sewage odors detected when arrivin;at the site (yes or no): ' 6 1' i i OFFICIAL INSPECTION FOR-NI — 'NOT FOR VOLL TARY ASSESS-ME:NTS SUBSURFACE SEWAGE DISPOSAL SYSTENI INSPECTION FOR-NI PART C SYSTENI I`+FORNIATION (continued)/ Property Address: E ( Owner: Date of Inspection: i yI BUILDING SEWER (locate on site plan) Depth below grade: -Ntaterials of construction: _cast iron 40 PVC _other(explain): Dist--nce from private -water supply well or suction line: Comments (on condition ofjoints, venting. evidence of leakage. etc.): SEPTIC TANK: _L_(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass oolvethvlene other(explain) If tank is metal list age: — Is age confirmed by a Certificate of Compliance (yes or no): _(aaach a copy dt certificate) Dimensions: Sludge deoth: Distance from cop of sluc;e to bottom of outlet tee or baffle: /S Scum thickness: Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bosom of outlet tee or baffle: �D How were dimensions determined: �t- Comments (on pumping recommendations, inlet and outlet ctee or battle condition,`structural integrit}'. liquid levels as related to outlet invert,_eidence of leakage,et �w y J� GREASE TRAP:_(Iocate on site plan) Depth below grade:_ Material of construction: _concrete_metal _fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum CO COp of outlet tee or baffle: Distance from bosom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrit,., liquid levels as'related to outlet invert, evidence of leakage, etc.): 7 I OFFICIAL INSPECTION FORM — NOT FOR VOLLNTARY ASS ESS:`IE`TS SUBSURFACE SEVVAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEivI I.NFORINIATION (continued) / Property Address: �jP- YJee —f-� Owner: Date of Inspecti n: �J TIGHT.or HOLDING TASK: (tank must be pumnped at time of inspection)(locate on site pi an) Depth below grade: Vfzterial ofconstructior.: concrete metal fiber�iass ool�ethvlene ot ,z:(expla:n): Dimensions: Capacity: gallons Design Flow: sallons!day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) yV Depth of liquid level above outlet invert: on to outlets equal, any evidence ofsolids cartiover, any evident:of Comments (note if box is level and distributi leakage into or out of box. etc.): PUMP CHAMBER: (locate on site plan) working order, yes or no): ' Pumps ►n or (. Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i 3 i OFFICIAL INSPECTION FORM — NOT FOR VOLL--.N'TAR�' ASSESS:`-IE`TS SUBSURFACE SEWAGE DISPOSAL SYSTEM I`iSPECTION FORM PART C SYSTEM INFO R.NMATIOtN (continued)) Property Address: t� 49- Owner: _ Date of Inspection: 16, 02 SOIL ABSORPTIO-N SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type _ leaching oils. number'. _ w leaching chambers, number: leeching galleries. number: leaching trenchm number, length: a ,/ leaching fields, number.dimensions: overflow cesspool, number: innovative!alternative system Tvpe!name of technology: ilure. level of ponding. damp soil. condition of vegetation. Comments (note condition of soil. signs of hydraulic fa et-.): e71 ©L!> ©7l" �- /�� CESSPOOLS: (cesspool must be pumped as oar,of inspection)(locate on site plan) dumber and configuration: Depth —top of liquid to inlet invert: Deoth of solids laver: Deoth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or 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.): OFFICIAL INSPECTION FORM — NOT FOR VOLUNNT.ARY aSSESS`IENTS SUBSURYACE SENVAGE DISPOSAL SYSTENI INSPECTION FORM PART C SYSTEM I`FOR-MATION (continued) Property' address: Owner: Date of Inspection: 2 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a s�etch of the sewage disposal system including ties to at least two permanent reverence landmarks or benchmarks. Locate all wells within 100 [etc. Locate where public«ater supply inters the owldlna. ------ l W l4TI-'R o i 1( IEFF,(u�wi f FF1- Jv Tkwx Full -r,9-w�- OW R p (ow mf /000 gAllo�o 0 0 C Tnive 8 Ro o m /000 qt,a-6r B 3 �e.fX0 Ptr a� e7�Q4�i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY AS�ESSNIE,NTS SUBSURFACE SEWAGE DISPOSAL SYSTE:NI INSPECTION FORM PART C / --SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXANI Slooe Surface water Check cellar Shallow wells Estimated depth to Around water>Iefeet Please indicate (check) all methods used to dete.