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HomeMy WebLinkAbout0032 GLEN ROAD - Health r .;. / 3�2:GlenRd Hyannis ` ��Q/�'A �� �� � .f ��-� UNr „�,' .. ���� A" —_ --- - --� - �a,�����o��� .Y ?. .: � �. -_- ��� � ___ �I�'� M �t I, �i flk �f° i� �� 7/- o t�, a !'� jt�, �, �, a a ,� �I h o �, �,� J �, o �� a; �` o _ �� �� � o ,� � o �� o o ;�� a88� o t9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is H annis ✓ Ma 02601 8-24-2020 required for every y 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 fortes A. Inspector Information on the computer, Daniel Hawkins use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 ' Company Address Sandwich Ma 02563 City/Town State Zip Code irieo; (508)477-0653 S114324 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 1 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawkins Digitally signed by Dan Hawkins Data:2020.08.25 15:15:11 o4'001 8-24-2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t51nsp.doc-rev.7/26/2018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: , -- . . ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection.if the existing tank is-replaced with a complying septic tank as approved by the Board of Health. . *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 l Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t � . j 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y St page. City/Town ate 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 T 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road 1 Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y St page. City/Town ate 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. 4 ,c. Other: I. 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes, No ❑ Q Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ a Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts - — Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No r ❑ ❑ Static liquid level,in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ n Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5lnsp.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 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town state Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed.The 1 owner or operator of any large system-considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ El Pumping information was provided by the owner,occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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? ❑ O 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ O 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)] I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 333/GPD Description: , 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes El No Does residence have a water treatment unit? ❑ Yes Q No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes I■❑ No Seasonaluse? ❑ Yes ❑g No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2019- 121,000gallons 2018- No info. Sump pump? ❑ Yes ❑■ No current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owners Name information is Hyannis Ma 02601 8-24-2020 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft!, etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): r 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: 2017 per plans Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2'1011 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Distance from private water supply well or suction line: Town waterfeet r Comments (on condition of joints, venting, evidence of leakage, etc.): t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i I , i Commonwealth of Massachusetts Title 5 Official Inspection Form v Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1'10" Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 21r Sludge depth: 3411 Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness 61r Distance from top of scum to top of outlet tee or baffle 16" Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? / Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 i 1 ' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grader NA Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): f Dimensions: Capacity: gallons Design Flow: gallons per day 151nsp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 , ' Commonwealth of Massachusetts Title 5 Official Inspection Form C I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): or, Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order akhe time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Ofricial 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 jr 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): NA I *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: I Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: 30'xl 5' 0 leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 ' J Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town State Zip Cade Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): The SAS was in working order at the time of inspection. No evidence of past back up was observed. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note conditiori of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): x t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 f Commonwealth of Massachusetts J _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 32 Glen Road Property Address William Connolly Owner Owner's Name information is Hyannis Ma 02601 8 24-2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 1 " Commonwealth of Massachusetts �d p Title 5 Official Inspection Form I1E Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 32 Glen Road Property Address William Connolly Owner Owners Name information is Hyannis Ma 02601 8-24-2020 required for every y St page. City/Town ate 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 No. Fee Q"THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-'BARNS TABJLEI MASSAGHUSETTS �is#lDsad�pstem QLorrstructicn,.0evnifit P.ermissioni Whereby gn�nted to C r Upgrade bnstrua( Repair . IP ( '). Abandon( ) . System located;st '1 C—� 1�dj�A•(•-� \//�llfl 1 /]I'1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with -Title 5 and.dw'following local provisions orspecial conditions. Provided:•Constructioft m�t comple ithin three years ofthe date of this pe it, Date L Approved byl TOW.N,OF BARNSTA.BLE --- -- LOCATION -37 G►-n— o • SEWAGE V1LL'AOE 41y1 rtit� ASSESSOR'S MAP&PARCEL 288-O r q 1NSTALLER'S NAME @ PHONE NO. _G{, 41 Exca..