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HomeMy WebLinkAbout0012 ELDRIDGE AVENUE - Health 12 EldridgeAvenue Hvannis F/R A= 292 280 o , a a9a- aka Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System For - at for Voluntary Assessments (p /c)- Elclt Property Address Owner Owner's Name • n information is D06O 3required for every _ Av►n�l /� _ ,J vZ page. City/Town State Zip Code Dat of Insp ction - 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 P A. Inspector Inf r ation � on the computer, use only the tab I e key move your Name of Inspector 0 T C. cursor-do not ./y` use the return Compandwl� y Name ��)) Q 5�l1 key. P� QV�C V V Company Address a /7 o �� City/To _j o �0 0 State Zip Code 3 o��U - �'l9 d Ile-- Teleph a Numb 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 maintena of on-site sewage disposal systems. After conducting this inspection I have determined that the s em: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails i Inspector 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. tsinsp.doo-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 1 Commonwealth of Massachusetts �. Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments tle- Property Address Owner Owner's Name n information is V 11 required for every N 4IS page. City/Town State Zip Code Date ection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System P ses: 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: 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 'i l Commonwealth of Massachusetts P Title 5 Official Inspection Form tilt, 'b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address a o� Owner Owner's Name information is 0a6o/ 3/e— C.required for every Gi✓Jylpage. City/Tow, State Zip Code Date of Ins Inspection Summary (cons.) 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form Not f r Voluntary Assessments /9-- C 140— Property Address / Owner Owner's Name information is 4 N I f Al required for every v 47dC0 page. CityTTown State Zip Code Date of lnsp6etion C. lnspe&don 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 .f sewage into facility or system component due to overloaded or ,Qlged 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 Subsurface Sewage Disposal System For -Nat or Voluntary Assessments -.1d, - Z-: 7 Property Address q p Owner Owner's Name information is � /� l required for every G N�� yd60 1 page. City/Town State Zip Code Date of In pectiol 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: ❑ Ft� Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 5l ^ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ EEro� 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. ❑ LK 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.] ❑ T e 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 t5insp.tloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage oisposai System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments Property Address f Owner Owner's Name information is / p�� 3 5 of required for every (/�!f C page. City/Town State Zip Code Date of ins ection 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 ❑ P mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ s the system received normal flows in the previous two week period? ElHave large volumes of water been introduced to the system recently or as part of is 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 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not f r Voluntary Assessments 44 z— cP Property Address Owner Owner's Name information is �/ ) n required for every A✓�h It 6dko f 3 O`.r) page. City/Town State Zip Code Date of Insp ction D. System nformation 1. Residential Flow Conditions: J Number of bedrooms (design): — Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: .j 000 6�- 54,�t ' �r, A- Z:W�IHf--4or 1c 7W Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes D-90 If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes No information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: C Date t5insp.doc•rev.7l26/2018 Tide 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of IS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / EJcr Jz,, /4 w-, Property Address a p Owner Owner's Name information is rS '1 O / a�• required for every page. Cityrrown State Zip Code Date of Inspe tion 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: Was system pumped as part of the inspection? ❑ Yes LJ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: — t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form IS Subsurface Sewage Disposal System Fo -N t for Voluntary Assessments Property Address .L aTO� Owner Owner's Name information is g�h f Owl 3 a 5 � required for every page. City/Town State Zip Code Date of I specti n D. System Information (cont.) 4. Type of S m: 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): Approxim age of all components, date installed (if known)and source