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HomeMy WebLinkAbout0042 CIRCLE DRIVE - Health 42 CIRCLE DR. ,HYAITNIS A=288. 039 I o �a I 4 E I i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Circle Dr Property Address Everett Walsh Owner Owner's Name/ information is required for every y H annis ✓ Ma 0260.1 1/27/20 page. Citylrown 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 l7 on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Q Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 S113522 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 1/27/20 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. Cityrrown 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: System contains a 1500 Gallon septic tank as well as a concrete distribution box and 4 2'x2'x20' Leaching trenches. 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): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form �= a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is Hyannis Ma 02601 1/27/20 required for every y page. Cityfrown 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: t5insp.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° y Assessments u 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. Citylrown 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 ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Circle Dr Property Address " Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ ® 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 water supply 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 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 ❑ ❑ 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,aI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... � 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 e. Cityfrown State Zip Code Date of Inspection page. P 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 ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C.is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form .II; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is Hyannis Ma 02601 1/27/20 required for every Y page. Cityfrown State Zip Code Date of Inspection D. System Information 1. 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 i Description: / r Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 188 Gpd 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 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: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Not provided 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U- 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Installed 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 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.): System is vented through the roof t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts ,p Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is Hyannis Ma 02601 1/27/20 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 p g feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4° Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is at normal level with no signs of leaking. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f . Commonwealth of Massachusetts :. Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day 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 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. Cityrrown 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): Depth of liquid level above outlet invert Level and at normal level 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.): No signs of push back from septic field. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 / r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 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 ❑ 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. 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: ® leaching trenches number, length: 4 20' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system i Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4�• 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. Cityrrown 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.): Perforated pipe in stone, no break out no ponding no signs of failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts �x ,, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Circle Dr Property Address '4 Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 1/27/2020 Assessing As-Built Cards " v TOWN OF BARNSTA,BL.E ' �1-.