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HomeMy WebLinkAbout0069 GOAT FIELD LANE - Health 69 Goat Field Lane x Hyannis P A = 248 259 p , a u °' 4 ° ° n ° ,. t • °"b ply q ". i Commonwealth of Massachusetts r Title 5 Official Inspection Form , ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , •� 0 69 Goat Field Lane ' iM Y.4 Property Address NZ Lisa M. Burgess Owner Owner's Name information is required for every Hyannis. Ma 02601 9/8/2020 page. City/Town State Zip Code Date of inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information 51 *r— j q'a` j filling out forms on the computer, use only the tab Raymond F. Dumas key to move your Name of Inspector cursor-do not Dumas Landscape Const. use the return Company Name key. 564 Old Stage Rd. ICI. Company Address Centerville Ma. 02632 City/Town State Zip Code 508-509-0210 S1437 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); [ have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails - 9/8/2020 Inspector's ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/28I2018 Title 5 Official Inspection Form: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 a� 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owner's Name information is Hyannis Ma 02601 9/8/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 316 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, riot leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ •ND (Explain below): ry t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5. official Inspection Form �- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goat Field Lane Property Address .Lisa M. Burgess Owner Owner's Name information is Hyannis Ma 02601 9/8/2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 1 3) ,Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, Y safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts . p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owner's Name information is required for every H y annis Ma 02601 9/8/2020 - page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or El ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ -® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. ' Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goat Field Lane L Property Address Lisa M. Burgess Owner Owner's Name information is required for every Hyannis Ma 02601 9/8/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Tale 5 Ofricishinspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owners Name information is required for every Hyannis Ma 02601 9/8/2020 - page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? I ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue El ® approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts ,IF Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �• 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owner's Name information is required for every Hyannis Ma 02601 9/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms.(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 440 Description: j Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2019 8400 cubic ft is 168 gallon per day/2020 6500 cubic ft or 129 gallon per day Sump pump? ❑ Yes ® No Last date of occupancy: occupied now Date t5insp.doc•rev.7/262018 Tdle 5 Official Inspection Fond: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 �w 69 Goat Field Lane Property Address. Lisa M. Burgess Owner Owner's Name information is Hyannis Ma 02601 9/8/2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: 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 _ I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: . Date Other(describe below): 3. Pumping Records: Source of information: As per town of Barnstable was pumped Oct. 2019 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: General Maint. l5insp.doc!rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owner's Name information is required for every Hyannis Ma 02601 9/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ' ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Upgraded 2/23/2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan):- I Depth below grade: 2.5 ft below grade feet Material of construction: a ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 24 ft across oter side of basement feet Comments(on condition of joints, venting, evidence of leakage, etc.): all good l5insp.doc•rev.7/26/2018 rdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goat Field Lane L Property Address Lisa M. Burgess Owner Owner's Name information is Hyannis Ma 02601 9/81/2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on.site plan): Depth below grade: 24 inches feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years i Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 1 inch Distance from top of scum to.top of outlet tee or baffle 6 inch Distance from bottom of scum to bottom of outlet tee or baffle 12 1 nshes How were dimensions determined? tape measure Comments(on pumping recommendations, inlet and outlet-tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 1 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owner's Name information is Hyannis Ma 02601 9/8/2020 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7128R018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form rVe Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 69 Goat Field Lane Property Address Lisa M. Burgess. Owner Owner's Name information is required for every Hyannis / Ma 02601 9/8/2020 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.): I *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at level inspect by camera Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no carryover and no evidence of leakage l t5insp.doc•rev.7J28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goat Field Lane Property Address \ Lisa M. Burgess Owner Owner's Name information is Hyannis Ma 02601 9/8/2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: . ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: as per plan Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology. Precast as per plan Loin.p.doc-rev.7reWO18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owner's Name information is required for every Hyannis Ma 02601 9/8/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Inspected by camera liquid 12 inches below bottom of pipe 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1.4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � � 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owner's Name information is required for every Hyannis Ma 02601 9/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate`on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): • t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f ; I I Commonwealth of Massachusetts Title 5 Official Inspection Form r • Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t 69 Goat Field Lane Property Address } Lisa M. Burgess 1 Owner Owner's Name i information is required for every Hyannis Ma 02601 9/8/2020 i page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t l i I I f 1 fit'. i t5insp.doc•rev.7R82018 TAIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 1 I c Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;V 69 Goat Field Lane Property Address f Lisa M. Burgess Owner Owner's Name information is required for every Hyannis Ma 02601 9/8/2020 page. Cityrrown State Zip Code Date of Inspection I D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells l Estimated depth to high ground water: 12 ft plus no water 5.4 ft below bottom of leach chambers as per plan l 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. 7/10/2003 Date { ❑ Observed site(abutting property/observation hole within 150 feet of SAS) II ❑ 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: no water as per plan II I i Before filing this Inspection Report, please see Report Completeness Checklist on next page. I ' 4 t5insp.doc•rev.720018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 I I I i Commonwealth of Massachusetts Title 5 official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goat Field Lane Property Address Lisa M. Burgess Owner Owner's Name } information is Hyannis Ma 02601 9/8/2020 1 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included I t5insp.doc-rev.7/2WO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 { vpsry PQ' ?��: Nor 7o sc E •' '=Sr `!o, _OCR it MtSi MY LFfi:1l '"uW%P')/✓.YnifON. +i ��]J CO.fR4 tO W,M I� Q / f1"'i(J.O i R iN9CD O,A iGP.NN T i 'rf�`-+tDSiN: NNE:•�"'•CG i W, d X i� � \ 7 -n*y+wnn I ES!yY:O..vcYel,T_ / 1 —�]� I G..OG✓S� \\ - .,, ., it ti a a .1 -_ a n ., rRL..ArE:��.v...i�iHc✓a w• _ 11 �- m 3c-.3 II -1:. — l l_- 7, I! JS.T, T•_'"'•..�---��mrtcv r.!t. %. ••I /`i•:i- I ;I it j�.;"y -j �.. ���rr>KN s.��xrwnra. "•5- I I� ,ra.;D•ec ' .BP-� ::%/.C:G./J 3?"• i 3z.G• it I :I DE'!ON DATA ;i y Ily 6?'�:W)6EDROOMS zIO6PD= - ;I SfP TANG:Y,�o z200%m 4°ob?D I� U�:/5_-GALLON PRELAsr sEPTG T-ANK I li LEAC411N&FA(.ILrY: ,: USE:��)s X s.s;<�'-� So of oe�•:uc.c.� it GAPAL!TY: li i; .✓o; - - - SIDEwn1: 13'x z l I`-��, Ii �G` nor=5 TJ3H 33.EC, _ 5- � TOrti: II I !LO\7RrtL70F•r06E R=SPOtJSG.-E FOR Tm-_LOLA7I7.,DF qLL IJrIIIES, II nbov=A`D;.�DER6R ",PRORTOAN C-%LAVn7t7NORLO.zhTRLV ON. I' Ij 2.sr_PiL5Y57EN TO OF N5'A)yED NLLI•P%.!tLE wile 506VR5O0:7TLE v ��•',': t,.. - A'„L7G7LlRMZP AREAS 70 re LOAVED AM•3EE7' L II `\ �O—__, �- \ �v� \\ ��f //// -� � S.LOLT?•AbiOR iO PRP�DE 2n ryA, j \` •• LOT Z°� P _ \ �I�rceroRA\ n. � C \.,\ �J /' \ / � i � `' 6. .c'ci-'i✓o.�r C-x>ti>ivG G �cr 4�iT.�Nn<.:c 'j \� //r>J95F \ } %' // / � /� \\ - Tij..vi-:��V BNG��.-.cC•wi. c C.. � ti it ,`i1\ `� ,� (� /% �i e` \�\ �• ; / rs-. AN dy//NV/�/aic7- la P,•Z PARED FOR: OiJ%/ ti/'=/✓/�/Z� lil it \ 'I� \ •1 a`plN•i V Ilj II \ 1D _l-� 1 _T STEVeN W - ill /� s �FUMT �), IaobNLnn6ER: ID,;nj 7-/�- s1EEl: it //8- ssslaiop I O -oz7 ;i VV-LLB & HSSOGI A I:.LS- _l i '' ----------"-_-- �_ — —_ `j ! ^' SUi7E rG G=�ERVIL'E, NA d16�2 iii I TEL.: (506) 775-07�55 - FA(: (508) 775-0754 FROFESSIONA_' =,\GINFFRS :< LAID 5ixZVEYGR5 j No /vi/ THE COMMONWEALTH OF MASSACHUSETTS Farerea in computer ✓ Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE,MASSACHUSETTS ftp[ication for Miopos;al bpotem Conotruction Permit Application for a Permit to Construct( )Repair(.,,%'Upgtade( )Abandon( ) ❑Complete System ❑Individual Components Location Addressor Lot No. 6q Gp�t "1. Owner's Nam Address and Tel. o. -- —- ts Nt 5 l)au i tP /Plena rt AssessorsMap/PGioel Installer's Name.Address.AtqW(CANCO i Designer's Name,Addrms and Tel.No. 350 Main Street I GtJiC/let W.Yarmoutr% MA 02673 •Iype•of BuMag: e�RpM, `t' Dwelling No.of Bedrooms Lot Sized sq.ft. Garbage Grinder( ) Other Type of Building _No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ✓b( dgallons per day. Calculated daily flown"gallons. Plan Date 7 / 3 Number of sheets Revision Date Title. Si fe Se o;s _ I Size of Septic Tank /S'�o Type of S.A.S. � Description of Soll Pet /?Z4 n � Nature of Repairs or Alterations(Answer when applicable) Date last inspected: _ Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro rtt`ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B of alitt. Signed Date Application Approved by 1 __Date Application Disapproved for the f owing reasons_ --Permit No. _— - _-------- Date Issued- Ut�—__..