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Home My WebLink About0008 FOURTH AVENUE (HYANNIS) - Health 8 FOURTH AVE. ,, HYANNTSPORT ;A-, 246-174 J j I ° d Commonwealth of Massachusetts a y(�_ I /Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 8 Fourth Ave �0 Property Address r1j Warren Sukernek Owner Owner's Name T� information is required for every W Hyannis Port ✓ Ma 02647 1/11/19 0, page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information r� filling out forms on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lane Q Company Address Cotuit Ma 02635 City/Town State Zip Code reaan 508-364-9587 SI 13522 Telephone Number License(dumber B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1/13/19 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i g. i Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave . `V Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 Gallon septic tank as well as a concrete distribution box and 4 H2O Maximizers. 10'x30'x2' 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts t' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. City✓rown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:subsurface Sewage Disposal System•'Paage 4 of 18' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 8 Fourth Ave V Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No I ❑ ❑ 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 El El Area 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 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 i should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: ' I Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health I ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ❑ Has the systern received normal flows in the previous two week period? ❑ ® Have large vclumes 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 or 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave �V Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. City(rown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 218 GPD 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ❑ No.. Last date of occupancy: Date 15insp.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 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ElYes ❑ No j Water treatment unit present? ❑ Yes ❑ No I If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 18 r Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 10/1/97 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. 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.): System is vented at the roof line t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityfrown State Zip Code Date of Inspection I D. System Information (cont.) 6. Septic Tank (locate on site plan): � 1 j Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 311 Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is at normal level. Tee's are h place. 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 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day i l5insp.doc-rev.7/26/20118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 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? El Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is W Hyannis Port Ma 02647 1/11/19 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.): * 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: 4 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave �v Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cant.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Dry with no signs of failure i i i i 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 16 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I i i l5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 I Commonwealth of Massachusetts - (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 1/13/2019 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION Q lamr-A a4le SEWAGE if I✓`'^S VILLAGE_kl, YO/9�o 7_ /ASSESSOR'S MAP&LOT �7 INSTALLER'S NAME&PHONE NO. BOltTl'GyJ�/��1i9 77/—�3�y SEPTIC TANK CAPACITY 15-0J LEACHING FACILITY:(type) /,L�,wFnrs �(size) NO.OF BEDROOMS 3 / BUILDER O� el-PAV PERMUDATE: /D 7 COMPLIANCE DATE: _141 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) l9 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching faculity) /t9 Feet Furnished by f 0 31 http://web.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar-246174&seq=1 1/2 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments < � 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 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: 8+ ft 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: 10/1/97 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data provided I Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.do6-rev.7/26/2018 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Warren Sukernek Owner Owner's Name information is required for every W Hyannis Port Ma 02647 1/11/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or checked ❑ C. Inspection Summary: I 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 I For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every ar)6 Ma 02647 9/29/2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General. Information on the computer, (I�•}�}—� jVl�/I UI use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. Di Buono Sewer and Drain Company Company Name 8 Johns Path Company Address B� Yarmouth ma 02664 City/Town State Zip Code 508-364-9587 Si 13522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address'and thatAe information reported below is true, accurate and complete as of the time of the inspection:The=inspeion was performed based on my training and experience in the proper function and maintenancerof on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1-513340 aS Title 5 (310 CMR 15.000). The system: i c71 f' ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10/02/2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall.submit the report to the.appropriate regional office of the DEP. The original should be sent to the system owner 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. d � al� i (Sins•3/13 Title 5 Offc at Inspectio r Subsurface Sewage Disposal System• age 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w.. 