-mir,e the high ground water e!evatiori: Obtained 'rom system design plans on record - if checked,date of design plan reviewed: Observed site(abutting p rope. iobservation 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 Xou established the high o ound water elevation: U 1 � f' se re2d t h I� nt?fire Pu rnose: The information .in this report is based on vis »I inspection of tIte listed propemf. This does not mean that that every defect vas discovered or u'r.covered. This report does not offer nor imply a warrantZ, to anv defect to the operation of this system. The process is to visually inspect, as much as possible,-the components of the septic system and to determine if this systerm meets the criteria outlined by this repot concerning Title Five regulations. This information is based from the conditions noted at the time of the inspection. There-is no indication given as to the remaining useful years or if the engineered design flow is at present use of this dwelling. The use of this information is with the uaderstanding that the above conditions are intezral to this report whether it is from the buyer or sellers position. A copy of this report will be kept by me and is a available to all parties concerned. If you require further information, please contact me directly at any time. Warren F. Reid 1-781-255-8839 Inspector .wised C</2$/9i1 Paga !a o! -. i y t ' r TOWN OF BARNSTABLE .& LOCATION � bS CI�TL�z-�i1L�S� C'/�. SEWAGE # 88 VILLAGE Mo%t fj L S ASSESSOR'S MAP 6t LOT i .114STALLER'S NAME & PHONE NO. KINIK) SEPTIC TANK CAPACITY L�000 LEACHING FACILITY:(type) 00 b (size) NO. OF BEDROOMS PRIVATE WELL O_ PUBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: Ld ss DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� _ ... � , � � '. �, .' � 'c ,� �, � �. d •� � G • ��( �n-/ "" r'' ��- - No.--. ... .Q.-� Fim.....o[ C ... ..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ��1 1!J�►�...................OF...... 1 .-............-----------........-........ Appliration for Bitivas al Works Tatuitr7an - rt rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ndividual Sewage Disposal System at: 11,S C A6T\-L%4 d0 D Om - - b--- —..................�Y��✓/✓�,5..................................................................................... Location.Address or Lot Igo. —VA!'�k ...........��.01TA.2 !!�.................................... .....I�UC�c.. .......`.�491...............nj�t i_%........ II vOwner i Address WW1 ............................ T h,. t PQ Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..................'.........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---..---..--................ Showers ( ) — Cafeteria ( ) R, Other fixtures --------------------•--------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.--..--.....gallons Length................ Width................ Diameter--------.--.---- Depth................ x Disposal Trench—No--------------------- Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.--................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. l................minutes per inch Depth of Test Pit.--.----............ Depth to ground water........................ (Zq Test Pit No. 2.......:........minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ----•-----------------------------------------------------------•-••----------------•••-•--------------- •------------------------------------------- •--------- 0 Description of Soil..................... x U •---------------•----------•-•----------....