of informatio o20 pA Q N l✓ ,-, ,4 e L_ Ae w S. �S goo/ Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: �� P 9 feet Material of construction: ❑cast iron 0 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition ofjoints, venting, evidence of leakage, etc.): i5insp.doc•rev.7f26/2018 Title 5 Official Inspection Forth.Subsurface sewage Disposal system•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner owner's Name information is �Y 1 required for every Dr 1�l i!J _ y �- I 3 a s page. City/Town State Zip Code Date of In pectin D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 0— feet Materi construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate ❑ Yes ❑ No Dimensions: Sludge depth: f/ Distance from top of sludge to bottom of outlet tee or baffle 3< Scum thickness Q !/ 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? 9/0-- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Nnsp.doc•rev.W262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Eld(i Property Address �-4 Owner Owner's Name ll// information is h ©d(Od required for every 1 page. City/Town State Zip Code Date of LAspectiont 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 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 16 Commonwealth of Massachusetts �. Title 5 Official Inspection Form '. Subsurface Sewage Disposal System Fo -Not for Voluntary Assessments Property Address I- -v Owner Owner's Name information is s A,4- a s required for every - page. City/Town State Zip Code Date o Inspec on 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 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.): 0 � Sp l f ---- /+101 �S t5insp.doc•rev.7126IM18 Title 5 Official Inspection Form:Subsurface Sevrage oisposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Fo -Not or Voluntary Assessments Property Address Owner Owner's Name _ information is required for everyP&ICU44411 — ✓yy uL page. City/Town State Zip Code Date of nspecti n 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: ❑ lea ing galleries number: ❑ leaching trenches number, length: _ leaching fields number, dimensions: ~�f ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: ------ -- t5insp.doc•rev.7/26/2018 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �• a I System Form -N t for,Voluntary Assessments I. Subsurface Sewage Disposal Syst ry 9 p _ .fir � 1 Property Address Ile Owner Owner's Name ����� r information is A f J 2 required for every -- page. CityrFown State Zip Code Dat of Insp ction 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.): Sol / _ G✓I �+ ''`� c7 /c' a v !l L _7"oilt4 le--� 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 Commonwealth of Massachusetts P Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -No for Voluntary Assessments X� -�� y� Property Address -- - Owner Owner's Name information is required ifs d for every a✓74 j page. City/Town State Zip Code Date of Inspe ion 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 Commonwealth of Massachusetts Tithe 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L� Property Address Owner Owner's Name /y information is A N N 1 C�/ - /� �rp©1 required for every _�J� page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view a sewage disposal system, including ties to at least two permanent reference landmarks enchmarks. Locate all wells within 100 feet. Locate where public water supply enters Vdin g. Check one of the boxes below: ketch in the area below g attached separately t5insp.doc•rev.7/262018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealtfrof Massachusetts Title 5 Official. Inspection Form Subsurface Sewage:Disposal System Form-Not for Voluntary Assessments 12 Eldridge Ave . Property Address Ryan Birch Owner 6;� s Name information is papered fbr every Hyannis Me 02601 8-27-18 page. CrtylTomm _StI.ate Zip Cade 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.Lute 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 '� i Drives D i i i E AC-14.W A 4242Z AE-5C SC-211 BD-3 BE-47.V 15in�.doe•rev.�riarmla rse 5 ofaar rmpection FaPin siarsarare savage asposa4 system•Fage 16 ot:18 Commonwealth of Massachusetts �a p Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lie I Property Address Ave— Owner Owner's Name information is G� /f O 1,O ] required for every __ _�-(p /__ page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date — ❑ erved site(abutting property/observation hole within 150 feet of SAS) Checked with local and of Health-explain: �cyl ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describ h Jou established th high ground w ter elevation: .