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HomeMy WebLinkAbout0118 GREENWOOD AVENUE - Health 118,Greenwood,Avenue - Hyannis,, Nf r #�� A 289 '123 i a P TOWN Or EA STABLE I re C n � SEW AGE"# LQQATiQN,._. S ASS ESSOWSIVW INSTALLER! ���io1dE NO Se c TAW CAPAolv 777777777- i.E�►c�m�c��►cTat tom} - �vu t�FER o� DA S�pazaiion t)isWnce:Betvivep�e Maxiiitti- A.lusted C'rmundwaterTable to the Bottom of L�tchEngFa�lity Feat Pnvate�►aier Supply well dad Zug Facf anyrells exist qri seta�r wittun Z(l�l sec of Iesiscg facluy} L Btige of WEetand and L t Ef any wetlands e�ust L v iitun 30 fee teactung fL Farrttshed by i •� R IZO ^1 1 ` Lr V ' „ ) � a r ' e 4 i D p Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for•Voluntary Assessments M 118 Greenwood Aven Property Address William Nolan _ Owner Owner's Nam ,a information is ,> 1 required for every Hyannis MA 02601 5-16-15 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. A. General Information 1. Inspector: , Shawn Mcelroy• Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I . i . - I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I'am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: i ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-16-15 I spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. Vol t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is Hyannis MA 02601 5-16-15 required for every y ' page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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. t *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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 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): t ❑ 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. t " ' 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ' ❑ Cesspool*or privy is within 50 feet of a surface water ` ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113, Title 5 Official Inspection Forth: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 118 Greenwood Ave Property Address William Nolan ` Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15' page. City/Town 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 - , El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ - Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or-privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ®- "Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® ° Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and.chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- ` 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the.Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system.the system must serve a facility with a design flow of,10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to.each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection El El 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 p g System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Greenwood Ave Property Address William Nolan ' Owner Owner's Name information is Hyannis MA 02601 5-16-15 required for every y page. City/Town State Zip Code Date of Inspection C. Checklist - Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health • ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ . - ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ,❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) - ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® El Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. • ® ❑ - Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information -Residential Flow Conditions: ' Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 II I Commonwealth of Massachusetts _ F Title 5 Official Inspection. Form im Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is Hyannis MA 02601 5-16-15 required for every y - page. CityfTown State Zip Code Date of Inspection D. System Information Description: IL ' Number of current residents: 0 Does residence have a garbage grinder?• ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 5-2015 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? El ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 l Commonwealth of Massachusetts a Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is H annis MA 02601 5-16-15 required for every y page. City/Town 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: N/A 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 El 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): - t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts , Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 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: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 14"feet ' Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" t5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Cisposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M s 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 page. City/Town 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 20" Scum thickness • ' 1" 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? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: _ ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System-Form -Not for Voluntary Assessments :+ 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) F , Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M s a'y 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis- MA 02601 5-16-15 page. City/Town' State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 III Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis- MA 02601 5-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and empty at inspection with no visible stain lines. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form =Not for Voluntary Assessments M 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): e , t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I I Commonwealth of Massachusetts ; Title 5 official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , w °'r 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately L ~. r r' 36 . P-6 L i t5ins-3113 : Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 1 ❑ Check Slope ❑ Surface water . . ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed- Date ® ' Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i w Commonwealth of Massachusetts = Title 5 Official In Form 'm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 118 Greenwood Ave Property Address William Nolan Owner Owner's Name information is required for every Hyannis MA 02601 5-16-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts `b �A F-P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is required for Hyannis Ma. 0 March 19, 2009 C�/Town every page. 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 Frank DeFelice cursor-do not Name of Inspector use the return key. The Building Inspector Company Name 53 Maki Way Company Address Wareham Ma. 02576 re<mn City/Town State Zip Code 781 254 4825 S 4 0110 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenanee;of on► `site sewage disposal systems. I am a DEP approved system inspector pursuant to ectionA.340a f Title 6(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fk)ils ,> ❑ Needs Further Evaluation by the Local Approving Authority :;3zz c March 19, 2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owners Name information is required for Hyannis Ma. 0 March 19,2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.). Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 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): t5ins•09/08 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 vy. 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name informatifor on is required Hyannis Ma. 0 March 19, 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) A B) System Conditionally Passes(cont.): �v ❑ 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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is required for Hyannis Ma. 0 March 19 2009 every page. City/Town 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 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 0 ® 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 '/day flow t5ins-MOB Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owners Name informatifor yon is required Hyannis Ma. 0 March 19, 2009 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis _and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone 11 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 Lt5inms8regional office of the Department. 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is required for Hyannis annis Ma. 0 March 19, 2009 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? J ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were-the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33330 gal per day t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is required for Hyannis Ma. 0 March 19, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? Z 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 ommercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ElYes ElNo Industrial waste holding tank present? ElYes ElNo Non-sanitary waste discharged to the Title 5 system? ElYes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is Hyannis Ma. 0 March 19 2009 required for + every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: presently occupied Date Other(describe below): General Information Pumping Records: Source of information: Present Owner 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): t5ins-09108 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 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is required for Hyannis Ma. 0 March 19, 2009 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: 2005/10-05 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): a " Depth below grade: 18 feet r q 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.): joints structurally sound, no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal tank Sludge depth: 21, t5ins-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is required for Hyannis Ma. 0 March 19 2009 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" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Physical Mease. Manuf. specs. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank structurally sound, tee in place, liquid levels ok, no evidence of leakage fel1 N\ Pt� 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name , information is required for Hyannis Ma. 0 March 19, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): �r - ight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•D9108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owners Name information is required for Hyannis Ma. 0 March 19, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box level, small amount of carryover, no signs of leakage Pump Chamber(locate on site plan): Pumps in working order: ElYes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is required for Hyannis Ma. 0 March 19, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4-500 gal. chambers ❑ 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.): Normal soil normal vegetation, "grass" no hydraulic failure and no damp soil or ponding Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owners Name information is Hyannis Ma. 0 March 19,2009 required for y , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 Title 5 Official Inspection Form:Subsurfaos Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is Hyannis Ma. 0 March 19, 2009 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑. hand-sketch in the area below ❑ drawing attached separately Na LU i> t5ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Comrhdhwealth of Massachusetts ltitMe 5. Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Greenwood Avenue Property Address Matt Ka inski Owner Owners Name information is Hy annis Ma. 0 March 19, 2009 required for — State Zip Cods Date of Inspection every page. Cftyrr6*n D. System Information (cont.) Site Exam: Check Slope Surface water ❑ Check cellar ❑ Shallow wells 12Ft+ 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: July 26 2005Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: as built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: as built plans July 26 2005 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 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 �r 118 Greenwood Avenue Property Address Matt Karpinski Owner Owner's Name information is Hyannis Ma. 0 March 19 2009 required for + every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file f t5ins•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 . y s THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( V) Upgraded ( ) Abandoned ( )by at i�g G��e 1-( ,she F as- constructed in accordance . with the provisions�f Title 5 and the for Disposal System Construction Permit N .» n1ed 9a Installer 1 ,� Designer' The issuance of 's a shall not be construed as a guarantee that rite Syil fort tin nsd �` a Date 10 011spetor — j/ ————— ----- ------- -- — —— i✓C/ Fee No. ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS i� a�aY *V!9tem Onztruction Permit , Permission is hereby granted to Construct( )Repair Upgrade( )Abandon( ) System located at 11g ��Y"Q`^`J�� , ���y�.h„`�3 t Construction Permit.The applicant recognizes his/her duty to and as described in the above Application for Dtspo 11 sal System pp g comply with Title 5 and the following local provisions or special conditions. Provided: C ton 'ustb pleted within three years of.the date offff . Date: Approved by - ' /. t TOWN OF BARNSTABLE LOCATION SEWAGE # 66 -�Z V'LLAGE �ilic-r+►^�� ASSESSOR'S MAP & LOT ~ �'33 INSTALLER'S NAME&PHONE NO. A,e Ley e.44 C� SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) V (size) �? NO.OF BEDROOMS__ to BUILDER O WNER i PERMITDATE: e16 5— 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 11 within 300 feet of le Feet _ Feet Furnished by � I } 1 tZ �e ,- •� � �4 No. ` Fee THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pphEatiOn for loizpogat *pgtem CConarurtion Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. i 1�' 0,�veewkzab✓ Owner's Name,Addref.ld Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.N Designer's Name,Address and Tel.No. Li G-V�°"� Type of Building: Dwelling No.of Bedrooms Lot Size `5 _sq.ft. Garbage Grinder OZ Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures 2 Z Design Flow 7 ' .gallons per day. Calculated daily flow J gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. n Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last'inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ued by this Bo d of Health. Signed . Date --� Application Approved by Date Application Disapproved'for the following reaso Permit No. A Date Issued No. �` i Fee i _ _ THE`COMMONWE.ACTH OF MASSACHUSETTS :. Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS f 01PPtirat0n for ni!6paaf 46raem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Comphte System ❑Indilvidual Components Location Address or Lot No 4 v ev�Qob�i $' Owner's ame,Addres' and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel N Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size `30 _sq.ft. Garbage Grinder Other " Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures _ Design Flow rgallons per day. Calculated daily flow gallons-' Plan Date Number of sheets Revision Date ' Title Size of Septic Tank Type of S.A.S. y u ty+ a Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: - Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ued by this o d of Health. Signed;� y� / /i x. Date Application Approved b �/r//�� f�( e f �f Date PP PP Y� - Application Disapproved for the following reaso fi Permit No. l'' 7 Date Issued ——————————————————— ————————————— . THE COMMONWEALTH'OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( V)Upgraded( ) Abandoned ( )by at �NR_ 011-e„wt)k has je, constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N .: dated Installer e.t4 Designer The issuance of 's e ml shall not be construed as a guarantee that the s it tion as d n d. J Date I O y to ,un 0 5- Inspector 11 — No. — _—.