� ,n U'1^1 OLcZ I SEPTIC TANK CAPACITY �ppp L$ACHING'FACILITY:(type) -• !d Pgr�C (size) /S r 3g>JL t NO.OF BEDROOMS I OWNER Ro'�er1 Qe-ec4ror� - :PERMIT DAT:T.:. COMPLIANCE DATE: Separation Distance Between the; Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility i _Private Water Supply Well and LeachingFeot Facility(If any walls exist on site or within 200 feet of teaching facility) I Edge of Watiand an. LeachingFacility Feet 300 feet of leaching facility) ty(If wetlands Guist within. I IFURNISHED By ' Feet Al A7-- i Bz- z " I B3- 2y'y" C3- y3'S" Sq- �{a•/�+" REAR A f C�- e/r L " C 9 Z ! 3 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 32 Glen Road Property Address William Connolly Owner Owner's Name information is required for every Hyannis Ma 02601 8-24-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' 15. Site Exam: ❑■ Check Slope 1] Surface water ❑� Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 128"feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record . 9-27-17 If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts ' Title 5 Official Inspection Form- 7,1 kvv Subsurface Sewage Disposal System Form -Not for Voluntary Assessments WV�o� 32 Glen Road Property Address j William Connolly Owner Owner's Name information is Hyannis Ma 02601 8-24-2020 required for every y page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: j �■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: `1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ❑� D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i i i t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSTABLE LOCATION 37- GlcnrN SEWAGE# Zon - WS VILLAGE ASSESSOR'S MAP&PARCEL ZVE-019 INSTALLER'S NAME&PHONE NO. G 4-'3 EXCcxymA . on LJIJ- &S3 i SEPTIC TANK CAPACITY 1000 qg6 1 LEACHING FACILITY-(type) F,'c lad- Ocrsi'o:D G: (size) NO.OF BEDROOMS 3 OWNER QoSg c c orb PERMIT DATE: /0 Z S J 11 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet .Private Water Supply Well and Leaching Facility(If any,wells exist on site or within 200 feet of leaching facility). Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of.leaching facility) Feet FURNISHED BY ,A2' i2,3,, � ✓ .Q3-..Zy 4 C3. 43.9 REAR n ;, 3 JK No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS � ftplitation for ]Dispo8 k*�hrm Construction Vermit Application for a Permit to Construct( ) Repair IS-Upgrade( ) Abandon( ) []Complete System ❑Individual Components Location Address or Lot No.3,, ien W H VA Owner's Name,Address,and Tel.No. Assessor's Map/Parcel_/y 7g$ O fLe��_G�� a �beeT T eees j- o Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. �-0 �XCC'7vojwo ����NT7���53 VH QAS506 608 - 3&2 DU Type of Building: Dwelling No.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3-3 d gpd Desi flow provided gpd Plan Date IZ�(�� Number of sheets Revision Date Title Size of Septic Tank e)Q5 in ( c� o QC'Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 06 —3 (1„6x Pf 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 S of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo ealth. Signed Date D ( i Application Approved by Date Application Disapproved by Date for the following reasons Permit No. S Date Issued d /' No. Fee /6 0 Entered in computer: L� t THE COMMONWEALTH OF MASSACHUSETTS Yes 3 PUBLIC HEALTH DIVISION - TOiw RNSTABLE, MASSACHUSETTS9ppfication for -Misposm Construction Permit Application for a Permit to Construct( Repair(�Upgrade( ) Abandon( ) ❑Complete System El Individual Components Location Address or Lot No.3,2441 eh � �'\/A Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Q '`�l/I a 'POrL�r�'" ' � T TeQP${i o Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. X�CavQti� 569- -0 VH�..A6sx 5o8 3Ca o DG3y �; Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) 1{ r Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Desi n flow provided �� gpd Plan Date C1 2-111i Number of sheets Revision Date Title t Size of Septic Tank jc)(I !S J ( l��X_) 9144 Type oftS.A.S. Description of Soil ; Nature of Repairs or Alterations(Answer when applicable) - - I �,-_ Date fast inspected: a Agreement: �f J The undersigned agrees to ensure the construction and maintenance of the afor cribed 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 Certificate of ,1 Compliance has been issued by this Board of Health. Signed t Date a IZkI Application Approved by Date Q Application Disapproved by Date for the following reasons Permit No. �? ,� 7 Date Issued THE COMMONWEALTH OF MASSACHUSETTS j BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(p4 Upgraded( ) Abandoned( )by at ias been constructed in accordance with the_pmyisions of Title 5 and the for Disposa System Construction Permit No. /7—V-5dated �/G a 5 '�2 . Installer IDesigner #bedrooms Approved design flow gpd The issuanAc of this ermit shall not be construed as a guarantee that the system ction ass designed. Date rl 7/, 1 Inspecto 1 - - - _____-____ 1 !!_ No. �(� — 7�a Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS -Misposal &pstem Construction Permit Permission is hereby granted to Construct( ) Repair('IQ Upgrade( ) Abandon( ) System located at r� -C�:2 L-),CA a and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be complet d within three years of the date of this permit. Date Approved by i I Town of Barnstable Regulatory Services Richard V.,,Scali, Interim Director �"AM Publics6g9. Uealth Division �0 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: /�/7 Sewage Permit# 3,� Assessor's Map\Parcel Designer: Installer: f� �' Tj L W k?- 7�0, Address: 612-jf,4`4111 Address: TorjW Zgl%e r A;�064?-Z On 1 7 was issued a permit to install a (date) —�— (installer)/ septic system at (5 j1&0 based on a design drawn by (address) dated —.2 7— (designer) �I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. 