&LL I OCAnON`l, - 81C q C I✓cJ r SEWAGE#I VII.L.AGB /Ztr�+^�;L� �A ASSESSOR'S KAJP&LOT_211-&V vSTALLFR'S NAME&PHONE NO: �_ SEPTIC TANK CAPACITY-1400 d. LEACHDVG FAaLny:(type) (aim) NO.OF BEDROOMS BUIIAER OR OWNER l _ y1 PERMITDATE:_II Zl ' COMPLIANCE DATE: 1--1'5 Separation Distance Between the:. Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (U 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 ,9 AA;35 2�rZy t;. httos://www.townotbamstable.us/Deoartments/ASSHq.inn/Pmnprty VaIIIAC/HMrlicnlnv acn?mnnnnr7AAnZQJtecn=1 �i� I cam, Commonwealth of Massachusetts x Form Title 5 Official Inspection Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Circle Dr u Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is Hyannis Ma 02601 1/27/20 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 8+ ft 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 ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Auger hole to 8 ft NGE 4' below SAS Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Circle Dr Property Address Everett Walsh Owner Owner's Name information is required for every Hyannis Ma 02601 1/27/20 page. Cityrrown 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. ❑ 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 ❑ 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form A e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyanliis MA 02601 8/4/2017 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, ' v use only the tab . 1. Inspector: key to move your cursor-do not Paul Martin use the return Inspector Name of Ins key. P Cape Cod Septic Services ry Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 SI5016 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 i 8/10/2017 Insp ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �o �s commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: System in working condition. 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. City/Town State Zip Code Date of Inspection. B. Certification (cont.) 2. System will fail unless the Board of Health (and Pub lic_Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for° Y Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 9p d. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 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): 110x3= 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M "r 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2015=144gpd 2016=134gpd Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): . Grease trap present? Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Pagel of 17 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 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: No Records 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 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: 1998 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 21211feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: +10, feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 1'6" feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500Ga1 Sludge depth: 8-10" 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 o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is Hyannis required for every MA 02601 8/4/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 4-611 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers 18" below grade. Recommend service of tank Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °t 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is Hyannis required for every MA 02601 8/4/2017 page. CityrFown 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 El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-6 with 1 line in and 4 lines out in good condition. Box is clean and level with minimal solids carryover. Outlets are even. No sign of overloading or hydraulic failure Cover 2' below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. Citylrown State . Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-4 laterals ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field with stone and 4 lateral lines. No standing effluent in lines at time of inspection. Stone probed and found dry. No sign of overloading or hydraulic failure Cesspools (cesspool must be.pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑_ No t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts u _ Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner . Owner's Name information is required for every Hyannis MA 02601 8/4/2017 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 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "l 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately e t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts u m Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Z. 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: 1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data per plan on file at BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of47 Commonwealth of Massachusetts - v. Title 5 Official Inspection on Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Circle Dr. Property Address Lillian Moore Owner Owner's Name information is required for every Hyannis MA 02601 8/4/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ' TOWN OF BARNSTABLE" LOCATION It,1 3 m5r 47 C 1!!J E l.)✓ SEWAGE M _ VU AGE i.an t S Q 1A ASSESSOR'S MAP&LOT)�x a INSTALLER'S NAME&PHONE NO. f�✓tp SEPTIC TANK CAPACITY z400 Q.-e I LEACHING FACILITY:(type) fir..A.L (s ) NO.OF BEDROOMS— J BUILDER OR OWNER PERMIID OMPLIANCE DATE J.'Z -•g Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Teaching 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 A t fi A-y° zb y� 6D-51 ��14 z p q0 l/v -• TOWN OF BARNSTA.BLP LOCATION d2�7 42 CIV' .J E- D✓ SEWAGE#- `' VILLAGE ASSESSOR'S MAP &LOT�� !i _Nz,—,INSTALLER'S NAME&PHONE NO. `SEPTIC TANK CAPACITY /46a -r" / r LEA.4:HING FACILITY:.(type) A-ew'AA (size) NO.OF BEDROOMS BIJILDER OR OWNER � M PERMIT DATE: 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 or site or within200 feet of leaching facility) Feet+ 1 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) .-'. Feet s Furnished by 4 j � 4 / oli, �. V,� -, z J \ J No. Fee THE OF MASSACHUSETTS Entered in computer: COMMONWEALTH Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppftcation for Xkgogar *pftem Congtructfon Vertu Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) complete System ❑Individual Components Location Address or Lot No.Lo7- #7 _ Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Desi ner's Name,Address and Tel No. ski IO,�vss�. 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 336) gallons per day. Calculated daily flow 330 gallons. Plan Date l/-Za _Cl(0 Number of sheets Revision Date Title 61AQ?.&E-0F 5 ys;2FNi Size of Septic Tank Type of S.A.S. i� 0"XZ' ZXj. Description of Soil Nature of Repairs or Alterations(Answ r when applicable) �''� E 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 byAi�Board of Health. Signed Date s Application Approved by Date Application Disapproved for We foll ing reasons ———Permit No. =ql- (��� �————— — Date Issued ...... ..:4,-_...,y. ."t a y •'7•y2Wa. �._:'`. a✓'a1.,. .st,�.'a.awVyw* �....,y,. - ., . a.ai .-� ,t.a..'+-v �.�.. , a.� _, � .� D3� a m ry: No: Fee —57 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ^� Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS t 0(pprication for Mitpaar *pttem Con.5truction Permit Application for a Permit to Construct O"' )'Repair Upgrade( )Abandon( ) complete System ❑Individual Components 1 Location Address or Lot No.,LOT 7 Owner's Name,Address and Tel.No. Assessor's Map/Parcel . e12 e-1,ve e- . viz Installer's Name,Address,and Tel.No. i Designer's Name,Address and Tel.No c aSy�•s� � v�� 'g'yo-rx c• ��L��/7� �����20 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 .33U gallons per day. Calculated daily flow *3 30 gallons. Plan Date ZZ, La -G!6 Number of sheets Revision Date * Title )75hl 1, Size of Septic Tank f Sob Type'of S.A.S. XZ 1 7,!Fk- & aer- i i Description of Soil • _Nature of Repairs or Alterations(Answer when applicable) �E Date last inspected: "k 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 issueBoard of Health. Signed Date Application Approved by Date Application Disapproved for e fol owing reasons Permit No. Date Issued ———————————————————————————————————�——— 1 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 ga4 4 has been constructed in accordance with the provisions of Title 5 and the for Disposal Sys m Construction Permit