--------•----•---------------------------...........------.....•-•------------------------------------------------•••-•--------...-----•--------••••------•• W ----------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- ----------- UNature of Repairs or Alterations—Answer when applicable.....-1 A_1 S ----------OP3.5----------x{-Oaf.........e p!;1 1*+ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ' the provisions of iITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Complianc een issued by the board ot health. Signed - -----------------------•----- t,e� Date— Application Approved By............ "....•-tea-- . —- ---------------------------------- g . Date Application Disapproved for the following reasons-------------•--•-•------•-----------•-----------------------------------------------•------••-••------........_ ..-•--------------------------------•----.....----••-----•--•------------••-----••-•----------...........---------------------------------•-•---.....--------------------------.....-----•-----...._.._. Date PermitNo.......$1-3..n--- ..................••• Issued....................................................... Date 7 . No..... 12.:.. �/ FIza..-...c�. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------�W........................OF...... �P ? r. .................................... Appliratiou for Bioposttl Works Towitr trtiou Famit Application is hereby made for a Permit to Construct ( ) or Repair ( "-fan Individual Sewage Disposal system at. �65 n�SZ�tiwoo� Q R. ...? Q--.� .. t .....................f:!.A.vw/-- ----j....._._.._......... _ Location-Address or t No. •+he �.Q!�.�!'�..-..._.. l��C�Craap �21 .._......__ Yap-Wi_ .- ,Owner :� 1t Address.................................. . k--•---•----•-•-------•----------------....._.....----- Installer j tj Address d Type of Building ~" ize Lot.............................Sq.,feet Dwelling—No. of Bedrooms- .......... ...,,;. .........Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ...........'"::___..._._. No. of persons____________________________ Showers ( ) Cafeteria ( ) 114 Other fixtures --------------..---------....----t t--------------.---------------------_------------------------------•-•---------.._.----........... _----------- w Design Flow............................................ allons-pert p I son per day. Total daily flow........_.__._-__.__..._.._.__._._-.........gallons. WSeptic Tank—Liquid'capacity__-.._-_.-_gallons Length.............. Width................ Diameter--.----------.-- Depth................ x Disposal Trench—No_ ____________________ Width...........-_'-_.__. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter......:............- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) t.�`'Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.--------------_._----- f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.--_-_.._..__._--_.---. a ---------------•--•--•-----••----------•-•---------------...---.....------------•--.............._..............................---------------------------- 0 Description of Soil........................................................................................................................................................................ x w UNature of Repairs or Alterations—Answer when applicable-------1.&'----'--\.-........... N�-._-•..-.-!;.00 0--_..-..EAU k Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een issued by the board of health. Sign d_ y. -::5 -•-- -----------------------• _ Date Application Approved B Date Application Disapproved for the following reasons:--_-•___•_____________________________________________________•__--_----______-_____..__.-..._.._____-.___-_____ ------•---------------------------•-•----•--•----------------......--•----•--------------...-•-----•----_.-..._.._....--•--------••--•-•--------------------••-----------•-•••-----•-----••-----•--_..... Date Permit No........