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. Strip out (if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the terms of the IAA approval letters (if applicable) (Installer's Signature) o VON HQNc 0 #1068 0 b 17 4(Designer'sZSeig�naZtu/re) A(Affix DesigfS S&mp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc - Town of Barnstable Department of Regulatory Services r Public Health Division DateMASS J t ►�� 200 Main Street,Hyannis MA 02601 rri Date Scheduled Time�_ Fee Pd. Iwo � _4 Soil Suitability Assessment, or Sewage Disposal Performed By: X�% U�� �, /�. Witnessed By: -'_ -`"LOCATION& G NERAL INFORAMTIQN. ;Location Address r�n,A '` Owner s Name' ` L t ,r Address Assessor's Map/Parcel: /0 I / Engineer's Name S NEW CONSTRUCTION REPAIR Telephone# ���� a 7 Land Use 1�g C/ 1'Ov4 Aa / Slopes ON Surface Stones el ftn�l Distances from: Open Water Body ft Possible Wet Area/eft Drinking Water Well / ft Drainage Way i L ft Property Line / fl Other fl `SKETCH:-(Street name,dimensions of lot,exact locations-oftestholes&perc tests,locate wetlands in proximity to holes) - n l` i IP � �,�', r �. •#�t.ti' .Ar `*� ) #�! __ I z7 5p_ Ala,/(/� Depth to Bedrock _ Parent material(geologic) Depth to Groundwater. Standing Water in Hole: 12— Weeping from Pit Face Estimated Seasonal High Groundwater " "-DETE NATION FOR*SEASONAL HIGH WATER TABLE- - Method Used: Gli1 Depth Obsery d standing in obs.holef' t`,4 in. Depth to soil mottles: : Depth to Weeping from side of o s.hole P 7 in. Groundwater Adjustment Index Well#�.Z eading Date: �' /7lndex Well level Adj.'factor�. �Adj.'Groundwater Level PERCOLATION TEST Dat,9 /_/nme Observation .,_. . ,r. . , Hole# Time at 9" 57 Depth of Pert. Tito,at 6" . to .. •J '1/ Start Pre-soak Time Q d l/l/ r T�'(9"-6") r , End Pre-soak ff, /�(/,///pry` `�,� �C� �•r Rate Min./Inch. • l� (� _ s Site Suitability',Assessment- `SitePassed_L,,-"" Site Failed:I r Additional.Testing Needed(Y/N). r Original: Pubfic Health Division Observation Hole Data To Be Completed on Back ***If percolation test is to be conducted within 100' of weiland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q.\SEPTIC\PERCFORM.DOC r . DEEP.OBSERVATION HOLE'-LOGY `.- Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Graven �s zlo S •r ,DEEP OBSERVATION LE LOG`, ` Hole# � 4 Depth from t Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. � Consistency.%Graven 9" 14 DEEP OBSERVATION.HOLE_ %OG Hole# Depth from Soil Horizon Soil Texture Soil Color t Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Graven -DEEP OBSERVATION HOLE LOG Hole#_ Depth from Soil Horizon 3oi1 Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Graven Flood Insurance Rate Mau: ;` Above 500 year flood boundary No— Yes "C z Within 500 year boundary No ✓ Yes r Within 100 year flood boundary No Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious ma rial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervi us material? Certification ` I certify that on A!dV (� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, pe '' a and exp 'ence described in 310 CMR 15.017. lr �� Signature Date 9-y7 7 f Q:\SEPTIC\PERCFORM.DOC �ZHE Tp� Town of Barnstable Barnstable .�~* Regulatory Services Department j ericaC j IARNWABU. I I `6 9. ,�� Public Health Division 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7015 1730 0001 4990 3813 September 14, 2017 BERESFORD, ROBERT J &DEBORAH A 32 GLEN RD HYANNIS, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 32 Glen Road, Hyannis, MA was inspected on 09/05/2017 by Mark Polselli, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level, <12" below inlet (per Town Code 360-9.1). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R:S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\32 Glen Road Hyannis MA.doc "� Town of Barnstable HAHI� Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-862-4644 Richard Scab,Director FAX 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES TO'REPAIR FAMED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) _ An`k"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or ponding of effluent to the surface of the ground . ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe, ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE(1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool; or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). ' •. TWO 2 *esspoioo����� • e ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) Leaching pit or cesspool with high liquid level, <12"below inlet (per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q\SEPTICCEADLINES TO REPAIR FAILED SYSTEMS.doc 79f�• wf Commonwealth of Massachusetts in Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �649,V�'— Owner �.��� information is Owner's Name / required for every c6vtvl15 /i7 �� 6O1 page. City/Town j State Zip Code Date of Insp ction Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms C on the computer, use only the tab key to move your 1 Inspector: cursor-do not use the return C4✓ d /S p�/� key. Name of Inspector ✓V v �� 7 G Company Name n lJ o `o� Company Address City/Town O____ 22 n O State Zip Code Telephone Number / 7 Y1941-4 License Number Bo 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 CHAR 15.000). The system: ❑ Passes ❑ Conditionally Passes eFails ❑ Needs Further Evaluation by the Local Approving Authority ��&' - Inspect '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 should be sent to the system owner and copies sent to the =—JZ-�J� 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 0 Owner Owner's Name Id information is required for every L4 4 y D� 0 page. City/Town B. Certification (cont.) State Zip Code Date of Inspecti n 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: 13) 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.doc•rev.6/16 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 2-2 ��P Property Address gyres ��Owner Ow ne�Na information is required for every OQ 6 0/ page. City/Town ,� State Zip Code Date of In ec' n Bo 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.doc•rev.6116 - 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 Property Address - (Owner Owne P/'e�•/ U/ r's Name information is p required for every ✓j!�/� //�/ �� �� / �^ page. City/Town State Zi Code P Date of In pecti n B. Certification (cont.) 2. System will fail unless the Board of Health (and Public!dater 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. I 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 o ❑ 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 ❑ E5' tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /-Q A Owner Owner's Name information is required for every Gi dJ 41 j page. City/Town State Zip Code Date of/I spe lion / Bo Certification (Cont.) Yes No ❑ quired pumping more than 4 times in the last year AfOT du obstructed pipe(s). Number of times pumped: y e to clogged or ❑ 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 �Jl ibutary to a surface water su I ppy pP y�❑ ny portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 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 a 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.doc-rev.6/16 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 Asse sments Property Address Owner Owner's Name -el ej -/,d information is / required for every G V, f page. City/Town Do Checklist State Zip Code Date of Inspection Check if the following have been done. You must indicate"yes"or"no"as to each of the following: � Yes o ❑ I ping information was provided