------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE•MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( .)-t7pgraded( ) Abandoned( )by �' /•_.!;`t:i at [*' )_ , N/r i f has been constructed in accordance with the provisions ofTitle 5 and the for Disposal System Construction Permit No.._,:`; ' dated Installer Designer The issuance of Idspe_rrait shall not be construed as a guarantee that the system will function as Assigned: Date Inspector No. Fee - T—I THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS ]Dfgpooal Opotem Q gp"tructton Permit Permission is hereby 3rag4d to Cott&rrttct( )l;epair( Otlpgrade( )Abandon( ) 3� .�••C'. 'a•�t se System located at 't-: / "of ° i * .'." ,.•, . and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to f comply with Title 5 and the following local provisions or special conditions. Provided.Construction must be completed within three years of the date of this permit. Date: --Approved by I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goatfeild Rd lug Property Address Doris Manard Owner Owner's Name information is Hyannis Ma. 02601 8-19-14 required for y every page. Cityrrown 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Matthew F. Gilfoy cursor-do not Name of Inspector use the return key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 �10 Cityrrown State Zip Code r (508)477-0653 SI13640 Telephone Number License Number i B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-19-14 Inspe or's Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Ins ibsurface Sewage Disposal System•Page 1 of 17 I • II Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which*indicates that any of the failure criteria described .in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.. 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or.high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if.(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑. N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will:pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced. ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction, is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**: Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that.no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate".Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. El ® Any portion.of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100'feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. 'Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 2.00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of 11 this inspection? ® 0 Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® '❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. El ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information . Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 459.9 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2012-12,600 cubic ft. 2013-13,700 cubic ft. Sump pump? ® Yes ❑ No Last date of occupancy: current • Date Commercialllndustrial 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: 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): I 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goatfeild Rd i Property Address Doris Manard Owner . Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 216„ Depth below grade: feet Material of construction: ❑ cast iron Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time'of inspection building sewer'appeared to be in good working order no sign of leakage. i I Septic Tank(locate on site plan): Depth below grade: 2feet Material of,construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is.metal, list age: ., years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. Sludge depth: 4" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" y Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15 How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Tank does not have risers and should have them installed. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass. ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping, Date t5ins-3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i Commonwealth of Massachusetts kiTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Cityfrown State Zip Code Date of Inspection D. System Information. (cont.) ' Comments(on.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of.inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): t *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - NotJor Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence.of leakage into or out of box, etc.): At time of inspection d-box appears to in.working order no sign of deteration, or carryover. Riser,not present on d-box. Pump Chamber(locate on site plan): j Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in.working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ' Type. . ❑ leaching pits number: ® leaching chambers number: 3 (33'6'X13'X2') ❑. 