--11.�..:__-q.!'1..........--••-----_. Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................OF........ �:. 5 �' .,.................................. (Irdif iratr of Tompliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by-•--•-i(_`_-t1!)---------tA!C 1«`T--•--•--•__________________________________•----__-______-__-_-_______-----______---_____-___-__________-__-____-----___-•-•----__•__-- Installer. at ••-•-- has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..---_-.._.F15r.--_.../.Q._rl-___. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.--•---•--.....--7..-._- - ..'. .`6........................... Inspector......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �...................oF.....3 .2 �a� -•----.-_...:-......-.....-............ �f't? � ....................... t NO........................ Diop000lWorks Totmtrtt tots Wrmit Permission is hereby granted - ! 'z ' -------------------------•----__-__-------------------________------- to Construct ( ) or Repair ( an Individual Sewage Disposalem at No. iC (1*6-t0,�S? ti 9 ------•-D�Z11••--------- -�Y AiJ 0_ 1 -•---•--•----• --------•-•-•-----_--•-- Street G as shown on the application for Disposal Works Construction Permit No... Dated.......................................... ` , ................................. '--------------------•----------....---------..._....----- -_:..6 DATE................. r 7-"- � ................................. Board of Health - -----� FORM 1255 HOBBS & WARREN. INC., PUBLISHERS -- -- ----- ---- 2 0 rr�;n. t,,J Cb 1-107- fop 0 el r?7117. G� ►ADS _--- ---- - -- Conc. covers , •4"cast iron or .`' � 2" layer o•P pv pipe cul mire. Min. washed/ pitc/7 1/4"per = r>,aX. p peaSfOne foot 4 Sc/7. yo pvc pipe Min. pitch flow line �� V clean Sanc/ a in inv. el. 3. hD inv.e ' • • T I •• O • • i . o 0 D o • . • o o . . inv e/ 0 O ., • O , . . o. , . r• , . • . O. . • • 5FiiLE in e/. e. e 3/4 , /�z washed• sfo/7e • ,� /j ;� 1 , 6 :,crushed„stone, base..•. ..dis o� � (o y 1 � inv. el. / ..� l yrounc( auafer fable e/ev, = Nz5T .4L.4oWEL7 boot" fest ho% e/ev. _ , bop SEWAGE• SYSTEM P RoF/LE - not 'fO SGQ/e. TS j � 5' zi p J � E S/G Aj D J9 7"iq/Z ` _� NUMBER O F BEDROOMS ` Fuj-��•1cr� T E S T H L o G LDn� _ GAP_B qGE D/SPOSAL U/l//T :. /</aT Xal1�D� �' TEST DATE : TOT�j�-, EST/MATED FL,�O / /.�//TA/ESSED BY: NoT ��C.r+C. � \ CLC�L GAL.1BJ2•1DAYx y BR): PEPeCOLAT/O/l/ F_J9TE . M/N.I(AJ H I o .-� Z G. '1 oAY tom- ELF-D��EI� �Y:��Y/T.��. j✓I , C \ /2EQ• SEPT/G TANK CAPAC/TY: GAL. HoL E 1 HoL E z A.GTUAL. SEPTIC TANS Oil —� ' :. � /._ l -. . I LEACH//VG A 12 E A RE Q �ti2 E M IV S A �p 9 �`l SJOEWA L .� GigL. y i �yU , -f BOTTOM 7-0 TA L LEAcH/NG APA � v1p RE SERVE C EACH/NG CAPACITY / / GAL. O 13� AJO T E S 1 W N MA S J ALL 0RkMASH/P AND TER AL - SHALLT CO/VFORM O -l ' /g / AND THE ToWAI OF � _1Z "� ► /OU�1�'Y! RULES J9ND REGUL PT/OAJS FOR / -��f SU5SUi2FACE D/SPOSA4- OP d S,9N/ TARP SEWAGE. �� ✓ �� �'QOPRS�_� ?�7 - U 2) COMPL/AIVCC- WITH 20/VJ/VG i2EGULAT/O/VS y� �l �k , _ � , rYIO►/�i -L= -LC.E'�4�� !;HALL 8E- DETERM/NED BY 8(J/4_O/NG /NSPE CToi2 /COJYIM/SS /OAJ& 2. - 3) S.X1S7/ll/G " AND F//VAL GRADES SHALL REMAIN ESSENTIALLY THE SAME, HE 77Y � E- to_ L� T O VE.�-0�}?70�.! b� q�..� !>TiCrT,�s cS�Wt�2 //-1 VZS e cSE /C ' B AD. OF H E A L T H <<-rrl NEB CsFCs .. �_747-10eOA • , AGENT �_v�A= 7 N r - RAR O P O S E G O AJ ST)2 UCT/O AJ 0 ,F-�T:____ ._ __ __ y�2 M�.r.�i'.5 • L. o c �9 7-1 o J�/ . ��t5 G I rL t�lt,�l EF E i2 E &I,C E• : ,` MwD 1�1R �`� t ?7z Q% S /T E' F�L A /V P i2 E P Je E D O Scale- CS U A F S CA C- - In , :�- w 3 9L LEGEilJO � �' e iStin 5 of e%v. = i s s �'' ��� �yP x P o avl �. : . a !' exlSt/n9 GOn•fOU!- .� - a_ o V -fyP Prof• fin. spot e/ev, o. o ? f Prof fin. contour Septic Upgrade Repair Plans �< J r W -f-est hole locatonwL o c A7- 40 -�- Ea st Sandwich, Massachusetts -