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is every west H annis o required for eve Y p rt Ma 02647 9/29/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This system contains a 1500 gallon concrete septic tank. Both inlet and outlet pvc Tee's are in place. A concrete distribution box that is at normal working level and does not show signs of decay at this time. The SAS is made up of 4 high capacity infultrators. One inch of standing water in the infultrators at time of inspection. 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): t l5ins•3/13 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 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name on isrequired for every West H annis port Ma 02647 9/29/2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) .System Conditionally Passes (cont.): ❑ Observatiomof 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West Hyannisport Ma 02647 9/29/2014 page. CitylTown 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 'h day flow t5ins•3113 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 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West Hyannisport Ma 02647 9/29/2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No � ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® z 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 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West H Yan nisport Ma 02647 9/29/2014 page. Cityrrown 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 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West H Yannis O P rt Ma 02647 9/29/2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: This system contains a 1500 gallon concrete septic tank.'Both inlet and outlet pvc Tee's are in place. A concrete distribution box that is at normal working level and does not show signs of decay at this time. The SAS is made up of 4 high capacity infultrators. One inch of standing water in the infultrators at time of inspection. Number of current residents: 2 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 readin s, if available last 2 ears usage d 2012 2800 cf g ( y g (gp )) 2013 3400 cf Detail: Average is 63 GPD over two years. Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West Hyannisport Ma 02647 9/29/2014 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Last date of occupancy/use: Currently OccupiedDate Other(describe below): . General Information Pumping Records: Source of information: Maintaned by Bortolotti 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): 15ins•3113 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 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West H annis ort Ma 02647 9/29/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 17 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments (on condition of joints, venting, evidence of leakage, etc.): Vented through the roof . Septic Tank(locate on site plan): Depth below grade: 1ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 Gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: } l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 o(17 t . Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West Hyannisport Ma 02647 9/29/2014 page. Cityrrown 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 18" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle Y Distance from bottom of scum to bottom of outlet tee or baffle 28 How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Levels are normal, Tees are in place. No evidance of leaking. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 15ins•3/13 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is re wired for every West H Yannis port Ma 02647 9/29/2014 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.): This system contains a 1500 gallon concrete septic tank. Both inlet and outlet pvc Tee's are in place. A concrete distribution box that is at normal working level and does not show signs of decay at this w time. The SAS is made up of 4 high capacity infultrators. One inch of standing water in the infultrators at time of inspection. 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 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West Hyannisport Ma' 02647 9/29/2014 page. Cityrrown 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 level, solid and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is level and in good working order and shows no signs of leaking or decay. 'Pump Chamber(locate on site plan):. Pumps in.working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in-working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 8 Fourth Ave Property Address Lila Belofski " Owner Owner's Name information is required for every West Hyannisport Ma 02647 9/29/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 infultrators ❑ 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.): 4 high capacity infultrators 10'x30'x2' 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..a 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West Hyannisport Ma 02647 9/29/2014 page. CitylTown 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.): No signs of hydrualic failure i 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 N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �., 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name information is required for every West Hy p annis ort Ma 02647 9/29/2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately 3/ / 3? t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA yp Nye! oqb 2+ man"";,.gam 'f r r�eti p�.