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.): At time of inspection leaching appears to in working order no sign of hydraulic failure. Water level 1'6" below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow. ❑ Yes ❑ No 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Comm6nwea1th:of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner ::Owner's Name information is Hyannis Ma. 02601 8-19-14 required for State Zip Code. Date of Inspection every page.. City/Town 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 Rear a�' house, . ---- OYeCEIan ._.............. O O A3' S3' r53 y0 3 O p t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW 122" 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 3 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: Plan on file at BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 69 Goatfeild Rd Property Address Doris Manard Owner Owner's Name information is required for Hyannis Ma. 02601 8-19-14 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed . Z System Information— Estimated depth.to high groundwater ® Sketch of Sewage Disposal System either drawn:on page 15 or attached in separate file t5ins-3/13 Title 5.Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE �- 'L ATION ! ���/">E � � � SEWAGE # 66�_ a3 'VILLAGE /UPS ASSESSOR'S MAP LOT ..INSTALLER'S NAME fa PHONE NO. A & B CANCO 775-6264 OPTIC TANK CAPACITY /5�� P/��S'7' LEACHING FACILITY:(type)s, l- � 1 r s(size) ,53,5 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERIA4A) BUILDER OR OWNER ' DATE PERMIT ISSUED: J La 3 6 q DATE COMPLIANCE ISSUED: FJ�" VARIANCE GRANTED: Yes No �1 �1 5 �- --- --� n D'V v� i n tt _ r No. uV q 0 3 Fee f Entered in computer: V THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zpplitation for Mi!5paal *p9tem Construction i3ermit' Application for a Permit to Construct( . )Repair(�pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. tOq ��q f ��el f�j e Owner's Name,Address and Tel.No. Assessor's Map/Pazcel �fl \ 1)AU i 69 era fGQ ' �y8las9 C��m Installer's Name,Address, &W(CANCO Designer's Name,Address and Tel.No. 350 Main Street W. Yarmoutr,WA 02673 �� S Type of Building: M Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures �// �� Design Flow ) :J fo(� 4gallons per day. Calculated daily flow " gallons. Plan Date 7"/ Number of sheets Revision Date -.011l4 Title Si>e -_Qa.acc ' Size of Septic Tank /S'� Type of S.A.S. Description of Soil Pe/� 4'6�1-7 Nature of Repairs or Alterations(Answer when applicable) Ill' 00/ ,,--7 Date last inspected. f Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B of alth. Signed l Date / 3 Application Approved by ks Date t' Application Disapproved for the Uowing reasons Permit No. U a y Date Issued 11.2 3 t) t UAL _ ;t' y�\[f-y�r1 1a } No. !_.���.� ,a� .''��' >. � Fee III EntBr in computer. THE�COMMONWEALTH OF MASSQ�tJSETTS � � ; PUBLIC HEALTH'DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes Appficationifor Migpooal *pztem Construction Permit Application for a Permit to Construct( )Repair(�Upgrade( )Abandon( ') ❑Complete System El Individual Components Location Address or Lot No. 65 C—dcz t FF-,e)dl /R!d C O m wner's Name,Address and Tel. o. Assessor's Map/Parcel i)Av Melia�c( o��l a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (,vac lie c Type of Building: Dwelling No.of Bedrooms A,,..Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures -// v Design Flows J(�b gallons per day. Calculated daily flow " gallons. Plan Date U 3 Number of sheets I` Revision Date Title .Si><e Tee .o C e Size of Septic Tank /S'o o Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) I; Date last inspected: V Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage,disposal system in accordance with the provisions of Title 5 of the EnKAI � tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Briar ofSigned \ ( Date Application Approved by �.)• Date 1 L� Application Disapproved for the following reasons t _- Permit No. ? U u u— 5 V Date Issued / .231U Y THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Graded( ) Abandoned( )by eo�.-Jti"o at &9 L�Da f Fi p/ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a U u V -(3 - dated !/a A Installer t Designer The issuance of s<permit shall not be construed as a guarantee that the system wjllrfunction as designed, Date 1 3 10 Inspector C/ 1... U ' V No.�UJ�I "r .��/ -------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS C)0 t PUBLIC HEALTH DIVISION - BARNSYABLES MASSACHUSETTS Miqu al *pgtem Co 4truction Permit li Permission is hereby ranted to Construct( )Repair( pgrade( )Aband�( �)/ System located at C� U070- j�%e� _ A and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. - Provided: Construction rust be completed within three years of the date of this er\mit. J r f 7 _ Date: I 1 >, U ��- Approved by TOWN OF BARNSTABLE LOCATION SEWAGE # D�T- 631 ."NILLAGE N1S ASSESSOR'S MAP Cz_ LOT 2 -) -:INSTALLER'S NAME& PHON'E NO. A & B CANCO 775-69-64 SEPTIC.TANK CAPACITY_� LEACHING FACILITY:(type),,--? %�'g� (sue) / NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERfA4A0k .':BUILDER OR OWNER DATE PERMIT ISSUED:_T��®7 DATE COMPLIANCE ISSUED: 3� I VARIANCE GRANTED: Yes No +j KA2 OeL.. l rol j LOj a , mpNK 4t �.