by the owner, occupant, or Board of Health ��ElWere any of the system components pumped out in the previous two weeks? o as 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 nspected 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? Xhe 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)] Do System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 god x#of bedrooms): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 17 I I I Commonwealth of Massachusetts Title 5 Official Inspection Fora i Subsurface Sewage Disposal System Form -Not for Voluntary Asses ments �a 77 Property Address Owner information is ;Own;er'sNameqrequired for every 'page. State Zip Code Date of Insp do D. System Information Description: / An� C/ X 6 C) v� Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i i COMMonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Asses ments M Property Address � �40 � 9 Owner Owner's Name �s - information is required for every ✓1 f ZA -b 0/ i page. �.ZnSy - / State Zip Code Date of Inspection ytem nformation (cont.) 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 S em: Septic tank, 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): D t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner ✓�—S/ l7� information is Owner's Name required for every 41 f / Y4 /°1_ 60/ / page. Cityfrown — D. System Information (cont.) State Zip Code Date of In pect' n Approximate age of all co/mpo/nnents, date installed (if k own)and souurce of information: l /V �— S (/�1 poG _ Were sewage odors detected when arriving at the site? ❑ Yes �40 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 belo grade: feet Matey' I 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 Ye ❑ No Dimensions: Sludge depth: _ t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 - I ' Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner /tee �/c/ Owner's Name information is required for every page. City/Town State ZipCode Date of Inspecti n D. System information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Le SS Distance from top of scum to top of outlet tee or baffle -- Distance from bottom of scum to bottom of outlet tee or baffle �� o How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): G 4✓ti ✓� O J ✓1 !o✓f � e t4 , Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass 9 El 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 COMMonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments file, Property Address Owner Owner's Name �' ' "/d information is required for every a A�l R— ' page. City/Town v= State Zip Code Date of Inspec' n 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 g ❑ Polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day -- Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 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 Property Address Z'140 III Owner vl-'es O/ information is Owner's Name required for every Gt t/f /f page. City/Town State Zip Code Date of Inspecti n D. System nforrnation (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Z�2 �R�/�/ , 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: l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 I Commonwealth of Massachusetts . Title 5 official Inspecti®n Subsurface Sewage Disposal System For ®�y -Not for Voluntary Assessments Property Address �- Owner Owner's Name ��`� - zc information is required for every 4 f page. CitYRown J State Zip Code Date of spec' n ®. system nformatlon (cont.) Type: J�C 0 L v 9� � 6� lT leaching pits / � �� number: ❑ leaching chambers number: ❑ 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.): Or/! / 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 I Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 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 Property Address Owner Owner's Name information is //55 required for every ✓7 dj U �/� V D 60� / page. City/Fown State Zip Code Date of Inspectio De 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.doc-rev.6116 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 Property Address �� Owner ✓�.S / f>�(,✓ information is Owner's Name aa Q required for every rgvl(S //�� / r page. City/Town J State Zip Code Date of Inspe tion 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 �i I a L a� t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface sewage Disposal system•Page 15 of 17 i ! Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C- L11 Property Address ! Owner owner's Name information is / required for every C,r4 4 page. CitylTown State Zip C— ode Date o Ins p ction D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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 describ w you establis�jed the high ground water elevation: J f l 6��G✓l CL f t -/—a �T �Ou1NGf,✓ OC o� ' 17-Y �Ot:, vl CC/-�,L _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins.doc•rev.6/16 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 M / J Property Address /�c/ �✓ 'fir Owner p/ information is Owner's Name required for every Qb✓I /—e- Ipage. City/TownState Zip Code Date of ion E, Repo Ompleteness Checklist Z ary:A, B, C, D, or E checked tr- ary D(System Failure Criteria Applicable to All Systems)completed n—Estimated depth to high groundwater e Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 'S.. .. _ ti.4 � _ � �J r ,14 A TO OF BARNSTABLE�?5±*R: OCA'1ON S VILLAGE ASSESSOR'S MAP&LOT �� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I j v A ,`�` ?� �. ` �� J®� a _ ;'� ` 4 - � � �� "� � � �` ® + e s� � � • j , PROPER Y ADDRESS: _ Glen Road 1� West Hyannisport ------------------------ _- Mass_ 02601 A --------------- :R[C?fyfO . NO V 2 9 1995 Ori the above date, I inspected the septic system at the above°saddr�e; ho This system consists of the following: 1 . 1 -1000 gallon septic tank. 2. 1 -1000 gallon Octagon Leach pit. y Based on my inspection, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code) 2. The system is operating properly at the present time. 3-. 