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HomeMy WebLinkAbout0096 FIFTH AVENUE (HYANNIS) - Health 96 Fifth Avenue Hyannis �246 099 I o y 0 } o u 6 a J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Cityrrown State Zip Code Date of Inspection M tYl 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. d"t When filling out A. General Information S/-rt /al,tv8 forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN cursor-do not Name of Inspector use the return key. D.A.BROWN INC Company Name V IA P.O. BOX 145 Company Address CENTERVILLE MA 02632 ISM Cityrrown State Zip Code 508-420-4534 S14297 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 11-15-16 :ipe 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 0 ffi i I c a Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments IV 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Citylrown 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: AT TIME OF INSPECTION SYSTEM MET ALL PASSING REQUIREMENTS. 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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 Voluntary Assessments 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Citylrown 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): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS BUILT SYSTEM CONSISTS OF A 1500 GALLON TANK D-BOX AND 2 500 GALLON CHAMBERS WITH 4 FT OF STONE Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2015-------107 2014------132GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENTLYOCCUPIED Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No . If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I 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 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2004 PER AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: LIGHT TO MODERATE t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Citylrown 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 LIGHT 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? WOODEN POLE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): RECOMMEND PUMPING AT TIME OF TRANSFER AND EVERY 2-3 YRS THERE AFTER FOR MAINTENANCE. 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 , 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every 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.): BOX LEVEL NO LEAKAGE OR SOLID CARRY OVER RECOMMEND INSTALLING RISERS TO BRING COVER CLOSER TO 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: NO RISERS FOUND CHAMBERS ARE DEEP t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): DUE TO THE DEPTH AND NO RISERS LOCATED THE CHAMBERS WERE NOT OPENED. AT TIME OF INSPECTION THERE WERE NO SIGNS OF FAILURE IN AREA OF S.A.S OR VIEWED THROUGH THE D-BOX. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. tY City/Town/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 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Cityrrown 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 6+ 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: ATTACHED SYSTEM AS-BUILT Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 FIFTH AVE Property Address SCOTT Owner Owner's Name information is required for WEST HYANNIS PORT MA 11-15-16 every 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION 9G A I A,, SEWAGE g AWY 979' VILLAGE .tea._ YAW111SASSESSOR'S MAP&LOT__a INSTALLER'S NAME&PHONE NO. /� s.Gf�4' lorw�><„,c fog+ Sb -4yF16 SEPTIC TANK CAPACITY IrM 61 C LEACHING FACII.rrY:(type) rob 6 I C.4wA-i C-2) (size) /3 ,tsar xo NO,OF BEDROOMS 3 BUILDER OR<5��_ PERMITDATE: COMPLLANCE DATE: U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fed 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 Dm y C& eepw .22 �6 b 40 0 0 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=246099&seq=1 12/7/2016 J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 96 Fifth Ave. t7 �i _ GI Q Property Address Mark Tomaiolo Owner Owner's Name ` information is required for W H annis ort Ma. 02672 11/15/2007 every 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. Important:When filling out A. General Information ` forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name P.O.Box 763 Company Address Centerville Ma. 02632 serum City/Town State Zip Code (508)428-4028 S14454 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 i ❑ Needs Further Evaluation by the Local Approving Authority i y C-7 l' 11115/2007 Inspe or's S ture Date t 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 alsha red%s stern 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. 