---—----- ------Fee--' j —/ �^ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mi5po.5a[ *p$tem on!6trurtion Permit Permission is hereby granted to Construct( )Repair 4 Upgrade( )Abandon( ) System located at 1k8" 0, �h��d.. and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 55/and the following local provisions or special conditions. Provided: C Etion 'ust b pleted within three years of the date of 's p Date:_.. �� Approved by s RECEIVE® ECOJECH mAP 2� JAN - 3 2005 OARCEL x I23 Environmental www.eco-tech.us -f �* JVdI��U��3Ai=.iJSTABLE ZALlH DEPT. THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC FISPECTIO Y THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION(revised 6/15/2000) TITLE 5 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION N Property Address: 118 Greenwood Avenue q ��! Hyannis Owner's Name: Barry and Janice Baker Owner's Address: 2810 North Dixie Highway pk New Smyrna Beach,FL 32168 � Date of Inspection. December 9, 2004 �I Name of Inspector: (Please Print) David D. Coughanowr,R.S. Company Name: Eco-Tech Environmental Mailing Address: 43 Triangle Circle Sandwich,MA 02563 Telephone Number: , (508)364-0894 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. I am a DEP approved system inspector pursuant to section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes X Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature Z. Date: ��a 30 , 20 p L� 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 NOTES AND COMMENTS Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. ****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 r Page 2 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10,2004 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 5.303 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. Answer yes, no, or not determined(Y,N,or ND). in the_for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not), is structurally unsound,exhibits substantial infiltration or exfiltration, or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level 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 Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced. ND explain 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 ND explain 2 f Page 3 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 C) Further Evaluation is Required by the Board of Health: Yes 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 and environment. 1 System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) System will fail unless the Board of Health (and public water supplier,if any)determines that the system is functioning in a manner that protects the public health,safety,and environment The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 by 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 3) OTHER Primary cesspool was uncovered and found to be constructed of concrete block and starting to collapse,thereby creatinga safety hazard 3 Page 4 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 D) System Failure Criteria applicable to all systems: You must indicate either"yes" or"no" to each of the following for all inspections: I have determined that one or more of the following failure conditions exist as described 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. yes no X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high groundwater elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well X 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 by 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) No (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 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 You must indicate either"yes" or"no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No Y _ Pumping information was provided by the owner,occupant or Board of Health. N Were any of the system components pumped out in the last two weeks? Y _ Has the system received normal flows in the previous two week period? N Have large volumes of water been introduced to the system recently or as part of this inspection? Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A) Y _ Was the facility or dwelling inspected for signs of sewage back-up? Y _ Was the site inspected for signs of breakout? Y _ Were all system components,excluding the SAS. located on site? _ N Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum.? Y _ Was the facility owner(and occupants, if different from owner)provided with information on the proper maintenance of subsurface disposal systems? For information on the proper maintenance of subsurface disposal systems please go to: WWW.ECO-TECH.US The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Y _ Existing information. For example,Plan at the Board of Health. N 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 Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—No plan on file at Health Dept. Number of current residents 2 Does the residence have a garbage grinder(yes or no): no. Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection requiredl Laundry system inspected (yes or no): n/a Seasonal use(yes or no): no Water meter readings, if available(last two year's usage(gpd): 82 gpd Sump Pump(yes or no): no Last date of occupancy: current COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CUR 15.203):: gpd Basis of design flow(seats/persons/sgft/etc.): Grease trap present: (yes or no)_ Industrial waste holding tank present: (yes or no): Non-sanitary waste discharged to the Title 5 system: (yes or no). Water meter readings, if available: Last date of occupancy/use:_ OTHER: (Describe): GENERAL INFORMATION PUMPING RECORDS Source of information: System not pumped in recent past(Owner) Was system pumped as part of the inspection: (yes or no) No If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM: Septic tank,distribution box, soil absorption system X Single cesspool X Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternate 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: Age 29+years—certificate of compliance issued 8/22/75 (sewage permit#272) Were sewage odors detected when arriving at the site: (yes or no) no 6 Page 7 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 BUILDING SEWER_(Locate on site plan) Depth below grade: 1 ft Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line 20+ Comments: (on condition of joints,venting,evidence of leakage, etc.) Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling SEPTIC TANK:none (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 Certificate of Compliance_(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined: Probe to top of tank Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): GREASE TRAP: none (locate on site plan) Depth below grade: 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: Comments: (on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 TIGHT OR HOLDING TANK: none (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/day Alarm present(yes or no):_ Alarm level: _ Alarm in working order(yes or no):_ Date of last pumping: Comments:(condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: none (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 is equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.) PUMP CHAMBER: none (locate on site plan) Pumps in working order: (yes or no) Alarms in working 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 SYSTEM INFORMATION(continued) Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan;excavation not required) If SAS not located, explain why: Type: _leaching pits,number _leaching chambers,number _leaching galleries,number _leaching trenches,number,length _leaching fields,number,dimensions X overflow cesspool, number 1 —innovative/alternate system Type/name of Technology Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.) Soils above overflow cesspool appeared unsaturated. No evidence of surface ponding breakout lush vegetation or other evidence of hydraulic failure was observed. CESSPOOLS: 1 Primary (cesspool must be pumped at time of inspection)(locate on site plan) Number and configuration: 2 total— 1 primary and one overflow described above Depth-top of liquid to inlet invert: at outlet invert Depth of solids layer: 2 in Depth of scum layer: 3 in Dimensions of cesspool: 5 ft x 5 ft approx Materials of construction: concrete block Indication of groundwater inflow(yes or no): no Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Soils above primary cesspool appeared unsaturated. No evidence of surface ponding breakout lush vegetation,or other evidence of hydraulic failure was observed. Primary cesspool is starting to collapse and structurally unsound PRIVY: none (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 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'(Locate where public water supply enters the building) LOCATIONS A B C 1 II f t 17 f t 2 21 Ft 21 ft PRIMARY OVERFLOW CESSPOOLO O CESSPOOL O2 WATER LINE A B C EXISTING DWELLING # 118 GREENWOOD AVENUE NOT TO SCALE 10 Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 118 Greenwood Avenue Hyannis Owner: Barry and Janice Baker Date of Inspection: April 10, 2004 SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to ground water: 18 feet Please indicate(check)all methods used to determine high ground water elevation: Obtained 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 local excavators, installers-attach documentation) Accessed USGS database You must describe how you established the high ground water elevation. Barnstable GIS department records indicate that property is 18 feet above groundwater table I 11 V i 1 - ." v Town of Barnstable Regulatory Services `Thomas F.Geller,Director WAK Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 " . Fax: 508.•790-6304 Installer &Nsigiier CerMcsitgu F_ orb Date: Designer.er. L S^ Address: 2 Address. 30_1�.o � i,..r. ' n1A C) o 1 On �e� C — was issued a permit to install a (date) er P f septic system at I l G- o 1w Wit✓ ny 5 based on a design drawn by (add.Yess) dated (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 1 distribution box andlor septic tank. I certify that the septic system referenced-above was installed with major chan es (i.e. greater fip W 10' lateral relocation of the SAS or any vertical relocation of any component of the sep46'system)burin accordance with State & Local Regulations. Plan revision or certified as-b'tilt by,desig�qr to follow. 0F'A4ss,,,e er'$ nature) .G��' .� . l l 4 A C''. 