'Soil intrusion in pit. Must be restoned for 21 4. Inlet pipe in tank is. iri the middle of the tank not the inlet. Must change'. and baffle knocked out and new tee set up installed. SIGNATURE: A 0 _ Ls Name: Jose-ph P_-Macomb_er Jr. Company: J_P_ -Macomber & Son INc . Address: --Centerville ,Mass_-02632 Phone:---5Q$-2Z5_-.333 8------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY C P. MACOMBER & SON, INC.anks-Cesspools-LeachfieldsPumped & InstalledTown Sewer Connections 66 Centerville, MA 02632-0066 775.3338 775-6412 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection YI(Illlam F.Weld aw.n+or e Trudy Coxe � S.c,.tary,EOEA David B.Struhs ' ConurJulon�r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 6 Glen Road W. Hyannisport Address of Owner: Date of Inspection: 11 /2 1 /9 5 (If different) Name of Inspector: Joseph P. Macomber Jr. o a Name Addres and Telephone Number: �. acomrber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails /. i���l�•'GIGI� - Date: Inspectors Signature: The System Inspector shall submit a copy of this in report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: _•A20 I have not found any information which.indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8115195) 1 • U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6 Glen Road West Hyannisport,Mass . 02601 Owner: Anthi Macheras Date of Inspection:11 /21 /9 5 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): 6 broken pipe(s) are replaced obstruction is removed distribution box is levelled.or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N Conditions exist which require further evaluation by the Board of'Health in order to determine if the system is failing to protect the public health, safety and the environment. `—1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system nas a }eutli. tdiik anj Xi; ibaurpliun syslen'- and i� %sithin 100 feet to a surface v.ater supply Cr tr:uutar'j (C a surface water supply. dQ/ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. dl9 The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The.systen•I has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D) SYSTEM FAILS: _ 1/0 1 have determined that the system violates one or more of the following failure criteria as defined in.310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. d1p Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION (continued) Property.Address: 6 Glen Road West' Hyannisport,Mas's Owner: Anthi Macheras Date of Inspection: 1 1 /21 /9 5 e D)SYSTEM FAILS (continued): 0 (1(9 Static liquid level,In the distribution box above outlet Invert due to an overloaded or dogged SAS or cesspool. Liquid depth in cesspool Is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of.a public well.. d& Any portion of a cesspool or privy is within 50 feet of a private water supply well. Al Any portion of a cesspool or privy-is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of-system is 10,000 gpd or greater(large'System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 0� the system is within 400 feet of a surface drinking water supply &fi -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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local,regional office of the Department for further information. (revised 8/15/95) 3 v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST e Property Address: ' 6 Glen Road West Nyann 8port,Mass . Owner: Anthi Macheras . . Date of Inspection: 11 /21'/9 5 Check if the following have been done: 2/pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been regeiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. the system does not receive non-sanitary or industrial waste flow , The site was inspected for signs of breakout. ZAII system components,eluding the Soil Absorption System, have been located on the site. , The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or h•a proximated by non-intrusive methods. e facility ovine: land occupants, if different from owner) were provided with information on the proper maintenance of Sub. Surface Disposal System. Recommendations . 1 . Sewage line entering the septic tank must be- changed. Line enters middle of.- tank. Must enter at the inlet end. Baffle must be removed and new sanitary tee be installed. 2. The leaching pit has a large soil intrusion problem. Top section of the octagon leaching pit must be restoned with 1j" stone with a '3/8" stone cap. (revised 8115195) 4 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Glen Road West Hyannisport,Mass . Owner: Anthi Macheras Date of Inspection:1 T/21 /9 5 FLOW CONDITIONS r RESIDENTIAL: Design flow: 3]22 Raonspwt Number of bedrooms: Number of current residents:; Garbage grinder(yes or no):_= Laundry connected to system (yes or no): Seasonal use (yes or no):&) Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL• Type of establishment:. /UA Design flow: ,J& aallons/day Grease trap present: (yes or no) 14 Industrial Waste Holding Tank present: (yes or no) Az—lr n-sanitary waste discharged to the Title 5 system:'(yes or no)A))? water meter readings, if available: Last date of occupancy:_ OTHER: (Describe) r Last date of occupancy:_ GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no)" If yes, volume pumped. gallons - Reason for pumping: TYPE OF SYSTEM /r Septic tank/&Ulbuticsa-bvx/soil absorption system O _ Single cesspool Overflow cesspool _Q_ Privy (I _Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) F APPROXIMATE AGE of all components, date installed (if known) and source of information: cage odors detected when arriving at the site: (yes or no) 5 (revised 8/15/95) 11/24/95 11:45 BARNSTABLE WATER COMPANY 001 i CUS OMER CONSUMPTION HISTORY 4UMBER 288 01 .M —xDSTAS RCHE ZA"U. .. _._.. . ;ZEn'ICE _OCATION 6 GLEN RO READING GATES READINGS USAGE CMMODYY.I....... . __..(..CCF) BALANCE rIRST 10 06 95 771? A 2S SECONO 07 07 9S 7S1 A 30 4ATER-USE— - 31 -THIRD -- 03' 31' 95 721"9 5 -4R Z .GATE WATER USE 63 FOURTH 01 0S 95 716 A q FIFTH 10 06 94 707 A 3S Rw �+ ...... — `�` -SE SEVENTH 04 05 94 612 A 21 EIGHTH 01 07 94 591 A 20 06 ..in.. _.._. 57* t"A 86. .. TENTH 07 07 93 485 A W7 ,�`�► sr.&ER FIRST REAOING ELEVENTH 04 02 93 438 A 15 .cw `r SECONQ-REA6ZIVG _—.... --- {- _.. ..0-�OS 93—... Z3 _--EoE7 METER NO. THIRTEENTH 10 Ob 92 409 A 5 FOURTEENTH 07 08 92 404 A ENTER = FIRST SC N PFKEY 14 PRINT SCREEN I . .0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address:6 Glen Road West Hyannisport.,Mass . Owner: Anthi Maeheras Date of Inspection: 1 1 /21 /9 5 a SEPTIC TANK: �� (locate on site plan) ,e Depth below grader Material of construction: �oncrete _metal •FRP —other(explain) Dimensions• Sludge depth: i Distance from top of Mudge to bottom of outlet tee or baffle: Scum thickness:_ i Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage etc.) PumiD se tic tank every 2-3 Years . Inlet tee must $laced at the inlet end of -the se tic—tanknot in e miaaie. Liquid level elevauion to outlet invert e tank is structuraily sound. No evi ence e kage. GREASE TRAP:" (locate on site plan) Depth below grade: Material of construction:lgconcrete _metal _FRP—other(explain) Dimensions: AM Scum thickness: Distance from top of scum to top of outlet tee