� 40 r s f 3Lp f X �- a � i Kit DID"dr INW MAS �' Laity � off° l3 & aOwrl ed me del' a WIN t 4ta - {��h+ I;f��lllllliir iNSb�KI�71111iI��j��Nr"7�`�"II�� 1111J ��Ihllllr 'I� �r„ ,µ�� li�ew`,.I uak, " fr�`� 1 Piz {, a Igir rr I,441 �N,=M a NOW a, t d'-a �1 tlu O, a ��( �Iil�I a Ji 1�V' ��h�i�.3a,� '' -rr 'P,��I1Y��" !'��I lil 111 lJ�♦i�+�ale ill l��11��II l�i:�r *�,. ,..��, rh r�.. t �1 r ��pr Bril 11 f`h ° nv! I t, �n P nMy r fr< I� i ill tah III � t, tau ra,� I r. ,�PYr �'i WINNOWS �-d r -!��. ` vr c � a 1 b .r ti4� '� non. nn f. moo ENTS" ERE' d ", = � a 5 { lots lox A o r � ," � aww� ar Y uTM ILL� P ..-- �.��: -,-r ,�_. e. � yy. _ ��';i�Y �."�" "�-..i`� ,,".„f >� ✓" s: i Wrh. r cap,= ¢"fv Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �., 8 Fourth Ave Property Address Lila Belofski Owner. Owner's Name information is required for every West Hyannisport Ma 02647 9/29/201.4 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 high ground water: feeetet ft' 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: USGS maps indicate no ground water within 5 ft of bottom of leaching. You must describe how you established the high ground water elevation: plan on file shows No ground water encountered 5ft below bottom of leaching area Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3113 �'' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 'Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments 8 Fourth Ave Property Address Lila Belofski Owner Owner's Name on isrequired for every West H annis ort Ma 02647 9/29/2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection'Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION APIA ak e SEWAGE # �7 S-S- VILLAGE /ASSESSOR'S MAP & LOT 2 INSTALLER'S NAME&PHONE NO. �Dd�7�Gd7'Cd'�1c9 77/-�3�� SEPTIC TANK CAPACITY /mod ��a C LEACHING FACILITY: (type) 1-4/4L LI M (size) /D /AJ0 '-X-2 1 NO.OF BEDROOMS 3 /� BUILDER O6OWNE elOf PERMIT DATE: /D --/`?- COMPLIANCE DATE: U 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_ Feet Furnished by i 3 1 F � i� 4:r^ r� 2 �e 71 No. ! ! 7� Feed_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rppriratton for Migaal *pgtem Congtrurtion Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) R Complete System O Individual Components Location Address or Lot No. �',�/_ ,�O Owner's Name, ddress and Tel.No. Assessor's Map/Parcel Installer's Name Address,and Tel.No. t Designer's Name,Address and Tel.No. 7_7GolGraS/ . 7 7 f3 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(�d Other Type of Building f j? No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1/Z�9 gallons per day. Calculated daily flow 1-430 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /SOD Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) // 1e Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b th's and f Healt Signed Date Application Approved by Date to — Application Disapproved for the ollowing reasons Permit No. cf 7 - ,5 5/ Date Issued rlr'A No.'t_"/ 7 ��/ r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I r Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Migozal *p!9tom Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) E�,Complete System ❑Individual Components Location Address or Lot No. Q 4u -7—h ave Owner's Name, dress and Tel.No. j 0 8e%/s/� 1 Assessor's Map/Pazcel ek (- 'T Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. .. �vr�oGo�iGoa y� 2 7/ Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( d Other Type of Building No. of Persons Showers( ) Cafeteria( ) -Other Fixtures Design Flow gallons per day. Calculated daily flow 3 J 4 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /Jr4D' Type of S.A.S. Description of Soil I Nature of Repairs or Alterations(Answer when applicable) 7-le r Date last inspected: e Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b th' d f Health--- Signed �� Date . Application Approved by �, Date I o - / - q Application Disapproved for the ollowing reasons Permit No. 7 " J�5 / Date Issued y -———————————————— L —————————————--——————— 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance � rf THIS IS TO CERTFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned ),b,yY !�O � � at f'durT�l4'!� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. `P7-S,`"/ dated Installer Designer The issuance of this permit)nn 6� ed as a guarantee that the sy tam 11 function as desi C Date Inspector l/ U, No. / / " tJ S J ---------------------Z -/7Z/ Fee i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS A r Mizpogaf *pztem Congtruction Permit Permission is hereby ranted to Cgnstruct( )Repair( )Upgrade Abandon'( ) System located at 100, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. , CERTIFICATION OF SKETCH AND A.PPLIC ATION FOR A DISPOSAL, WORKS CONSTRUCTION PERMIT NVTTHOUT DESIGNED PLk SI Terebv �e�r�n. :��at-.he snriicatien or _is�c_ai �orc� �0^SutiCtil r e.T?IL :v_nZ: ri e �?ai2Q I/Jl�!7 once t. bell --- �:..._ _ �. fir:•- _- �.._ -_-. ._ . ._-. _- �� - -�= -SIGNED . JA1 1 LICENSED SEPTIC SYSTEM.INSTALLER!ti=tom' TOWN OF BARNSTABLE N, - MER [.attach a sketch plan of the proposed system.Also if ate !icensed installer?osesses a certified plot liar.. this plan should be submitted]. q:baNh fol J r ' j � I J1 TOWN OF BARNSTABLE LOCATION Q APIA aleve , SEWAGE # 7 .S—S— VELLAGE_ I(/, ASSESSOR'S MAP & LOT 17 INSTALLER'S NAME&PHONE NO. _1161 m4rovlzd&5J'`- SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �,v�L A"d <1� (size) _/�1 �X JD �(.? i NO.OF-BEDROOMS 3 // BUII.DER O :OWNE el��S� ,� y PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feed.. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �/19 Feet ' Furnished by t 3 3