1,709S s1b ' ihtUre>° ( x pre ru OF T - � 1 5EW&C;E_PERMIT UP. - -VII.LhGE - - - ----- - _. - --.. - - -I LhISTALLER� ►J� E_ � ADDRESS_ -.- _ -- -- --- _ -_SU1t_DER 5 Al t�IIE AD_DRE SS %J6 THE COMMONWEALTH OF MASSACHUSETTS BARD OF H� /LTH '2 OF. Appliration -fear Miipuiitti Works C omitrurtion Urrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an ividual Sewage Disposal System at �.._... Loca n•Ad ress 7 or Lot No. ..................................... ................... -•-........_...........----._._._.....--------- Owner Address Installer Address Q Type of Building Size Lot............•---------------Sq. feet U Dwelling—No. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building -----------_---------------- No. of persons.---------------------------- Showers ( ) — Cafeteria ( ) P4Other fixtures ------------------------------------------------------ W Design--'F.low.._.:'......................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------ -._gallons Length________________ Width..._- ......_.. Diameter---------------- Depth.-..-.-_--.----- x Disposal Trench—No_ _________________ _ Width-------------------- Total Length------------------.. Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet-------------------- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------•--------•--------------------------------------------- Date---•----•-•---------------------------.. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water......._.-._-_-_-_..__.. L14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.-.-_--_------_-__-._. 9 ---------------------------------------------------------•--......................--•......---...---......................................................­ 0 Description of Soil................................................................................... ------------------------------------------------------- ---------------------------- x V W ------------------------------------------------------------------------------------------------------ --- --------- -------------- ------------ -- V Na 're of Repairs or Alter iogts— swer when applicable.. !a�n ..r� _ _____ _^_. Q. _d.... .......... ...: ---------- pre greement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b n issued by the board of he.. I. > T� ,)Signe ... �- Y ��1�1 � ' f� •- ® Al Dale amp Application Approved By----------- 4__AA4 -°�- ------------- --�- �--- I Date Application Disapproved for the following reasons:.................................................................. ............................................. •.............••••••••....-•••-••-•••-••--••-•-...-.-----•---------------•--•-•---•-----------------••--•-----•------•-----•-------•-----•---------•-----------•----------------------------------_----- PermitNo......................................................... Issued....... ---------............ F ..---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD,-0 OF HENLTHH ------------ Applira#inn -fur Uiipniittl Workii Towarnr#inn Vrrnti# Application is hereby made for a Permit to Construct ( ) or Repair ( ) Individual Sewage Disposal System at• -------•---- --- ----- ................ .•----- ---••----•-- Locat{on•Address or Lot No. �] Owner Address rWa ...-- .. — Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons_-_______-_______-_--__---- Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - W Design Flow--------------------------------------------gallons per person per day. Total daily flow-----------------------------_-_-__-..-----gallons. WSeptic Tank—Liquid capacity.-.----___gallons Length---------------- Width................ Diameter------.--------- Depth---------------- x Disposal Trench—No..................... Width-..-___-__--_-._-__- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.•______-______-_-_- Depth below inlet.................... Total leaching area-------.----------sq. it. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------- ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......--.---..-.--.----. G14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-----------.-__.-------- 9 ---•--...•-•---------------•-------------•-----------••-------------------------------------...-----.........................................•..........---- 0 Description of Soil------------ _-------------------------------------------------------------------------------------------------------- ------- ------------------------------------- x U ............------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W ----------------------------------------------------- --------------------------------------------------- are oRep � — swer when applicble.-N _ _-`_. �__ _a _ C ---- ----------U greement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ,bf'' n issued by the board of heaSignec� .. 'r .. n....1-� r v ... Date ApplicationApproved By-----------------------------------------------------------------------------------•.............. -•--•----------------------------------- Date Application Disapproved for the following reasons:--•---••---•---------•--------•-------•----------------•-------------------------------------------------------- ••-•.._..-------•-••-.....---•--•------------------------------------------------------------•--------......-•--------•-----•----•--•--------------------------------------------------...---------.----- Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF"EALTH .......... ? '' 1..........OF..............! ..... {/t ....................................... (Irr#if irate of T.Ompliaurr THIS IS TO ER" 'VY, That the In uldual Sewage Disposal System constructed ( ) or Repaired (� --- ------------------------------------------------------------------- i Installer ?`-=- ------- ...... ... ... .:............•--•-•----•--•--•------------- 6 has been installed in accordance with the provisions of Article XI of The State anitary Code as described in the PP P '� a lication for Disposal Works Construction Permit No.:............... ..^_____________. dated_._..-..__.:.._°)_.dr__7-5.-__._.__. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................... -----------------------------•--------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS y � BOARD OF HEALTH d7 ........, ............................OF.................................................................................... - No......................... FEE."?....•............ Uinpntitt1 nrk� nn #rnr#in$trrmi# Permission is hereby granted--=_---- 1 '�-----• --•----------••-•------------------------•------------_----.---•-•-----•-•-•---•---------..--•--- to Construct ( or epaW ( an IndividuAl Sewage Disposal Sy tem- Street ,•. as shown on the application for Disposal Works Construction Permit :.____J_ _ � f --------- Dated ------ ----- -------------------- �? � - - • ^ Board of Health DATE---; ------------ ------------ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1500 GALLON TANK DISTRIBUTION BOX FLOW DIFFUSERS CROSS SECTION LOCUS PLAN NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE NOT TO SCALE 102.01 MIN Z% 99.9 N7 ---------COVER TO BE WITHIN 6"OF GRADE MIN. 1211 COVER 2" 1/8"- 1/21' WASHED S1�3NE x /A MAX Lu 4"SCH.40 P.V.C. 3"MINIMUM 0 P.V.0 4"SCH.40 P.V.0 lk 4 W PAINE PAINE975957.7 .13" 3" IE9 HE EHI [E��) 19�1 EE EE EE HA KE .9 EE�l [E�l FEE] . . . . . . 14" 95.95 96- 975.9 94.58 2' N Y47-1.I/1"DOUBLE WASHED STONE 4.0' 95.7 -b X/1 . . . . . . MAR3TON MIN AVr 21 32' --2' L 2'-,- 4' 21 . . . . . . . 36' 81 10.5' BOTTOM OBS 88.4' SITE SPECIFIC NOTES FLOOR PLAN DESIGN CALCULATIONS GENERAL NOTES ALL PIPING TO BE SCHEDULE 40 P.V.C. CESSPOOL TO BE PUMPED AND FILLED NOT TO SCALE EXISTING BEDROOMS 2 0 110 G.P.D. ALL LOCATIONS OF UTILITIES SHOWN ARE AS MIN DESIGN - 3 BED 330 G.P.D. MARKED BY DIG-SAFE AND ARE TO BE INSTALLER TO NOTIFY DESIGNER 24 HOURS VERIFIED BY INSTALLER PRIOR TO PRIOR TO BEGINNING OF JOB TO COORDINATE CONSTRUCTION INSPECTIONS NO. OF UNITS 4 DEPTH BELOW INV. 2' THERE ARE NO KNOWN WETLANDS WITHIN WIDTH 8' 150' OF THE PROPOSED LEACHING FACILITY LENGTH 36' UNLESS SHOWN. FIRST FLOOR THERE ARE NO KNOWN POTABLE WELLS WITHIN SIDEWALL AREA 288 150' OF THE PROPOSED LEACHING FACILITY. M289 P123 BOTTOM AREA 176 P# 119047 TOTAL SQUARE FEET 464 SF THERE ARE NO KNOWN IRRIGATION WELLS WITHIN 50' OF THE PROPOSED LEACHING CAPACITY SIDEWALL 00.74 130.2 G.P.D. FACILITY CAPACITY BOTTOM 0 0.74 213.1 G.P.D. THIS PROPERTY DOES NOT FALL WITHIN A DECK CAPACITY TOTAL 343.3 G.P.D. FLOOD ZONE AS SHOWN ON FIRM MAP THIS DESIGN DOES NOT REQUIRE VARIANCES TO TITLE 5 (310 C.M.R. 15.00 ,3o ACRES THIS SYSTEM NOT DESIGNED TO SUPPLEMENTAL REGULATIONS.) OR BARNSTABLE ACCOMODATE A GARBAGE ALL CONSTRUCTION SHALL BE IN ACCORDANCE WITH TITLE 5 AND BARNSTABLE SUPPLEMENTA <�AL' L C IATI'H DISPOSAL REGULATIONS. KrrCHEN FAMILY E IN-LINE ELEVATIONS PROPOSED AS-BUELT SURVEY INFORMATION SAS 4 FteV­D�� ROOM BEDROOM 8'X36' ® HOUSE 97.7 PROPERTY LINE DATA FROM ZNV'INTO TANK 96.2 TERRY WARNER SURVEYING INV OUT OF TANK 95.95 APRIL 24, 2005 DINING ROOM BEDROOM INV INTO D-BOX 95.9 PLAN TO BE USED FOR INSTALLATION OF SEPTIC SYSTEM ONLY INV OUT OF D-BOX 95.7 INV INTO CHAMBER 95.5 BOTTOM OF CHAMBER 94.58 NOT FOR DETERMINING PROPERTY LINLS ' 't BOTTOM OF STONE 93.5 "n BOTTOM JF O BENCH MARK - F,S HOLE �38­4 Fence 'ORNER OF BULKHEAD r NONE ENCOUNTERED 102.11 (ASSUMED) 100.00 "� Stocky • WATER TABLE PK/SEI 100.22 o 0 0 83 4 MIL VIN YL M V DATE: OBSERVED BY: WITNESSED BY: UP/]1 0 7EFBRANE 0!- SOILLOGS July 26, 2005 LISA C. LYONS DON DESMARAIS 0 T I TO BE INSTALLEE ej SOIL EVALUATOR BOARD OF HEALTH Benchmark set ("a A OBS. HOLE #1 OBS. HOLE #2 SLAB Orange point on sonotulbe E 99.7 LEV-. DEPTH E 100.0- 0LEV. DEPTH 11 El.=99.70 (Assumed) A LOAMY SAND A LOAMY SAND _z 6 IOYR 3/2 1 OYR 3/2 Pa d Bri e 98-95- 9" 99.3 81, 0 ` LOAMY SAND LOAMY SAND B 10YR 5/6 B I OYR 5/6 Deck CLEAN OUT 97.5 1�97-7 -28" CRAWL C MEDIUM SAND I C 43' MEDIUM SAND 2.5Y 5/6 48" [BUILDING SEWER LINE TO BE SLEEVE 2.5Y 6/6 1 FROM ELBOW for 10' WITH 6' SCHE.0 4,]9 k 55" 1 60" O 1 -P TCF=99.60 � 36 4 " 89.5 -426" (Assumed) Shed88. I 0 GROUNDWATER ENCOUNTEREJ NO GROUNDWATER ENCOUNTERE < C PERC RATE<2 MINS. INCH PERC RATE<2 NUNS. INCH Edge OF pavement AvENUE p,AINE I% C PLAN SHOWING: _4S PROPOSED SEPTIC SYSTEM REPAIR IN BARNSTABLE FOR: DRAWN BY: LISA C. LYONS RY BAKER DESIGNED & CHECKED BY: Lit. JAN&BAR LISA C. LYONS 1'c DATF: • LOCATION: so 118 GREENWOOD AVE, HYANNIS REVISIONS: DESCRIPTION: N't" �f"ED SnAlk\Vv LOT#: DATE.AUG 8,2005 M289 P123 r LISA C. LYONS,JR.S. SCALE 1 : 30 1 CERTIFY THAT THIS PLAN CONFORMS TO Ll SA C . LYON S , R , S . (508) 790-9270 TITLE 5 AND BARNSTABLE B.O.H. REGULATIONS HYANNIS, MASSACHUSETTS (774) 487-1638 (EXCLUDING WAIVERS SPECIFIED)