� 4c, ,9' S s4ev-7 os a) - --- ` — u (^/`Q-fir` - --- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7126f2018 Title 5 Official Inspection Form:Subsurface SewaSe Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address G Owner Owner s Name � lAsectfion information is ��� s60required for every page. City/Town State Zip Code Dateof E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. ification: Signed& Dated and 1, 2, 3, or 4 checked C. Inspection Summary: , 2 , or 5 completed as appropriate Z4 Fa4 (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 Oisposal System-Page 18 of 18 c Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I ; 12 Eldridge Ave u Property Address M Ryan Birch l :r Owner Owners Name ; p information is I^f required for every Hyannis ✓ Ma 02601 8-27-18 page. City/Town State Zip Code Date of Inspection ; l 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 on the computer, use only the tab Brett Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 4:1 Company Address Sandwich Ma 02563 City/Town State Zip Code repro (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. ❑Q Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails oreBa��sIBreE M Bre11 MIUey Brett Hickey oB:m-&.��,�.. o...ma,a.m�,..a��.�o..a,.��B 8-27-18 Oaie:20B.08.2B O:J2:5]Oa'BB' 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 Offdal Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 cc Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave v Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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 r r es a year due to broken or obstructedpipe(s). The ❑ Y q P P 9 Y 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 12 Eldridge Ave v Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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: ' I 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El 0 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave u Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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 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 '/2 day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ O ' Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E 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. ❑ El 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 40,000 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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 0 ❑ 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? E ❑ 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? Q ❑ 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? 0 ❑ Was the site inspected for signs of break out? El ❑ 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? ❑ 0 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: El ❑ Existing information. For example, a plan at the Board of Health. El El 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 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ..........., 12 Eldridge Ave L Property Address Ryari Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 393/gpd Description: 5 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence•have a water treatment unit? ❑ Yes Q 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 Seasonal use? ❑ Yes E No See below Water meter readings, if available(last 2 years usage(gpd)): .Detail: "'2016-27,676gallons 2017-25,432gallons"" Sump pump? ❑ Yes M No Last date of occupancy: currentDate 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 12 Eldridge Ave v' Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA 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: Owner- last pumped 1 year ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave L Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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 co of latest ( Y ) co py inspection of the I/A system b system operator under contract Y Y Y P ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1-16-02 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 1 r8n 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 c� Commonwealth of Massachusetts �a Title 5 Official Inspection Form m la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave. Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 811 Depth below grade: feet Material of construction: ■❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 3„ Sludge depth: 3311 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured 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 not in need of pumping at this time and should be pumped every two years for maintenance. I t5insp.doc•rev.7/26/2018 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 12 Eldridge Ave Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: NAfeet 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): I 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 12 Eldridge Ave v Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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): Oil 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts , �n Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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 ❑ No" Alarms in working order: ❑ Yes ❑ 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: ❑ leaching trenches number, length: (4)Hi Cap.infiltrators Q leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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 order at the time of inspection and was 1/2 when viewed. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts -�w p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Eldridge Ave Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): NA 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 , Commonwealth of Massachusetts •�n Title 5 Official Inspection Form +' � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 9 P Y rY u 12 Eldridge Ave Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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: ❑0 hand-sketch in the area below ❑ drawing attached separately C Driveway B E AC-14.6' AD-42.8' AE-9 SC-21' SD-39' BE-47.6' t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - � 9 p Y rY u— 12 Eldridge Ave Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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: No GW @ 132"feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record 1-11-02 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: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Tile 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 12 Eldridge Ave V Property Address Ryan Birch Owner Owner's Name information is Hyannis Ma 02601 8-27-18 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. ■❑ 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 4 ' TOWN OF BA�RNSTABLE LE)CATION SEWAGE # ���7. D I!e VILLAGE 6L.Vlln-G ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 1. - 0.1 i NO. OF BEDROOMS BUILDER OR OWNER LJa {d q' . PERMI'TDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet --- Furushed by l 6 Q�t po GO (5j C;j r� n TOWN OF BARNS ABLE LOCATION SEWAGE # a VII;LAGE 1-1YA—n1?/J ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Ido0 LEACHING FACILrrY: (type) Z 72-p4c/l (size) �� / �Je , NO.OF BEDROOMS BUILDER OR OWNER 00, A4941St PERMUDATE: �,; 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 o a o Sot'-• No. �.VO��. .� FEE Board of Health, MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repairx Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location 12 (Yr/CF �e Gi(/e- a Owner's Name Map/Parcel# 2Cr Address Lot# �/ Telephone# Installer's NameAA Designer's Name �d L�Tu�� < jy y °e,s, Address Address Telephone# Telephone# 7-3J6 Z Type of Building ICJC_� Lot Size 3- sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 730 gpd Calculated design flow Design flow provided 3 gpd Plan: Date 9J al" f/. TI-06>Z-- Number of sheets Revision Date Title Q d c, V6 G Z-- 6keA ine Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator 6, Date of Evaluation DESCRIPT19N OF REPAIRS ORALTERATIONS VA-0 °fa A!&jam, A Wr- III OeMAV��j The undersigned agr s to in a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a s to not o plac the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date D�J� o v Inspections � x . n. No. �,UQ FEE h Board of Health, �a'''� MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit'to'Construct( ) RepairK Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location 12 F 1d r iq�e I&e H (/Q Owner's Name (,(/SQL.0 e Map/Parcel# 2 Of Z .. �� 1 Address 2PA l Lot# Telephone# Installer's Name Av. ' Designer's Name�� � fit! �-�y� lopS� Address , Address Or Z COta Telephone# Telephone# 5V?—,qZ 386 Type of Building I�-.f ! C'e- Lot Size (0 / q.ft. Dwelling-No.of Bedrooms Garbage grinder ( Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) 3 gpd Calculated design flow ? Design flow provided 393 3 gpd Plane Date,_ A•t-t Number of sheets Revision Date Title PrrWekecf J J7c U 6.a-0 ok /*,'IC4 A-JL L.P 00!G!7� r Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator 60 14r"t Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS r A-0 /P GC cfsl e �t �.P C.[/� Ph 11G+ �"'/ -T? A- /o. P�L ''C P�Ci`l C 4-7,3 1) • fry- Z O C �h �' �4 O�J w Y The undersigned agr.es to ins�ie above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ag s to not to plac the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed7 Date Inspections No. ?-01 FEE COMMONWEALT14 ®f MASSACHUSETTS 2 'Z?;0 Board of Health, O.-v—A., 6 MA CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: ?' at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 00) -of dated 0 Approved Design Flow (gpd) Installer �� �.• / / Designer: Inspector: V � ' �nl 71 X_- - Date: (�! ! / �dl� The issuance of this permit shall not be construed as a guarantee that the system will function as designed.