96 fifth ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is required for W Hy p annis ort Ma. 02672 11/15/2007 every 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: ® 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 septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup'or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is p required for y W H annis ort Ma. 02672 11/15/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): i ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: / C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 96 fifth ave.-08/06 Title 5.Ofricial Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is W H annis ort Ma. 02672 11/15/2007 required for y p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used.to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 96 Fifth Ave. Property Address P Y Mark Tomaiolo Owner Owner's Name information is W H annis ort Ma. 02672 11/15/2007 required for Y p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow.of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large . system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 96 fifth ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is W H annis ort Ma: 02672 11/15/2007 required for y p every page. City/Town State Zip Code Date of Inspection C.-Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, 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)] J J 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is required for W.Hyannisport Ma. 02672 11/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 330 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No r Seasonal use? ® .Yes ❑ v No Water meter readings, if available last 2 ears usage d 2006:9,000 9 ( Y 9 (gpd)): 2007:9,000 Sump pump? ❑ Yes ® No Last date of occupancy: unknown 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: r Last date of occupancy/use: Date Other(describe): 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c,M 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is required for W Hy p annis ort Ma. 02672 11/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® 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) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source(of information: System installed 2004 ` Were sewage odors detected when arriving at the site? ❑ Yes ® No 11 fifth ave.•08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r ^M 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is W H annis ort Ma.. 02672 11/15/2007 required for y p - every page. City/Town State Zip Code Date of Inspection - D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet 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.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): 1' 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 Dimensions: 1 0'6"x5'1 0"x5'8" 211 Sludge depth: v Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 1 a 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 96 Fifth Ave.. Property Address P Y Mark Tomaiolo Owner Owner's Name information is required for W HY p annis ort Ma. 02672 11/15/2007 every page. City/Town State Zip Code 'Date of Inspection D. System Information (cont.) . Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every 2-3 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below.grade; feet Material of construction: concrete metal fiberglasspolyethylene other(explain): ❑ ❑ ❑ 9 ❑ ❑ Dimensions: Scum thickness A Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): 96 fifth ave.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is _required for W.Hy p annis ort Ma. 02672 11/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information '(cont.) Tight or Holding.Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): - *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box ('if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is level.Box has two outlet lateral with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r ,M 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is required for W Hy p annis ort Ma. 02672 11/15/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallon ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: s ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Leaching chambers were dry at time of inspection. 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is p required for y W H annis ort W. 02672 11/16/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped.as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Map Page I of 2 Town of Barnstable Geographic Information System Parcel Viewer] Custom Ma Abutters Ma SizeEl Zoom Out ' �I I In �I crr a �F R r SYTY� • >i i i� ��� J .�j II��I E _ II II I _ I I, r O .� II O a 2f ;, O'e Feet` �ti 4. 