� ' F iloil, 33,S�ict3`X�' C m d N O Q `s o 0 LOT 2-4 a < 17479 S.F. ' -- *,o0° \\' . V OF �U I LP I N O LOGAT I ON PLAN MgsJ' LOCATION: 69 GOAT FIELD LN., HYANNISPORT, MA ° VEN W tiN �„� Faz DAVID & DORIS MENARD rn o U3 BA SCALE: DRAWN PY. I" = 3d TMW (A9OFESSIO�P J06 NLMbFR: DATE: SHEET: SUM Q ;2�a�, 03-O27 AUGUST 23, W04 GPI'-I WELLER & A6SO6 1 ATES 195 FAIJvI0Ufh RP N SUITE 4G CEKrMVU-F-, W OUX TFL: (508) - -om - FAX: (508) 775-0754 PROFESSIONAL ENGINEERS & LAND SURVEYORS I LOCATION OF PROPERTY LINES MAY NOT BE ACCURATE STANDARD LEGEND NOTE:not all symbols will appear on a map — GOLF COURSE FAIRWAY EDGE OF DECIDUOUS TREES EDGE OF BRUSH \ 1 ORCHARD OR NURSERY Ma 248 r"r'--:P--ri EDGE OF CONIFEROUS TREES OO MARSH AREA / EDGE OF WATER # 9 = _ _ = DIRT ROAD O :- __` DRIVEWAY P 2 2 4 8 I� PARKING LOT E�PAVED ROAD r1 7 — — DRAINAGE DITCH PATH/TRAIL Ma 48 # O\ — — — — - PARCEL LINE** _ MAP I to-c— --MAP# ` 21-< PARCEL NUMBER # `69 #1860— HOUSE NUMBER 1 FOOT CONTOUR LINE to 10 FOOT CONTOUR LINE \ Elevation based on NGVD29 ' l//�J "4.9 SPOT ELEVATION J�-� i i ` 248 00o STONE WALL -X—X— FENCE r _ w1p, # RETAINING WALL —f—i--F—H RAIL ROAD TRACK STONE JETTY ` + ' SWIMMING POOL L > PORCH/DECK Map 47 ❑ BUILDING/STRUCTURE Y ODOCK/PIER \\ ' • # 49 HYDRANT K r w \ E) VALVE OO MANHOLE O POST pr' FLAG POLE T O W N O F B A R N S T A B L E G E O G R A P H 1 C I N F O R M,A T 1 O N S Y S T E M S U N 1 T a SIGN ® STORM DRAIN N PRINTED SCALE:IN FEET *NOTE:This map is an enlargement of o **NOTE:The.parcel lines are only graphic representations DATA SOURCES:Planimehics(man-made features)were interpreted from 1995 aerial photographs by The James ` 1°=100'scule map and may NOT meet of properly boundaries.They are not hue locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD o UTILITY POLE ° TOWER w e 0 25 50 National Map Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Planimetrics,topography,and vegetation were mopped to meet Notional Mop Accuracy Standards 4 LIGHT POLE O ELECTRIC 80X 'T� 1 INCH=50 FEET* enlarged scale. on the map. of o scale of 1°=100'. Parcel lines were digitized from FY2003 Town of Barnstable Assessor's tax maps. Commonwealth of Mossachusetfsa FB � John,G>t ci ExecuWe Office of ErMrorvnental Affairs �+ � D.E: ,11�tIe Vgis ptic Itsspector artment of P.O. ' < 2119 Environmental ��ronmental Protectl Teaticl el A U2336 �� 64-G813 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 69 Goa Id Lane W. HyannisPort Address of Owner: Date of Inspection:1113197 (If different) Name OF Inspector:John Gracl Cheryl Lahey:913 Boylston St.Boston Ma.02115 Company Name,Address and Telephone Number: 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: X Passes This Inspection Is based on criteria defined In Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system is performing at the time of the inspection.My inspection does _ Needs Further Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fails septic system and any of Its components useful life. Inspector's Signature: �titi Date: 212197 The System Inspector shell submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] 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 al[instances. If "not determined",explain why not.)i _ 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 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 69 Goatneld Lane W.HyannisPort Owner: Cheryl Lahey:913 Boylston SL Boston Ma.02115 Date of Inspection:1113197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced , obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced , obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water 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 has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface.water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is . free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER 1 D] SYSTEM FAILS: I 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 in facility or system component due to an 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 cesspool. SAS is in hydraulic failure. (revised 11115195) 1 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 69 GoaVleld Lane W.MyannlsPort Owner: Cheryl Lahey:913 Boylston St Boston Ma.02115 Date of Inspection:1113197 D] SYSTEM FAILS(continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6°below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 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 11115195) 3 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 69 Goatrield Lane W.HyannlsPort Owner: Cheryl Lahey:913 Boylston SL Boston Ma.e2115 Date of Inspection:1113197 Check if the following have been done: x Pumping information was requested of the owner,occupant, and Board of Health. ' X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n►aAs built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling.was inspected for signs of sewage back-up. x The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X 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. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance.of Sub- Surface Disposal System. (revised 11115195) ' 4 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 69 Goatfleld Lane W.HyannlsPort Owner: Cheryl Lahey:913 Boylston St Boston Ma.02115 Date of inspection:1113197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 0 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: n1a Last date of occupancy: 3 weeks ago COMMERCIAL/INDUSTRIAL: Type of establishment: da Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings.if available: n1a Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPI NG RECORDS and source of Information: System has not been pumped In the last two years. System pumped as part of inspection:(yes or,no)No If yes,volume pumped: 0 gallons Reason for pumping: n1a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) I APPROXIMATE AGE of all components,date installed(if known)and source information: 1984 Sewage odors detected when arriving at the site:(yes or no) No (revised 11If 5195) 5 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 Goattleld Lane W.HyannlsPort Owner: Cheryl Lahey:913 Boylston St.Boston Ma.02115 Date of Inspection:1113197 SEPTIC TANK: X (locate on site plan) Depth below grade: 8' Material of construction:X concreate_metal_FRP_other(explain) Dimensions: L 8'6'H 5'7"W 4'10' Sludge depth:4' Distance from top of sludge to bottom of outlet tee or baffle: 23' Scum thickness:4' Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 14' 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.) Septic tank and all components are structurally sound.Recommend pumping system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metai_FRP_other(explain) Dimensions: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) nla f (revised 11115195) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 Goatneld Lane W.HyannlsPort Owner: Cheryl Lahey:913 Boylston SL Boston Ma.02115 Date of Inspection:1113197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nla .Material of construction:_concrete_m eta l_FRP_other(explain) Dimensions: rda Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nla DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) n1a PUMP-CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: ' (note condition of pump chamber,condition of pumps and appurtenances, etc.) n1a I (revised 11/15/95) 7 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 69 Goatfleld Lane W.HyanrdsPort Owner: Cheryl Lahey:913 Boylston SL Boston Me.02115 Date of Inspection:1113197 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: n1a Type: • leaching pits, number: 1,000 gallon leach pit leaching chambers,number:n1a leaching galleries,number: n1a leaching trenches,number, length: n1a leaching fields,number,dimensions:n1a overflow cesspool,number:n1a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The leach pit is structurally sound and functioning property,It was 112 full. CESSPOOLS: (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: nia Depth of solids layer: n1a Depth of scum layer: n1a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nla PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: nla Depth of solids: nla Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) nla (revised 11115195) t3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) " Property Address: 09 Goatfield Lane W.HyannlsPort Owner: Cheryl Lahey:913 Boylston St.Boston Ma.02115 Date of Inspection:1113197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' AA RC 0& e DEPTH TO GROUNDWATER 1 f Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195(' 9 4- O � h • � � z � v � N N N C v v N � 39 J z a i -- r i I 9 _ . -� r, �: ,^.: � N � —t� �s ,� N � . : 6` ,. ,�_�� I _ _. , �, _ ,. THE COMMONWEALTH OF MASSACHUSEETTS BOARD—OF TrH .................OF.......... I'- .. ........----....._.......------•----.......... Apli irtt#iun for Diupuuttl Moro Tunu#rnr#iun eruti# Application is hereby made for ermi to Construct ) or Repair ( ) an Individual Sewage Disposal System at: �•`i �` ---....... . cation ddr s or Lo o. J� �� er L Ad ress ....... ..�... ... .G.S�.... ..... . .. . iJ........................ ...... :.._._.. ....... ... .d 4 ' .............. Installer � dre s II !!�� dType of Building Size Lot...L_.1_ ....._Sq. feet U Dwelling—No. of Bedrooms.............. .....................Expansio Attic ((�� Garbage Grinder aOther—Type of Building��o..�-?_._........ No. of persons..... Showers ( Cafeteria ( ) d Other fixturesA1O ....................................... W Design Flow...............� .................gallons per person per day. Total Pi/flow __._.__._......_.___gal on . WSeptic Tank—Liquid capacityLb-".gallons Length.td.- ..... Width............ Diameter................ De x Disposal Trench—No. .....V_n dF,. Width.................... Total Length.................... Total leaching area..:=.__._..sq. ft. Seepage Pit No--------------------­ Diameter.................... Depth below inlet.................... Total leaching a -------,---------sq. ft. Z Other Distribution box ( ) Dosing to ( ) '-' Percolation Test Resul s Performed by....... .. ttili �• Date '� minutes per inch De th of Te Pit. �...--- Depth to ground water. �t� Test Pit No. e p p p gr . . 4..-. PLO Test Pit No. 2................minutes per inch Depth of Test.Pit.................... Depth to ground water........................ O Description of Soil______________ _ __`.l i_d� .•........................................ x ----•..............••-•-••......_.._..._...... g........ ... .........................................................0 W .......................................................................-•---••-••-----.....•-:...---................------.......•-•....--•••.....•--••-•-•-•-••••••-•••••......••-•-•......•-•-_•-•-- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------•----------------------•-------•--.....------------.......-•---••---•---............................------------------......--•-••-•--------=------------------...............•-----••.••-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in. operation until a Certificate of Compliance hail issued ar f alth. Signed .... .... ... ... •...•.................