—��� No. 200.2- FEE C®MMONWEALT14 OF MASSACHUSETTS -Z— 07 Z -- 2 ?V Board of Health, &0--r-o j6r� r 6z— ,MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT , Permission is hereby granted too* Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system at / as described in the application for Disposal System Construction Permit No. )Uo? -U/ dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date a Board of Health� v �_ pp TOWN OF BJA�RNSTABLE j LOCATION SEWAGE # OCR VILLAGE 'S t'c� ASSESSOR'S MAP &LOT a1 Z_ IN NAME&PHONE NO. SEPTIC TANK CAPACITY la LEACHING FACILITY: (type) / a O (size) J t X, 0?" NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: {— 'L (Q C) Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on 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) Furushed by ;.3J [001 a-c � D 37 , 0 5M/01 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM s S hereby certify that the engineered plan signed by me dated / �� , concerning the property located at l Z r l d rz J e ,4�c"`�t �y�hH;S meets all of the following criteria: ..! This failed system is connected to a residential dwelling only. There are o commercial or business uses associated with the dwelling. y�, :..f The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. L/ There is no increase in flow and/or change in use proposed There are no variances requested or needed. - - 1+/ The bottom of the proposed leaching facility will not be located less than fourteen (14) feet abovd the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicable)' Please complete the following: A) Top of Ground Surface Elevation (using GIS information) 446 B) G.W. Elevation + adjustment for high G.W. — ZT `DIFFERENCE BETWEEN A and B Z SIGNED : DATE: NOTICE 3 Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. ASSMSORSMAP PARCEL Commonwealth of Massachusetts Executive Office of Environmental Affairs John Grad D.E.P. Title V Septic Inspector Department of P.O. Box 2119 .Environmental Protection Teaticket, MA 02536 (508) 564-6813 William F.Weld 3oMmor Trudy t:oxe Becrr .ry,EOEA " David B.Struhsp C rnmioioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.' `' PART A A CERTIFICATION Property Address: �(3C!e., )Pil ��C10 C\\S Address of Owner: Date of Inspection: (If different) Name of Inspector: Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I certifl, 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 inspection. The inspection was performed based on my training and experience in,the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further fvaluation By the local Approving Authority -Fe i is Inspector's Signature: Date: S�Liyl q(o The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sen; to the buyer; if applicable and the app.ro,ing authority. INSPECTION SUMMARY: Check A, B, C, o Aj SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined_. in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 81 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y,,N, or ND), Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is _ P imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 o FAX(617)GWI049 a Telephone(617)292-NO Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address- Owner: Date of Inspection: � y�C KO B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy,is within 50 feet of a surface water r Cesspool or privy` is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 1hP >�G!eni na> a >euuc tdnh dnu buii absorption system and IS v.iilull iuv frci iG q Sulia.c :'.atC. G t:, i. surface water supply. _ The s%�!P- ha> a Sept c tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from`a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen.and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: y ITEhave determined that the system violates one or more of the following failure criteria as defined in 310'CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determ+ne what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an overloaded or dogged,SAS or cesspool. Discharge or ndin of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or _ Po 8 . cesspool. {revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner:T l�Q S� vv Date of t s coon: D) SYSTEM FAILS (continued): 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. 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. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following"conditions exist: 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 11 of a public water supply well The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �,c)t k c CyR— , � Owner �Q Date of ns ection: j\ Q�o Check if the following have been done: - Pumping information was requested of the owner, occupant, and Board of Health. _L.,-P4bne 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. f1�\(-'CA5 built plans have been obtained and examined. Note if they are not available with N/A. _!,�e facility or dwelling was inspected for signs of sewage back-up. _efhe system does not receive non-sanitary or industrial waste flow ✓fhe site was inspected for signs of breakout. -YAII system components, excluding the Soil Absorption System, 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. fie