No. dated Installer Designer The issuance of this permit shall not be c nstrued as a guarantee that the syste wa.lfunction as designed. Date Ct Inspector , No. Fee S/�= THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE., MASSACHUSETTS ligoal *pztem Congtruction Permit Permission is hereby granted to Construct(. )Re air( )Upgrade(�Abandon( ) System located at �/11 V 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 this pe it. Date: 41 - )L Approved by 4 TOWN OF BARNSTABLA 1 LOCATION � y SEWAGE# .i VILLAGEASSESSOR'SMAP&LOT INSTALLER'S NAME&PHONE NO: SEPTIC TANK CAPACITY /OO LEACHING FACILITY: (type) �!!.rc� (size) NO:.OF BEDROOMS ' BUILDER OR OWNER PERMPTDATE: I L'�,�- -� COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwaiei'Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet or,site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) r - et 4 Furnished by _ J a D.; S ` . � [ — 70 r= ��. 8 A6,; L4 Mill 3", ,FIRST FLOOR SOILS",:, SEPTIC :SYSTEM PROFILE . 'GRAD OVER FIN.'� GR FIN.' FIN. GRADE OVER ELEVATION 219 FIN. GRADE,OVER ADE ':'HOUS TANK�,�'� T, T AT bIST. BO� SOIL ABSORPTION SYSTEM E-� " ' , �' -SEPTIC ' PERCOLATION TEST P 0 f 21 T :2 TEST HoLE- 2 05 0-2 EST HOLE I � 20.7 F 0 N b A' ION T 2 -M % IN.'GRADE ,­ 'R1 W T777A- MOT" EVATION,:,�� 0" ELEV.' ELEV. EL' 'GRA IN JIN 6`OF F1 DE VERT, �0 , 2".MIN.-DO LE WASHED-] STON UB, /8" - 1/2" fOUNDATION 'ELEVATION =­.Q :077,7.7-.. 7T : FL 3 rK7— PERF. 4' SCH.,40 PVC 9 0.005 w w 17.10 V4,1, - w/2". DOUBLE WASHED_11 j J CRUSHED STONE ON LEVEL BASE PRECAST 'C.I. OR P.V.C. TEES DIST. BOX ' ­ 'ON' ' --GALL 20'-0" 'EFFECTIVE LENGTH 0 or AN H 10 --, ,LOADING 'SEPTIC ",T A MENT- FLOO 'A S6 R H 10 LOADIN TO BE SET ON' ELEVATION LEVEL STABLE 6" BASE _,(�CRUSHED STONE,BASE ACME DB- OR .10. ' APPROVED EQUAL. ) EFFECTIVE HEIGHT SE PTIC TANK,SET LEVEL AND TRUE TO GRADE ON 6" CRUSHED STONE BASE ON -Pro f#6 not to scale :MECHANICALLY COMPACTED NATURAL MATERIAL I oil 2 - OBSERVED GROUND WATER: BETWEEN EFFECTIVE TRENCHES -' WIDTH , ADJUSTED GROUND WATER: PERCOLATION RATE: MIN /INCH 4 HES: TOTAL NUMBER OF TRENC SOIL CLASS: EFFLUENT,LOADING 'RATE: GPD/SF SOIL�EVALUATOR: - DETAIL , RENCH CATION NUMBER: tERTIFIT S: WITNES BOARD�OF.HEALTH, TOWN OF, DATE OF TEST DESIGN DATA NUMBER OF BEDROOMS 110 G.P.D. G.P.D./BEDROOM G 1 0 G.P,D. TOTALDAILY FLOW 33 ENERAL NOTES NO - 2*x2 ------- x20', GARBAGE DISPOSAL HE Nq ................... 330 G.P D.� LEACH. TRE LEACHING ,REQUIRED , 1. ELEVATIONS BASED UPON -U.S.G.'s. DATUM. LEACHING PROVIDED 379 G.P.D. 2. �ELEVATIONS AND LOCATIONS SHOWN ON THIS PLAN 20.0 UIRED SEPTIC TANK REQ 1500 GALLONS -, ARE NOT TO CHANGE WITHOUT �,WRITTEN, APPROVA 1500 OF, (6 SEPTIC TANK PROVIDED GALLONS.- THE ENGINEER "AND',THE TOWN HEALTH AGENT. 88.0 , S.F 3. ALL SYSTEM COMPONENTS 'ARE ,,TO BE -INSTALLED IN "LOT 7 SIDEWALL AREA . 40.6 , CCORDANCE WITH'S.E.C.�T TITLE 'AND�'L -HE � A V OCAL: ALTH BOTTOM AREX� S.F 5,650± S.F., ' TOTAL,PROVI '128.0 SP." x 0.74 w,94'72 .P.D. RULES ,AND RE WELLS/WETLAND N Im DED= GULATIONS, ,� P,iV.C. SCH.,40. :�� WITHII`)I/150'_ 'E8 2-O.P.1) '4 ALL PIPES �ARE TO BE CAST!1RO,N,OR_, 94.72 G.P.D./TRENCH x, 4 TREN RE' C S = _'OF,1HEALTH AND/OR ENGINEER TO �B �5. THE BOARD E OR LOWER AS SOIL OTIFIED WHEN SYSTE N M IS, COMPLETELY INSTALLED NOTE:', EXCAVATE TO EL. 0 �AND RE 1500 ADY FOR;INSPECT! N. CONDITIONS REQUIRE TO REMOVE LL TOPSOIL""SUBSOIL TING CESSPOOL OR SOLAR G AL. UAY, OR OTHER'UNSUITABL'e4.MATERIAL BENEATH 6. NORTH,:ARROW 'IS NOT TO BE11USED r BE PUMPtD our THE 4) �ORIENTATION. A VO c\j S.T. T' SOILASSORPTION SYSTEM FOR, 'RE7,10VED EXIS INLET INVERT,OF THE ECK ,� BACKFILL 'WITH CLEAN D A DISTANCE OF,5 ,MIN.," SAND, PEW316dMR 15.255:3, EXISTING 'LO DWELLING HSE. #42 20.5 Ut 'DATE.: -DESCRIPTION REV BY S Y'S' "LOT 6 , F8E' WAGE� DISPOS L � No.i 127 UPGRADE A vt W SIMMONS _HSE ' #42- C IRCLE,%DRIVE POND LOT, ' A N N I S. LOCUS, �HY A, 'A OF ft APPL : ,,ELIZAIJE IdANT' 4 TH HANLEY 1�11 14 R - 5 .00' ADDRM,: 42 CIRCLE DRIVE, ;:',-,,HY4NNIS.�Mk, E NOWEER: MRMAN' .: AN E* 0 TH, L jEAST'FALMOU ELEVATIOW%,"ZO FLOOD �R '-ROAD SCALE-.'I", 20006,' :"� VIEV� LOCUS JMAP,�T", I 10AASH �ZONEJ ICT'l CIRC E:,.DRIVE� ' 506 IR E �A 484920 N.- BY,/, DW ' CK'D BY1 :'HSE -.PLAN NO. SEC Ap DATE 'PLAN, ERE S 039 S�.N TED�_, j NG- H�;:449' 20' ,288 NOV.:;20.",19!§6' SIT LE",URNii,tNTYi�OE E" CA PLAN