••••-•...... .....9_13�Ct . •� Date Application Approved BY ........... Date Application Disapproved for the following reasons:......................................................n...................................................... easons:..............................•-•----....---•---------n•••••-•---•-••-•-•-.......••--•-.....------------•.... ---•-•--....•••-•••••-••......----••-•--•-••••••....•-•-••-••••-•••••-•••••-•--••••.................•••--.--•••.....••-•--•••-------••••••-•-••----•-•••-•••-•••--•-•-•---••-•••••••-•••••••-•-.......--- Date PermitNo......................................................... Issued............-•-•--•---•---.........------............. Date No........................ FEm.............................. THE COMMONWEALTH OF MASSACHUSETTS E10ARD- F I TH ..................OF. ..... .................................................. AVVfirafivu for '11iiiVaiial Wor ongtrurtion ramit Application is hereby made for aPermit to Construct or Repair an Individual Sewage.Disposal System at: 0!r m at. . .. ........... .......... ...... ... ........ ----- ----------- Lo Bond ss 0 .............. < ly .......... ..... ->. ..................................... ..................... ... ... .. .. . ..... ... r A Ire m .................................. .. ... ... ........................ ......... ..........? In"taller" d,e Size .< Type of Building Lot.._..... .....Sq. feet U > xpansi Attic Garbage Grinder Dwelling—No. of Bedrooms.............13.....................E so ..�& Cafeteria 04 Other—Type*of Building Lse.Q.0..-)>.......... No. of per ns.. ................. Showers 04 Other fixtures, lvoaji�,........... ...................................I............................. . < ...... ...............gallons per person Design Flow...................> .. flow.......per day. Total . .. ..............gallonv 0� Septic Tank—Liquid:capacityl:6tr0gallons Length.1-42...... Width:_. ......... Diameter................ Depth...... ...... Disposal Trench—No. .....VGrjS,Width.................... Total Length.................... Total leaching area--266 ---sq. f t. Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area.... ..........sq. ft. Z Other Distribution box Dosing to ( ) 1 4 MAa4w— llr:�., —Percolation Test Resu4s' Performed by....... Date... .. .. S. ? T Depth to ground lter.4006._- �_l ­......Test Pit No. I_��_minutes per inch Depth of e Pit.-0, 1 ................ r14 Test Pit No. 2................minutes per inch Depth of Test Pit....._......._..._.. Depth to ground water____._.............._... 9 ................ .............I.... ............................................................ ............. 0 Description of Soil.------. . . ........ ................................................................ 2............ ........ ---------------------------------------------------------------- U ............................... .............................................................................................................................................;.......................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed' Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees,h*ot to place the.system in operation until a Certificate of Compliance ha issued b r f� issued 181th. Signed_ .... .............................igned Date ApplicationApproved By............................................................ ...................... .....................Da.t.e.............. Application Disapproved for the fallowing reasons:............................................................................................ .................... ......................................................................................................................................................................................................... Date PermitNo.......................................................... IssuedL....................................................... ,Date THE COMMONWEALTH OF MASSACHUSETTS BOARF��OF JE_4%H ..T� ...... ..................OF....... L...................................... (Irdifirate of Tantphaurr THIS IS T FY, That t Individual Sewage Disposal System constructed Repaired (.4 r by............... ........................... .....*------- -------------- ------- ------------ AhN ..............................................................at......IdIte . ... has been installed in accordance with theprovisions of TIT 5 of Th State Sanitary Code as)desqribed in the application for Disposal Works Construction Permit No.......JA? ........... dated... ........ .............. THE ISSUANCE OF.THIS CERTIFICATE SHALL NOT BE CONS UE. GUARANTEE THAT THE SYSTEM WILK .�F�U T N SATISFACTORY. ...........DATE...,/��. .7.............................................. Inspector....... ........................................................................ TZ That t T1 UE or...... ---_------------------------ THE COMMONWEALTH OF MASSACHUSETTS A L BOAR F H P,�q =jft ..........OF........... . .. ........A. ............................................... Noil I el'1'7................ FEE..... .............. Napo trwtion "amit V Creby granted....... ... ..................................................... Permission is'k --------_-------------- - - - ------------------ --------------- ta I.......... ... . . . to Construct Re it a wirtual SewaCe qfposal System . .. .............................at No...................... A+ ...... Street as shown on/thhea/ficat' n for Disposal Works Construction Permit .....