or baffler_ Distance from bottom n( From in bottom of outlet tee or baftle:AM � Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth-of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) NONE I (revised 8/15/95) 6 i SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6 Glen Road West Hyanni sport,Mass . Owner: Anthi Maeheras Date of Inspection: 11 /21 /9 5 0 TIGHT OR HOLDING TANK:09 (locate on site plan) Depth below grade:AIA Material of construction:Woncrete _metal _FRP—other(explain) AA Dimensions: AJA Capacity: VA gallons Design flow: A)J9 gallons/day Alarm level: /00 _ Comments: (condition of inlet tee, condition of alarm and float switches, etc.) f19f� L DISTRIBUTION BOX: P1Vi (locate on site plan) Depth of 1'iquid level above outlet invert: NA .Comments: (note ii level and distribut,oi. eyua% evidence of solids carryover, evidence of leakage into or out of box,•etc.) A 1bru-P_ PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no),LQ_ Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) 7 iILI SUBSURFACE SEWAGE DISPOSAL,SVSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6' Glen Road West Hyannisport.,Mass . Owner: Anthi Maeheras Date of Inspection: 1 1 /21 /9 5 SOIL ABSORPTION SYSTEM (SAS):, ` (locate on site plan, if possible; excavation not required, but 0 lay be approximated by non-intrusive methods) If not determined to be present, explain: c _ , Type: leaching pits, number: leaching chambers, number:_O_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dime sons: overflow cesspool, number: I m C ments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) S�oil;Loamy sand to fine medium sand-:Nn signs of h3xd-"@;j1j2 ggligg. of ponding.Grohd sinking aralind leac 4 Pitmus e CESSPOOLS: (locate on site plan) Number and configuration: kA Depth-top of liquid to inlet invert:h)61 Depth of solids layer: KI A Depth of scum layer: to Dimensions of cesspool: Materials of construction: Indication of groundwater: 1L inflow (cesspool must be pumped as part of inspection) AtA Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:,AQ s. (locate on site plan) Materials of construction:' ld Dimensions: Depth of solids:,• Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)_ 12Z (revised 8/15/95) B t'' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:6 Glen Road West Hyanni sport,Mass . Owner: Anthi Macheras Date of Inspection: 11 /21 /9 5 SKETCH OF SEWAGE DISPOSAL SYSTEM: • include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Town Water DEPTH TO GROUNDWATER Depth to groundwater. 1 5 , feet method of determine' In allqc� rWerA stems in this area. Test hole 12' No water encountered. _ l (revised 6/15/95) 9 ..... -ar-:z r._—res.--• -- ......_ ... _.. .--. -. _ —�r:s�zrr--r-.�-rr..-.-..F - rrne+:rn:•r�.•rr•'Zcr:.�•nn�rT..r•.r...-.r.:•.•r.�r.r:.rt---+. 1' TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION - �•.•-:•;•T.:-::r-r.:t--.--•:.r.-n•r.:r.:-:r•.•.-:-.--v:�-r•s•^:.---r-r-rcrs,-rr r.�.r..r - -.- ... .. zrn r.�rmrnrsrrmsrr�r...-rrr r. n. r -TYPE OR PRINT C1.EARLY- PROPERTY INSPECTED STREET ADDRESS 6 Glen Road West H.yannisport,Mass . ASSESSORS MAP , BLOCK AND PARCEL # • OWNER' s NAME Anthi Mach-eras PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P. Macomber Jr. . COMPANY NAME J.P.Macomber & Son Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 - Street Town or City State LIP COMPANY TELEPHONE (508 J 715 - 3338 FAX (508 1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and complete as of the time ! of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : XXXXXXSystem PASSED Conditionally ' The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , •3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . i Inspector Signature-4 Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF HEALTH. * If the inspection FAILED, the owner or " perator shall upgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 310 CMR 15 , 305 . t U) �7 S�j'V �71 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT 'KNOWN THAT ' s Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8. 1995 Zf 7- Acting Director of the - •ion of Water Pollution Control ^ \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 32 Glen Rd. Hyannis Owner's Name: Tim Fuller Owner's Address: Date of Inspection: — 9 3 Name of Inspector: (please print) Wi 1 1 i am E_ • Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: ( 5 0 8 ) 7 7 5-8 7 7 6 CERTIFICATION STATEMENT 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.1 am a DEP approved system inspector pursuanZses tion 15.340 of Title 5(310 CMR 15.000� The system: . Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails / Inspector's Signature: 41 ► < .�, Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh,,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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 �� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Glen Rd. _Hyannis Owner: Fuller Date of Inspection: - — Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m 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: r ��: �a r✓� 1 yl � ��J System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or rep fired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla . e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsoun ,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existin tank is replaced with'a complying septic tank as approved by the Board of Health. •A me 1 septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicati g that the tank is less than 20 years old is available. ND ex p ain: bservation of sewage backup or break out or high static water level in the distribution box due to broken or obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approva of Board of Health): broken pipe(s)are replaced ` obstruction is removed ! distribution box is leveled or replaced JI ND expla Th system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspe tion if(with approval of the Board of.Health): broken pipe(s)are replaced obstruction is removed ND explain: I� Page 3 of 11 • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Glen Rd- Hyannis Owner: Fulle Date of Inspection: 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 fail g to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s tem 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. Sy tem will fail unless the Board of Health (and Public Water Supplier,if any)determines that the isyste 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 s race 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 pri ate water supply well**.Method used to determine distance ** Fhis system passes if the well water analysis,performed at a DEP certified laboratory, for coliform ba teria and volatile organic compounds indicates that the well is free from pollution from that facility and thi presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other fa lure criteria are triggered. A copy of the analysis must be attached to this form. 3. then. 3 1 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 32 Glen Rd'. yannis Owner: Fuller Date of Inspection: G —i3—a 1 D. ystem Failure Criteria applicable to all systems:. You ust indicate`yes"or"no"to each of the following for all inspections: Yes o _ 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 '/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 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 wz= supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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 ystems: To be consi ered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must in icate either"yes"or"no"to each of the following: (The follow' criteria apply to large systems in addition to the criteria above) yes no the ystem is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary.to a surface drinidng water supply th system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Z ne II of a public water supply well If you have swered"yes"to any question in Sectina E the system is considered a significant threat,or answered "yes"in Sec ion D above the large system has failed.The owner or operator of any large system considered a significant t eat 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. 4 Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 32 Glen Rd. Hyannis Owner: Fuller Date of Inspection: 'U Check if the following have been done You must indicate"yes"or"no"as to each of the following: I Yes No /Pumping information was provided by the owner,occupant,or Board of Health /a 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: Yes no 1/ _ 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(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION I Property Address: 32 Glen Rd. Hyannis Owner: Fuller Date of Inspection: —I —0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 3 6 Number of current residents: 4 Does residence have a garbage grinder(yes or no):Zd Is laundry on a separate sewage system(yes or no):L dd [if yes separate inspection required] Laundry system inspected(yes or no):;A—a Seasonal use:(yes or no):fe-Y Water meter readings,if available(last 2 years usage(gpd)): 1 9 9 8—9 9 76, 500 gal. Sump pump(yes or no): /L., a 9 —2 0 0 0 78, 000 gal. i Last date of occupancy: 1.i/-d CO' ERCIAL/INDUSTRIAL Type o stablishment: Design w(based on 310 CMR 15.203): gpd Basis of sign flow(seats/persons/sgft,etc.): Grease tra present(yes or no): Industrial aste holding tank present(yes or no): Non-sari waste discharged to the Title 5 system(yes or no): Water me er readings,if available: Last date f occupancy/use: OTHE describe): GENERAL INFORMATION Pumping Records O Source of information: Was system pumped as part of the inspection(yes or no):—e) If yes,volume pumped: ,,� gallons--How was quantity pumped determined? Reason for pumping: TYP F SYSTEM eptic 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: Were sewage odors detected when arriving at the site(yes or no): CI 6 Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Glen Rd. Hyannis Owner: Fuller l Date of Inspection: — / 'V B DING SEWER(locate on site plan) Dep below grade: Mate ials of construction:_cast iron _40 PVC_other(explain): Dis ce from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance.(yes or no):_(attach a copy of certificate) ' ► '' Dimensions: Sludge depth: ! e 3 > > Distance from top of sludge to bottom of outlet tee or baffle:�— Scum thickness: 6 _ i 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): v /too �/ T h/- 0, F�� 3 � c i GREAS TRAP:_(locate on site plan) Depth bel w grade:_ Material o construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensio s: Scum thi ess: Distance om top of scum to top of outlet tee or baffle: Distanc from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Comm nts(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as re ted to outlet invert,evidence of leakage,etc.): i 7 k Page 8 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Glen Rd _ Hyannis Owner• Date of Inspection: 6-1 3-0 d T\eh T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dbelow grade: Mal of construction: concrete metal fiberglass__polyethylene other(explain): Dime ions: Capaci gallons Design Flow: gallons/day Alarm resent(yes or no): Alarm 1 vel: Alarm in working order(yes or no): Date of ast pumping: Comme is(condition of alarm and float switches,etc.): DIST BUTION BOX: (if present must be opened)(locate on site plan) Depth f liquid level above outlet invert: Comme is(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage i to or out of box,etc.): PUMP C MBER: (locate on site plan) Pumps in w king order(yes or no): Alarms in w rking order(yes or no): Comments note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION(continued) Property Address: 32 Glen Rd_ Hyannis Owner: Fu I 1 Pr Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (Iocate on site plan,excavation not required) If SAS not located explain why: TYPe leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: 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.): G CE POOLS: (cesspool must be pumped as part ofinspection)(locate on site plan) Numbe and configuration: Depth— op of liquid to inlet invert: Depth o olids layer: Depth of cum layer: Dimensio s of cesspool: Materials f construction: Indication f groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Material of construction: Dimens' ns: Depth of olids: Comment (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 2 Glen Rd- Hyannis Owner: Fuller Date of Inspection: 3`� 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. a 10 Page 11 of 11 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 32 Glen Rd. Hyannis Owner: Fuller Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 9 feet Please indicate(check)all methods used to determine the high ground water elevation: btained from system design plans on record-If checked,date of design plan reviewed: /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 descr a how ou established the high ground water elevation: , y 19 I1 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ���0� ASSESSOR'S MAP & LOT D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I,f dO I I LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT'DATE: COMPLIANCE TE: � Separation Distance Between the: S�6 w D /°Affm /0/ . Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by pl� l :tt f � - t s 1In allqc� gee era's stems in this area. Test icountered. 9 � o` ASSESSOR'S MAP: 288 Q9 GENERAL NOTES: C" PARCEL: 019 0 v9 . Smith St i REFER NCE�, PL. BK. 86 PG. 127 0 1. VERTICAL DATUM: __Assumed_________ �'/i ° Glen R v 2. MUNICIPAL WATER �S AVAILABLE. FLOOD ZONE: X Town of Barnstable 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT #25001 C0568J(07/16 4) ' °', SYSTEM UNLESS OTHERWISE NOTED. 4. ALL PRECAST R CAHTIUNITSOHTOOCONFORM TO LOCUS --- ------ �s 5• PIP' " PITCH-1/4" PER FOOT UNLESS OTHERWISE NOTED. /? 007� 6• ALL CONSTRUCTION DETAILS TO BE IN CONFORMANCE Morchont's Mill R WITH MA ENVIR. CODE (TITLE 5) AND LOCAL REGULATIONS. LOCUS MAP N.T.S. , ,.A......,. :.•'... '.:: :.:: `.. ;. 7• CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. ^mot c LEGEND: o 11• Lot 6 ��0+�t5,2 4t sf moo..'.; �� osr 99 �, PROPOSED CONTOUR ,aJ• 99 PROPOSED SPOT GRADE 2. aaa 9 ° — 40 EXISTING CONTOUR X 30.23 EXISTING SPOT GRADE TEST PIT y� _ / � ?� ��ch ° , ��J�� �6 ® EXISTING WATER SERVICE /. �i o X o WORK LIMIT LINE NOTE:/ Pum and removal failed leach pit and all contaminated soils within 5' sR^.. 21 of proposed leach field. Existing �1� OF Mgff septic tank to remain. Contractor to o ( / verify all elevations prior to start of o AMY L. o I construction. (Replace existing tank if o VON HONE CL °s Sh Existing Dwelling ti damaged or failed with minimum 1500 U No. 1068 ti (A , Top Fndn. El. 22.5' p gal tank at proposed elevation Inlet a (Full Foundation) I EL.19.55 and minimum 10' off F�ISTER� bulkhead.) f 79 19 719 I (Sonotubes—no Fnd.) 'S �/� 10 2'6� NOTE: This plan is to be used for septic 0 o pec •., rt system purposes only and is not to be ' 44 k - _ used for any other purpose. 0 8 82 G, .o � L Exist. Tank '� y TH-1 32 GLEN ROAD 430' 'TO to remain d 1�93 , HYANNISPORT, MA �•, TH_ 4 5, �6�, _ ��� Benchmark: Use PREPARED / o —4.5 ^y —22� `s Corner of Concrete at associates ... Bulkhead El. 22.2' SEPTIC SYSTEM DESIGNS FOR: Robert Beresford a..... 9 .. 3 i 2'9 3 . .:................ ....... ,•. � Law" + —23-- Sandwich. MA 02563 Septic System 32 Gen Road (o)508.833.0041 Design Plan Hyannis, MA 02601 Stockade Fence (c)508.27a.007a 95.00' Exist. Surging Bldg. AHOjala Surveying (No ArneH. Ojala,P.L.S. 211 Maple Street DATE REVISED SCALE SHEET NO. Cellar) west Barnstable. MA 02668 508-362-0934 09/27/17 1" = 20' 1 of 2 i Install risers w/covers over inlet and Provide Riser over D-box NOTE: All components to be marked with T.O.F. (Full) outlet to within 6" of final grade to within 6" of final grade magnetic tape or similar prior to final cover. NOTE: To prevent breakout, final EL. 22.5 (Access Covers min. 20" diam. per Code) grade of EL. 18.61 to be carried (Cover to be watertight) out a minimum 15' beyond edge F.G. EL: 20.3-21.7 F.G. EL: 21.6 F.G. EL: 21.5 Maintain Min. 2% slope over leach facility to of leach facility. Existin �� revent ondin F.G. EL: 21.0-21.5 Min. 2" of 1/8" - 3/4" Washed Stone or S Geotextile Fabric L=10'' t i '' 3/4" - 1 1/2" Double Washed Sto e� Inspection Port within 3 to grade Exist. invert 4" SCH 40 _ L=15' L=10' Cast Iron 4 . to• 4" SCH 40 PVC 4' SCH 40 PVC 0.005� slop Top of Peastone or Geotextile Fabric EL 18.61 CAS=8.7� 2 EL. 19.75 14• ®S=17 1% s " Cap Ends - EL. 18.13 EL. 18.63 �7 ©5=0.6% 0.5%MIN 6 Effective Depth Install Gas Baffle EL. 18.48 EL. 18.31 EL. 18.88 PROPOSED DB-3 EL. 18.25 Use Leach Field Bottom EL. 17.63 H-20 DISTRIBUTION BOX 30' Long x 15' Wide x 6" Deep 5' (Install PVC Outlet Tees) Watertest for levelness with 3 - 4" Perf. PVC Laterals EXISTING 1000 GALLON if moreoutletn one SEPTIC SYSTEM PROFILE H-10 SEPTIC TANK EL. 12.63 Adjusted Groundwater TH-1 N.T.S. SOIL LOG ADDITIONAL NOTES DESIGN CRITERIA Number of Bedrooms:Existing 3 Bedrooms SOIL EVALUATOR: AMY VON HONE, R.S. S.E. #2517 1 Contractor to confim soil suitability prior to installation. Contact BOH and INSPECTOR: DONALD DESMARAIS, R.S., BOH Design Sanitarian in the event of varying soils from original soil test. Soil Type: Class I DATE: SEPTEMBER 27, 2017 10:00 AM PERMIT: #15483 Percolation Rate: <2 min/Inch PERCOLATION RATE:<2 MIN/INCH IN C1 2. Pump and remove Failed Leach Pit. Any contaminated materials within 5' of proposed Leach Facility to be removed. Replace with clean fill per Title Daily Flow: 110 G.P.D./Bedrm x 3 =330 G.P.D. TH - 1 TH - 2 5 specifications. Design Flow: 330 G.P.D. (Min. Required) EL. 21.0 EL. 21.4 3. Water line to be sleeved at any sewerline crossings and within 10' of any Garbage Grinder: Not Allowed Fill septic components, as needed, per Water Department requirements. Sandy Loam Contractor to verify location of water line prior to construction. Leaching Area (330)/0.74 = 445.94 S.F. 10YR3/2 Required: 14" A 19.83 9" 20.65 4. Distribution Box to be placed on 6" crushed stone or compacted, level Septic Tank Required: 330 G.P.D. x 200% = 660 G.P.D Sandy Loam Lo m sand base. Minimum 1000 Gallon (Existing) 10YR3/2 10YR5/8 16" 19.67 19" 19.42 SEPTIC TIES Use Leach Field 30'L x 15'W x 6"D: 3 - 4" Perf. B Ct PVC Laterals Double Washed Stone Loamy Sand Coarse Sand N.T.S. 10YR5/8 2.5Y6/4 Living Sidewall Area: NOT ALLOWED. 26" 18.83 Bed 3 Bed 2 C1 Room 30 x 15'= 450.0 S.F. Perc Bar E Bottom Area: 450.0 S.F. ® Total Area: Coarse Sand Desi n Flow Provided: ( )_ 2.5Y6/4 37" Bottom Bed 1 0.74 450.0 S.F. 333 G.P.D. m Kitchen °t f Existing Dwelling ' Bo Top Fndn. El. 22.5'` 32 GLEN ROAD d• a (Full Foundation) 100" 12.63 105" 12.62 �o Dining/Family \ H YA N N I S P O R T, MA `° ' (Son0tubes-no 128" 10.33 133" 10.32 Room 5 Fnd.) associates PREPARED 138" 9.5 136" 10.07 ISEPTIC SYSTEM DESIGNS FOR: Robert B e r e s f o r d 24 Gallons ® 4:00 min. PERC RATE: <2 MIN/INCH C1 Horizon FLOOR PLAN Deg 320 cotuit Rood Se tic System J Sandwich. MA 02563 P Y 32 Glen Road Well MIW29, Zone B, Aug. 2017 (8.05') N.T.S. , 34 5' (0)508.833.0041 Design Plan Hyannis n n i s MA 02601 Groundwater adjustment: 2.3' 1 g 4 (c)soa.2�a.00�a �/ , I, Amy L. von Hone, R.S., hereby certify that I am currently approved by 3�' 39' surveying by. the DEP pursuant to 310 CMR 15.017 to conduct soil evaluations and I 4.5 AHOjala Surveying that the above analysis has been performed b me consistent with the ArneH. Ojala,P.L.S. requirements of 310 CMR 15.017. F further certify that I have 0 4.5' 211 Maple street DATE REVISED SCALE SHEET N0. q Y west Barnstable. MA 02668 n successfully passed the Soil Evaluator's Exam on November, 1994. 5oB-362-0934 09/27/17 1 = 20, 2 of 2