size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. Ke faci!ie. rn-— ;,2n rrri,in�ntc if diflarPnl from o"np,) were provided with information on the proper maintenance of Sub- Surface Disposal System. i (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address Owner: , Date of Inspectior: Q nS FLOW CONDITIONS RESIDENTIAL Design flow: �alIons Number of bedrooms: Number of current residents: Garbage grinder (yes or no):Cz Laundry connected to system (yes or no): �5 Seasonal use (yes or no): Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL: CAP[ Type of establishment. Design flow:__$allons/day Grease trap 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 occupancy: P cy: OTHER: (Describe) Last date of occu an GENERAL INFORMATION PUMPING CORDS and source of information: s wicy) Ylgs ncs - „vipen lrl he last ti4?cy System pumped as pan of inspection: (yes or no If yes, volume pumped gallons. Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/so.il,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) and source of information: Qs �4�S Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION (continued) Property Address: owner: Date of Inspection: S11y`a� SEPTIC TANK:a/-," (locate on site plan) 1 Depth below grader material of construction:�--concrete _metal _FRP_other(explain) Dimensions: Sludge depth: Distance from top of sludgeedge to bottom of outlet tee or baffle: bit Scum thickness: Distance from top of scum to top of outlet tee or baffle: QV e< 'et,Q*' Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, conditio f inlet and outlet tees or ba lies, de th of liquid level in relation to outlet invert, structural integrity, evict nce akage, etc.) V t w l ais GREASE TRAP:n (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thicklwe -. Distance from top of scum to top of outlet tee or baffle: Di5tan.ce from bottom ni from in bottom of outlet tee of 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, etc.) (revised 8/.5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner:•fi 4(1'3 Date of spedton: `— ANON-TIGHT OR HOLDING TANK:2 (locate on site plan) Depth below grade: Material 'of construction: concrete metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOXi��� (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distributwn 15 eyuni, e%ldcrice of.solid� car)o,er, e%idence of leakage into or but of box, etc.) PUMP CHAMBER:N (locate on site plan) . Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c SYSTEM INFORMATION (continued) Property Address:`� C.�C�l 16yL Owner:. S�t Date of p on: (y1�� 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, number: leaching chambers, number:_ leaching galleries, number.- leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Co ments: (n a condition of soil, igns of hyd ulic failure, level of pgnding, c it' n of vegetation,etc.) \i CESSPOOLS:C&P, (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 ground..a:r-. inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:fllt 1 (locate on.site plan) Materials of construction: Dimension Depth of solids: Comments: (note condition of soil,signs of hydraulic.failure,,level of pond.ing, condit(ott,of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ,a E\& aG PV& Owner' �� Date o Inspection.: 5�►`\\q L SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' qA �'7 l:J g At 30 DEPTH TO GROUNDWATER Depth to groundwater:,�feet method of determination or approximation: 'F Qt'Is (revised 8/15/95). • 9 yY 1 No. 7411-- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppYication for Mi!gpogar *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Al Installer's Name,Address,and,Tel.No. Designer's Name,Address and Tel.No. 0716 C*pe- �fi� i a-o /&.g,c f ea jQ Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 provisioge �by Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is thisBo f Id h. /SignedDate <b Application Approved by G - /(- 9l Application Disapproved for the following reasons Permit 14 No. � — �L.��� Date Issued ———————————————————————————————— — _ No. 4 Fee 4- � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -,TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplication for Migpogai *pgtem Congtruction permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. fed Installer's Name,Address,and,Tel.No. Designer's Name,Address and Tel.No. 100716 Okpe\5eQ f �f Io IS9xfPrz led, Type of Building: k Dwelling No.of Bedrooms Garbage-Grinder( } i Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) i 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 f Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss e by this Bo f H h. / Signed Date Application Approved by � ( - Application Disapproved for the following reasons Permit No. //, Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced ✓)on by��+, ,S _ for as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated L, -/r - Use of this system is conditioned on compliance with the provisions set forth below: i No. J Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS wigpogal *pgtem Con! truction Vermit Permission is hereby granted to to construct( )repair( X�an On-site Se Age System located at ` and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: h " I�-- �� Approved by J\JSITE PLAN / e£ARS£S N SCALE: 1 "=20' ' FRANBIL BENCH MARK ON CORNER OF SITE WOOD DECK ELEV.