-'177 Dated..........qA'A? .......................... . ......... --- ------ .. ..... ............. ....... f d of Heal DATE-.-- .. ...... .. ..................................................... FORM 1255 A. M. SULKIN, INC.. BOSTON ' A lDor. W�t�rrf i t, �oT 23 \ � 01 �- ,A, . ? �. t i G. D " �r CE N T - OsT �r�z��-� �� // Of Mq >:OERT pyMA.yr,. O C MISy H OF MSS Na 29874 0 A D J o ROBE'RT `�. Gl rni BRUCE 4 ST p MORSE y g EtDRED y' No.10951 O Q G►STEP�\�Q``' TEP aQ FFSSIONA\-��� �&D SU��'_� LEGEND CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION OxO EXISTING CONTOUR -- 0 --- ASH OF FINISHED SPOT ELEVATION � .�� I 1~v7 �,14( PlItAJ 6k, a ? • � is - FINISHED CONTOUR 0 iN APPROVED , BOARD OF HEALTH " BERG "3TEFt�� ;+'; Rev. G /6 1 84- DATE AGENT ��NALENG � SCALE] 1° - qO' DATEI q�13 k LDREDGE ENGINEERING CO. IN CLIENT. I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO.�O (12- BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER URVEY R DR.BYt J OF BARNSTABLE, MASS 712 MAIN STREET CH. BY' RQf-• AA)' G NYANNIS MASS. SHEET- - � ��`- R - •�"�� O F _2 _ D TE " RtG. LAND SURVEYOR 14 0 Al � in OKi W K 'V) ca LL � OwOa k1 oa • � 14fA U v � � Z W w2 vil � r z ocDi o ti [ W � 2 h • � � � W 44 r~ o ri IN �e rc T Illy � • . . �• . • • • � O Q D p y � J y O Ar ,_ 'K i W . . . a 14 V •� Its-s7-. 41 1 SAC '. �' •. _ . . . . . ( � ` � 1 (14 Wk Ab vet -J h uj Iq Pt ra- �24 N o h W Wh b y �' W 2� — - WO 0 co F 14 � C W {Ql 'ltl cCC�114. , a SETTS 07 cri -t tij tq z ? fit a 2 �: pJgV � W � e "0ww03 e� 8 4r11-4 v � � S � i o'c WoW � u � � z G�JtTTs d a v k. Mwo13 _. I y� f ' � � 0 C A T I N ld .1� E W A C E PERMIT NO. �.o �* �O ®at VILLAGE, / INSTA LLER'S NAME a. ADDRESS . s s Ijo R UILD-E OR OWNER � d , - DATE - PERMIT ISSUED DA`T E C0MPL1. ANCE ISSUED 11 t t, 18'-0" --------------------------------------------- D •a 5'-3?" 5'-9" proposed crow) space under kitchen expansion D 12" sauna tubes to be 4' deep ,a f ——9 12' -- 0" ---------------------------------------------------------------------- 77 1 - � G. . •______________________________ p __ _-.________-__-_-___ ____-_ ___ ___-_____ ___-_--_______-__--_________ ______________---_____ ___________________.______________ ' C` bathroom cut thru existing ° u;ndation to ea provide access ;t dw addition D cut 4' of foundation provide h D access to ne odditi • D r bedroom 4 oa a t existing garage CIj N D [V .a �• N bedroom 3 111111 familyroom >C 41 - 1 '4" _ 1 ' --- ------ .. .o c Ti_______________���_____-____ _____v-________________--__-__-_____-__________ _- _--_______ ----_-_____-__________________________ a ° ip _______v__a _____________v_ _e_____ °u I C - ------------------------------- --23'-6" 13'-10?" Mr & Mrs. David Menard SCALE 1/4" = 1' APPROVED IDRAWN BY Rick DATE 8/20/04 IREVISED Foundation Plan DRAWING NUMBER 'r 1r 1 i ' t 18'—8?„ 5' '3?" 5'-9" proposed kitchen addition �r :12" sauna tubes to be 4' eep —2 11'-9?" < 2'-8" 2'-9?" x 3'-5'/." 3' b f master bath both t 2 master bedroom T p 2'-6" o ;Proposed addition to i a bedrooms 3 1b • N 2,-6" garage �j ct N > living room O � bedroom 2 O o A 2"-9?" x 4'-1%" 2"-9?" x 4'-1%" 2'-9?" x 4'-1'k" 9'-0" • 8 6 x 4 0 t _ 23'-2'/a i • . Mr & Mrs. David Menard f SCALE 117 = 1 APPROVED DRAWN BY Rick DATE 8/20/04 IREVISED Existing Floor Plan DRAWING NUMSET- i 1� /y PRO'IL_f: NOT TO SGALE V, r A G�/ ELF •. FIRST P1PE LFl k37N Z'L/YER OF S/S"PEl15TOt� / N OVER 7/,4"—I V2"DDUME „/u.�/� Z7 Ztao TOP r,WATiON GOv-R5 TO WITHIN TO Gt StT l�Vt1 WA51'4ED srOr- DATE:_ . f ,� , b" cr rlN16t-ED 6RAX rOR MIN. 2• 7E5T 1�Y: O,/p l y--' ,�' • ro : a' Q yC 3 z PERG RATE: 0,,,- a (N Tcp 0 EL Sy, Z o 3� , ! L IrbrnLwoov,u�N 33.. ct N ntc r rrs J DIST. DOX w' 5FJ'TIG TAr`K 6' wore PA6C I 6�0 Z(; Dl-3 CAN DATA DAILY FLOW: (�)BEDROOMS x 112 ePD= I �� yip&PD S; PTL TANK: yIVOOPD 4-00%=e3OOPP U3zf:/f00OALLON PRE(A5T 5EP70 TANK LEA6hIWoFA ,ILFY: USE:._t%�' ✓-'�C 8.Sx � '�- So U�-,D,�/GCJr. GC...S 5 z-v .v�- GAPAGITY: ! 61PEWALL: !X Z X o,75/ AOTTOM:" 3.�Sxal7Y 30--Z, 3 GENERAL NO TOTAL: \ l GONTRAGTOR TO 1�E RE5PONS1L.E FOR TIME LOGA70NOF ALL UTLFES, ABOVE AND UNDEReROUN,?,PROR TO ANY EXOAVATION OR GONSTRUGTON. SEPTO 5Y5TEM TO�lE N51-ALLED N GOMPLWNGE WIT113 2 GMR 15 VO:T(CLE V A. ALL DISTURBED AREAS TO Ir)E LOAMED AND SECDt P I 5. GONTRAGTOR TO PROVDE 24 hOUR NOT Off-FOR ANY REQUIRED NSPEGTON`_"= I' �?/0 �_ �• _ ,���� .o vd i c4 z E.4 z.Y,,o/7- I n /Clvo �'. 2°��' 5 TE�Cf�C� F—'LAN LOCATION:: f�T / U.� PREPARED FOR: ,Liz /Z- -� /, ,�✓'�,Tz DRAWN f5Y: OF STEVEN W f o RUM J0f5 NLWf-R: DATE: -/� 0 73 51 t�T: 0 . Q suw\4 II IGA-5 FALMOUTh RD - SUIrE 46 GENTERVILLE, MA 02-4/M LID TEL.: (508) 775-0735 ti I=AX: (508) 775--0754 PR0EE66IONAL ENGINEERS & LAND SURVEYORS / qs 3 S� L _ r) — , E fi 1 LLi I � t IjVL t I a Fo Sp f t f Cb UL f DATE !!' r) DONALD I. MEYER RE\,ISEE) z Professional Building Designer vP.O. Box 532 _._ 3 So. Yarmouth,MA 02664 DRAWING rvuMeH W *16 (548)394-5296 VA '. '; ',' B-� - --- -- — AL VFW � �. ,.� T � ✓1. /' �� "`�...,-, �_ _; P i ' F 1l •, : : f 6 04 _ ©N a j 1 + AA i _ --_------_ _ ` 1c) , r CL - a, m . U � i J `.\ - T L � L Q DATE DONALD I. MEYER REUSED s qProfessional Building Designer 0 P,0. Box 532 e s So. Yarmouth,MA 0266I oRAwlNc Nurna f z Y i 1 N t c y { �5t* " 17 _ E �YLY)7. - 4- ._. r t y 111 it I V j�f� c.�' �r� I l�y,� �v� 1�•►_..� a DA rE s Lh i l DONALD 1. MEYER REVIStD -- Professional Building Designer 2 Q DRAWING NUMBED' c; 532 So. Yarmouth, 02664 s 3 (508) 394-5296h.� '" 2