1 Set Scale 1" = 20 I Aerial Photos r—...inht 9MF-')007 Tn... of Rar—f.hle AAA All rinhi.raeena- ' http://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=246099&ma... 11/19/2007 Commonwealth of Massachusetts Title 5 Official Inspection Form 'Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 96 Fifth Ave. Property Address Mark Tomaiolo Owner Owner's Name information is required for W.Hy p annis ort Ma. 02672 11/15/2007 every page: City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. t 96 fifth ave.•06/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts W Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 96 Fifth Ave. a Property Address Mark Tomaiolo Owner Owner's Name information is required for y p W H annis ort Ma. 02672 11/15/2007 every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells Estimated depth to ground water: Bottom of leaching 10' 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: 5/24/2004 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: i You must describe how,you established the high ground water elevation: USED :Gaherty& Miller model 12/16/94 groundwater elevations. USED:USGS Observation Well Data June 1992. USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. S 96 fifth ave.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 TOWN OF BARNSTABLE � LOCATION F, S /9✓. SEWAGE # ��y "`7Y YILLAGE tiny HYAWN 1SASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. a�.>��' SEPTIC TANK CAPACITY /San Ga C LEACHING FACILITY: (type)' fgXr Gn C1a.A,-i (size) /3 '.yt NO.OF BEDROOMS 3 BUILDER OR& `4 PERMTTDATE: t.14 Ae 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 i within 300 feet of leaching facility) Feet shed by o_ r R O u O"O �V-e9ff No. o�`� / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for Migogal *pztem Construction Permit Application for a Permit to Construct( . )Repair(I/)Upgrade( )Abandon( ) e Complete System El Individual Components Location Address or Lot No. ®,6 /_� , / Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1-4011 N� p Installer's Name,Address,and Tel.No. /� �c / Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size 84W sq.ft. Garbage Grinder(�®' Other Type of Building P.>/e:?'_No.of Persons Showers( ) Cafeteria( ) Other Fixtures U Design Flow gallons per day. Calculated daily flow '�% gallons. Plan Date D Number of Aheq# A / vision Date Title ele Size of Septic Tank ? Type of S.A.S. Description of Soil 2` x/jXZ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee ' d by t=Bd Health. Siifned Date Application Approved Date Application Disapproved for the following reasons Permit No. �� �� Date Issued �— G� No. -2 �. . . . ... . . . . . Fee AJ THE COMMONWEALTH OF MASSACHUSETTS ^i rEn=rred in computer: � � / r Yes V a, PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE., MASSACHUSETTS 2ppfication for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(1/)Upgrade( )Abandon( ) n Complete System ❑Individual Components Location Address or Lot No. l}/ �r f Q,l Owner's Name,Address and Tel.No. 7�6 / / </l z l_ h411-/P111 Assessor's Map/Parcel r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. CV e Type of Building: Dwelling No.of Bedrooms 3 Lot Size 9,dW sq.ft. Garbage Grinder( d Other Type of Building t°� No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3a gallons per day. Calculated daily flow gallons. Plan Date _Si /5`/4��. Number of shee s Revision Date ' Title ,f Size of Septic Tank /.��/2 9 L" Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has be i by t,is B d,o�flHea•th. _/�� /C Si ned � — :Date Application Approved b Date. Application Disapproved for the following reasons " Permit No. �© �� 4_f Date Issued a' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site S age Disposal System Constructed( )Repaired ( �Upgraded( ) Abandoned SS )by .� Of /O / t�Odl S J`. at _9f�_ _r�/�r� C/G'1° !�L'• ��y/1fs�4o/T� has been constructed in1acc9Ydance with the provisions of Title 5 and the for Disposal System Construction Permit No. o�u 0�I' a 7y dated— Installer Installer Designer The issuance of . ' 6 t shall not be construed as a guarantee that the sy stem w fu c�ion as d ig e Date Inspector •+�� _ �� No. -------------------------Fee — O THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS,. w 1WigPoga1 *pgtem ongtruction Permit ~` Permission is hereby gr to to�jonst ct(/ )Re air( )Upgrade( bandon System located, t � I` f/'' and'as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.____ Provided:Construc•ton st be completed within three years of the data of this permit. Dater_ Approved by { TOWN OF BARNSTABLE C LOCATION GIG I S A�� SEWAGE # j VILLAGE At, f11Aasn,s A,--1 Ia`W ASSESSOR'S MAP & LOT ;Y6'0 INSTALLER'S NAME&PHONE N0. y17-kVe SEPTIC TANK CAPACITY /Scm Ga L • LEACHING FACILITY: (type) Qo 4, J GO (size) /3 AAr X-V ' 4� NO.OF BEDROOMS .3 BUILDER O WNE r/• PERMITDATE: O COMPLIANCE DATE: /1/0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Pew4J CA& y y, A) ti �re o - p � 0 0 C� JUL-16-2004 09 :43 AM DOWN CAPE ENGINEERING 508 362 9880 P. 02 Town of Barnstable Regulatory Services Thomas F. Geiler, Director is Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 509-790-6304 Installer& Designer Certification Form Date: Sewage Permit# Assessor's Map\Parcel 0��6 r Designer: -bow 2 ,J �. Installer: Address: 93f r� Address: t7 A fir%1, 114 - On was issued a permit to install a (date) installer) septic system at 94J4k W. [A)eoIt a A nM _based on a design drawn by (address) - r p U!wc.,P e&,tf dated (d esign ) I certify that the septic system referenced above was installed substantially according to the desi.4n, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. CNo. (Installer's Signature) (Designers Signatu (Affix VelhooA4135imp Here) pyEASE RETURN TO BAR STABLE PUBLIC HEALIDIVISION. CERTIFICATE OF COMPLIANCE WILL NOT 15E ISSUED UNT11L BOTH THIS, FORM AND A'5�1ILT CARD ARE RECEIVED BY THE BAR_STABLE PUBLIC HEALTH DIVISION, THANK�U.; Q;Health/Septic/Designer Certification Farts 3-26-04.doc I TOP FNDN. AT EL. 31 .1 ' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN ACCESS COVER (WATERTIGHT) TO. 6",OF FINISH GRADE LISA LYONS, RS ENGINEER: CRAIGVILLE BEACH RD. 24.6' - O' MINIMUM .7�' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 25.0 - DAVE STANTON RS 25.5 WITNESS, RUN PIPE LEVEL 2" DOUBLE WASHED'PEASONE DATE: 5/7/04 .I o FOR 'FIRST 2' EXIST PIPING PROPOSED 1500 3' MAX. PERC. RATE _ < 2 MIN/INCH IS VERTICAL rr"3 E CRAWLSTHROUP 22.61 ' GALLON SEPTIC 22.36' 10716 FLOOR* TANK (H- 10 ) 22.5 CLASS I SOILS P# GAS PINE WAY 74.` 1 .77 00 ao 2 BAFFLE � [� Cl [� C7 0 21.94 a 21.67' 0 0 CJ 0 EO M E D 0'.M t4' AROUNDa ( _N % SLOPE) �6" CRUSHED STONE OR MECHANICAL E� E� m E7 CI m C7 E� E� M COMPACTION. (15.221 [21) 27 113 E7 [1 E7 17-7 = 13 0' 0 p 19.67' Q ELEV. LOCUS DEPTH OF FLOW = '4 ( 1 % SLOPE) ( 1 % SLOPE) " Ott 24.0' TEE SIZES 3/4 TO 1 1/2 DOUBLE WASHED STONE A INLET DEPTH = 10" LS OUTLET DEPTH = 14" 1 1 " 10YR 3/3 B LOCATION MAP NTS FOUNDATION- 18' SEPTIC TANK 42' D' BOX 12' LEACHING FACILITY LS ASSESSORS MAP 246 PARCEL 99 6, 29" 10YR 5/6 *THE INSTALLER SHALL VERIFY THE 21.58' LOCATIONS OF ALL UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM PERC C I 13.67' F/MS BENCH MARK -- CORN OF CONC, PATIO EL. = 29.3 2.5Y 5/6 PINE WA Y 29.4 Cy LA W + 32.5 + 32.8 _) 124 13.67' 29. + 31.6 DIRT ROAD w ( NGWE GRASS,,.PARKING N NOTES: I + 30. 32.1 _ _. 32.2 _ _.._ � a 1 . DATUM IS ASSUMED - -- - SEPTIC DESIGN: I 3 31.6 � 32.5100.00 + (GARBAGE DISPOSER IS NOT Al j �wFn ) 2. MUNICIPAL WATER IS EXISTING DESIGN FLOW: _3 BEDROOMS ( 110 GPD) = 330 GPD 31.8 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. . 300 USE A 330 GPD DESIGN FLOW OAKS + 3 .9 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H-- 10 1 W CONC. WALK SEPTIC TANK: 330 GPD ( 2 ) = 660 5. PIPE JOINTS TO BE MADE WATERTIGHT. 1 i 1 ��3 +-130.3 29.8 USE A 1500 GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. + 29.5 + 29.7 _LEACHING: ENVIRONMENTAL CODE TITLE V. 9.8 LOTS s85 2(25 + 12.83) 2 {.74) 11 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT P.PINE 30 SIDES: �- TO BE USED FOR ANY OTHER PURPOSE. EXIST. DWELL. BOTTOM: 25 x 12.83 (.74) = 237 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. ►.� (CRAWLSP) I 00 \� _ 9.1 EXIST. DWELL. 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT I o I \� CONCONC. TF f 37 1 + 2 OTAL: 472 S.F. 34P GPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED PATIO + ' G 6 USE _(2) 500 GAL. LEACHING CHAMBERS (ACME OR FROM BOARD OF HEALTH. 7.3 EQUAL) WITH 4' STONE ALL AROUND 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING SEPTIC SYSTEM O (SLAB EL. a +„ o TH 2S LEGEND N A 25 O ti� 100.0 PROPOSED SPOT ELEVATION TI TL E S SITE PLAN NOTE: WATERLINE MUST i 24 �y� ?3 BE SLEEVED WHERE 23 ?21 s 100x0 EXISTING SPOT ELEVATION OF 96 FIFTH AV E N U E WITHIN 10 OF + -''`�� IN THE TOWN OF: PROPOSED LEACHING 2 �--` 21 C�- 100 PROPOSED CONTOUR FACILITY ' (OR RE-ROUTED AS 2 100.00 21 0 20 - 100 EXISTING CONTOUR (WEST HYAN N I S PO RT) BARN STABLE NECESSARY) �, 19.9 2 + 19s PREPARED FOR: G EXISTING GAS LINE BORTOLOTTI CONSTRUCTION/HURLEY ti EXIST. DWELL. W EXISTING WATER LINE 21.6 20 0 20 40 60 BOARD OF HEALTH MA SCALE: 1 " 20' DATE: MAY 15, 2004 APPROVED DATE off 508-362-4541 fox 508 362-98M OF IAA6 c t,ajH OF M Clown cape engineering, inc. AR H. y� ?�v ARNE cy° o OIIL H. � C`lVIL N N - CIVIL ENGINEERS A No. 3o792 OJALA� No, LAND SURVEYORS ° F� s �P�a\��� .e 26348 04_-1_09 _ 939 vain st. yarmouth, rya 02675 s v Z _ --