=100.67' ASSUMED, GENERAL NOTES z o T. ADDRESS: 12 ELDRIDGE AVENUE - 2. ASSESSORS NUMBER: MAP 292, PARCEL. 280 X 0 3. DEVELOPER'S LOT: LOT 110 EEpRiDGE AVE. o Ty 0 4. TOPOGRAPHIC INFORMATION WAS COMPLIED FORM AN ON THE GROUND INSTRUMENT SURVEY. 5. MUNICIPAL WATER IS PROVIDED TO SITE AND 2 / 6 0 7 SURROUNDING PROPERTIES. ".. }� 6. REFERENCE PLAN: PLAN BOOK 260, PAGE 79,_..- 0 0 7. NO WETLANDS ARE LOCATED WITHIN 100 FEET OF SAS. Lo 0 0 0 or 0 o C{� ° 0 8. NO POTABLE WELLS ARE LOCATED WITHIN FEET OF SAS. .......X NO SCALE 0 � c� � Q, e 'sting � �)G(Q� H. -� ie ch trenc 98,93 ;` ��� ca� Jp�� (` (to e abando ed) existing septic tank to be pumped Inspected for structural integrity °, T,H. replace If necessary, Design Calculations 7 94 B . 0 Number of Bedrooms: 3 5 L V !� D BOX 56 O ° M . o Garbage Grinder: No �\ .... o 98,78 ;�,! •`��.,. _ � I '� Leaching Capacity Required:. 330 Gal./Day 98 7 X o/ ,ao o Leaching Area Required: 330 Gal./(0.74 G01./Sq.Ft.)=446 Sq.Ft. o f o Proposed Leaching Structure: 1-33'L X 10.8'W X 2.0'D Leaching Trench install 4" d�a. observation par iJ 0 ' X-,• 6.66 ! %Q Leaching Area Provided: 531 Sq.Ft. within 6 of grade. \ t°Glo hed Proposed Lecching Capacity: 393 gpd > 330 gPd. re 'd.00 Lf E-4 , �/o O - o 98 09 �x Novo `_''' ���;°°°°' 90 A/o. o, dirt drive 00 CONSTRUCTION NOTES LOT 1 10 ��o 1. Contractor is responsible for Digsafe notification J AREA — 16,735 { S 0. FT. o and protection of all underground utilities and pipes. O ;'� 2. The septic tank and distribution box shall be set 97,8 level on 6" of 3/4"-1 1/2" stone. 0 03, Backfill should be clean sand or grovel with no 0 o stones over 3" in size, �o 4. This system is subject to inspection during installation by Glen E. Harrington, R.S. 5. The contractor shall install this system in accordance �o �( 9 6 6 5 with Title V of the Massachusetts Environmental Code o and the Regulations of the Town of Barnstable. " i2o O 2 / 6: Provide 4 H-20 High Capacity Infiltrators and a 5 Hole i H-10 D—Box or equal. 7. No vehicle or heavy machinery shall drive over the / 0 0 septic system unless noted as H-20 septic components. s D/y / 0 8. install gas baffle or equal on septic tank outlet tee end. 8 V 2•lJ 0 L/ o 9. Provide 4" dia. observation port as shown on site plan. 10. All existing inverts and site conditions shall be verified by contractor. l ea c h i n g t re n c h using 4 H—2 0 1 1. Existing leaching trench to be abandoned in lace. 0 0 9 9 P H I(v A� INFILTRATORS with 4' of o 12. Existing septic tank to be pumped & inspected for structural integrity. " V Replace, if necessary with o 1500 gal H-10 Acme Precast or equal. stone on sides £� 4' on ends. oo SOIL EVALUATION \ Date of Soil Eval.: January 5, 2002 34 Test Performed By: GLEN E. HARRINGTON, R.S., CSE Excavator: Michael Leary Percolation Rate: <2 mpi assumed in C!—('3 T10Test Hole " T6" No. 1 DEPTH SOILS ELEV. 0 97 94' 4 H-20 HI CAP INFILTRATORS Ap END—SECTION °a')'s NOT TO SCALE 6" 1orR5/2 7.44' , ow 36" I°iov�s 6d 94.94" C1 med. sand 62" 1orR7/6 92.77' C2 - med San g4' 25y7/4 0.94' OF PROPOSED SEPTIC SYSTEM UPGRADE �( /�j4� C 3 u^ coarse sand �� '9 PREPARED FOR t0YR6/8 132" 86.94' E _k MICHAEL LEARY NO GROUNDWATER ENCOUNTERED H RIN IN 4 LEGEND '1Ufn AT ® 12 ELDRIDGE AVENUE NOTE: ALL PIPES ARE TO BE 4" DIA. SCHEDULE 40 P.V.C. EXISTING 1000 GAL. �fr'`�" 1p " 10' min. from NOTE: INSTALL GAS BAFFLE OR EQUAL ON SEPTIC TANK OUTLET TEE. O O IT BARNSTABLE (HYANNIS), MA house to septic tank H-10 SEPTIC TANK Septic Conk covers must be Finished grade over system=2% slope away Existir House within 6" of finished grode 5 HOLE X104.46 DENOTES EXISTING PREPARED BY: 9 D—Box cover must be DIST. BOX SPOT GRADE To of Pndn. Elev.=1PD.0• ithin 6" of f nished grade N P � E?;ISTi ADE Existing Grade Elev.=97J'3 \J _ . - ----95---- -- EXISTING CONTOUR GLEN E. 2" m n. f u l l S 0.02 Min 2"-1 36" max. 9 L E D A ROSE L A N E NN 5=.01 Level for 2' cellar D 1000TIGAL. 0 55' S=.Ot washed clone Top Peastone Elev.=95.96' DEEP TEST HOLE M A R S TO N S MILLS MA 02648 r` SEPTIC TANK > 0 4' See Nate �12 Approx. location GAS BAFFLE rn u u, o, n m -_ - ff-'h' OR EOUAL a" Mill. x ..----- --... -- --- g TEL. 508 428-3862 p11 `� Bottom of Leach existing -water service v 33' , ench Lev.= s' FAX: 508-428-3862 ' _ LEACH TRENCH 15L6" OF 3/4"-11/2"STONE `� gA rox. location JAN. 11 , 2002 m of T.H. 1 Elev.=86.94' Approx. SCALE: 1 "=20' DRAWN BY: GEH a . SYSTEM PROFILE o NO GROUNDWATER ENCOUNTERED existing GAS Service 6" OF 3/4"-14/2" STONE Not to scale — FILE: ELDRIDGE.DWG SHEET 1 OF 1